Maternal Newborn "Moderate"
A nurse is preparing to obtain a newborn's temperature. Which of the following methods should the nurse use? A. Axillary B. Temporal C. Tympanic D. Rectal
A. Axillary An axillary temperature is the most accurate and safe way to obtain a newborn's temperature. - The nurse should check the temperature after obtaining respirations and pulse since the baby may cry or struggle when the nurse holds the arm in place. - B & C: A temporal or a tympanic temperature are not considered reliable for checking a newborn's temperature. - D: Rectal temperatures are contraindicated for newborns due to the risk of rectal perforation.
A nurse is teaching a client with pre-eclampsia who is scheduled to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching? A. Elevated blood pressure B. Feeling of warmth C. Hyperactivity D. Generalized pruritus
B. Feeling of warmth The nurse should tell the client to expect a feeling of warmth all over her body while the magnesium sulfate is infusing. - A: The client should expect a decrease in blood pressure while the magnesium sulfate is infusing. - C: The client will feel sedated while the magnesium sulfate is infusing. - D: Generalized pruritus can be a manifestation of al allergic reaction to magnesium sulfate.
A nurse is teaching a client who is in the third trimester of pregnancy and has herpes genitalis. Which of the following instructions should the nurse include? A. Clean the lesions twice a day with hydrogen peroxide B. Apply a hot compress to the affected areas C. Talk with your doctor about a prescription for acyclovir to treat your symptoms D. Expect to receive penicillin prior to delivery
C. Talk with your doctor about a prescription for acyclovir to treat your symptoms Acyclovir is an antiviral medication that helps reduce the manifestations of a genital herpes simplex infection. However, topical acyclovir is a pregnancy risk category C medication, so the provider and the client should weigh the risks and benefits of this therapy. - A: The nurse should instruct the client to clean the lesions twice per day with a saline solution. - B: The nurse should instruct the client to take a warm sitz bath with baking soda in the water. - D: Herpes simplex is a virus; penicillin treats bacterial infections, not viral infections.
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? A. You will have a cesarean birth prior to the onset of labor B. Your baby will receive erythromycin eye ointment after birth to treat the infection C. You should take oral metronidazole for 7 days prior to 37 weeks gestation D. You should schedule a cesarean birth after your water breaks
A. You will have a cesarean birth prior to the onset of labor Whenever possible, a cesarean birth should be scheduled prior to the onset of labor or rupture of membranes to reduce the risk of neonatal transmission of herpes. - B: Erythromycin provides prophylaxis against ophthalmia neonatorum. It is given to prevent gonorrhea and chlamydia infections in newborns. - C: The client who has active herpes should receive a prescription for acyclovir. Metronidazole should be prescribed for bacterial vaginosis. - D: A cesarean birth should be planned prior to the rupture of membranes. If rupture of membranes occurs, an emergency cesarean birth should be done as soon as possible, but every attempt should be made to prevent this situation.
A nurse is caring for a client who is in labor and received meperidine for pain 1 hr prior to entering the second stage of labor. Which of the following actions should the nurse take? A. Assess the client's reflexes B. Assess the newborn for respiratory depression C. Assess the client for bradycardia D. Assess the newborn for signs of opiate withdrawal
B. Assess the newborn for respiratory depression Meperidine should not be administered to laboring clients who are expected to deliver within 4 hours of the medication administration. This medication crosses the placenta and causes respiratory depression in the newborn, which peaks in 2 to 3 hours after administration. Narcan is ineffective at reversing the respiratory depression caused by this medication. - A: Meperidine does not affect the client's reflexes. It reduces the transmission of pain impulses through stimulation of the mu and kappa opioid receptors. - C: Meperidine can cause tachycardia, nausea, vomiting, dizziness, and altered mental status. - D: Neonatal abstinence syndrome occurs in newborns who are exposed to opioids over a long period of time during pregnancy. A client receiving an opiate during labor would not lead to opiate dependence in the newborn.
A nurse is testing the reflexes of a newborn to assess neurological maturity. Which of the following reflexes is the nurse assessing by quickly and gently turning the newborn's head to one side? A. Rooting B. Moro C. Tonic neck D. Babinski
C. Tonic neck To elicit the tonic neck reflex, the nurse should quickly and gently turn the newborn's head to one side when the newborn is sleeping or falling asleep. - The newborn's arm and leg should extend outward to the same side that the nurse turned the head while the opposite arm and leg flex. - This reflex persists for about 3 to 4 months. - A: To elicit the rooting reflex, the nurse should touch the newborn's lip, cheek, or corner of the mouth. The newborn should turn toward that side and open the mouth. This reflex usually persists for 3 to 4 months but can last for 1 year. - B: To elicit the Moro reflex, the nurse should hold the newborn in a semi-sitting position and allow the trunk and head to far back by about 2.5 cm (1 in). The newborn should abduct and extend the arms symmetrically, and the fingers should fan out and form a "C" with the thumb and forefinger. This reflex is the strongest during the first 8 weeks and usually disappears in about 4 to 5 months. - D: To elicit the Babinski reflex, the nurse should stroke the bottom of the newborn's foot upward along the lateral edge and then along the ball of the foot with a finger. The newborn's toes should hyperextend while the big toe dorsiflexes. This reflex persists for about 1 year.
A nurse is teaching a client who is breastfeeding about strategies for preventing mastitis. Which of the following instructions should the nurse include? A. Take an herbal galactagogue B. Gradually increase the time between findings C. Wear an underwire bra D. Use your finger to release suction after feeding
D. Use your finger to release suction after feeding Releasing the newborn's grasp on the nipple with a finger before removing the newborn from the breast helps prevent injury to the nipples, which can lead to mastitis. - A: Galactagogue medications and herbs can increase the client's milk supply. This intervention can increase the risk of mastitis if the infant does not completely empty the breasts. - B: Waiting too long between feedings can result in clogging or plugging of the nipples, which can increase the risk of mastitis. - C: Wearing an underwire bra is associated with an increased risk for mastitis due to blocking the breast from emptying completely.
