Maternal Newborn Practice Questions

What is most likely cause for early decelerations in the fetal heart rate (FHR) pattern? a. altered fetal cerebral blood flow b. umbilical cord compression c. uteroplacental insufficiency d. spontaneous rupture of membranes

a. altered fetal cerebral blood flow Early decelerations are the fetus response to fetal head compression these are considered benign and interventions aren't necessary. Variable decelerations are associated with umbilical cord compression. Late decelerations are associated with uteroplacental insufficiency. Spontaneous rupture of membranes has no bearing on the FHR unless the umbilical cord prolapses, which would result in variable or prolonged bradycardia.

A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicate understanding of the teaching? a. "The newborn will have decreased muscle tone." b. "The newborn will have a continuous high pitched cry" c. "The newborn will sleep for 2-3 hrs" d. "The newborn will have mild tremors when disturbed."

b. "The newborn will have a continuous high pitched cry" A continuous high pitched cry is often an indication of CNS disturbances

Which nursing interventions is paramount when providing care to a client with preterm labor who has received terbutaline? a. Assess DTRs b. Assess for dyspnea and crackles c. Assess for bradycardia d. Assess for hypoglycemia

b. Assess for dyspnea and crackles Terbutaline is a beta2-adrenergic agonist that affects the mother's cardiopulmonary and metabolic systems.

A laboring woman is reclining in the supine position. What is the most appropriate action at this time? A. Ask her to turn to one side B. Elevate her feet and legs C. Take her blood pressure D. Determine whether fetal tachycardia is present

A. Ask her to turn to one side The womans supine position may cause the heavy uterus to compress her inferior vena cava, thus reducing blood return to her heart and reducing placental flow. Elevating legs will not relieve this pressure. If the woman continues to stay in supine, fetal tachycardia may occur. The most appropriate action is to prevent that from occurring which is why you would turn her on her side. Take a blood pressure when she is in a safe position but is not until after she has changed positions.

The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response? A. The purpose of the NST is to assess the fetal CNS B. The purpose of the NST helps determine gestational age C. The purpose of the NST is to determine fetal lie D. The purpose of the NST is to determine fetal breathing

A. The purpose of the NST is to assess the fetal CNS This is the primary purpose of a NST. The test monitors the response of the FHR to fetal movement. This allows the nurse to assess the FHR in relationship to the fetal movement.

A nurse is caring for four newborns. Which of the following newborns is at greatest risk for 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 LGA newborns are those whose weight is at or above the 90th percentile. One of the most common etiologies of LGA 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 SGA, premature newborns, and newborns who have perinatal hypoxia.

A nurse is caring for a client who is receiving oxytocin for induction of labor. Which of the following actions should the nurse take? A. perform continuous FHR monitoring B. measure maternal temp every hour C. evaluate maternal contraction pattern every hour D. check bp every 5 min

A. perform continuous FHR monitoring When oxytocin is administered to an antepartum client, the FHR must be used to continuously monitor the FHR and maternal contractions

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? A. respiratory depression B. hypothermia C. hypoglycemia D. jaundice

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

Which client is most likely to experience strong and uncomfortable afterpains? A. A woman who experienced oligohydramnios B. A woman is a gravid 4, para 4-0-0-4 C. A woman who is bottle feeding her infant D. A woman whose infant weighed 5 pounds, 2 ounces

B. A woman is a gravid 4, para 4-0-0-4 Afterpains are most common in women who have had multiple pregnancies, polyhydramnios, breastfeeding, or delivering a large infant.

During an assessment of a patient that is bottle feeding her infant, the nurse notices that both breasts are swollen, warm, and tender on palpation. Which guidance should the nurse provide to the client at this time? A. Run warm water on her breasts during the shower B. Apply ice to the breasts for comfort C. Express small amounts of milk from the breasts to relieve the pressure D. Wearing a loose-fitting bra to prevent nipple irritation

B. Apply ice to the breasts for comfort Applying ice packs and cabbage leaves to the breasts for comfort is an appropriate intervention for treating engorgement in a mother who is bottle feeding. The ice packs should be applied for 15 min and off for 45 min to avoid rebound engorgement. A bottle feeding mother should avoid any stimulation to the breasts like pumping or expressing milk. A bottle feeding mom should continuously wear a well-fitted support bra or breast binder for at least the 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression.

