Maternal newborn ati proctored exam

fourth degree laceration

skin and muscles of perineum and anal sphincter and anterior rectal wall

first degree laceration

skin of perineum

A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching?

"I can administer oxytocin 4 hours after the insertion of the medication"

before administering pictocin where should the fetus be?

0 station

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 feeding for 24 hours prior to obtaining the specimen"

latent phase of labor

0-3 cm, mild to moderate contractions q5-30 min lasting 30-40 seconds

A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"I should take 600 micrograms of folic acid every day"

A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching?

"I will likely need to use alternative positions for sexual intercourse".

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?

"You can still become pregnant if you are breastfeeding"

A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a non-stress test. Which of the following instructions should the nurse include?

"You should press the handheld button when you feel your baby move."

A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5kg. The amount available is 0.4 mg/ml. how many ml should the nurse administer?

0.25

first stage of labor

1-1.5 cm

A nurse is caring for a newborn who weighs 4lb. How many kg does the newborn weigh?

1.8

CVS can be done at

10-12 weeks gestation

FHR can be heard by a doppler at

10-12 weeks gestation

how long should the newborn nurse?

15-20 min

when can a quad screen be done

15-20 weeks gestation

MSAFP screening is done at

15-22 weeks gestation

AFP can be measured from amniotic fluid between

16-18 weeks

MSAFP can be done when

16-18 weeks gestation

pregnant women should consume how much water each day?

2-3 liters of water each day

postpartum mother should consume ___ mL of water each day

2000-3000 mL

labor occurs ___ hours after ROM

24 hours

recommended weight gain during pregnancy

25-30 pounds, 3-4 pounds first trimester and 1 pound per week last two trimesters

normal newborn weight

2500-4000g

normal newborn respiratory rate

30-60 breaths per minute

GBS can be tested when?

35-37 weeks gestation

active phase of labor

4-7 cm, moderate to strong contractions q3-5 min lasting 40-70 seconds

A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many mL/hr?

50 ml/hr

postpartum lactating women should consume additional ___ calories per day

500 calories

recommended folic acid intake for lactating pregnant women

500 mcg

moderate variability

6-25 contractions per min, normal

newborns should have how many wet diapers per day?

6-8 wet diapers and 3-4 stools per day

normal newborn BP

60-80/40-50

recommended amount of folic acid intake during pregnancy

600 mcg

BPP normal score

8-10

transition phase of labor

8-10 cm, strong contractions q2-3 min lasting 45-90 seconds

normal newborn temp

97.7-98;9

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

A client who is at 11 weeks of gestation and reports abdominal cramping

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

A newborn who is 18 hr old and has an axillary temperature of 99.9° F

A nurse is caring for four newborns. Which of the following newborns is at greatest risk for hypoglycemia? A newborn who is large for gestational age A newborn who has an Rh incompatibility A newborn who has pathologic jaundice A newborn who has fetal alcohol syndrome

A newborn who is large for gestational age Large for gestational age (LGA) newborns are those newborns whose weight is at or above the 90th percentile. One of the most common etiologies of LGA newborns is a mother who is diabetic. LGA newborns, especially those born to mothers who have diabetes, are at increased risk for hypoglycemia. Other newborns at risk for hypoglycemia are small for gestational age (SGA) newborns (those below the 10th percentile), premature newborns, and newborns who have perinatal hypoxia.

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

A reduction in respiratory distress in the newborn

A nurse in a prenatal clinic is caring for a client who is within the recommended guidelines for weight. The client asks the nurse how much weight is safe for her to gain during her pregnancy. Which of the following responses should the nurse make? "Your provider can discuss an appropriate amount of weight gain with you." "A weight gain of about 14 pounds each trimester is suggested." "If you eat nutritious foods when you feel hungry, the amount of weight gain is insignificant." "A weight gain of about 25 to 35 pounds is good."

A weight gain of about 25-35 pounds is good A weight gain of 25 to 35 lb is associated with good fetal outcome. A gain of 4 lb in the first trimester and 12 lb each for the second and third trimester is recommended.

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 hx should the nurse recognize as a contraindication to oral contraceptives? (SATA) A. Cholecystitis B. Hypertension C. HPV D. Migraine headaches E. Anxiety

A,B,D 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. Human papillomavirus is incorrect. The presence of human papillomavirus is not a contraindication for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives. Anxiety disorder is incorrect. The presence of an anxiety disorder is not a contraindication for the use of oral contraceptives.

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (SATA) A. Flaccid uterus B. Cervical laceration C. Excess vaginal bleeding D. Increased afterbirth cramping E. Increased maternal temperature

A,C, Answer: Flaccid uterus is correct. Oxytocin increases the contractility of the uterus. Cervical laceration is incorrect. Bleeding resulting from a cervical laceration continues even when the uterus is contracted and firm. It will require repair by the provider. Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding. Increased afterbirth cramping is incorrect. The use of oxytocin will increase, rather than decrease, afterbirth cramping. Increased maternal temperature is incorrect. The use of oxytocin will have no effect on maternal temperature.

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?

Abruptio placenta

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect?

Acrocyanosis Positive Babinski reflex Two umbilical arteries visible is correct

A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication for the use of this medication? Prolonged rupture of membranes at 38 weeks of gestation Intrauterine growth restriction Postterm pregnancy Active genital herpes

Active genital herpes The use of oxytocin is contraindicated for clients who have an active genital herpes infection. The newborn can acquire the infection as they pass through the birth canal. Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection.

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 seizure. After turning the client head to the side, which of the following actions should the nurse take immediately after the seizure?

Administer oxygen via a nonrebreather mask

A nurse is discussing epidural anesthesia with a client who is receiving oxytocin for induction of labor. Which of the following statements should the nurse make? "An epidural given too early during labor can cause maternal hypertension." "An epidural given too early during labor will not be effective in active labor." "An epidural given too early can cause fetal depression." "An epidural given too early can prolong labor."

An epidural given too early can prolong labor Clients who receive anesthesia before the active phase of labor usually find the progression of their labor to slow. The medication depresses the central nervous system. Therefore, it will take longer for the cervix to dilate and efface.

A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1g orally now." Available is 250 mg tablets. How may tablets should the nurse administer?

Answer: 4

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect? A. Decreased platelet count B. Increased erythrocyte sedimentation rate (ESR) C. Decreased megakaryocytes D. Increased WBC

Answer: Decreased platelet count A. Decreased platelet count A client who has ITP has an autoimmune response that results in a decreased platelet count. B. Increased erythrocyte sedimentation rate (ESR) An increased ESR is an indication of chronic renal failure. C. Decreased megakaryocytes A client who has ITP will have megakaryocytes within the expected reference range. D. Increased WBC An increased WBC is an indication of infection.

A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching? A. "You will need to drink the glucose solution 2 hours prior to the test." B. "Limit your carbohydrate intake for 3 days prior to the test." C. "A blood glucose of 130 to 140 is considered a positive screening result." D. "You will need to fast for 12 hours prior to the test."

Answer: "A blood glucose of 130 to 140 is considered a positive screening result." A. "You will need to drink the glucose solution 2 hours prior to the test." The nurse should instruct the client to drink the glucose solution 1 hr prior to the test. B. "Limit your carbohydrate intake for 3 days prior to the test." The nurse should instruct the client that she should not limit her carbohydrate intake. C. "A blood glucose of 130 to 140 is considered a positive screening result." The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus. D. "You will need to fast for 12 hours prior to the test." The nurse should instruct the client that fasting is not required for a 1-hr glucose tolerance test.

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A. "I should have a goal of maintaining my fasting blood glucose between 100 and 120." B. "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." C. "I will continue taking my insulin if I experience nausea and vomiting." D. "I will ensure that my bedtime snack is high in refined sugar."

Answer: "I will continue taking my insulin if I experience nausea and vomiting." A. "I should have a goal of maintaining my fasting blood glucose between 100 and 120." The nurse should teach the client to maintain her fasting blood glucose level between 60 and 99 mg/dL. B. "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." The nurse should teach the client to avoid exercise during periods of hyperglycemia and when positive urine ketones are present. C. "I will continue taking my insulin if I experience nausea and vomiting." The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes. D. "I will ensure that my bedtime snack is high in refined sugar." The nurse should teach the client to avoid snacks and foods that are high in refined sugar.

A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicated an understanding of the teaching? A. "I will eat foods that taste good instead of balancing my meals." B. "I will avoid having a snack before I go to bed each night." C. "I will have a cup of hot tea with each meal." D. "I will eliminate products that contain dairy from my diet."

Answer: "I will eat foods that taste good instead of balancing my meals." A. "I will eat foods that taste good instead of balancing my meals." Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet. B. "I will avoid having a snack before I go to bed each night." Clients who have hyperemesis gravidarum should avoid going to bed with an empty stomach. The nurse should instruct the client to eat a healthy snack before going to bed. C. "I will have a cup of hot tea with each meal." Clients who have hyperemesis gravidarum should alternate liquids and solids every 2 to 3 hr to avoid an empty stomach and over filling at each meal. D. "I will eliminate products that contain dairy from my diet." Clients who have hyperemesis gravidarum do not need to eliminate dairy products from their diet. The client should be encouraged to consume dairy products, because they are less likely to cause nausea than other foods.

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? A. "I will get injections of the medication once daily until my labor stops." B. "My blood sugar may be low while I'm on this medication." C. "I will have blood tests because my potassium might decrease." D. "My blood pressure may increase while I'm on this medication."

Answer: "I will have blood tests because my potassium might decrease." A. "I will get injections of the medication once daily until my labor stops." Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr. B. "My blood sugar may be low while I'm on this medication." An adverse effect of terbutaline is hyperglycemia. C. "I will have blood tests because my potassium might decrease." An adverse effect of terbutaline is hypokalemia. D. "My blood pressure may increase while I'm on this medication." An adverse effect of terbutaline is hypotension.

A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the following statements by the client indicated an understanding of the teahing? A. "I will receive this medication if my baby is Rh-negative." B."I will receive this medication when I am in labor." C. "I will need a second dose of this medication when my baby is 6 weeks old." D. "I will need this medication if I have an amniocentesis."

Answer: "I will need this medication if I have an amniocentesis." A. "I will receive this medication if my baby is Rh-negative." Rho(D) immune globulin is administered to a client who is Rh-negative and gives birth to an Rh-positive newborn. B."I will receive this medication when I am in labor." Rho(D) immune globulin is administered at 28 weeks of gestation or after birth if the newborn is Rh-positive. C. "I will need a second dose of this medication when my baby is 6 weeks old." Rho(D) immune globulin is administered at 28 weeks of gestation to clients who are Rh-negative and following the birth of a newborn who is Rh-positive. D. "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 teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make? A. "The nurse will carry your newborn to the nursery for procedures." B. "We will document the relationship of visitors in your medical record." C. "Your baby will stay in the nursery while you are asleep." D. "Staff members who take care of your baby will be wearing a photo identification badge."

Answer: "Staff members who take care of your baby will be wearing a photo identification badge." A. "The nurse will carry your newborn to the nursery for procedures." The nurse should instruct the client that newborns will be transported in their bassinets and never carried outside the client's room to reduce the risk for falls. B. "We will document the relationship of visitors in your medical record." The nurse should instruct the client that they can have anyone visit them on the unit. There is no documentation of a visitor's relationship to the client entered into the medical record. C. "Your baby will stay in the nursery while you are asleep." The nurse should instruct the client to place the baby in the bassinet on the side of the bed furthest from the door while she is sleeping. D. "Staff members who take care of your baby will be wearing a photo identification badge." The nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs.