A nurse is reviewing recent laboratory values during a prenatal visit for a client who is pregnant. The nurse notes a hemoglobin level of 10 g/dL. Which of the following actions should the nurse take? A. Review the medical record for a history of gastric bypass surgery B. Advise the client to start iron and vitamin C supplementation C. Review the medication list to determine if the client is taking an anticonvulsant D. Request an order for sickle cell anemia screening
B. Advise the client to start iron and vitamin C supplementation Anemia during pregnancy is defined by hemoglobin levels less than 10.5 to 11 g/dL, depending on the client's gestational age. Iron-deficiency anemia is characteristically microcytic. It is treated with iron supplementation with added vitamin C to aid in iron absorption. - A: Clients who have a history of gastric bypass surgery are at risk for anemia caused by folate deficiency, not iron deficiency. Folate-deficiency anemia is characteristically megaloblastic, not microcytic. - C: Clients who are receiving anticonvulsant therapy are at risk for anemia caused by folate deficiency, not iron deficiency. Folate-deficiency anemia is characteristically megaloblastic, not microcytic. - D: Hemoglobin levels in clients who have sickle cell anemia are significantly lower than 10.4 g/dL, at approximately 6 to 8 g/dL.
A nurse is caring for a client who is in active labor and whose birth plan requests only non-pharmacological pain relief strategies. Which of the following strategies should the nurse offer as a form of cutaneous stimulation? A. Breathing techniques B. Counter-pressure C. Biofeedback D. Use of a focal point
B. Counter-pressure The nurse should implement counter-pressure as a non-pharmacological cutaneous stimulation strategy. - Other cutaneous stimulation strategies include walking, effleurage, water therapy, and the application of heat or cold. - A: The nurse should implement breathing techniques as a non-pharmacological sensory-stimulation strategy. - C: The nurse should implement biofeedback as a non-pharmacological cognitive-stimulation strategy. - D: The nurse should implement the use of a focal point as a non-pharmacological sensory-stimulation strategy.
A nurse is providing teaching for a client about hormonal changes during pregnancy. The nurse identifies that which of the following hormones plays a key role in preventing miscarriage? A. Oxytocin B. Prolactin C. Progesterone D. Estrogen
C. Progesterone Progesterone maintains the endometrium and has a relaxant effect on the uterus so that the fetus is not expelled. - A: Oxytocin stimulates uterine contractions and is responsible for the excretion of milk during lactation. - B: Prolactin prepares the breasts to synthesize and secrete milk. - D: Estrogen stimulates uterine contractility and growth of the uterus and breast glandular tissue. Estrogen levels rise near the end of pregnancy to prepare for the onset of labor.
A nurse is caring for 4 newborns. Which of the following newborns is at the greatest risk of hypoglycemia? A. A newborn who is large for gestational age B. A newborn who has an Rh incompatibility C. A newborn who has pathologic jaundice D. A newborn who has fetal alcohol syndrome
A. A newborn who is large for gestational age Large for gestational age (LGA) newborns have a weight 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 an increased risk of hypoglycemia. - Other newborns at risk of hypoglycemia are small for gestational age (SGA) newborns (those below the 10th percentile), premature newborns, and newborns who have perinatal hypoxia. - B: A newborn who is Rh-positive and born to a mother who is Rh-negative will have jaundice as a result of hyperbilirubinemia and the breakdown of RBCs. This is also called erythroblastosis fetalis. - C: A newborn who has pathologic jaundice has hyperbilirubinemia that can lead to acute bilirubin encephalopathy. - D: A newborn who has fetal alcohol syndrome (FAS) will exhibit respiratory manifestations such as tachypnea, nasal flaring, and chest retractions. Neurological manifestations of FAS include irritability, tremors, and incessant crying. Gastrointestinal manifestations of FAS include an uncoordinated sucking swallowing reflex, incessant hunger, and vomiting.
A nurse is caring for a client who is at 38 weeks gestation and reports no fetal movement for the past 24 hours. Which of the following actions should the nurse take? A. Auscultate for a fetal heart rate B. Have the client drink orange juice C. Reassure the client that a term fetus is less active D. Palpate the uterus for fetal movement
A. Auscultate for a fetal heart rate The presence of a fetal heart rate is a reassuring manifestation of fetal wellbeing. The nurse should auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action. - B: This is an appropriate action to stimulate a sleeping fetus; however, the client has not felt any movement for 24 hours. Therefore, this is not the priority nursing action. - C: Lack of fetal movement for 24 hours is not an expected finding. Therefore, reassuring the client is not the priority action. - D: Palpating for fetal movement is not a reliable method of determining fetal wellbeing.
A nurse is caring for a client in active labor whose membranes have ruptured. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first? A. Turn the client onto her left side B. Palpate the client's uterus C. Administer oxygen to the client D. Increase the client's IV fluids
A. Turn the client onto her left side The nurse should turn the client onto her left side since late decelerations indicate 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 pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply. - B: The nurse should palpate the client's uterus to assess for tachysystole. However, another action is the priority. - C: The nurse should administer oxygen at 8 to 10 L/min by nonrebreather face mask to enhance placental perfusion. However, another action is the priority. - D: The nurse should increase the client's IV fluids to boost circulating volume. However, another action is the priority.