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

B. contractions that last for 60 seconds each with a 3-min rest between contractions

HELLP syndrome stands for: A. Hypertension, edema, languor, and low potassium B. Hemolysis, elevated liver enzymes, and low platelets C. Hemolysis, edema, languor, and low potassium D. Hypertension, epigastric pain, and low platelets

B. hemolysis, elevated liver enzymes, low platelets

A nurse is assessing a newborn who is 12 hr old and noes mild jaundice of the face and trunk. Which of the following actions should the nurse take? A. administer phytonadione IM B. obtain a stat prescription for a bilirubin level C. obtain a bagged urine specimen D. perform a gestational age assessment

B. 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 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? A. atelectasis B. retinopathy C. interstitial emphysema D. necrotizing enterocolitis

B. retinopathy o2 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 speaking with an expectant father who says that he feel resentful of the added attention others are giving to his wife since the pregnancy was announced several weeks ago. Whihc 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 to expectant fathers in early pregnancy C. i'm sure that it's really hard to accept this when it's your baby, too D. it would be wise for you to peak to a therapist about these feelings

B. these feelings are common to expectant fathers early in pregnancy

Which clinical finding or intervention might be considered the rationale for fetal tachycardia? A. Magnesium sulfate administration B. Umbilical cord prolapse C. Maternal fever D. Regional anesthesia

C. Maternal fever Fetal tachycardia can be considered an early sign of fetal hypoxemia and may also result from maternal or fetal infection. The other options are wrong because they would more likely result in fetal bradycardia instead.

A nurse is caring for a client who is in labor. A vaginal examination reveals the following info: 2 cm, 50%, +1 right occiput anterior. Based on this info, 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 in the client's right side. Based on the presentation of the fetus, the position is vertex

Which statement regarding monitoring techniques is the most monitoring techniques is the most accurate? A. CVS is becoming more popular because it provides early diagnosis B. MSAFP screening is recommended only for women at risk for for NTDs C. PUBS is one of the triple marker tests for Down Syndrome D. MSAFP is a screening tool only; it identifies candidates for more definitive diagnostic procedures

MSAFP is a screening tool only, not a diagnostic tool. CVS provides a rapid result, but it is declining in popularity because of advances in noninvasive screening techniques. An MSFAP screening is recommended for ALL women. MSAFP screening, not PUBS, is part of the triple marker test for Down syndrome.

Rh immune globulin (RhoGAM) will be ordered postpartum if which situation occurs? a. Mother Rh, baby Rh+ b. Mother Rh, baby Rh c. Mother Rh+, baby Rh+ d. Mother Rh+, baby Rh

a. Mother Rh, baby Rh+ A Rh mother delivering an Rh+ baby may develop antibodies to fetal cells that enter her bloodstream when the placenta separated. RhoGAM works to destroy the fetal cells in the maternal circulation before sensitization occurs. If mother and baby are both Rh+ or Rh (alike blood types)- not antibody formation would be anticipated. If the Rh+ blood of the mother comes in contact with the Rh blood of the infant, no antibodies would develop because the antigens are in the mother's blood not the infants.

An infant was born 2 hours ago at 37 weeks of gestation and weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: a. Birth injury. b. Hypocalcemia. c. Hypoglycemia d. Seizures.

c. Hypoglycemia Hypoglycemia is common in the macrosomic infant. S/s of hypoglycemia include jitteriness, apnea, tachycardia, cyanosis

A nurse is assessing a client who is receiving magnesium sulfate as treatment for pre-eclampsia. Which of the following clinical findings is the nurse's priority? A. resp. 16/min B. urinary output 40 mL in 2 hr C. reflexes +2 D. fetal heart rate 158/min

urinary output 40 ml in 2 hr 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 reviewing discharge teaching with a client who has premature rupture of membranes (PROM) at 26 weeks of gestation. Which of the following instructions should the nurse include in the teaching? a. Use a condom with sexual intercourse b. Avoid bubble bath solution when taking a bath c. Wipe from back to front d. Keep a daily record of fetal kick counts

d. Keep a daily record of fetal kick counts Client should perform daily kick counts and report contractions to nurse. Nothing should be inserted in the vagina, baths should be avoided (showers instead), and you wipe front to back.