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for bedamethasone. Which of the following statements should the nurse make about the indication for medication administration? A. "This medication will stop your labor." B. "This medication stimulates fetal lung maturity." C. "This medication will decrease your risk for uterine infections." D. "This medication will increase your baby's weight."

Answer: "This medication stimulates fetal lung maturity." A. "This medication will stop your labor." Betamethasone is not a tocolytic and does not stop labor. B. "This medication stimulates fetal lung maturity." The nurse should inform the client that betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of enzymes that release lung surfactant. C. "This medication will decrease your risk for uterine infections." Betamethasone is not given to decrease the client's risk for uterine infections. D. "This medication will increase your baby's weight." Betamethasone does not increase fetal weight.

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? A. ????? B. "This procedure should have no effect on your sexual performance or adequacy." C. "You'll be fine. I can't imagine you and your partner will have any problems with sexual function." D. "If this concerns you, perhaps you should reconsider and use another form of contraception."

Answer: "This procedure should have no effect on your sexual performance or adequacy." A. ?????? The nurse is dismissing the client's question, providing no information to help the client make an informed decision. B. "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. C. "You'll be fine. I can't imagine you and your partner will have any problems with sexual function." The nurse is giving the client unwarranted reassurance without addressing the information the client is seeking. D. "If this concerns you, perhaps you should reconsider and use another form of contraception." The nurse is giving the client unwarranted advice which might imply that there is a reason to be concerned about the effect of the procedure on sexual function.

A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make? A. "You can miss your period for several other reasons. Describe your typical menstrual cycle." B. "If you have been sexually active and haven't used protection, it is likely that you are pregnant." C. "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" D. "Because you have missed your period, you should try taking a home pregnancy test before you start worrying."

Answer: "You can miss your period for several other reasons. Describe your typical menstrual cycle." A. "You can miss your period for several other reasons. Describe your typical menstrual cycle." Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions. B. "If you have been sexually active and haven't used protection, it is likely that you are pregnant." The nurse's response is assuming and confirming that the client is pregnant based only on the client's statement, which can increase the client's anxiety level. C. "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" The nurse's response is making a false assumption that the client is pregnant based only on the client's statement. The nurse should gather more information from the client before making any false assumptions. D. "Because you have missed your period, you should try taking a home pregnancy test before you start worrying." The nurse's response dismisses the client's concerns and does not answer or address the client's question, which can increase the client's anxiety level.

A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of spina bifida occulta? A. The nurse should identify this as an image of spina bifida occulta. External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area. B. The nurse should identify this as an image of spina bifida manifesta in the form of a myelomeningocele that is closed. External indications of this neural tube defect include a herniated sac over the site of the defect that is covered with skin. C. The nurse should identify this as an image of spina bifida manifesta in the form of a myelomeningocele that is open. External indications of this neural tube defect include an open area over the defect that allows for leakage of cerebrospinal fluid and entry of microorganisms. D. The nurse should identify this as an image of Mongolian spots. These bluish-black pigmented areas are most commonly found on the buttocks and back of newborns of Mediterranean, Asian, African, and Latin American ethnicity and can be incorrectly identified as areas of ecchymosis.

Answer: A

A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching? A. "You can share your room with your baby for the next few weeks." B. "Cover your baby with a light blanket while sleeping." C. "Check the temperature of your baby's bath water with your hand." D. "Your baby can nap in the car seat during the daytime."

Answer: "You can share your room with your baby for the next few weeks." A. "You can share your room with your baby for the next few weeks." The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome. B. "Cover your baby with a light blanket while sleeping." The nurse should instruct the parents to place the newborn in a sleep sack or a one-piece sleeper. Covering the newborn with a blanket or quilt increases the risk for sudden infant death syndrome. C. "Check the temperature of your baby's bath water with your hand." The nurse should instruct the parents to check the temperature of the newborn's bath water with their elbow, which is more sensitive to temperature than the hand. The hot water heater should be set at or below 49° C (120.2° F) to prevent burns. D. "Your baby can nap in the car seat during the daytime." The nurse should instruct the parents to lay the newborn in a bassinet or crib on her back to sleep. Sleeping in a supine position on a firm mattress decreases the risk of sudden infant death syndrome.

A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching? A. "You should replace the diaphragm every 5 years." B. "You should leave the diaphragm in place for at least 6 hours after intercourse." C. "You should use an oil-based product as a lubricant when inserting the diaphragm." D. "You should insert the diaphragm when your bladder is full."

Answer: "You should leave the diaphragm in place for at least 6 hours after intercourse." A. "You should replace the diaphragm every 5 years." The client should replace the diaphragm every 2 years. B. "You should leave the diaphragm in place for at least 6 hours after intercourse." The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy. C. "You should use an oil-based product as a lubricant when inserting the diaphragm." The client should avoid using oil-based products because they can weaken the rubber in the diaphragm. D. "You should insert the diaphragm when your bladder is full." The client should have an empty bladder prior to inserting the diaphragm.

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching? A. "You should take the medication within 72 hours following unprotected sexual intercourse." B. "You should avoid taking this medication if you are on an oral contraceptive." C. "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test." D. "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it."

Answer: "You should take the medication within 72 hours following unprotected sexual intercourse." A. "You should take the medication within 72 hours following unprotected sexual intercourse." Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse. B. "You should avoid taking this medication if you are on an oral contraceptive." Levonorgestrel, an emergency contraceptive, has no effect on the other oral contraceptive the adolescent might be taking. To prevent pregnancy, this medication should be taken if an adolescent misses a dose of oral contraception. C. "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test." The adolescent should be evaluated for pregnancy if she does not menstruate within 21 days following administration of this medication. D. "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it." Levonorgestrel is an emergency contraceptive that prevents or delays ovulation. Therefore, the nurse should inform the client that she will not be protected from pregnancy if she has unprotected sexual intercourse in the days and weeks after receiving this medication.

A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching? A. "You will receive IV fluids prior to this test." B. "The procedure will take approximately 10 to 15 minutes." C. "You will be offered orange juice to drink during the test." D. "You will need to sign an informed consent form each time you have this test."

Answer: "You will be offered orange juice to drink during the test." A. "You will receive IV fluids prior to this test." The nurse should state that IV fluids are initiated for an oxytocin-stimulated contraction test, rather than a nonstress test. B. "The procedure will take approximately 10 to 15 minutes." The nurse should instruct the client that the procedure will take 20 to 40 min. C. "You will be offered orange juice to drink during the test." A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate fetal movements during the procedure, helping to obtain results. D. "You will need to sign an informed consent form each time you have this test." A nonstress test is a noninvasive procedure. Therefore, the client does not need to provide informed consent.

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? A. "Let me help you into a comfortable pushing position so you can begin bearing down." B. "I am going to call the doctor to get a prescription for medication to ripen your cervix." C. "I will give you some IV pain medicine to strengthen your contractions." D. "Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions."

Answer: "Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions." A. "Let me help you into a comfortable pushing position so you can begin bearing down." The nurse should not instruct the client to start bearing down until the second stage of labor. B. "I am going to call the doctor to get a prescription for medication to ripen your cervix." A cervical ripening agent is not used during the active stage of labor. C. "I will give you some IV pain medicine to strengthen your contractions." Administering IV pain medication can decrease the intensity of uterine contractions. D. "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.

A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority? A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL B. A client who is at 34 weeks of gestation and reports epigastric pain C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria

Answer: A client who is at 34 weeks of gestation and reports epigastric pain A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL A fasting blood glucose of 120 mg/dL is above the expected reference range for a client who has gestational diabetes, which is a nonurgent finding. Therefore, another client is the nurse's priority. B. A client who is at 34 weeks of gestation and reports epigastric pain When using the urgent vs nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority. C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL This finding is a manifestation of anemia in a client who is pregnant, which is a nonurgent condition. Therefore, another client is the nurse's priority. D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria Dysuria can indicate a urinary tract infection, which can cause preterm labor. Dysuria in a client who is at 39 weeks of gestation is a nonurgent condition which will require antibiotics. Thereofre, another client is the nurse's priority.

A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions? Exhibit 1: Diagnostic Results​ Lecithin/sphingomyelin (L/S) ratio 1.4:1Phosphatidylglycerol (PG) absentABO-Rh B-negative Exhibit 2: Medication Administration Record​ Terbutaline 0.25 mg SQ every hr PRN contractionsRho(D) immune globulin 300 mcg IM onceNalbuphine 10 mg IV every 3 hr PRN pain Exhibit 3: Progress Report 1655 - Amniocentesis completed, tocotransducer and external fetal monitor applied1700 - Fetal heart rate 130/min with moderate variabilityUterine contractions q 5 to 8 min lasting 30 to 60 sec durationUterine contractions palpated at 1+ intensityClient reports uterine contraction pain of 2 on a scale of 0 to 10 A. Administer terbutaline. B. Discuss possible genetic anomalies with the client. C. Administer nalbuphine. D. Discontinue external fetal monitoring.

Answer: Administer terbutaline. A. Administer terbutaline. The nurse should administer terbutaline to stop contractions because the laboratory results indicate that the fetus's lungs are not mature enough for birth. B. Discuss possible genetic anomalies with the client. There is no indication of genetic anomalies based on the results of the amniocentesis. C. Administer nalbuphine. Nalbuphine is an analgesic used for moderate to severe pain. A report of 2 on a scale of 0 to 10 is mild pain. D. Discontinue external fetal monitoring. The nurse should not discontinue external fetal monitoring. Because the client is exhibiting manifestations of preterm labor, fetal well-being and contraction patterns should be continuously monitored to continue to assess for preterm labor and provide necessary interventions to stop contractions.

A nurse is planning discharge for a client who is 3 days postpartum. Which of the following non-pharmacological interventions should the nurse include in the plan of care for lactation suppression? A. Place warm, moist packs on the breasts. B. Apply cabbage leaves to the breasts. C. Wear a loose-fitting bra. D. Put green tea bags on the breasts.

Answer: Apply cabbage leaves to the breasts. A. Place warm, moist packs on the breasts. The client can use cold compresses to decrease breast discomfort during lactation suppression. B. Apply cabbage leaves to the breasts. Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement. C. Wear a loose-fitting bra. A tight-fitting bra will provide support to the breasts during engorgement, which can decrease pain. D. Put green tea bags on the breasts. Tea bags are used to relieve nipple soreness in breastfeeding clients. Answer: Apply cabbage leaves to the breasts.

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 next? A. Place a rolled towel beneath one of the client's hips. B. Apply internal upward pressure to the presenting part using two gloved fingers. C. Administer oxygen to the client via a nonrebreather mask at 10 L/min. D. Increase the IV infusion rate.

