Maternal Newborn
During a breast examination on a 24-year-old client the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?
An irregularly shaped, nontender lump is palpable in the right breast. Irregularly shaped, nontender lumps are consistent with the diagnosis of breast cancer.
A nurse is caring for a client who reports unrelieved episiotomy pain 8 hrs following a vaginal birth. Which of the following action should the nurse take?
Apply an ice pack to the affected area. During the first 24 hours, ice packs and cold water sits baths are used. They reduce edema and promote comfort. The client may also apply witch hazel compresses to reduce edema the nurse should instruct the client on the use of prescribed anesthetic creams, sprays, and ointments.
A nurse in a clinic is caring for a client who is three weeks postpartum following the birth of a healthy newborn. The client reports feeling down and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?
Ask the client if she has considered harming her newborn.
A laboring clients membranes have just ruptured. What is the nurses next action?
Assess the fetal heart rate and pattern. Fetal heart rate is the primary concern because the fetal environment has changed and there is an increase risk of prolapsed cord immediately following rupture of the membranes.
Postpartum client fundus is firm, 3 cm above the umbilicus and displaced to the right. Which of the following intervention should the nurse take?
Assist the client to void and then reassess the fundests. Displacement of the uterus is a sign of bladder discension. The nurse should assist the client to void and then reassess the Fundus.
The nurse is caring for a client with uncomplicated gestational hypertension. Which are expected findings of the disorder? SATA
BP 155/92 BP returns to normal after pregnancy Uncomplicated gestational hypertension occurs during pregnancy with a BP of 140/90 and above, without Adema or proteinuria. The elevated BP will return to the normal range after the pregnancy.
A postpartum complication a client is at risk for is deep vein thrombosis. Which of the following is a factor strongly associated with this post partum complication?
Cesarean birth Cesarean birth doubles the risk for deep vein thrombosis.
A nurse is caring for a laboring client and notes that the fetal heart rate begins to decelerate after the contraction has started. The lowest point of deceleration occurs after the peak of the contraction. What is the priority nursing action?
Change the client's position Late decelerations are associated with insufficient placental perfusion which requires immediate intervention to restore adequate blood flow. Changing the clients position will displace the weight of the uterus off of the Vena cava and thus increase the maternal circulation to the placenta.
Following delivery, the nurse places the new born under a radiant heat warmer. Which of the following is this action used to prevent?
Cold stress The use of a radiant warmer following delivery prevents cold stress which can lead to increased metabolism and physiological demands.
A pregnant clients last menstrual period was May 4, 2018. What is this clients estimated delivery date using Naegele's rule?
February 11, 2019 To determine the due date using Naegele's rule, three months is subtracted from the date of the last menstrual period and then seven days and one year are added.
A home care nurse is following up with a postpartum client. Which of the following is a risk factor that place is this client at risk for postpartum depression?
Hormonal changes with a rapid decline in estrogen and progesterone levels.
A nurse is teaching the parent of a newborn about bottlefeeding. Which of the following statements by the parent indicates a need for further instruction?
I will tip the nipple so air is present as my baby sucks.
A nurse has provided education to a client who has been prescribed oral contraception. Which of the following client statement indicates a need for further education?
If I miss three pills I will double up each day until back on schedule. In the event of missing a dose the nurse should instruct the client that if one pill is missed to take it as soon as possible. If two or three pills are missed the client should follow the manufacturers instructions and use an alternative form of contraception.
A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?
Maintain an eye mask over the newborns eyes. Maintaining an eye mask over the newborns eyes protects the corneas and retinas from phototherapy.
A nurse is planning care for a newborn who is small for gestational age. Which of the following is the priority intervention and the nurse should include in the newborns plan of care?
Monitor blood glucose levels Decreased stores of glycogen and a lower rate of glucogenesis place newborns who are SGA at higher risk for hypoglycemia. Monitoring a blood glucose levels is a priority intervention.
A laboring client received my parody IV one hour prior to delivery. Which of the following medication should the nurse have available to counteract the effects of this medication on the new born?
Naloxone Naloxone is used to reverse the effects of narcotics such as meperidine
A client has been prescribed raloxiphene. As the nurse you know that raloxiphine is used to treat:
Osteoporosis It is used to prevent and treat bone loss in women after menopause.
A nurse is caring for a client two hours after a spontaneous vaginal birth and the client has saturated to peroneal pads with blood in a 30 minute period. Which of the following is a priority nursing intervention at this time?
Palpate the clients uterine fundus. Although the expectation is moderate leading in the first two hours after delivery, saturating a peroneal pad in 15 minutes or less indicates excessive blood loss. The priority nursing intervention is to palpate the clients fundus to determine the presence of uterine atony, followed by fundal massage to stimulate uterine muscle tone.
A nurse is assessing a newborn following a vacuum assisted delivery. Which of the following findings should the nurse report to the provider?
Poor sucking Vacuum assisted bath involves attaching a vacuum cup to the fetal head and using negative pressure to assess the birth of the head, placing the newborn at risk for a subdural hematoma. The nurse should report manifestations of cerebral irritation, such as listlessness and poor sucking to the provider.
A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?
Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux. The effects of progesterone on the G.I. tract include relaxation of the cardiac sphincter and delayed gastric emptying.
A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the clients tolerance of the procedure, which of the following assessment should the nurse perform?
Pulse rate A sitz bath causes vasodilation; therefore, the nurse should monitor the clients pulse rate. Orthostatic hypotension can occur upon standing causing the client to feel faint.
A nurse is caring for a client who is experiencing urinary incontinence. Which of the following recommendations should the nurse include in the teaching plan for this client?
Reduce intake of caffeinated and carbonated beverages.
A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia do to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?
The clients blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and caused hemolysis of red blood cells in newborns. If the RH negative client has been exposed to Rh positive fetal blood, she will produce antibodies against Rh factor. These antibodies can cross the placenta and destroy the red blood cells of the Rh positive fetus. This accelerated rate of blood cell destruction results in the increased release of bilirubin. The newborns a serum bilirubin level can rise quickly.
A nurse is caring for a client who is 37 weeks of gestation and has placenta previa. The client asked the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?
This could result in profound bleeding. Pelvic rest is essential for clients who have placenta previa because any disruption of placental blood vessels in the lower uterine segment could cause premature separation of the placenta and life-threatening hemorrhage. This means no vaginal examination, no douching, and no vaginal intercourse.
True or false. For breast engorgement, fresh cabbage leaves placed inside the bra can help alleviate pain associated with breast engorgement.
True
Prior to an amniocentesis, what action by the client will need to be completed?
empty bladder Prior to the amniocentesis procedure the nurse will instruct the client to empty her bladder prior to the procedure to reduce its size and reduce the risk of inadvertent puncture.
Which of the following would increase the clients risk of ovarian cancer?
endometriosis
A nurse is caring for a post menopausal client prescribed the aromatase inhibitor, anastrozole for the treatment of breast cancer. Which of the following should the nurse tell the client she may experience?
muscle and joint pain Muscle and joint pain are potential side effects of anastrozole and can be treated with mild analgesic as prescribed.
A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?
petroleum jelly
A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?
the lowermost portion of the fetus is at the level of the ischial spines