A nurse at a family-planning clinic is preparing to teach a class about how to use a diaphragm. Which of the following pieces of information should the nurse plan to include in the teaching? A. Use spermicidal jelly whenever you use your diaphragm B. Insert the diaphragm about 8 hr before sexual activity C. You should remove the diaphragm 30 min after intercourse D. A diaphragm comes in a single size and does not require fitting
A. Use spermicidal jelly whenever you use your diaphragm A diaphragm is a barrier device that helps prevent pregnancy. Use of a diaphragm alone is not 100% effective in preventing pregnancy, but the accompanying use of spermicidal jelly increases the effectiveness of the device. - B: Women should insert their diaphragm up to 6 hours before vaginal intercourse. - C: Women should wait at least 6 hours after vaginal intercourse before removing the diaphragm. Removal prior to 6 hours increases the change of pregnancy by allowing semen to enter the uterus. - D: A diaphragm comes in several sizes and must fit correctly to work effectively. The client might require a different size diaphragm if her weight changes significantly.
A nurse is caring for a client at 12 weeks gestation who has a BMI of 45. Which of the following pieces of information should the nurse provide for the client regarding the recommended weight gain during her pregnancy? A. You should plan to gain no more than 20 pounds during your pregnancy B. You should plan to gain between 25 and 35 pounds during your pregnancy C. You should not plan to gain any weight during your pregnancy because you are already well-nourished D. Since you have higher energy needs than an average-sized pregnant client, you should plan to gain 45 to 50 pounds
A. You should plan to gain no more than 20 pounds during your pregnancy Women who have a BMI above 30 should limit their weight gain to 11 to 20 pounds during pregnancy. Excessive weight and weight gain increase the risk of complications during and after pregnancy. - B: This is the recommended weight gain for a pregnant client who has a BMI of 18.5 to 25. - C: Pregnancy is not an appropriate time for the client to be dieting. Clients who are overweight or obese should be counseled to gain enough weight to compensate for the fetus, placenta, and amniotic fluid, which amounts to 11 to 20 pounds. - D: Women with a BMI above 30 should limit their weight gain to 11 to 20 pounds during pregnancy.
A community health nurse is planning care for 4 high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first? A. A 1-week-old newborn who needs another phenylketonuria screening test B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy C. A 10-day-old newborn who is small for gestational age and requires daily weighing D. A 2-week-old newborn who was born at 35 weeks gestation and weighed 2,268 g (5 lb) at discharge
B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy An elevated bilirubin level can lead to kernicterus; therefore, it is imperative for the nurse to initiate phototherapy immediately to help prevent this dangerous outcome. - A: Phenylketonuria is an inborn error of phenylalanine metabolism. Without treatment with a phenylalanine-free diet, newborns who have this disorder can develop severe, irreversible developmental delays. Blood collection for this test prior to 24 hours after delivery can result in inconclusive results and the need for another specimen collection after at least 2 days of breast or formula feeding. The nurse should collect this specimen promptly; however, another client is the priority. - C & D: The nurse should monitor this newborn's weight to identify whether further intervention is needed to promote growth and development; however, another client is the priority.
A nurse is providing care to a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make? A. This could indicate a possible uterine infection B. The bleeding is minimal until I discontinue your IV medication C. You might have retained some fragments of your placenta D. You will require additional medication to increase your bleeding
B. The bleeding is minimal until I discontinue your IV medication The flow of lochia is often scant while receiving oxytocic medication until the effects of the medication wear off. - This can be observed regardless of the administration route of the oxytocic medication. - A: Increased, not decreased, bleeding can indicate an infection during the postpartum period. A fever or foul-smelling discharge could also be indications of an infection. - C: Increased, not decreased, bleeding can indicate retained placental fragments. On postpartum days 7 to 14, clients might have a brief, sudden increase in bleeding as sloughing of eschar occurs over the placental site. This should subside in 1 to 2 hours. - D: The flow of lochia is often scant while receiving an oxytocic medication, and no additional medication is warranted at this time to induce bleeding. Once the effects of the oxytocin wear off, the lochia will return to a more normal flow.
A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure? A. Send a sample of amniotic fluid to the laboratory to screen the client for chlamydia B. Send a sample of amniotic fluid to the laboratory to test for an elevated Rh-negative titer C. Administer immune globulin to the client to prevent fetal isoimmunization D. Administer intravenous antibiotics to prevent an infection
C. Administer immune globulin to the client to prevent fetal isoimmunization Because the client is Rh-negative, Rh immune globulin is administered after the procedure to prevent fetal isoimmunization or help ensure maternal antibodies will not form against any placental red blood cells that might have accidentally been released into the maternal bloodstream during the procedure. - A: The provider screens the client for chlamydia during a pelvic examination rather than through an amniocentesis. - B: Testing the client's blood for Rh antibodies is done at the beginning of pregnancy and repeated at 28 weeks. This diagnostic test is performed on the client's blood rather than amniotic fluid. - D: The provider performs the amniocentesis with sterile technique; although infection is a risk with any invasive procedure, the routine administration of prophylactic antibiotics is not indicated.
A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take? A. Prepare to initiate a warm water site bath for the client's perineum B. Encourage the client to sit on a soft pillow C. Apply cold ice packs to the client's perineum D. Administer an acetaminophen suppository rectally
C. Apply cold ice packs to the client's perineum A third-degree laceration extends from the perineum to the external sphincter of the rectum. This can cause severe discomfort. Cold ice packs are used on the perineal area during the first 24 hours to decrease edema, pain, and discomfort. - A: Warm sitz baths are appropriate after the first 24 hours postpartum. A cool sitz bath is recommended within the first 24 hours to reduce edema and promote comfort. - B: The nurse should encourage the client to sit on firm surfaces. The client should avoid soft pillows and donut pillows because they separate the buttocks and decrease venous blood flow, resulting in more pain and discomfort to the perineal area. - D: The use of suppositories or enemas is contraindicated for a client who has a third-degree perineal laceration due to the severity of the laceration.