Answer: Apply internal upward pressure to the presenting part using two gloved fingers. A. Place a rolled towel beneath one of the client's hips. The nurse should place a rolled towel under the client's left or right hip to alleviate some of the pressure; however, evidence-based practice indicates that the nurse should take a different action first. B. Apply internal upward pressure to the presenting part using two gloved fingers. Using evidence-based practice, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand. C. Administer oxygen to the client via a nonrebreather mask at 10 L/min. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. The nurse should administer oxygen via a nonrebreather mask at 10 L/min; however, evidence-based practice indicates that the nurse should take a different action first. D. Increase the IV infusion rate. The nurse should increase the IV infusion rate; however, evidence-based practice indicates that the nurse should take a different action first.

A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take? A. Apply sacral counterpressure. B. Perform transcutaneous electrical nerve stimulation (TENS). C. Initiate slow-paced breathing. D. Assist with biofeedback.

Answer: Apply sacral counterpressure. A. Apply sacral counterpressure. The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position. B. Perform transcutaneous electrical nerve stimulation (TENS). The nurse should perform TENS during the first stage of labor. C. Initiate slow-paced breathing. The nurse should transition a client to pattern-paced breathing during this stage of labor. D. Assist with biofeedback. The nurse should teach the client about biofeedback during the prenatal period for it to be effective during labor.

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the unbilicus. Which of the following interventions should the nurse perform? A. Reassess the client in 2 hr. B. Administer simethicone. C. Assist the client to empty her bladder. D. Instruct the client to lie on her right side.

Answer: Assist the client to empty her bladder. A. Reassess the client in 2 hr. The nurse should assess the client more frequently after birth to determine the position of the uterus and to intervene as soon as possible if necessary. B. Administer simethicone. The nurse should administer simethicone to reduce bloating, discomfort, or pain caused by excessive gas. C. Assist the client to empty her bladder. The nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage. D. Instruct the client to lie on her right side. Lying on her right side will not resolve the client's displaced uterus. Answer: Assist the client to empty her bladder.

A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider? A. Bilirubin 9 mg/dL B. Hemoglobin 18 g/dL C. Platelets 175,0000/mm3 D. Hematocrit 45%

Answer: Bilirubin 9 mg/dL A. Bilirubin 9 mg/dL A bilirubin level of 9 mg/dL is above the expected reference range for a newborn who is 4 hr old. The expected reference range for a newborn who is less than 24 hr old is 2 to 6 mg/dL. The nurse should report this finding to the provider. B. Hemoglobin 18 g/dL This hemoglobin level is within the expected reference range of 14 to 24 g/dL for a newborn and does not require reporting. C. Platelets 175,0000/mm3 This platelet count is within the expected reference range of 150,000 to 300,000/mm3 for a newborn and does not require reporting. D. Hematocrit 45% This hematocrit level is within the expected reference range of 44% to 64% for a newborn and does not require reporting.

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client? A. Percutaneous umbilical blood sampling B. Amnioinfusion C. Biophysical profile (BPP) D. Chorionic villus sampling (CVS)

Answer: Biophysical profile (BPP) A. Percutaneous umbilical blood sampling Percutaneous umbilical blood sampling, commonly called cordocentesis, is the most common method used for fetal blood sampling and transfusion. This is not a diagnostic test used for clients who have a positive contraction stress test. B. Amnioinfusion An amnioinfusion of normal saline or lactated Ringer's is instilled into the amniotic cavity through a transcervical catheter introduced into the uterus to supplement the amount of amniotic fluid. The instillation reduces the severity of variable decelerations caused by cord compression for clients who are in labor. This is not a diagnostic test used for clients who have a positive contraction stress test. C. Biophysical profile (BPP) The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. D. Chorionic villus sampling (CVS) CVS is the assessment of a portion of the developing placenta, which is aspirated through a thin sterile catheter inserted through the abdominal wall or intravaginally through the cervix under ultrasound guidance. This procedure is done during the first trimester. This is not a diagnostic test used for clients who have a positive contraction stress test.

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? A. Hgb 20 g/dL B. Total bilirubin 5 mg/dL C. Blood glucose 30 mg/dL D. WBC count 20,000/mm3

Answer: Blood glucose 30 mg/dL A. Hgb 20 g/dL This value is within the expected reference range of 14 to 24 g/dL for a newborn who is 24 hr old. B. Total bilirubin 5 mg/dL This value is within the expected reference range of 2 to 6 mg/dL for a newborn who is 24 hr old. C. Blood glucose 30 mg/dL Newborns less than 24 hr old should have a blood glucose of 40 to 60 mg/dL. Newborns who are greater than 24 hr old should have a blood glucose of 50 to 90 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. D. WBC count 20,000/mm3 This value is within the expected reference range of 9,000 to 30,000/mm3 for a newborn who is 24 hr old.

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? A. Decreased heart rate B. Chin quivering C. Pinpoint pupils D. Slowed respirations

Answer: Chin quivering A. Decreased heart rate The heart rate will increase when a newborn is experiencing pain. B. Chin quivering Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow. C. Pinpoint pupils When experiencing pain, a newborn's pupils typically dilate. D. Slowed respirations When experiencing pain, a newborn's respirations are typically rapid and shallow.

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? A. Cover the newborn's eyes while under the phototherapy light. B. Keep the newborn in a shirt while under the phototherapy light. C. Apply a light moisturizing lotion to the newborn's skin. D. Turn and reposition the newborn every 4 hr while undergoing phototherapy.

Answer: Cover the newborn's eyes while under the phototherapy light. A. Cover the newborn's eyes while under the phototherapy light. Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light. B. Keep the newborn in a shirt while under the phototherapy light. It is acceptable for the nurse to keep a diaper or other covering over the newborn's genitals and buttocks, but the nurse should remove all other clothing and blankets to expose as much body surface area as possible to the phototherapy light. C. Apply a light moisturizing lotion to the newborn's skin. The nurse should not apply any cream or moisture to the newborn's skin because it can absorb heat and cause burns. D. Turn and reposition the newborn every 4 hr while undergoing phototherapy. The nurse should turn and reposition the newborn every 2 to 3 hr to allow for maximum exposure of body surfaces to the phototherapy light.

A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? A. Discuss contraceptive options with the client and her partner. B. Repeat information to ensure client understanding. C. Listen to the client and her partner as they reflect upon the birth experience. D. Demonstrate to the client how to perform a newborn bath.

Answer: Demonstrate to the client how to perform a newborn bath. A. Discuss contraceptive options with the client and her partner. The discussing of contraceptive options occurs during the letting-go phase. This phase focuses on moving forward as a family with interchanging members. B. Repeat information to ensure client understanding. The repeating of information to ensure client understanding occurs during the taking-in phase. During this phase, which is experienced on the first postpartum day, the client displays dependent and passive behaviors. Due to excitement and fatigue, the client is unable to retain information. Therefore, the nurse should repeat instructions to ensure that the client understands what is being said. C. Listen to the client and her partner as they reflect upon the birth experience. Listening to the client and her partner reflect upon the birth experience occurs during the taking-in phase. During this phase, the new mother is focused on herself and meeting her basic needs. There is also much excitement about the newborn and the birth experience. Therefore, the nurse should allow the client to reflect, ensuring a healthy transition and a successful adaptation into the new family unit. D. Demonstrate to the client how to perform a newborn bath. Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new parent moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new parent confidence and promote maternal adjustment.

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first? A. Determine respiratory function. B. Increase the IV fluid rate. C. Access emergency medications from cart. D. Collect a maternal blood sample for coagulopathy studies.

Answer: Determine respiratory function. A. Determine respiratory function. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation. B. Increase the IV fluid rate. The nurse should increase the IV fluid rate to maintain circulation. However, this is not the first action the nurse should take. C. Access emergency medications from cart. The nurse should access emergency medication to assist in resuscitative efforts. However, this is not the first action the nurse should take. D.Collect a maternal blood sample for coagulopathy studies. The nurse should collect a maternal blood sample in preparation for a blood transfusion. However, this is not the first action the nurse should take.

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interperate the client's statement as an indication of which of the following? A. Emotional lability B. Focusing phase C. Cognitive restructuring D. Couvade syndrome

Answer: Emotional lability A. Emotional lability The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason. B. Focusing phase The focusing phase is the third phase of the father's emotional response to the pregnancy. It is characterized by his active involvement in the pregnancy and his relationship with the child. C. Cognitive restructuring Cognitive restructuring is accepting the idea of pregnancy and assimilating it into the woman's life. The degree of acceptance is shown in the mother's emotional responses. D. Couvade syndrome Couvade syndrome is pregnancy-like manifestations experienced by the expectant father. Manifestations include nausea, weight gain, and other physical manifestations of pregnancy.

A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take? A. Tell the client to follow up with a dermatologist. B. Explain to the client this is an expected occurrence. C. Instruct the client to increase her intake of vitamin D. D. Inform the client she might have an allergy to her skin care products.

Answer: Explain to the client this is an expected occurrence. A. Tell the client to follow up with a dermatologist. An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an increase in the pigmentation of the skin during pregnancy. Treatment by a dermatologist will not affect the client's condition. B. Explain to the client this is an expected occurrence. Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery. C. Instruct the client to increase her intake of vitamin D. An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an increase in the pigmentation of the skin during pregnancy. Increasing her vitamin D intake will not affect the client's condition. D. Inform the client she might have an allergy to her skin care products. An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an increase in the pigmentation of the skin during pregnancy. Changing skin care products will not affect the client's condition.

A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include? A. Shortness of breath when climbing stairs B. Swelling of feet and ankles at the end of the day C. Headache that is unrelieved by analgesia D. Braxton Hicks contractions

Answer: Headache that is unrelieved by analgesia A. Shortness of breath when climbing stairs Shortness of breath is related to the enlarging uterus interfering with the expansion of the diaphragm and is an expected manifestation at 35 weeks of gestation. B. Swelling of feet and ankles at the end of the day Swelling of feet and ankles is due to the enlarging uterus interfering with blood return to the heart and is an expected manifestation at 35 weeks of gestation. C. Headache that is unrelieved by analgesia A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider. D. Braxton Hicks contractions Braxton Hicks contractions are an indication that the uterus is preparing for labor and is an expected manifestation at 35 weeks of gestation.

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? A. Hemoglobin 10 g/dL B. WBC count 15,000/mm3 C. RBC count 5.8 million/mm3 D. Hematocrit 34%

Answer: Hemoglobin 10 g/dL A. 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. B. WBC count 15,000/mm3 This white blood cell count is within the expected reference range of 5,000 to 15,000/mm3 for a client who is pregnant. This finding is does not require reporting. C. RBC count 5.8 million/mm3 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. D. Hematocrit 34% This hematocrit is within the expected reference range of greater than 33% for a client who is pregnant and does not require reporting.

A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following action should the nurse take? A. Perform a vaginal exam to determine cervical dilation every 2 hr. B. Instruct the client to ambulate in the hallway once every 4 hr. C. Administer betamethasone to the client via IM injection. D. Initiate continuous external fetal monitoring.

Answer: Initiate continuous external fetal monitoring. A. Perform a vaginal exam to determine cervical dilation every 2 hr. A client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should place the client on pelvic rest and should not perform vaginal or rectal examinations. B. Instruct the client to ambulate in the hallway once every 4 hr. A client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. Ambulating frequently could potentially stimulate labor and increase vaginal bleeding. Therefore, the nurse should place the client on bed rest with bathroom privileges. C. Administer betamethasone to the client via IM injection. Betamethasone is given to enhance fetal lung maturity for clients who are experiencing preterm labor. It is given to clients between 24 and 34 weeks of gestation. D. Initiate continuous external fetal monitoring. The nurse should identify that a client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor laboratory values. Also, the nurse should implement interventions to prepare for an emergency birth.