Transvaginal ultrasounds are performed during the first trimester. While preparing a 6 week gestational client for this procedure, she asks why this test is necessary. The nurse should explain that this diagnostic test may indicated for which situations? Select all that apply A. Obesity B. Multifetal gestations C. Fetal abnormalities D. Amniotic fluid volume E. Ectopic Pregnancy

A. Obesity B. Multifetal gestations C. Fetal abnormalities E. Ectopic Pregnancy Transvaginal ultrasounds are useful in women who are obese whose thick abdominal layers cannot be penetrated with traditional abdominal ultrasound. This procedure is also used to identify multifetal gestation, ectopic pregnancy, estimating gestational age, confirming fetal viability, and identifying fetal abnormalities.

The nurse suspects that a client has early signs of an ectopic pregnancy. The nurse should be observing the client for which signs and symptoms? Select all that apply A. Pelvic pain B. Abdominal pain C. Unanticipated heavy bleeding D. Vaginal spotting and light bleeding E. Missed period

A. Pelvic pain B. Abdominal pain D. Vaginal spotting and light bleeding E. Missed period A missed period or spotting can be easily mistaken as an early sign of pregnancy. More subtle signs depend on where implantation occurs. The nurse must be thorough in her assessment because pain is not normal symptom of early pregnancy. As the fallopian tube tears open and the embryo is expelled, the client often exhibits severe pain accompanied by intrabdominal

A woman in preterm labor at 30 weeks of gestation receives two 12 mg intramuscular (IM) does of betamethasone. What is the purpose of this pharmacological intervention? A. To stimulate fetal surfactant production B. To reduce maternal and fetal tachycardia C. To suppress uterine contractions D. To maintain adequate maternal respiratory effort and ventilation during mag sulfate therapy

A. To stimulate fetal surfactant production Antenatal glucocorticoids administered as IM injections to the mother accelerates fetal maturity.

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? A. have you told your husband about these feeligns B. these feelings are quite normal at the beginning of pregnancy C. perhaps you should see a counselor to discuss these feelings D. i am quite concerned about these feelings. could you explain more?

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

Client is at 38 weeks of gestation and reports no fetal movement for 24 hours. What priority action should the nurse take? A. Auscultate for fetal heart rate B. Have client drink orange juice C. Palpate for fetal movement D. Continue to monitor

A. Auscultate for fetal heart rate presence of FHR is a reassuring manifestation of fetal well being. Nurse should auscultate for fetal heart rate using Doppler device or an external fetal monitor. This is the priority action; Orange juice is an appropriate action to stimulate a sleeping fetus but not the priority. Palpating the fetal movements is not a reliable method to ensure fetal well being.

Which newborn reflex is elicited by stroking the lateral sole of the infant's foot from the heel to the ball of the foot? a. Babinski b. Tonic neck c. Stepping d. Plantar grasp

A. Babinski The babinski reflex causes the toes to flare outward and the big toe to dorsiflex. The tonic neck reflex (fencing reflex) refers to the posture assumed by newborns when in a supine position. The stepping reflex occurs when infants are held upright with their heel touching a solid surface when the area below the toes is touched, the infants toes curl over the nurses fingers.

A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. Which findings should be included in the discussion? Select all that apply A. Breast tenderness B. Warmth in the breast C. Area of redness on the breast resembling shape of a pie wedge D. Small white blister on nipple E. Fever and flu-like symptoms

A. Breast tenderness B. Warmth in the breast C. Area of redness on the breast resembling shape of a pie wedge E. Fever and flu-like symptoms Breast tenderness, warmth in the breast, redness on the breast, and fever and flu-like symptoms are commonly associated with mastitis and should be included in discussion. A small white blister on the tip of nipple generally is not associated with mastitis but is commonly seen in women with a plugged milk duct.