The parents of a child with phenylketonuria (PKU) ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns responsible for PKU? A. X-linked recessive B. X-linked dominant C. Autosomal recessive D. Autosomal dominant
C. Autosomal recessive PKU is inherited by autosomal-recessive gene patterns. - In these types of disorders, neither parent may actually have the disorder, but both mother and father must carry and contribute a variant gene for it to occur. - Other autosomal-recessive disorders are cystic fibrosis and sickle cell anemia. - A: PKU does not have an X-linked recessive pattern of inheritance. In X-linked recessive disorders, the abnormal gene is carried on the X chromosome. In males, only 1 copy of the abnormal gene is required for the disorder to be expressed in males since the Y chromosome does not carry the disorder. Females must have 2 copies of the gene. Examples of this type of disorder are hemophilia and color blindness. - B: PKU does not have an X-linked dominant pattern of inheritance. In X-linked dominant disorders, the abnormal gene is carried on the X chromosome. Only 1 copy of the abnormal gene is necessary for the disorder to occur. However, males are more likely to be severely affected due to the homozygous expression. There are only a few disorders that follow this pattern of inheritance. Examples include vitamin D-resistant rickets and Rett syndrome. - D: PKU does not have an autosomal-dominant pattern of inheritance. In these disorders, only 1 copy of the variant gene is necessary for the disorder to occur. Examples of this type of disorder are neurofibromatosis and Treacher Collins syndrome.
A nurse is assessing a pregnant client who is at 38 weeks of gestation. The client reports that her breathing has become easier but notes an increased frequency of urination. The nurse should document this occurrence as which of the following? A. Effacement B. Dilation C. Lightening D. Quickening
C. Lightening Lightening describes the engagement of the fetal head into the pelvis. When this occurs, breathing becomes easier, but urination is more frequent. - A: Effacement is the thinning of the cervical tissue. - B: Dilation is the widening of the cervix during labor. - D: Quickening is the first occurrence of fetal movement.
A nurse is assessing a newborn. For which of the following findings should the nurse notify the provider? A. Heart rate 136/min B. Acrocyanosis C. Mottling D. Respiratory rate 60/min
C. Mottling The nurse should report mottling to the provider as an indication of hypothermia or respiratory distress. - A: A heart rate of 136/min is within the expected reference range for a newborn. The nurse should notify the provider if the newborn's heart rate is below 80/min while asleep or above 180/min while crying. - B: Acrocyanosis (a bluish discoloration of the hands and feet) is an expected finding in a newborn. The nurse should notify the provider if the newborn has central cyanosis. - D: A respiratory rate of 60/min is within the expected reference range for a newborn. The nurse should notify the provider if the newborn's respiratory rate is under 25/min or above 60/min.
A nurse is caring for a client who had a precipitous delivery. Which of the following assessments is the priority during the fourth stage of labor? A. Obtaining the client's temperature B. Inspecting the client's perineum C. Palpating the client's fundus D. Checking the client for hemorrhoids
C. Palpating the client's fundus A precipitous delivery follows a labor of <3 hours. Regardless of the cause of the rapid delivery, uterine atony can result, causing postpartum hemorrhage. The nurse should palpate the fundus and massage as needed to monitor for and reduce the risk of hemorrhage. - A: The nurse should monitor the client's temperature during the fourth stage of labor; however, another assessment is the priority. - B: The nurse should assess the client's perineum, especially if an episiotomy or laceration is present; however, another assessment is the priority. - D: The nurse should check the client for hemorrhoids during the fourth stage of labor; however, another assessment is the priority.
A nurse is discussing the expected changes related to pregnancy with a client who is at 8 weeks gestation. Which of the following findings should the client report to the provider during the first trimester? A. Breast tenderness B. Urinary frequency C. Persistent vomiting D. No fetal movement
C. Persistent vomiting Intermittent nausea and vomiting during the first trimester are common. - However, the nurse should inform the client that persistent vomiting suggests hyperemesis gravidarum and increases the risk of fluid and electrolyte imbalance. - In this situation, maternal and fetal health might be compromised, and symptoms should be reported to the provider. - The cause of hyperemesis gravidarum is unknown but might result from human chorionic gonadotropin (hCG) levels. - The client should be encouraged to eat dry crackers upon awakening, eat 5-6 small meals daily, and avoid fried, odorous, or spicy foods. - A: The nurse should inform the client that breast tenderness and tingling sensations are expected changes during the first trimester of pregnancy and can persist throughout the second and third trimesters. Hypertrophy of mammary glandular tissue and increased vascularization to the breast tissue can cause tenderness. Other breast tissue changes include prominence of nipples that might darken and enlarge due to hormonal stimulation. The client should wear a supportive bra to life the breast tissue and minimize discomfort. - B: The nurse should inform the client that increased frequency and urgency of urination are expected findings during the first and third trimesters of pregnancy. Vascular engorgement and altered bladder function caused by hormones occur during the first trimester, and bladder capacity is reduced by the enlarging uterus during the third trimester. The client should empty the bladder regularly, perform Kegel exercises, limit fluid before bedtime, and report burning or pain during urination. - D: The nurse should inform the client that fetal movement is not expected during the first trimester. Quickening is the firs perception of fetal movement and occurs as early as 14 to 16 weeks of gestation.
A nurse in an outpatient setting is providing education for a client who is pregnant. Which of the following statements should the nurse include in the teaching? A. During the last trimester, you should sleep mainly on your back B. During the second trimester, you will notice increased urinary frequency and urgency C. You will probably first notice your baby moving when you are around 20 weeks gestation D. You should plan to gain 40 to 45 pounds during your pregnancy
C. You will probably first notice your baby moving when you are around 20 weeks gestation Fetal movement is typically noted by a pregnant client at 18 to 20 weeks gestation. Multiparous clients might notice the movement earlier. - A: Clients should avoid supine position during the latter half of pregnancy due to the risk of vena cava compression. - B: This is a common finding during the first and third trimester due to fetal pressure on the bladder. Urinary frequency and urgency during the second trimester should be reported to the provider. - D: Recommended weight gain during pregnancy is typically 25 to 30 pounds.