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care? A. Maintain the client NPO throughout the procedure. B. Place the client in a supine position. C. Instruct the client to massage the abdomen to stimulate fetal movement. D. Instruct the client to press the provided button each time fetal movement is detected.

Answer: Instruct the client to press the provided button each time fetal movement is detected. A. Maintain the client NPO throughout the procedure. There is no indication for the client to be NPO. Sometimes clients are encouraged to drink liquids to promote adequate hydration. B. Place the client in a supine position. The client should be placed in a semi-Fowler's or sitting position and tilted to the right or left to promote uterine perfusion and prevent supine hypotension. C. Instruct the client to massage the abdomen to stimulate fetal movement. Massaging the abdomen does not stimulate fetal movement. D. Instruct the client to press the provided button each time fetal movement is detected. Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.

A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients? A. Calcium B. Vitamin E C. Iron D. Vitamin D

Answer: Iron A. Calcium The recommendation for calcium intake during pregnancy is the same as that for women who are not pregnant: 1,300 mg/day for women younger than 19 years old and 1,000 mg/day for women between the ages of 19 and 50 years old. B. Vitamin E The recommendation for vitamin E intake during pregnancy is 15 mg/day, the same as that for women who are not pregnant. C. Iron The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old. D. Vitamin D The recommendation for vitamin D intake during pregnancy is 600 IU/day, the same as that for women who are not pregnant.

A nuse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect? A. Jitteriness B. Hypertonia C. Abdominal distention D. Mottling

Answer: Jitteriness A. Jitteriness Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia. B. Hypertonia Hypotonia, rather than hypertonia, is a manifestation of hypoglycemia. Hypertonia is a manifestation of opioid withdrawal. C. Abdominal distention Abdominal distention is not a manifestation of hypoglycemia. Abdominal distention is a finding in newborns who have hypocalcemia. D. Mottling Mottling is not a manifestation of hypoglycemia. It can be a normal variation seen in newborns. Also, it is a manifestation of opioid withdrawal.

A nurse is assessing the newborn of a client who took selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? A. Large for gestational age B. Hyperglycemia C. Bradypnea D. Vomiting

Answer: Vomiting A. Large for gestational age Low birth weight is an expected manifestation of fetal exposure to SSRIs. B. Hyperglycemia Hypoglycemia is an expected manifestation of fetal exposure to SSRIs. C. Bradypnea Tachypnea is an expected manifestation of fetal exposure to SSRIs. D. Vomiting Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days. Answer: Vomiting

A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)? A. Just above the umbilicus B. Just above the symphysis pubis C. The right lower quadrant D. The left lower quadrant

Answer: Just above the symphysis pubis A. Just above the umbilicus The nurse should assess FHT using the Doppler stethoscope just above the umbilicus if the fetus is in a transverse or breech presentation and the client is at a minimum of 22 weeks of gestation. B. Just above the symphysis pubis At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis. C. The right lower quadrant At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse might not hear FHT in the right lower quadrant. D. The left lower quadrant At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse might not hear FHT in the left lower quadrant.

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication? A. Increased fetal movement B. Leakage of fluid from the vagina C. Upper abdominal discomfort D. Urinary frequency

Answer: Leakage of fluid from the vagina A. Increased fetal movement Decreased fetal movement is a potential complication that should be reported to the provider. B. Leakage of fluid from the vagina Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider. C. Upper abdominal discomfort Upper abdominal discomfort is not a potential complication associated with an amniocentesis. D. Urinary frequency Urinary frequency is not a potential complication associated with an amniocentesis.

A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart? A. Left upper quadrant B. Right upper quadrant C. Left lower quadrant D. Right lower quadrant

Answer: Left lower quadrant A. Left upper quadrant The fetal heart tones of a fetus in the left sacrum anterior position are best heard in the left upper quadrant. B. Right upper quadrant The fetal heart tones of a fetus in the right sacrum anterior position are best heard in the right upper quadrant. C. Left lower quadrant The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant. D. Right lower quadrant The fetal heart tones of a fetus in the right occipital anterior position are best heard in the right lower quadrant.

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? A. Massage the client's fundus. B. Insert an indwelling urinary catheter. C. Administer oxygen at 10 L/min. D. Elevate the client's right hip.

Answer: Massage the client's fundus. A. 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. B. Insert an indwelling urinary catheter. The nurse should insert an indwelling urinary catheter to monitor perfusion of the kidneys. However, this is not the next action the nurse should take. C. Administer oxygen at 10 L/min. The nurse should administer oxygen at 10 L/min via rebreather face mask to enhance perfusion. However, this is not the next action the nurse should take. D. Elevate the client's right hip. The nurse should elevate the client's right hip to enhance perfusion. However, this is not the next action the nurse should take.

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? A. Place the client in a supine position for 30 min following the first dose of anesthetic solution. B. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution. C. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. D. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution.

Answer: Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. A. Place the client in a supine position for 30 min following the first dose of anesthetic solution. The nurse should plan to position the client upright to allow the anesthetic solution to flow downward. If additional pain management is needed for a cesarean birth, the nurse can place the client supine with her head and shoulders elevated and at a lateral tilt to increase perfusion to the fetus. B. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution. The nurse should plan to administer 500 to 1,000 mL of lactated Ringer's or 0.9% sodium chloride 15 to 30 min prior to the administration of the first dose of anesthetic solution to decrease the maternal risk for hypotension. The nurse should not administer dextrose because it can cause maternal hyperglycemia and neonatal hypoglycemia. C. 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. D. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution. The nurse should not plan to restrict the client's intake prior to the epidural placement and the first dose of anesthetic solution because NPO status is not indicated for this procedure.

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring? A. Oligohydramnios B. Hyperemesis gravidarum C. Leukorrhea D. Periodic tingling of the fingers

Answer: Oligohydramnios A. Oligohydramnios The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis. B. Hyperemesis gravidarum Hyperemesis gravidarum is not an indication for further fetal assessment using electronic fetal monitoring unless complications occur. C. Leukorrhea Leukorrhea is a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring unless complications occur. D. Periodic tingling of the fingers Periodic tingling of the fingers is a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring.

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? A. Place the shoulder harness in the slots above the newborn's shoulders. B. Place the retainer clip at the level of the newborn's armpits. C. Place the newborn at a 60° angle in the car seat. D. Place the newborn in a blanket before securing them in the car seat.

Answer: Place the retainer clip at the level of the newborn's armpits. A. Place the shoulder harness in the slots above the newborn's shoulders. The nurse should instruct the parents to place the shoulder harness in the slots that are at or just below the newborn's shoulders. B. 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. C. Place the newborn at a 60° angle in the car seat. The nurse should instruct the parents to position the newborn at a 45° angle to minimize the risk of airway obstruction from slumping forward. D. Place the newborn in a blanket before securing them in the car seat. The nurse should instruct the parents to refrain from placing extra padding, including blankets, between the newborn and the straps of the car seat. Extra padding creates air pockets that decrease the effectiveness of the restraint and can lead to injuries.

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? A. Hct 39% B. Serum albumin 4.5 g/dL C. WBC 9,000/mm3 D. Platelets 50,000/mm3

Answer: Platelets 50,000/mm3 A. Hct 39% An Hct of 39% is within the expected reference range and does not indicate a postpartum complication. B. Serum albumin 4.5 g/dL 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. C. WBC 9,000/mm3 A WBC of 9,000/mm3 is within the expected reference range and does not indicate a postpartum complication. D. 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 calculating a client's expected date of birth using Nagele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth?

Answer: September 3rd A. September 3rd When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.

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? A. Shortness of breath B. Breakthrough bleeding C. Vomiting D. Breast tenderness

Answer: Shortness of breath A. 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. B. Breakthrough bleeding Breakthrough bleeding outside the menstrual period is a common adverse effect of combined oral contraceptives. C. Vomiting Nausea and vomiting are common adverse effects of combined oral contraceptives. D. Breast tenderness Breast tenderness is a common adverse effect of combined oral contraceptives.

A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include? A. Insert the syringe tip before compressing the bulb. B. Suction each of the nares before suctioning the mouth. C. Insert the tip of the syringe into the center of the newborn's mouth. D. Stop suctioning when the newborn's cry sounds clear.

Answer: Stop suctioning when the newborn's cry sounds clear. A. Insert the syringe tip before compressing the bulb. The client should compress the bulb before inserting the syringe tip. Compressing the bulb after it is in the newborn's nares or mouth could push the secretions and mucus further inside. B. Suction each of the nares before suctioning the mouth. The client should suction the mouth before suctioning the nares. Otherwise, the newborn could gasp and inhale pharyngeal secretions when the syringe tip touches the nares. C. Insert the tip of the syringe into the center of the newborn's mouth. The client should insert the tip of the syringe into the side of the newborn's mouth. Inserting it into the center of the newborn's mouth can trigger the gag reflex. D. Stop suctioning when the newborn's cry sounds clear. The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus.

A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse? A. Acrocyanosis of the extremities B. Murmur at the left sternal border C. Substernal chest retractions while sleeping D. Positive Babinski reflex

Answer: Substernal chest retractions while sleeping A. Acrocyanosis of the extremities Acrocyanosis of the extremities is an expected manifestation in newborns. Acrocyanosis is a bluish discoloration of the newborn's hands and feet. B. Murmur at the left sternal border An audible murmur heard at the left sternal border is an expected manifestation in newborns. C. Substernal chest retractions while sleeping Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This manifestation requires further assessment and intervention by the nurse. D. Positive Babinski reflex A positive Babinski reflex is an expected manifestation in newborns. This reflex is elicited when a newborn's sole is stroked with a finger upward along the lateral aspect of the sole and then across the ball of the foot and, in response, the toes hyperextend, and the large toe dorsiflexes.

A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?

Minimal arm recoil

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? A. Swelling of the face B. Varicose veins in the calves C. Nonpitting 1+ ankle edema D. Hyperpigmentation of the cheeks

Answer: Swelling of the face A. Swelling of the face Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema. B. Varicose veins in the calves Varicose veins are an expected finding in the second trimester. The increase in hormones during pregnancy causes the relaxation of the smooth muscle of the vascular system, leading to vessel dilation and vasocongestion. Additionally, the weight of the enlarging uterus on the pelvic veins decreases the return of blood from the lower extremities. C. Nonpitting 1+ ankle edema Nonpitting edema of the lower extremities is an expected finding in the third trimester. Warm weather, sitting or standing for prolonged periods of time, and tight clothing can increase edema. D. Hyperpigmentation of the cheeks Hyperpigmentation of the cheeks, areola, vulva, and linea nigra are expected findings in the second trimester. The anterior pituitary increases the production of melanocyte-stimulating hormone, which leads to hyperpigmentation of the skin.

A nurse is planning care for a client who is in labor and is having an amniotomy. Which of the following assessments should the nurse identify as the priority? A. O2 saturation B. Temperature C. Blood pressure D. Urinary output

Answer: Temperature A. O2 saturation Assessing the client's O2 saturation is important during labor. However, another assessment is the nurse's priority. B. 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. C. Blood pressure Assessing the client's blood pressure is important. However, another assessment is the nurse's priority. D. Urinary output Assessing the client's urinary output is important during labor. However, another assessment is the nurse's priority.