Which intervention can nurse use to prevent evaporative heat loss in the newborn? A. Drying the baby after birth, and wrapping the baby in a dry blanket B. Keeping the baby out of drafts and away from air conditioners C. Placing the baby away from the outside walls and windows D. Warming the stethoscope and the nurses hands before touching the baby

A. Drying the baby after birth, and wrapping the baby in a dry blanket The infant is wet with amitotic fluid and blood, heat loss by evaporation by evaporation quickly occurs. if the heat loss is caused by placing the baby near cold surfaces or equipment, it is referred to as a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold surfaces.

Which component of the physical examination are Leopolds maneuvers unable to determine? A. Gender of the fetus B. Number of fetuses C. Fetal lie and attitude D. Degree of the presenting parts descent into the pelvis

A. Gender of the fetus Leopold maneuvers help identify the number of fetuses, the fetal lie and attitude, and the degree of descent of the presenting part into the pelvis. The gender of the fetus cannot be determined performing leopold maneuvers.

A nurse is preparing to administer naloxone to a newborn. which of the following conditions can require administration of this medication? A. IV narcotics administered to the mother during labor B. maternal drug use C. hyaline membrane disease D. meconium aspiration

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

What is the most critical nursing action in caring for the newborn immediately after the birth? A. Keeping the airway clear B. Fostering parent-newborn attachment C. Drying the newborn and wrapping the infant in a blanket D. Administer eye drops and vitamin K

A. Keeping the airway clear The care given immediately after the birth focuses on assessing and stabilizing the newborn. Although fostering parent-newborn attachment is an important task for the nurse, it is not the most critical nursing action in caring for the newborn immediately after birth. The nursing activities in order of importance to maintain a patent airway, to support respiratory effort, and to prevent cold stress by drying the newborn and covering them up with a warmed blanket or placing under radiant warmer. After the newborn is stabilized, the nurse assesses the newborns physical condition, weighs and measures the newborn, administers eye ointment and vitamin k injection, affixes an identification bracelet, wraps the newborn in warm blankets and then gives the newborn to the partner or to the mother of the infant.

A woman has come to the clinic for preconception counseling because she wants to start trying to get pregnant. Which guidance should she expect to receive? A. Make sure you include adequate folic acid in your diet B. Discontinue all contraception now C. You may take any medications you've been regularly taking D. Lose weight so that you can gain more during pregnancy

A. Make sure you include adequate folic acid in your diet A healthy diet before conception is the best way to ensure adequate nutrients are available for the developing fetus. A womans folate or folic acid intake is of particular concern in the preconception period. Neural tube defects are more common in infants of women with poor folic acid intake. Depending on the type of contraception that she is using, discontinuing all contraception at this time may not be appropriate.

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? A. do not become pregnant for at least 1 year B. seek genetic counseling for yourself and your partner prior to getting pregnant again C. you should have an hCG level drawn in 6 weeks D. have your blood pressure checked weekly for the next month

A. 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 increased incidence of choriocarcionma associated with molar pregnancies. Pregnancy must be avoided for 1 year so the client can be closely monitored for manifestations of the condition. A baseline hCG level should be obtained following evacuation of the mole and then weekly until levels are normal for 3 consecutive weeks. Additional hCG levels should be obtained every 4 weeks for the next 6-12 months

A nurse in an antepartum clinic answers a phone call from a client who is at 37 weeks of gestation and reports, "I became 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? A. instruct the client about vena cava syndrome and measures to prevent it B. arrange for the client to come to the clinic for assessment C. check the client's chart for gestational diabetes mellitus D. schedule a NST

A. instruct the client about vena cava syndrome and measures to prevent it

The nurse is preparing to administer a hepatitis B (HBV) vaccine to a newborn. Which intervention by the nurse is correct? A. obtaining a syringe with 25 gauge, 5/8 inch needle for medication administration B. Confirming that the newborns mother has been infected with the HBV C. Assessing the dorsogluteal muscle as the preferred site for injection D. Confirming that the newborn is at least 24 hours old

A. obtaining a syringe with 25 gauge, 5/8 inch needle for medication administration The HBV vaccine should be administered in the vastus lateralis muscle at childbirth with a 25 gauge, 5/8 inch needle and is recommended for all infants. If the infant is born to an infected mother who is a chronic HBV carrier, then the hepatitis vaccine and HBV immunoglobulin should be administered within 12 hours of childbirth.