A nurse is assessing a female client 24 hr after delivery and notes the fundus is 2 cm above the umbilicus. Which of the following actions should the nurse take? A. Administer a tocolytic medication B. Apply a hearing pad to the mid-abdominal area C. Reassess the fundus in 2 hr D. Ambulate the client to the bathroom
D. Ambulate the client to the bathroom An increased fundal height in the postpartum period is a sign of a non-contracted uterus, which increases the risk for hemorrhage. The most common postpartum cause of an elevated final height is an over-distended bladder. - A: A tocolytic medication will cause further uterine muscle relaxation and increase the risk of postpartum hemorrhage. - B: A heating pad over the uterus will increase vasodilation and relaxation of the uterine muscle and further increase the risk of hemorrhage. - C: The uterus should be a finger-breadth below the umbilicus at 24 hours postpartum. Waiting 2 hours before taking action greatly increases the risk of hemorrhage.
A nurse is discussing epidural anesthesia with a client who is receiving oxytocin to induce labor. Which of the following statements should the nurse make? A. An epidural given too early during labor can cause maternal hypertension B. An epidural given too early during labor will not be effective in active labor C. An epidural given too early can cause fetal depression D. An epidural given too early can prolong labor
D. 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 slows. The medication depresses the central nervous system, extending the time needed for the cervix to dilate and efface. - A: Epidural anesthesia will cause the maternal blood pressure to decrease rather than increase because of CNS depression. - B: An epidural will be most effective when the client is in active labor, which occurs when uterine contractions occur at least every 3 to 5 minutes, last between 40 and 70 seconds, and are moderately strong in intensity. - C: An adverse effect of epidural anesthesia is maternal hypotension, which can cause bradycardia in the fetus. This adverse effect has nothing to do with the timing of the epidural and is usually prevented by administering a bolus of 500mL of IV fluid prior to the insertion of the epidural catheter.
A nurse is providing care for a pregnant adolescent who is at 12 weeks gestation and verbalizes a fear of gaining weight during pregnancy. Which of the following actions should the nurse take? A. Have the client watch a video on fetal growth and development during pregnancy B. Supply pamphlets that discuss the importance of nutrition during pregnancy C. Explain how poor nutrition can prevent the baby from growing properly D. Provide examples of how eating well will help maintain a healthy weight during pregnancy
D. Provide examples of how eating well will help maintain a healthy weight during pregnancy Adolescents are typically preoccupied with self and lack the ability to understand outcomes that will occur in the future. Effective teaching for this age group should mainly focus on benefits to the client and positive outcomes that will occur in the near future. - A: Watching a video may be helpful for some clients but does not address this client's concerns about weight gain. - B & C: Providing information about proper nutrition may be effective for some clients but will typically not meet the needs of an adolescent client who is expressing concerns about gaining weight.
A nurse is performing an admission assessment of a client who just arrived at the labor and delivery unit. Which of the following findings should the nurse identify as the priority? A. The client reports a pain level of 8 on a scale from 0 to 10 during contractions B. The client's blood pressure is 148/92 mmHg C. The client's temperature is 38.3c (101f) D. The fetal heart rate is 90/min
D. The fetal heart rate is 90/min Fetal bradycardia indicates that this client is at greatest risk for fetal consequences due to a cardiac disorder or infection, leading to hypoxia and asphyxiation; therefore, this is the priority finding. - A: The nurse should intervene to help ease the client's pain; however, another assessment finding is the priority. - B: The nurse should recheck the client's blood pressure in 30 minutes after the client has relaxed and between contractions to help rule out preeclampsia; however, another assessment finding is the priority. - C: The nurse should notify the provider and perform a thorough assessment to rule out an infection such as chorioamnionitis; however, another assessment finding is the priority.
A nurse is caring for a client who is at 35 weeks of gestation and is scheduled to undergo an amniocentesis. Which of the following statements should the nurse make? A. You will have to drink 3 5-8-oz glasses of water to fill your bladder B. This procedure will not rupture your membranes or cause premature labor C. You might feel light pressure during the collection of a blood sample from the baby D. You will feel some mild discomfort during the procedure
D. You will feel some mild discomfort during the procedure During an amniocentesis, the client might feel slight uterine cramping when the needle comes into contact with the uterus. - A local anesthetic is applied to the client's skin, so the client should not feel pain when the needle pierces the skin. - A: Filling the bladder by drinking water is necessary for an ultrasound procedure, not for an amniocentesis. For an amniocentesis, the client should empty her bladder to reduce the risk of an accidental puncture during the procedure. - B: Potential complications of amniocentesis include preterm labor, leaking of amniotic fluid, fetal injury, and placental abruption. - C: Amniocentesis involves withdrawing amniotic fluid, not blood, into a syringe. Some clients report a pulling sensation when the syringe is withdrawing the fluid.
A nurse is assisting with fetal heart monitoring during labor for a client who is at 40 weeks of gestation. The nurse should identify that which of the following findings on the fetal monitoring tracing requires intervention? A. A fetal heart rate of 180/min for 15 minutes B. A deceleration that returns to baseline at the end of the contraction C. An acceleration of 20/min for 18 seconds during a contraction D. An occasional variable deceleration in fetal heart rate
A. A fetal heart rate of 180/min for 15 minutes A heart rate of more than 160/min for 10 minutes or longer is considered fetal tachycardia, which can indicate fetal hypoxemia; therefore, this finding requires intervention by the nurse. - B: Early decelerations (when the fetal heart rate decreases but returns to baseline at the end of a uterine contraction) are harmless and do not require intervention. - C: Accelerations in the fetal heart rate of at least 15/min for 15 seconds or more with a return to baseline less than 2 minutes later are an indication of fetal wellbeing and do not require intervention. - D: Occasional variable decelerations are harmless and do not require intervention. However, persistent variable decelerations require intervention.