A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take? A. Restrict hourly fluid intake to 150 mL/hr. B. Have calcium gluconate readily available. C. Assess deep tendon reflexes every 6 hr. D. Monitor intake and output every 4 hr.

Answer: The nurse should have calcium gluconate readily available A. Restrict hourly fluid intake to 150 mL/hr. The nurse should restrict hourly fluid intake to no more than 125 mL/hr. The client's urine output should be 30 mL/hr or greater. B. Have calcium gluconate readily available. The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity. C. Assess deep tendon reflexes every 6 hr. The nurse should assess deep tendon reflexes every 1 to 4 hr during continuous infusion of magnesium sulfate. D. Monitor intake and output every 4 hr. The nurse should monitor intake and output hourly for clients who are receiving a continuous infusion of magnesium sulfate.

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? A. Active B. Transition C. Latent D. Descent

Answer: Transition A. Active The active phase of labor is characterized by a cervical dilatation of 4 to 7 cm and contractions every 3 to 5 min, each lasting 40 to 70 seconds. B. 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. C. Latent The latent phase of labor is characterized by cervical dilation of 0 to 3 cm and contractions every 5 to 30 min, each lasting 30 to 45 seconds. D. Descent The descent phase of labor is characterized by active pushing with contractions every 1 to 2 min, each lasting for 90 seconds.

A nurse is providing discharge teaching to a client who is postpartum. For which of the following manifestations should the nurse instruct the client to monitor and report to the provider? A. Persistent abdominal striae B. Temperature 37.8° C (100° F) C. Unilateral breast pain C. Brownish-red discharge on day 5

Answer: Unilateral breast pain A. Persistent abdominal striae Persistent abdominal striae are caused by the separation of the underlying connective tissue and are an expected postpartum finding. B. Temperature 37.8° C (100° F) The nurse should instruct the client to report a temperature of 38° C (100.4° F) or higher because it could be an indication of infection. C. Unilateral breast pain Sudden onset of chills, fever, malaise, body aches, headaches, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this manifestation to the provider. C. Brownish-red discharge on day 5 Brownish-red discharge is an expected manifestation during days 3 to 10. The client should report a large amount of lochia and large clots to the provider.

A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first? A. Confirm the newborn's Apgar score. B. Verify the newborn's identification. C. Administer vitamin K to the newborn. D. Determine obstetrical risk factors.

Answer: Verify the newborn's identification. A. Confirm the newborn's Apgar score. The Apgar score is a physiological assessment that occurs 1 min following birth and again at 5 min. The nurse should confirm the score when the newborn arrives in the nursery. However, there is another action the nurse should take first. B. Verify the newborn's identification. When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery. C. Administer vitamin K to the newborn. The nurse should administer IM vitamin K to the newborn soon after birth to increase clotting factors and prevent bleeding. However, the injection can be delayed until after initial bonding time and the first breastfeeding if necessary. Therefore, there is another action the nurse should take first. D. Determine obstetrical risk factors. The nurse should identify obstetrical risk factors to determine if interventions are required for the newborn. However, there is another action the nurse should take first.

A nurse is assessing a client on the first postpartum day. Findings include fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3 C (99.2 F), and pulse rate 52/min. Which of the following actions should the nurse take? Report the vital signs to the provider. Massage the fundus. Ask the client when she last voided. Administer an oxytocic agent.

Ask the client when she last voided Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be found firm at midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void.

A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) Immune Globulin? While the client is in labor Following an episode of influenza during pregnancy Prior to a blood transfusion At 28 weeks of gestation

At 28 weeks of gestion The nurse should administer Rh(D) Immune Globulin to a client who is pregnant and has Rh-negative blood at 28 weeks of gestation. Rh(D) Immune Globulin consists of passive antibodies against the Rh factor, which will destroy any fetal RBCs in the maternal circulation and block maternal antibody production.

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?

BUN 25 mg/dL

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke". Which of the following interventions is the nurse's priority?

Begin FHR monitoring

A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic test?

Biophysicial profile

A nurse is caring for a client who has a prescription for naloxone. Which of the following is the intended action of the medication in relation to the central nervous system? Accentuate effects of narcotics on the CNS Depress activity of the CNS Block effects of narcotics on the CNS Stimulate activity of the CNS

Blocks effects of narcotics on the CNS By blocking the effects of narcotics on the CNS, naloxone prevents CNS and respiratory depression in the newborn following delivery.

A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect?

Blurred Vision

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

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. Which of the following actions should the nurse include in the plan of care? Keep four side rails up while the client is in bed. Monitor fetal heart rate every hour. Insert an indwelling urinary catheter. Check the cervix prior to analgesic administration.

Check the cervix prior to analgesic administration Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix is dilated. If administered too close to the time of delivery, the analgesic could cause respiratory depression in the newborn.

A nurse is providing teaching about nonpharmological 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

A nurse is caring for a newborn who has irregular respirations of 52/minute with several periods of apnea lasting approximately 5 seconds. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? Administer oxygen. Place the newborn in an isolette. Continue to routinely monitor the newborn. Assess the newborn's blood glucose.

Continue to routinely monitor the newborn

A nurse receives report on a client who is in labor and is experiencing contractions 4 minutes apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? Contractions that last for 60 seconds each with a 4-min rest between contractions Contractions that last for 60 seconds each with a 3-min rest between contractions A contraction that lasts 4 min followed by a period of relaxation Contractions that last 45 seconds each with a 3-min rest between contractions

Contractions that last for 60 seconds each with a 3-minute rest between contractions A contraction interval is how often a uterine contraction occurs. The nurse will measure the interval from the beginning of one contraction to the beginning of the next contraction. A contraction lasting 60 seconds with a relaxation period of 3 min is equivalent to contractions every 4 min.

A nurse administers betamethasone to a client who is at 33 weeks gestation to stimulate fetal lung maturity. Which planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? Hyperthermia Increased blood glucose Rapid pulse rate Irritability

Decreased blood glucose Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery. It is important to assess the newborn's blood glucose level within the first hour following birth and frequently thereafter until blood glucose levels are stable.

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

A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching? "Do not become pregnant for at least 1 year." "Seek genetic counseling for yourself and your partner prior to getting pregnant again." "You should have an hCG level drawn in 6 weeks." "Have your blood pressure checked weekly for the next month."

Do not become pregnant for at least 1 year Hydatidiform moles are uncontrolled growths in the uterus arising from placental or fetal tissue in early pregnancy. There is an increased incidence of choriocarcinoma associated with molar pregnancies. Pregnancy must be avoided for 1 year so the client can be closely monitored for manifestations of this condition.

A nurse is planning care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care? Swaddle the newborn in a receiving blanket during the treatment. Maintain NPO status until the newborn's bilirubin is within the expected reference range. Ensure the newborn's eyes are closed before applying the eye shield. Apply lotion to the newborn's skin twice per day.

Ensure the newborns eyes are closed before applying the eye shield Overexposure to the lights during treatment can cause damage to the newborn's corneas. Therefore, the nurse should gently close the newborn's eyes prior to applying the eye shield.

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? Extended periods of sleep Poor muscle tone Respiratory rate 50/min Exaggerated reflexes

Exaggerated reflexes A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the central nervous system (CNS). Exaggerated reflexes are indicative of CNS irritability.

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

non reactive NST indicates

FHR did not accelerate adequately with fetal movement

A nurse is caring for a newborn who was born to a client who has a narcotic use disorder. Which of the following nursing actions should the nurse identify as a contraindication for the care of the newborn? Promoting maternal-newborn bonding Tight swaddling of the newborn Small frequent feedings Frequent stimulation

Frequent stimulation This newborn needs a quiet, calm environment with minimal stimulation to promote rest and reduce stress. A stimulating environment can trigger irritability and hyperactive behaviors.

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?

Fundal Height Measurement

A nurse is planning care for a client who is at 35 weeks of gestation. Which of the following laboratory tests should the nurse obtain? Rubella titer Blood type Group B streptococcus ß-hemolytic 1-hour glucose tolerance test

Group B streptococcus B-hemolytic The nurse should obtain a vaginal/anal group B streptococcus ß-hemolytic (GBS) culture at 35 to 37 weeks of gestation to screen for infection. Prophylactic antibiotics should be given during labor to the client who is positive for GBS.

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 positions

A nurse is performing a physical assessment of a newborn. Which of the following clinical finding should the nurse expect?

Heart Rate 154/ min Respiratory rate 58/ min Weight 2,600 g (5lb 12 oz)

A nurse is reviewing the prenatal laboratory value for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider

Hemoglobin 10 g/dL

A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication?

Hypertension

A nurse is caring for a client who is in labor and has an epidural for pain relief. Which of the following is a complication from the epidural block? Nausea and vomiting Tachycardia Hypotension Respiratory depression

Hypotension Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of epidural anesthesia in order to decrease the likelihood of this complication.

A nurse is teaching a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching? "I know not to eat anything after midnight." "I will have medication given to me to cause contractions." "I should press the button on the handheld marker when my baby moves." "I will have to stimulate my breast to cause contractions."

I should press the button on the handheld marker when my baby moves The purpose of the test is to assess fetal well-being. The client should press the button on the handheld marker when she feels fetal movement.

A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching? "I should clean my diaphragm with alcohol each time I use it." "I should leave the diaphragm in place 4 hours after intercourse." "I should replace my diaphragm every 2 years." "I should use a vaginal lubricant to insert my diaphragm."

I should replace my diaphragm every 2 years The diaphragm is a flexible rubber cup that is filled with spermicide and is inserted over the cervix prior to intercourse. The diaphragm is a prescribed device fitted by the provider. It should be replaced every 2 years.

A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication? IV narcotics administered to the mother during labor Maternal drug use Hyaline membrane disease Meconium aspiration

IV narcotics administered to the mother during labor The nurse should administer naloxone to reverse respiratory depression due to acute narcotic toxicity, which can result from IV narcotics administration during labor.

A nurse is performing a vaginal exam 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

A nurse in an antepartum clinic answers a phone call from a client who is at 37 weeks of gestation and reports, "I become very dizzy while lying in bed this morning, but the feeling went away when I turned on my side." Which of the following actions should the nurse take? Instruct the client about vena cava syndrome and measures to prevent it. Arrange for the client to come to the clinic for an assessment. Check the client's chart for gestational diabetes mellitus. Schedule a nonstress test for the client.

Instruct the client about vena cava syndrome and measures to prevent it This is the typical finding of vena cava syndrome, or hypotension that occurs in clients who are pregnant upon assuming a supine position. It is caused by compression of the inferior vena cava by the gravid uterus with a consequent reduction in venous return. A side lying position promotes uterine perfusion and fetoplacental oxygenation.

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?

Jaundice

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

A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the infusion of the oxytocin infusion and should be reported to the provider?

Late Decelerations

A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior?

Lays the newborn across her lap and gently sways

A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take?

Maintain the client of bed rest

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

Massage the client's fundus

A nurse is caring for a client who is 2 hours postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse take first? Check for a full bladder. Massage the fundus. Measure vital signs. Administer carboprost IM.

Massage the fundus The primary cause of early postpartum bleeding is uterine atony manifested by a relaxed, boggy uterus. Thus, the greatest risk for the client is hemorrhage. The nurse should massage the client's fundus first.