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? A. turn the client on her left side B. palpate the client's uterus C. administer o2 to the client D. increase the client's IV fluids

A. 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 teh o2 to the placenta and thus the fetus. Turning the client on her left side will relieve the pressure and facilitate better flood flow to the placenta, therby increasing the fetal o2 supply

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? A. 20-gauge needle, administer using z-track method B. 22-gauge needle, administer deep into the thigh C. use a 25-gauge needle, administer into deltoid muscle D. 18-gauge needle, administer into rectus femoris muscle

A. use a 20-gauge needle, and administer the med using z-track method The nurse should administer iron using the z-track method to prevent staining of the tissue. 20-gauge needle is the correct size. Use ventrogluteal muscleA 22-gauge needle is too small for iron injections. The nurse should administer the iron into the ventrogluteal muscle, not the thigh.A 25-gauge needle is very small and is not suitable for iron because iron is thicker than this gauge allows. This needle is short and typically only used for subcutaneous injections. The nurse should administer iron deep into the muscle. In addition, iron is never given in the deltoid, only the ventrogluteal muscle, as this is a larger muscle mass.An 18-gauge needle is too large. The nurse should administer the iron using the Z-track method into the ventrogluteal muscle.

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? A. you should eat some crackers before rising from bed in the morning B. you should eat foods served at warm temperature C. you should sip whole milk withe breakfast D. you should brush your teeth immediately after meals

A. you should eat some crackers before rising from bed in the morning morning sickness is caused by the buildup of 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.

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 c-section 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 of gestation D. you should schedule a c-section after your water breaks

A. you will have a c-section birth prior to the onset of labor Whenever possible, the c-section birth should be scheduled prior to the onset of labor or rupture of membranes to reduce the risk of neonatal transmission of herpes

A womans obstetric history indicates that she is pregnant for the fourth time, and all of her children from previous pregnancies are living. One was born at 39 weeks of gestation; twins were born at 24 weeks of gestation; and another child born at 35 weeks of gestation. What is her gravidity and parity using the GTPAL system? A. 3-1-1-1-3 B. 4-1-2-0-4 C. 3-0-3-0-3 D. 4-2-1-0-3

B. 4-1-2-0-4 G is # of times pregnant=4 T=full term pregnancies=1 P=preterm pregnancies=2 A=lost pregnancies=0 L=living children= 4 Twins are only one pregnancy**

A nurse is caring for a client who is in the transition phase of labor and reports that they need to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make? A. Assist client to bathroom B. Prepare for impending delivery C. Prepare for fecal impaction D. Encourage client to take deep, cleansing breaths

B. Prepare for impending delivery The urge to have a bowel movement indicates fetal descent and complete dilation. Therefore B is the best answer. Deep cleansing breaths are encouraged between contractions but the client would also be encouraged to due to the sensation of a bowel movement indicating complete dilation and fetal descent.

A 26 yr old pregnant woman, gravida 2, para 1-0-0-1, is 28 weeks pregnant when she experiences bright, red painless vaginal bleeding. On her arrival at the hospital, which diagnostic procedure will the client most likely have performed? A. Amniocentesis for fetal lung maturity B. Transvaginal ultrasound for placental location C. Contraction stress test (CST) D. Internal fetal monitoring

B. Transvaginal ultrasound for placental location The presence of painless bleeding should always alert the health care team to the possibility of placenta previa., which can be confirmed through ultrasonography. Amniocentesis is not performed on a woman who is experiencing bleeding. In the event of an imminent delivery, the fetus is presumed to have immature lungs at this gestational age, and the mother is given corticosteroids to aid in fetal lung maturity. A CST is not performed a preterm gestational age. Furthermore, bleeding is a contraindication to a CST. Internal fetal monitoring also is contraindicated while bleeding.