A nurse is performing an initial physical assessment of a newborn following a vaginal birth. Which of the following findings should the nurse report to the provider? A. Small, pinpoint, reddish-purple spots on the chest B. Bluish coloring of the feet C. Overlapping suture lines D. White, cheese-like substance covering the skin
A. Small, pinpoint, reddish-purple spots on the chest These marks are petechiae, which are commonly found above the neck if the umbilical cord was around the newborn's neck at birth. Petechiae in any other circumstance should be reported because this finding can indicate infection or a low platelet count. - B: Bluish coloring of the feet is acrocyanosis, which is often present on the hands and feet of a newborn. This is an expected finding. - C: Cranial bones overlap during a vaginal delivery to help the fetal head move through the birth canal. This is called molding, and it is an expected finding after vaginal birth. - D: After 35 weeks of gestation, a cream cheese-like white substance (vernix cases) attaches to the fetus' skin. It helps hydrate and protect the newborn's skin after birth. This is an expected finding.
The guardian of a 3-day-old female newborn tells the nurse that he noticed a small amount of blood-tinged mucus discharge on the newborn's labia. Which of the following responses should the nurse make? A. The blood-tinged mucus is a result of pseudomenstruation B. The blood-tinged mucus indicates a urinary tract infection C. The blood-tinged mucus is due to uric acid crystals D. The blood-tinged mucus is a result of the initial genital examination
A. The blood-tinged mucus is a result of pseudo-menstruation Pseudo-menstruation is a result of the loss of maternal hormones at birth, resulting in vaginal discharge with withdrawal bleeding. It is an expected finding in female newborns. - B: An infection in the urinary tract might cause blood in the urine but not blood from the vagina. - C: Uric acid crystals can appear as pinkish spots on the diaper, but they are in the newborn's urine, not vaginal discharge. They are an expected finding during the first week after birth. - D: Newborns undergo a comprehensive physical examination by the provider shortly after birth, including an examination of the genitalia. However, the examination should not cause traumatic vaginal bleeding.
A nurse is caring for a client who is at 20 weeks gestation. The client asks the nurse what the baby looks like at this point. Which of the following answers by the nurse provides an accurate response? A. Lanugo has disappeared B. The fetus resembles a human C. The arm and leg buds are noticeable D. Subcutaneous fat gives the body a wrinkled appearance
B. The fetus resembles a human By 20 weeks of gestation, the fetus resembles a very thin human. - A: Lanugo covers the body at this fetal age. - C: Leg and arm buds become noticeable between weeks 5 and 6. - D: A lack of subcutaneous fat makes the body appear wrinkly.
A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? A. Terbutaline B. Nifedipine C. Magnesium sulfate D. Methylergonovine
D. Methylergonovine The nurse should administer methylergonovine, an ergot alkaloid, which promotes uterine contractions. - A: The nurse should administer terbutaline, a smooth muscle relaxant, to a client who is experiencing preterm labor. - B: The nurse should administer nifedipine, a smooth muscle relaxant, to a client who is experiencing preterm labor. - C: The nurse should administer magnesium sulfate to a client who has preeclampsia to lower blood pressure and minimize the risk of seizures.
A nurse is reviewing the laboratory report of a newborn who has a blood type of B-negative. The mother's blood type is O-positive. The laboratory results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse expect? A. Hyperbilirubinemia B. Central cyanosis C. Intracranial hemorrhage D. Cardiomyopathy
A. Hyperbilirubinemia The nurse should identify that some infants of mothers with type O blood are at an increased risk for developing hyperbilirubinemia because these mothers possess naturally occurring A and B antibodies, which are transferred across the placenta to the fetus. - B: Central cyanosis in newborns occurs due to congenital cardiac defects rather than blood type. - C: Risk factors for intracranial hemorrhage include forceps- or vacuum-assisted birth, precipitous or prolonged second stage of labor, and increased fetal size. - D: Cardiomyopathy in newborns generally occurs due to poorly controlled maternal diabetes.
A nurse is assessing a client who reports that she might be pregnant. Which of the following findings should the nurse identify as a presumptive sign of pregnancy? A. Nausea in the morning B. Positive home pregnancy test C. Increased sensitivity of the cervix noted upon examination D. Gestational sac observed by transvaginal ultrasound
A. Nausea in the morning Nausea is a presumptive sign of pregnancy-- that is, a subjective symptom reported by the mother that could have a cause other than pregnancy. - B: A home pregnancy test assess for the presence of human chorionic gonadotrophin in the client's urine. This test is an objective finding, but a positive test could have other causes such as the presence of a hydatiform mole of certain cancers. Therefore, a positive home pregnancy test is considered a probable sign of pregnancy. - C: An increase in sensitivity of the cervix and vagina is an objective finding noted by the examiner and a probable sign of pregnancy. - D: Visualization of the gestational sac is a positive sign that can only be attributed to pregnancy.
A nurse is teaching a parent of a newborn how to care for the newborn's umbilical cord stump. Which of the following instructions should the nurse include? A. Cover the cord with the edge of the diaper B. Clean the cord stump with tap water C. Apply a damp cloth over the cord stump once each day D. You should gently tug on the cord stump in 5 days if it has not yet fallen off
B. Clean the cord stump with tap water The nurse should instruct the parent to cleanse around the cord stump with tap water to promote healing and prevent infection. - A: The nurse should instruct the parent to fold the edge of the diaper below the cord to ensure that it stays dry to promote healing and prevent infection. - C: The nurse should instruct the parent to keep the cord stump clean, dry, open to the air, and loosely covered by clothing. - D: The nurse should instruct the parent not to put pressure on or pull the cord stump. The cord will dry and fall off naturally within 10 to 14 days after birth.