A nurse is caring for a client who desires an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for the use of this device? Hypertension Menorrhagia History of multiple gestations History of thromboembolic disease

Menorrhagia An IUD is a small plastic or copper device placed inside the uterus that changes the uterine environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia, severe dysmenorrhea, or history of ectopic pregnancy.

A nurse is caring for a client who is at 15 weeks gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?

Monitor the FHR

A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?

Monitor the FHR continously

A nurse is caring for a client who is at 36 weeks of gestation and has preeclampsia. Which of the following findings should the nurse identify as the priority? 1+ proteinuria Blood pressure 140/98 mm Hg Nonreactive nonstress test Fundal height 33 cm

Nonreactive nonstress test In a nonreactive nonstress test, there are no accelerations. Absence of FHR accelerations suggests that the fetus might be going into distress.

A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority? "My ankles are swollen at the end of the day." "I can feel the baby kicking my ribs, and it is very uncomfortable." "I'm growing more and more worried every day." "My heart feels as if it is racing."

My heart feels as if it is racing The primary action of terbutaline is to cause bronchodilation and relax smooth muscles. However, an adverse effect is tachycardia. If the pulse is greater than 130/min, the terbutaline needs to be held until the provider is notified.

Indomethacin

NSAID that suppresses preterm labor and uterine contractions

A nurse is assessing a client who is receiving morphine via IV bolus for pain following a C-section. The nurse notes a respiratory rate of 8/min. Which of the following medications should be administered?

Naloxone

A nurse is assessing a newborn who is 12 hours old and notes mild jaundice of the face and trunk. Which of the following actions should the nurse take? Administer phytonadione IM. Obtain a stat prescription for a bilirubin level. Obtain a bagged urine specimen. Perform a gestational age assessment.

Obtain a stat prescription for a bilirubin level Jaundice in the first 24 hr of life is pathologic. The nurse should notify the provider and obtain a stat prescription for a bilirubin level.

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old in accepting the new family memeber?

Obtain an gift from the newborn to present to the sibling

A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn

Place the newborn skin to skin on the mothers chest

A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? Anemia Frequent urinary tract infections Previous cesarean birth Pelvic inflammatory disease (PID)

Pelvic inflammatory disease (PID) An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop there. The most common site is within a fallopian tube, but ectopic pregnancies can occasionally occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, PID places the client at risk for an ectopic pregnancy.

A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?

Perform Leopold Maneuvers

A nurse is caring for a client who is receiving oxytocin for induction of labor. Which of the following actions should the nurse take? Perform continuous fetal heart rate monitoring. Measure maternal temperature every hour. Evaluate maternal contraction pattern every hour. Check blood pressure every 5 min.

Perform continuous fetal heart rate monitoring When oxytocin is administered to an antepartum client, the fetal monitor must be used to continuously monitor the fetal heart rate and maternal contractions.

A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect?

Petechiae over the head

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

Picture of nurse palpating top of belly; where bottom is

A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following should the nurse identify as a risk factor for the development of preeclampsia

Pregestational Diabetes Mellitus

A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications?

Premature rupture of membranes

A nurse is creating a plan of care 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?

Protects the client's head and feet from cold air

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

A nurse is assessing a 2 day old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. What pieces of info should the nurse provide to the mother when she inquires about the finding? a. this will resolve within 3-6 wks without treatment b. this will resolve on its own within 3-4 days c. this is expected at birth so you don't need to worry about it d. the provider might drain this area with a syringe

a. this will resolve within 3-6 wks without treatment

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbillirubinemia. Which of the following actions should the nurse include in the plan?

Remove all clothing form the newborn except the diaper

A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?

Report the client's condition to the local health department

A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect?

Reports increased urinary output

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?

Reports of decreased fetal movement

A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? Respiratory depression Hypothermia Hypoglycemia Jaundice

Respiratory depression Magnesium sulfate can cause respiratory and neuromuscular depression in the newborn. The nurse should monitor the newborn for clinical manifestations of respiratory depression.

A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?

Respiratory distress

A nurse is caring for a client who is at 30 weeks 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

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication from the oxygen therapy? Atelectasis Retinopathy Interstitial emphysema Necrotizing enterocolitis

Retinopathy Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. It is a disorder of retinal blood vessel development in the premature newborn. In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fills the back of the eye. It can reduce vision or result in complete blindness.

A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?

Schedule an ultrasound examination

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in order of performance. Use all the steps.)

The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.

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 2.2 kg (4.8 lb)

A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that what lab test will be used to confirm her pregnancy? a. urine test for presence of HCG b. urine test for the presence of HCS c. blood test for presence of estrogen d. blood test for the amount of circulating progesterone

a. urine test for presence of HCG

A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?

Substernal Retractions

A nurse is assessing a client who is at 37 wks gestation and has a suspected pelvic fracture due to blunt abd trauma. What findings should the nurse expect? a. uterine contractions b. bradycardia c. seizures d. bradypnea

a. uterine contractions The nurse should expect the client to be experiencing uterine contractions due to abdominal trauma.

erythema toxicum

newborn rash during first 3 weeks

reactive NST

normal FHR baseline with moderate variability and two accelerations 15 beats per minute for at least 15 seconds over 20 minute period

BISHOP score when ready for labor

nuliparas 9 multipara greater than 5

A nurse is assessing a newborn who was born at 39 wks gestation. What finding should the nurse expect? a. symmetric rib cage b. lanugo abundant on the back c. dry, wrinkled skin d. vernix over the entire body

a. symmetric rib cage A newborn who is born at 39 weeks of gestation is full-term and should have normal, smooth skin with good turgor and the presence of subcutaneous fat pockets. A postmature newborn, greater than 42 weeks of gestation, will have dry, cracked skin with a wrinkled appearance.

A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse make? "Has your wife sensed your anger toward her and the baby?" "These feelings are common to expectant fathers in early pregnancy." "I'm sure that it's really hard to accept this when it's your baby, too." "It would be wise for you to speak to a therapist about these feelings."

These feelings are common to expectant fathers in early pregnancy

A nurse is caring for a client who is at 8 weeks of gestation with twins and primigravida. The client states that even though she and her husband planned this pregnancy, she is experiencing many ambivalent feelings about it. Which of the following responses should the nurse make? "Have you told your husband about these feelings?" "These feelings are quite normal at the beginning of pregnancy." "Perhaps you should see a counselor to discuss these feelings." "I am quite concerned about these feelings. Could you explain more?"

These feelings are quite normal at the beginning of pregnancy This client needs reassurance that these feelings are normal and there is no reason for concern.

A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound?

To locate the pocket of fluid

A nurse is caring for a client whose membranes have ruptured and is in active labor. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first? Turn the client onto her left side. Palpate the client's uterus. Administer oxygen to the client. Increase the client's IV fluids.

Turn the client onto her left side Late decelerations indicate that the client is experiencing uteroplacental insufficiency. The client might be experiencing pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to the fetus. Turning the client onto her left side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply.

A nurse is assessing a client who is receiving magnesium sulfate as treatment for preeclampsia. Which of the following clinical findings is the nurse's priority? Respirations 16/min Urinary output 40 mL in 2 hr Reflexes +2 Fetal heart rate 158/min

Urinary output 40ml in 2 hours Urinary output is critical to the excretion of magnesium from the body. The nurse should discontinue the magnesium sulfate if the hourly output is less than 30 mL/hr

A nurse is caring for a client who is at 16 weeks of gestation and has severe iron deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication? Use a 20-gauge needle, and administer the medication using the Z-track method. Use a 22-gauge needle, and administer the medication deep into the thigh. Use a 25-gauge needle, and administer the medication into the deltoid muscle. Use an 18-gauge needle, and administer the medication into the rectus femoris muscle

Use a 20-guage needle, and administer the medication using the Z track method The nurse should administer iron using the Z-track method to prevent staining of tissue. A 20-gauge needle is the correct size.

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

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 band

meds given for postpartum hemorrhage

oxytocin, methergen, cytotec, hembate

dystocia

prolonged and difficult labor

A nurse is caring for a client who is in labor. A vaginal examination reveals the following information: 2cm, 50%, +1, right occiput anterior. Based on this information, which of the following position should the nurse document in the medical record? Transverse Breech Vertex Mentum

Vertex ROA describes the relationship of the presenting part of the fetus to the client's pelvis. In this case, the occipital bone is the presenting part and is located anteriorly in the client's right side. Based on the presentation of the fetus, the position is vertex.

A nurse is caring for a client who is in labor. The client questions the application of an internal fetal scalp monitor. Which of the following responses should the nurse make? "Don't worry. Your baby is fine." "You will need to ask your provider." "Your provider feels it would be best." "We need to observe your baby more closely."

We need to observe your baby more closely The client has asked an information-seeking question. This therapeutic response provides information to the client in an honest, nonthreatening manner. The use of an internal fetal scalp monitor, or an internal spiral electrode, provides a more accurate assessment of fetal well-being during labor.

mongolian spots

purple spots of pigmentation

A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions?

Wipe eyes Wash Neck Cleanse skin around umbilical cord stump Wash legs and feet Clean diaper area

A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse provide to the client about the treatment plan? "Your partner needs to be cultured and be treated with metronidazole only if his cultures are positive." "You and your partner need to take the medication and use a condom during intercourse until cultures are negative." "If both you and your partner are treated simultaneously, you may continue to engage in sexual intercourse." "Only you will need to take the metronidazole, but you should not have intercourse until your culture is negative."

You and your partner need to take the medication and use a condom during intercourse until cultures are negative Trichomonas vaginalis is the organism that causes the sexually transmitted infection trichomoniasis. Both men and women can be infected with trichomoniasis. Clinical findings include yellowish to greenish, frothy, mucopurulent, copious discharge with an unpleasant odor, as well as itching, burning, or redness of the vulva and vagina. Trichomoniasis can be treated easily with metronidazole. However, for the treatment to work, it is important to make sure both sexual partners receive treatment to prevent reinfection. Instruct the client to use condoms during sexual intercourse while being treated.

A nurse is caring for a client who is pregnant and reports nausea and vomiting. Which of the following instructions should the nurse provide the client? "You should eat some crackers before rising from bed in the morning." "You should eat foods served at warm temperatures." "You should sip whole milk with breakfast." "You should brush your teeth immediately after meals."

You should eat some crackers before rising from bed in the morning Morning sickness is caused by the buildup of human chorionic gonadotropin (hCG) in the mother's system. Dry foods eaten before rising in the morning tend to reduce the risk of nausea in clients who are pregnant.

milia

raised white spots (normal)

amnioinfusion used to

reduce variable decelerations and dilute meconium stained amniotic fluid

A nurse is teaching a client who has active genital herpes simplex virus, type 2. Which of the following statements should the nurse include in the teaching? "You will have a cesarean birth prior to the onset of labor." "Your baby will receive erythromycin eye ointment after birth to treat the infection." "You should take oral metronidazole for 7 days prior to 37 weeks of gestation." "You should schedule a cesarean birth after your water breaks."

You will have a cesarean birth prior to the onset of labor Whenever possible, the cesarean birth should be scheduled prior to the onset of labor or rupture of membranes to reduce the risk of neonatal transmission of herpes.