What are the various modes of heat loss in the newborn? Select all that apply A. perspiration B. convection C. radiation D. conduction E. urination

B. convection C. radiation D. conduction Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn.

A nurse administers betamethasone to a client who is at 33 weeks of gestation to stimulate fetal lung maturity. When planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? A. hyperthermia B. decreased blood glucose C. rapid pulse rate D. irritability

B. decreased blood glucose Betametasone causes hyperglycemia, 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. Does not have an affect on the newborn's vital signs

A nurse is caring for a client who is 2 hr 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? A. check for a full bladder B. massage the fundus C. measure vital signs D. administer carboprost IM

B. massage the fundus The primary cause of early postpartum bleeding is uterine atony manifested by a relaxed, boggy uterus. 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 has trichomoniasis and a prescription for metronidazole. Which of the following should the nurse provide to the cilent 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 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. Easily treated 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.

Nurses who provide care to victims of IPV should be keenly aware of what? A) Relationship violence usually consists of a single episode that the couple can put behind them. B) Violence often declines or ends with pregnancy. C) Financial coercion is considered part of IPV. D) Battered women are generally poorly educated and come from a deprived social background.

C) Financial coercion is considered part of IPV. Economic coercion may accompany physical assault and psychologic attacks. IPV almost always follows an escalating pattern, rarely ends with a single episode. IPV often begins with and escalates during pregnancy. It can include both psychologic attacks and economic coercion. Race, religion, social background, age, and education level are not significant factors in differentiating woman at risk.

While working with the pregnant client in her first trimester, what information does the nurse provide regarding when CVS can be performed (in weeks of gestation)? A. 4 B. 8 C. 10 D. 14

C. 10 CVS can be performed in the first or second trimester, ideally between 10-13 weeks of gestation. During this procedure, a small piece of tissue is removed from the fetal portion of the placenta. If performed after 9 completed weeks of gestation, then the risk of limb reduction is no greater than in the general population.

At 35 weeks of pregnancy, a woman experiences preterm labor. Although tocolytic medications are administered and she is placed on bed rest, she continues to experience regular uterine contractions and her cervix is beginning to dilate and efface. What is an important test for fetal well being at this time? A. PUBS B. Ultrasound for fetal size C. Amniocentesis for fetal lung maturity D. NST

C. Amniocentesis for fetal lung maturity Amniocentesis is performed to assess fetal lung maturity in the event of preterm birth. NST measures the fetal response to fetal movement in a noncontracting mother. Ultrasound is not indicated in this scenario and fetal size by ultrasound is performed in 2nd trimester. Indications for PUBS include prenatal diagnosis or inherited blood disorders, karyotyping of malformed fetuses, detection of fetal infection, determination of acid-base status of the fetus with IUGR and assessment and treatment of isoimmunization and thrombocytopenia of the fetus.

A primigravida is being monitored at the prenatal clinic for preeclampsia. Which finding is of greatest concern to the nurse? A. Blood pressure increase to 138/86 B. Weight gain of 0.5 kg during the past 2 wks C. Dipstick value of 3+ protein in her urine D. Pitting pedal edema at the end of the day

C. Dipstick value of 3+ protein in her urine Proteinuria = 1+ or greater on dipstick. 3+ alerts the nurse that additional assessments are needed as it can indicate preeclampsia. A 24 hr urine collection is preferred over dipstick, it's more accurate. Hypertension is typically define as 140/90 or an increase of systolic pressure of 30 or more or diastolic 15 or more. Preeclampsia weight gain is often rapid and more than 2kg a week. Edema occurs in many normal pregnancies, as well as women with preeclampsia.

A first time mom is concerned that her 3 day old daughter's skin looks yellow. In the nurses explanation of physiologic jaundice, what fact should be included? A. Physiologic jaundice is also known as breast milk jaundice B. Physiologic jaundice occurs during the first 24 hours of life C. Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life D. Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types

C. Physiologic jaundice becomes visible when serum bilirubin levels peak between the second and fourth days of life Physiologic jaundice becomes visible when the serum bilirubin reaches a level of 5 mg/dl or higher when the baby is approximately 3 days old. This finding is within normal limits for a newborn. Pathological jaundice, NOT physiological jaundice, occurs within the first 24 hours of life and is caused by blood incompatibles that result in excessive destruction of erythrocytes; this condition must be monitored. Breast milk jaundice occurs in one third of breastfed infants at 2 weeks and is caused by an insufficient intake of fluids. Lowdermilk 12th pg 469-470

What is the primary purpose for magnesium sulfate administration for clients with preeclampsia and eclampsia? A. To improve patellar reflexes and increase respiratory efficiency B. To shorten duration of labor C. To prevent convulsions D. To prevent a boggy uterus and lessen lochial flow

C. To prevent convulsions Magnesium sulfate is the drug of choice used to prevent convulsions, although it can generate other problems. Loss of patellar reflexes and respiratory depression are signs of magnesium toxicity. Magnesium sulfate can also increase the duration of labor. Women are at risk for a boggy uterus and heavy lochial flow as a results.