A nurse is assessing a client who is in the first stage of labor and has preeclampsia. Which of the following findings should the nurse expect? A. Severe hypotension B. Proteinuria C. Elevated platelet count D. Seizures
B. Proteinuria The nurse should expect a client with preeclampsia to have proteinuria and impaired kidney function. - A: The nurse should expect a client who has preeclampsia to have hypertension over 140/90 mmHg. - C: The nurse should expect a client who has preeclampsia to have thrombocytopenia with a platelet count of under 100,000. - D: The nurse should expect a client who has eclampsia to have seizures.
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? A. Your partner needs to be cultured and be treated with metronidazole only if his cultures are positive B. You and your partner need to take the medication and use a condom during intercourse until cultures are negative C. If both you and your partner are treated simultaneously, you may continue to engage in sexual intercourse D. Only you will need to take the metronidazole, but you should not have intercourse until your culture is negative
B. 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: Treatment of the male partner is done without a culture if his female partner has trichomoniasis. - C: Trichomoniasis can be easily treated with metronidazole. However, for the treatment to work, the client must avoid sexual intercourse while being treated or use a condom. - D: Both men and women can be infected with trichomoniasis. Unless both partners are treated, the male will likely reinfect the female.
A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min and respiratory rate of 36/min. The newborn has well-flexed extremities, responds to stimuli with a cry, and has blue hands and feet. Which Apgar score should the nurse assign to the newborn? A. 7 B. 8 C. 9 D. 10
C. 9 The nurse should use the Apgar scoring system to perform a quick assessment of the newborn at 1 minutes and 5 minutes after birth. The nurse should assign a score of 0, 1, or 2 to each of 5 categories. - The nurse should assign a score of 2 for a FHR >100/min - The nurse should assign a score of 2 for a good, strong cry, which shows normal respiratory effort - The nurse should assign a score of 2 for well-flexed extremities, which shows normal muscle tone - The nurse should assign a score of 2 for responding to stimulation with a cry, cough, or sneeze - The nurse should assign a score of 1 for blue hands and feet, which is known as acrocyanosis - A, B, & D: These are not the correct Apgar scores for this newborn.
A nurse is assessing a 12-hour-old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take? A. Perform chest percussion B. Place the newborn in a prone position C. Continue routine monitoring D. Request a prescription for supplemental oxygen
C. Continue routine monitoring The nurse should continue routine monitoring because the newborn's assessment findings indicate adaptation to extra-uterine life. - A: The nurse should expect short periods of apnea for a 12-hour-old newborn and should not perform chest percussion. - B: The nurse should place the newborn in a side-lying position or supine to promote sleep and decrease the risk of respiratory distress. - D: Manifestations of abnormal breathing patterns that can indicate a need for supplemental oxygen include tachypnea, nasal retractions, stridor, and gasping.
A nurse is planning care for a client who is at 35 weeks gestation. Which of the following laboratory tests should the nurse obtain? A. Rubella titer B. Blood type C. Group B streptococcus B-hemolytic D. 1-hour glucose tolerance test
C. Group B streptococcus B-hemolytic The nurse should obtain a vaginal/anal group B streptococcus B-hemolytic (GBS) culture at 35 to 37 weeks gestation to screen for infection. - Prophylactic antibiotics should be given during labor to clients who are positive for GBS. - A: The nurse should obtain a rubella titer at the first prenatal visit to determine immunity to rubella. A client who is pregnant and does not have a titer to rubella must be counseled to avoid exposure. - B: The nurse should obtain a maternal blood type and Rh factor at the first prenatal visit to determine if the client will need to receive Rho(D) immune globulin at 28 weeks gestation. - D: The nurse should obtain a 1-hour glucose tolerance test at 24 to 28 weeks gestation to screen for gestational diabetes.
A nurse is caring for a client in active labor who is experiencing hypotension following epidural placement. Which of the following actions should the nurse take? A. Decrease IV fluids B. Give oxygen at 2 L/min via nasal cannula C. Place the client in a lateral position D. Administer indomethacin
C. Place the client in a lateral position The nurse should place the client in a lateral position to increase uterine perfusion to the fetus. - A: The nurse should increase IV fluids for a client who is experiencing hypotension following an epidural placement. - B: The nurse should administer oxygen at 10 to 12 L/min via nonrebreather face mask. - D: The nurse should administer a vasopressor to increase maternal blood pressure. Indomethacin is used as a tocolytic for preterm labor.
A nurse is caring for a client who had pelvic measurements recorded by the provider. The client asks, "Since my pelvis is gynecoid, will I be able to deliver vaginally?" Which of the following responses should the nurse make? A. The shape of your pelvis will make vaginal childbirth difficult, but it is still possible B. The shape of your pelvis will require a cesarean delivery C. The shape of your pelvis is ideal for vaginal childbirth D. The shape of your pelvis will change as you near deliver, and the provider will determine if vaginal delivery is possible
C. The shape of your pelvis is ideal for vaginal childbirth The nurse should inform the client that a gynecoid pelvis is well-rounded with a wide pubic arch. This is ideal for vaginal childbirth. - A & B: A client who has an android, anthropoid, or platypelloid pelvic shape might have difficulty with vaginal childbirth, resulting in the need for a cesarean delivery. - D: The shape of a client's pelvis does not change as delivery nears unless trauma occurs.
A nurse is caring for a client who is in labor. A vaginal examination reveals the following findings: 2cm, 50%, +1 right occiput anterior (ROA). Based on this information, which of the following fetal positions should the nurse document in the medical record? A. Transverse B. Breech C. Vertex D. Mentum
C. 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 on the client's right side. Based on the presentation of the fetus, the position is vertex. - A: A transverse position indicates that the fetus is lying horizontally in the pelvis and is presenting with a shoulder. - B: The breech position indicates that the fetus is upright in the uterus and is presenting with the buttocks or feet. - D: Mentum indicates that the fetus has fully extended the head and is presenting with the chin.