A nurse is assessing a client who is at 35 weeks of gestation and has mild gestational HTN. What finding should the nurse identify as the priority? a. 480 mL urine output in 24 hrs b. 1+ protein in the urine c. +2 edema of the feet d. BP 144/92

a. 480 mL urine output in 24 hrs When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is 480 mL of urine output in 24 hr because the minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of preeclampsia to preeclampsia with severe features, which requires immediate intervention. Therefore, this is the priority finding.

A nurse is teaching a client who is at 13 wks gestation about the treatment of incompetent cervix with cervical cerclage. What statement by the client indicates an understanding of teaching? a. I should go to the hospital if I think I may be in labor b. I should expect bright red bleeding while the cerclage is in place c. I am sad that I won't be able to get pregnant again d. I can resume having sex as soon as I feel up to it

a. I should go to the hospital if I think I may be in labor Cervical cerclage prevents premature opening of the cervix during pregnancy. The client should immediately go to a facility for evaluation if she experiences any manifestations of labor while the cerclage is in place. If the client experiences preterm uterine contractions she might require tocolytic therapy.

A nurse is caring for a client who is at 38 wks of gestation and reports no fetal movement for 24 hr. What action should the nurse take? a. auscultate for a FHR b. reassure the client that a term fetus is less active c. have the client drink orange juice d. palpate the uterus for fetal movement

a. auscultate for a FHR Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The nurse should auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action.

A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client becomes frightened when she has a gush of dark red blood from her vagina. What following statements should the nurse make? a. blood pools in the vagina when you are lying a bed b. the amount of blood flow will increase during the first few days after giving birth c. you might have retained placental fragments in your uterus d. you might have a damaged blood vessel

a. blood pools in the vagina when you are lying a bed In the early postpartum period, lochia will pool in the vagina when the client is lying in bed and will flow out of the vagina when the client stands up. After the initial gush, the bleeding will slow down to a trickle of bright red lochia.

A nurse is assessing a 12 hr old newborn and notes a resp rate of 44 with shallow respirations and periods of apnea lasting up to 10 seconds. What action should the nurse take? a. continue routine monitoring b. place newborn prone c. request a script for supplemental o2 d. perform chest percussion

a. continue routine monitoring The nurse should continue routine monitoring because the newborn's assessments findings indicate he is adapting to extrauterine life. placing in sidelying or supine

A nurse is caring for a client who is at 35 wks gestation and has severe pre-eclampsia. What assessment provides the most accurate info regarding the client's fluid and electrolyte status. a. daily wt b. bp c. severity of edema d. I&O

a. daily wt

A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via continuous IV infusion. The nurse notes that the client is having contractions every 2 min which last 100-110 seconds that the fetal heart rate is reassuring. What action should the nurse take? a. decrease the dose of oxytocin by half b. administer oxygen via nonrebreather mask c. decrease the infusion rate of the maintenance IV fluid d. administer terbutaline 0.25mg subq

a. decrease the dose of oxytocin by half The nurse should decrease the dose of oxytocin by half because the client is experiencing uterine tachysystole.

A nurse is reviewing lab results for a client who is at 37 wks gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic strep, and has a blood type O neg. What action should the nurse take? a. instruct the client to obtain a rubella immunization after delivery b. request a script for an antibiotic until delivery c. inform the client that she will have to deliver via c-section d. administer a dose of Pho(D) immune globulin

a. instruct the client to obtain a rubella immunization after delivery

A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. What action should the nurse take? a. obtain blood samples for baseline lab values b. place a spiral electrode on the fetal presenting part c. prepare the client for a transvaginal ultrasound d. perform a vaginal exam to determine cervical dilation

a. obtain blood samples for baseline lab values The nurse should obtain samples of the client's blood for baseline testing of hemoglobin and hematocrit levels.

A nurse is caring for a client who believes she may be pregnant. What finding should the nurse identify as a positive sign of pregnancy? a. palpable fetal movement b. amenorrhea c. chadwick's sign d. positive pregnancy test

a. palpable fetal movement

A nurse is caring for a newborn immediately following delivery. What actions should the nurse take first? a. place the newborn directly on the client's chest b. administer erythromycin ophthalmic ointment c. give the newborn vit K IM d. perform a detailed physical assessment

a. place the newborn directly on the client's chest the greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client's chest will help maintain the newborn's temperature.

A nurse is caring for a client who has oligohydraminios. What fetal anomalies should the nurse expect? a. renal agenesis b. atrial septal defect c. spina bifida d. hydrocephalus

a. renal agenesis

terbutaline (brethine)

relaxes uterine smooth muscle to stop uterine contractions

A nurse is teaching a client who is at 10 wks gestation about an abd. ultrasound in the first trimester. What info should the nurse include in the teaching? a. you will need to have a full bladder during the ultrasound b. you will have a non stress test prior to the ultrasound c. the ultrasound will determine the length of your cervix d. you will experience uterine cramping during the ultrasound

a. you will need to have a full bladder during the ultrasound MY ANSWER The nurse should tell the client that a full bladder helps to lift the gravid uterus out of the pelvis during the examination. Therefore, it is important to ensure that the client has a full bladder to obtain the most accurate image of the fetus.

positive contraction stress test (CST) is

abnormal and indicates late decelerations on more than half of the contractions

thrombophlebitis arm positioning

above the level of the heart

when should a nurse start measuring a woman's fundal height?

after 12 weeks gestation

when is amniocentesis is performed

after 14 weeks gestation

non stress test (NST)

assesses fetal well being during third trimester

A nurse is assessing a newborn 1 min after birth andnotes a hr of 136/min, resp 36, well flexed extremities, responding to stimuli with a cry, blue hands and feet. What Apgar score should the nurse assign to the newborn? a. 10 b. 9 c. 8 d. 7

b. 9

A nurse is administering a rubella immunization to a client who is 2 days postpartum. What statement indicates to the nurse the client needs further instruction? a. I cannot receive rubella immunization during pregnancy b. I can conceive anytime i want after 10 days c. I can continue to breastfeed d. I wills till need to have my provider perform a rubella titer with my next pregnancy

b. I can conceive anytime i want after 10 days A client who receives a rubella immunization should not conceive for at least 1 month after receiving the rubella immunization to prevent injury to the fetus.

A nurse is caring for a client whose last menstrual period began july 8. Using Nageles rule, the nurse should identify the client's estimated DOB as what? a. oct 15 b. april 15 c. oct 1 d. april 1

b. april 15

A nurse is caring for a client who is at 32 wks gestation and is experiencing preterm labor. What meds should the nurse plan to administer? a. misoprostol b. betamethasone c. poractant alfa d. methylergonovine

b. betamethasone

A nurse is providing teaching to a client who is at 8 wks gestation about manifestations to report to the provider during pregnancy. What info should the nurse include in the teaching? a. nausea upon awakening b. blurred or double vision c. increase in white vaginal discharge d. leg cramps when sleeping

b. blurred or double vision

A nurse is assessing a client who is at 12 wks gestation and has hydatidiform mole. What findings should the nurse expect? a. hypothermia b. dark brown vaginal discharge c. fetal heart tones d. decreased urinary output

b. dark brown vaginal discharge A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of the chorionic villi, which gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grapelike clusters.

A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. What instructions should the nurse include in the teaching? a. use prepackaged commercial wipes to clean the circumcision site b. encourage nonnutritive sucking for pain relief c. remove the yellow exudate with each diaper change d. apply the diaper tightly over the circumcision area

b. encourage nonnutritive sucking for pain relief Allowing the newborn to suck on a pacifier is an effective form of nonpharmacological pain management.

A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about expected adverse effects. What adverse effects should the nurse include in the teaching? a. elevated BP b. feeling of warmth c. generalized pruritis d. hyperactivity

b. feeling of warmth The nurse should tell the client to expect the feeling of warmth all over her body while the magnesium sulfate is infusing.

A nurse is reviewing the med record of a client who is at 39 wks gestation and has polyhydramnios. What finding should the nurse expect? a. total pregnancy wt gain of 3.6 kg b. fetal GI anomaly c. gestational HTN d. fundal height of 34 cm

b. fetal GI anomaly Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurologic disorders are expected findings for a fetus experiencing the effects of polyhydramnios.

A nurse is assessing a newborn 1 hr after birth. What assessment findings should the nurse report to the provider? a. acrocyanosis b. jaundice of the sclera c. resp rate 50 d. cbg 60

b. jaundice of the sclera If the newborn has jaundice within the first 24 hr of life, this can indicate a potential pathological process such as hemolytic disease. Pathologic jaundice can result in high levels of bilirubin that can cause damage to the neonatal brain.

A nurse is caring for a client who has a soft uterus and increased lochia. What meds should the nurse plan to administer to promote uterine contractions? a. mag sulfate b. methylergonovine c. terbutaline d. nifedipine

b. methylergonovine The nurse should administer methylergonovine, an ergot alkaloid, which promotes uterine contractions.

A nurse is reviewing the medical record of a client who is at 33 wks gestation and has placenta previa and bleeding. What scripts should the nurse clarify with the provider? a. insert a large-bore IV catheter b. perform a vaginal exam c. perform continuous external fetal monitoring d. obtain a blood sample for lab testing

b. perform a vaginal exam When a client has a placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta and increased bleeding.

PG on fetal lung test indicates

respiratory distress

APGAR score less than 3

severe distress

A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. What instructions should the nurse include in the teaching? a. stand under hot shower with your breasts exposed b. place ice packs on your breasts c. limit fluid intake to 1 L per day d. wear a loose-fitting, comfortable bra

b. place ice packs on your breasts The nurse should instruct the client to place ice packs on her breasts using a 15 min on and 45 min off schedule, to decrease swelling of the breast tissue as the body produces milk.

A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue What action should the nurse take? a. check the newborns temp using temporal thermometer b. place the naked newborn on the mothers bare chest and cover both with a blanket c. apply an o2 hood over the newborns head and neck d. give the newborn glucose water between feedings

b. place the naked newborn on the mothers bare chest and cover both with a blanket Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding.

A nurse is caring for a newborn who is premature in the neonatal ICU. what action should the nurse take to promote development? a. discourage the use of pacifiers b. position the naked newborn on the parents bare chest c. provide frequent periods of visual and auditory stimulation d. rapidly advance oral feedings

b. position the naked newborn on the parents bare chest

A nurse is caring for a postpartum client 8hrs after delivery. What factors place the client at risk for uterine atony? select all a. oxytocin infusion b. prolonged labor c. mag sulfate infusion d. small for gestational age newborn e. distended bladder

b. prolonged labor Prolonged labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus from contracting. c. mag sulfate infusion Magnesium sulfate is a smooth muscle relaxant and can prevent adequate contraction of the uterus. e. distended bladder After birth, clients can experience a decreased urge to void due to birth-induced trauma, increased bladder capacity, and anesthetics, which can result in a distended bladder. The distended bladder displaces the uterus and can prevent adequate contraction of the uterus.