A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching? A. You should supplement your baby with formula until you notice that your breasts become firm and full B. You should adhere to a schedule when feeding your baby to ensure she is getting enough to eat C. Your milk supply will noticeably increase in volume around the third or fourth day after delivery D. It is typical for your nipples to hurt for the first few weeks while you are breastfeeding
C. Your milk supply will noticeably increase in volume around the third or fourth day after delivery As the colostrum transitions to mature breast milk, the value of milk produced will also increase. Typically, the postpartum client will notice that 72 to 96 hours after delivery her breasts feel fuller and firmer and that milk is leaking from her nipples. - A: Colostrum is present in a mother's breasts before the newborn is delivered. Unless there is a medical indication, there is no need for formula supplementation. - B: Newborns and infants should be breastfed on demand. Adhering to a strict timing for feedings can lead to a failure to meet nutritional needs of the newborn/infant. - D: Painful nipples during breastfeeding are an indication that the newborn is not correctly latched onto the breast. The baby should be removed from the breast and re-latched. Breastfeeding clients should report only a tugging sensation on their nipples.
A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take? A. Encourage the client to ambulate B. Provide a site bath with warm water for the client C. Instruct the client to perform Kegel exercises D. Apply anesthetic cream topically each hour while the client is awake
B. Provide a site bath with warm water for the client The nurse should provide a client who is postpartum with a site bath to decrease episiotomy discomfort. - The use of a site bath provides warm, moist, direct heat to the incision area, which helps relieve the pulling and stinging associates with the healing incision. The warm water increases blood flow to the area through vasodilation, which also promotes healing and comfort.
A nurse is caring for a client who is at 33 weeks of gestation and reports dark red vaginal bleeding and contractions that do not stop. Which of the following actions should the nurse take first? A. Check the fetal heart tones B. Assess the uterine contraction pattern C. Measure maternal vital signs D. Obtain a biophysical profile
A. Check the fetal heart tones The greatest risk to this client is fetal mortality from placental abruption; therefore, the priority assessment is immediate auscultation of fetal heart tones to determine the status of the fetus. - B: The nurse should assess the uterine contraction pattern to determine the imminence of spontaneous preterm birth; however, another assessment is the priority. - C: The nurse should measure maternal vital signs to assess any decline in hemodynamics from the loss of blood; however, another assessment is the priority. - D: The nurse should obtain a biophysical profile because the various tests involved will help determine fetal wellbeing and indicate the need to provide with or prevent preterm delivery; however, another assessment is the priority.
A nurse is providing discharge teaching about circumcision care to the parent of a newborn who has undergone a Gomco clamp procedure. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. I will apply petroleum jelly to my baby's penis for the first few days B. I will use pre-moistened towelettes to clean my baby's penis C. I will remove any yellow crusts when I clean my baby's penis D. I will wrap my baby's penis in dry gauze until it heals
A. I will apply petroleum jelly to my baby's penis for the first few days The client should apply petrolatum to the penis with each diaper change to protect the incision from contact with urine and feces. - B: Towelettes might contain alcohol, which would irritate the skin at the circumcision site. - C: The client should not attempt to remove any yellow exudate or crusting, as they are part of the healing process. Disrupting these findings can cause pain and bleeding. - D: Wrapping the penis should interfere with blood circulation to the healing circumcision site. Additionally, dry gauze could adhere to the incision and cause pain and bleeding when it is removed.
A nurse is obtaining the blood pressure of a client who is pregnant. The client's blood pressure is 142/90 mmHg. Which of the following actions should the nurse take? A. Repeat the measurement immediately using the opposite arm B. Repeat the measurement after allowing the client to sit for 5 to 10 minutes C. Repeat the measurement after repositioning the client so that her feet are off the floor D. Repeat the measurement while ensuring the client's arm is dangling at her side
B. Repeat the measurement after allowing the client to sit for 5 to 10 minutes A blood pressure of 142/90 mmHg. When an elevated reading is obtained, the nurse should allow the client to rest for 5 to 10 minutes before repeating the measurement. - A: Repeating the blood pressure immediately can cause a false reading and should be avoided. - C: To obtain an accurate blood pressure reading, the nurse should instruct the client to have both feet on the floor. - D: To obtain an accurate blood pressure reading, the nurse should have the client's arm supported on a table.
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? A. Has your wife sensed your anger toward her and the baby? B. These feelings are common for expectant fathers in early pregnancy C. I'm sure that accepting this situation is challenging when it's your baby too D. You should speak to a therapist about these feelings
B. These feelings are common for expectant fathers in early pregnancy The father needs reassurance that these feelings are expected. The nurse should reassure him that when the pregnancy becomes obvious, he will feel more involved. This therapeutic response addresses the client's feelings by providing information. - A: This response suggests that the father's anger could be a cause for concern, instead of a common response to early pregnancy. - C: This response appears empathetic, but it suggests that the father has every right to be resentful. This response will probably accelerate negative feelings and is not therapeutic. - D: This response suggests that these feelings need to be studied further. However, they are common for expectant fathers in early pregnancy.
A nurse is teaching a client during the client's first prenatal visit. Which of the following instructions should the nurse include? A. A fetal stethoscope can first detect your baby's heart rate at 22 weeks B. After week 16, we can see if your baby is a boy or a girl C. A Doppler device can detect your baby's heart rate at 12 weeks D. You will first feel the baby move at about 8 weeks
C. A Doppler device can detect your baby's heart rate at 12 weeks The nurse should be able to detect the fetal heartbeat with a Doppler device toward the end of the first trimester, often as early as 10 weeks of gestation. - A: The nurse should be able to hear fetal heart tones with a fetoscope by the end of the 16th week of gestation. - B: Typically, the sex of the fetus is distinguishable on a sonogram by the end of the 12th week. - D: Quickening (feeling fetal movement) is typically possible at 14 to 16 weeks in multiparous clients; however, it is sometimes not possible until week 18 or later in nulliparous clients.