A nurse is teaching a client who is at 8 wks gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. What info should the nurse include? a. you will have to undergo a c-section birth because of the fibroid b. the fibroid can increase the risk for postpartum hemorrhage c. the fibroid will shrink during pregnancy d. you will receive an injection of medroxyprogesterone acetate to shrink the fibroid

b. the fibroid can increase the risk for postpartum hemorrhage

second stage of labor

birth

A nurse is providing teaching to the parents of a newborn about home safety. What statement by the parents indicates an understanding of the teaching? a. I will use an infant carrier when I drive to places close to the house b. I will tie my baby's pacifier around his neck with a piece of yarn c. I will place my baby on his back when it is time for him to sleep d. I will keep my babys crib close to heat vents to keep him warm

c. I will place my baby on his back when it is time for him to sleep

A nurse is caring for a newborn who is premature at 30 wks gestation. What finding should the nurse expect? a. heel creases covering the bottom of the feet b. good flexion c. abundant lanugo d. dry, parchment-like skin

c. abundant lanugo Newborns who are premature have abundant lanugo, fine hair, especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinnas, and forehead.

A nurse is caring for a client who is receiving mag sulfate by continuous IV. What meds should the nurse have available at bedside? a. naloxone b. protamine sulfate c. calcium gluconate d. atropine

c. calcium gluconate The nurse should have calcium gluconate available to give to a client who is receiving magnesium sulfate by continuous IV infusion in case of magnesium sulfate toxicity. The nurse should monitor the client for a respiratory rate less than or equal to 12/min, muscle weakness, and depressed deep-tendon reflexes.

A nurse is assessing a client who is 34 wks gestation and has mild placental abruption. What finding should the nurse expect? a. decreased urinary output b. fetal distress c. dark red vaginal bleeding d. increased platelet count

c. dark red vaginal bleeding The nurse should expect the client who has a mild placental abruption to have minimal dark red vaginal bleeding.

A nurse is caring for a client who is to receive a continuous IV infusion of oxytocin following a vaginal birth. What assessment findings should the nurse monitor to evaluate the effectiveness of the med? a. pulse rate b. bp c. fundal consistency d. output

c. fundal consistency Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective.

A nurse is providing teaching to a client who is planning to breastfeed her newborn. What statement by the client indicates an understanding of the teaching? a. I must drink milk every day in order to assure good quality breast milk b. drinking lots of fluids will increase my breast milk production c. it is normal for my baby to sometimes feed every hr for several hours in a row d. after the first few weeks, my nipples will toughen up and breastfeeding wont hurt anymore

c. it is normal for my baby to sometimes feed every hr for several hours in a row Cluster feeding is an expected finding for newborns who are breastfeeding. The mother should follow her newborn's cues and feed her 8 to 12 times per day.

A nurse is assessing a newborn for congenital hip dysplasia. What finding should the nurse expect? a. temp of one leg differing from that of the other b. symmetrical gluteal folds c. limited abduction of one hip d. legs that are shorter than the arms

c. limited abduction of one hip A newborn who has congenital hip dysplasia can have limited abduction because the head of the femur might have slipped out of the acetabulum. asymmetrical gluteal folds

A nurse is planning care for a client who is postpartum and has cardiac disease. For what script should the nurse seek clarification? a. initiate bedrest with HOB elevated b. initiate high-fiber diet for client c. monitor clients wt wkly d. monitor client's I&O

c. monitor clients wt wkly The nurse should weigh the client daily to monitor for fluid overload.

A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor. What action should the nurse take? a. prepare the client for emergency c-section b. perform endotrach suctioning as soon as the fetal head is delivered c. prepare equipment needed for newborn resuscitation d. prepare the client for an ultrasound exam

c. prepare equipment needed for newborn resuscitation The nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.

A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For what finding should the nurse monitor to identify a cervical laceration? a. a gush of rubra lochia when the nurse massages the uterus b. continuous lochia flow and flaccid uterus c. slow trickle of bright vaginal bleeding and a firm fundus d. report of increasing pain and pressure in the perineal area

c. slow trickle of bright vaginal bleeding and a firm fundus The nurse should monitor for bright red bleeding as a slow trickle, oozing or outright bleeding,and a firm fundus to identify a cervical laceration.

A nurse is teaching a client who is at 12 wks gestation about manifestations of potential complications that she should report to her provider. What info should the nurse include in the teaching? a. intermittent nausea b. white vaginal discharge c. swelling of the face d. urinary frequency

c. swelling of the face

A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. What action should the nurse take? a. apply barrier ointment to the newborn's perianal region b. offer the newborn glucose water between feedings c. use photometer to monitor the lamp's energy d. keep the newborn's eye patches on during feedings

c. use photometer to monitor the lamp's energy The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective.

A nurse is caring for a client who is at 39 wks gestation and is in the active phase of labor. The nurse observes late decels in the FHR. What finding should the nurse identify as the cause of late decels? a. umbilical cord compression b. fetal head compression c. uteroplacental insufficiency d. fetal ventricular septal defect

c. uteroplacental insufficiency

A nurse is teaching a client who is at 30 wks gestation about warning signs of complications that she should report to her provider. What finding should the nurse include in the teaching? a. 10 fetal movements per hour b. mild constipation c. vaginal bleeding d. nasal congestion

c. vaginal bleeding Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a complication such as placental abruption, placenta previa, or preterm labor.

A nurse is caring for a client who is at 26 wks gestation and reports constipation. What responses by the nurse is appropriate? a. you should drink 1 ounce of mineral oil q morning b. you should eat at least 3 ounces of red meat/day c. you should walk for at least 30 minutes q day d. you should stop taking your prenatal

c. you should walk for at least 30 minutes q day The nurse should encourage the client to participate in moderate physical activity, such as walking or swimming, every day. This activity increases intestinal peristalsis, which will help alleviate constipation.

nevus flamues (port wine stains)

capillary angioma purple or red on newborns face that does not go away

discontinue oxytocin if

contraction frequency more than every 2 min and last longer than 90 seconds with no relaxation period between contractions

high risk of ____ with external cephalic version

cord prolapse

A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. What action should the nurse take? a. position the client supine with legs elevated b. instruct the client to pant during contractions c. encourage the client to soak in a warm bath d. apply pressure to the client's sacral area during contractions

d. apply pressure to the client's sacral area during contractions

A nurse is caring for a client who reports intestinal gas pain following a c-section. What action should the nurse take? a. encourage client to drink carbonated beverages b. instruct the client to splint the incision with a pillow c. have the client drink fluids through a straw d. assist the client to ambulate in the hallway

d. assist the client to ambulate in the hallway Walking can help stimulate peristalsis, which will promote expulsion of gas.

second degree laceration

skin and muscles of perineum

third degree laceration

skin and muscles of perineum and anal sphincter

A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bm since delivery. What action should the nurse take? a. notify the provider about the elevated temp b. massage the client's fundus c. administer bisacodyl supp d. assist the client to empty her bladder

d. assist the client to empty her bladder When the client's fundus is deviated to the right or left it can indicate that her bladder is full. The nurse should assist the client to empty her bladder to prevent uterine atony and excessive lochia.

A nurse is providing teaching to the parents of a newborn about bottle feeding. What instructions should the nurse include? a. discard unused refrigerated formula after 72 hrs b. prop the bottle with a blanket for the last feeding of the day c. dilute ready-to-feed formula if the newborn is gaining wt too quickly d. boil water for powdered formula for 1-2 min

d. boil water for powdered formula for 1-2 min The parents should run tap water for 2 min and then boil it for 1 to 2 min before mixing it with the formula to decrease the risk of contamination.

A nurse is caring for a newborn directly after birth. What medications should the nurse administer to the newborn within 1-2 hr of delivery? a. poractant alpha b. rotavirus immunization c. naloxone d. erythromycin ophthalmic ointment

d. erythromycin ophthalmic ointment Every newborn born in the United States should receive erythromycin ophthalmic ointment to prevent gonorrheal or chlamydial infections that the newborn can contract during birth.

A nurse is testing the reflexes of a newborn to assess neurologic maturity. What reflexes is the nurse assessing when she quickly and gently turns the newborn's head to one side? a. moro b. babinski c. rooting d. tonic neck

d. tonic neck To elicit the tonic neck reflex, the nurse should quickly and gently turn the newborn's head to one side when he is sleeping or falling asleep. The newborn's arm and leg should extend outward to the same side that the nurse turned his head while the opposite arm and leg flex. This reflex persists for about 3 to 4 months.

A nurse is assessing a client who is at 35 wks gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. What finding should the nurse report to the provider? a. DTR 2+ b. resp 16 c. BP 150/96 d. urinary output 20 mL/hr

d. urinary output 20 mL/hr The nurse should report a urinary output of 20 mL/hr because this can indicate inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary output can also indicate a decrease in renal perfusion secondary to a worsening of the client's pre-eclampsia.

A nurse is caring for a client who is at 37 wks gestation and is undergoing a nonstress test. The FHR is 130 without accelerations for the past 10 min. What action should the nurse take? a. request a script for an internal fetal scalp electrode b. auscultate the FHR with a doppler transducer c. report the nonreactive test result to the provider immediately d. use vibroacoustic stim on the client's abd for 3 seconds

d. use vibroacoustic stim on the client's abd for 3 seconds The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR.

A nurse is teaching a client who is at 12 wks gestation and has HIV. What statement should the nurse include in the teaching? a. you will be in isolation after delivery b. abstain from sexual intercourse throughout pregnancy c. breastfeed your newborn to provide passive immunity d. you should continue to take zidovudine throughout the pregnancy

d. you should continue to take zidovudine throughout the pregnancy -can be transmitted through breastfeeding -she can continue to have sex The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmission of HIV to her newborn.

cold cabbage leaves

decreases swelling and relieves breast soreness

third stage of labor

delivery of placenta

amniocentesis requires the bladder to be

empty

formula fed newborns should be burped

every 15-30 mL

BPP assesses for

fetal well being

telangectiatic nevi

flat pink or red marks that easily blanch

client's bladder needs to be ____ before an ultrasound

full

betamethasone

glucocorticosteroid given to enhance fetal lung maturity

signs of respiratory distress

grunting, nasal flaring, chest retractions

postpartum hemorrhage vital signs

hypotension and tachycardia

complications of postpartum hemorrhage

hypovolemic shock and anemia

if a BPP comes back as a 6

it should be retested

between 18-30 weeks the fundal height should measure what?

it should equal the week of gestation

avoid sexual intercourse until

laceration has healed and vaginal discharge has turned white

foods high in folic acid

leafy greens, dried peas, dried beans, seeds, orange juice

low birth weight

less than 2500g

BPP abnormal score

less than 4

minimal variability

less than 5 contractions per min

fetal bradycardia

less than 60 beats per min

smoking tobacco during pregnancy is associated with

low birth weight

APGAR score 4-6

moderate distress

fetal tachycardia

more than 110 beats per min

marked variability

more than 25 contractions per min

fourth stage of labor

stabilization of vital signs first four hours postpartum

APGAR score greater than 7

stable newborn

postpartum mother should not lift anything heavier than

the newborn

A nurse is providing teaching for a client who have birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching?

the person who comes to take my baby's pictures will be wearing a photo identification badge

regarding kick counts what are the signs the woman needs further evaluation?

there are less than 3 kicks in one hour or there are no signs of fetal movement for 12 hours

subinvolution

uterus fails to return to normal size

postpartum hemorrhage blood loss

vaginal more than 500 mL and c-section more than 1000 mL

what vitamin increases absorption of iron

vitamin c

when can bathing immersion be done?

when the umbilical cord has fallen off and the circumcision site has completely healed