What information should the understand fully regarding rubell and Rh status? A. Rh immunoglobulin is safely administered intravenously because it cannot harm the infant B. Breastfeeding mothers cannot be vaccinated with the MMR vaccine due to it being a live virus C. Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for at least a month D. Rh immunoglobulin boosts the immune system and thereby enhances the effectiveness of vaccinations

C. Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for at least a month Women should understand that they should practice contraception for at least 1 month (28 days) being vaccinated for rubella. It is not communicable in breast milk and breastfeeding mothers can be vaccinated. It is administered IM and suppresses the immune system and therefore might thwart the rubella vaccination.

A nurse is assessing a client on the first postpartum day. Findings include fundus firm and one fingerbreadth above to the the right of umbilicus, moderate lochia rubra with small clots, temp 37.3 (99.2 F), pulse 52/min. Which of the following actions should the nurse take? A. report vital signs to the provider B. massage the fundus C. ask client when she last voided D. administer oxytocin agent

C. ask the client when she last voided Fundus is easily displaced when the bladder is full. Should be found firm at midline.

A nurse is caring for a client who has prescription for naloxone. Which of the following is the intended action of the medication in relation to the CNS? A. accentuate effects of narcotics on the CNS B. depress activity of the CNS C. block effects of narcotics on the CNS D. stimulate activity of the CNS

C. 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 caring for a newborn who has irregular respirations of 52/min with several periods of apea lasting approximately 5 seconds. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? A. administer oxygen B. place the newborn in an isolette C. continue to routinely monitor the newborn D. assess the newborn's blood glucose

C. continue to routinely monitor the newborn This newborn is exhibiting a normal resp. rate and rhythm. No additional measures are needed at this time.

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? A. swaddle the newborn in a receiving blanket during the treatment B. maintain NPO status until the newborn's bilirubin is within the expected reference range C. ensure the newborn's eyes are closed before applying the eye shield D. apply lotion to the newborn's skin twice per day

C. ensure the newborn's 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 planning care for a client who is at 35 weeks of gestation. Which of the following laboratory tests should the nurse obtain? A. rubella titer B. blood type C. group B strep B-hemolytic D. 1-hour glucose tolerance test

C. group B streptococcus B-hemolytic Should obtain a vaginal/anal GBS culture at 35-37 weeks of gestation to screen for infection. prophylactic antibiotics should be given during labor to the client who is positive for GBS. Rubella titer at first prenatal visit Blood type and Rh factor at first prenatal visit to determine if Rhogam is given at 28 weeks 1 hr GTT at 24-28 weeks to screen for gestational diabetes

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? A. n/v B. tachycardia C. hypotension D. respiratory depression

C. 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? A. i know not to eat anything after midnight B. i will have medication given to me to cause contractions C. i should press the button on the handheld marker when my baby moves D. i will stimulate my breast to cause contractions

C. 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 movementThe client does not need medication to induce contractions. Oxytocin is used to induce contractions for an oxytocin challenge test.

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

C. i should replace my diaphragm every 2 years The diaphragm is a flexible rubber cup that is filled spermicide and is inserted over the cervix prior to intercourse. The diaphragm is a prescribed device fitted by the provider and should be replaced every 2 years. Should remain in place 6 hrs after intercourse should be cleaned with mild soap and water and dried gently. Contraceptive jelly should be applied prior to placing the device into the vagina

A nurse is caring for a client who desires an IUD for contraception. Which of the following findings is a contraindication for the use of this device? A. htn B. menorrhagia C. history of multiple gestations D. history of thromboembolic disease

C. menorrhagia contraindication for women who have menorrhagia, severe dysmenorrhea, history of ectopic pregnancy

A nurse is caring for a client who is at 36 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse identify as the priority? A. 1+ proteinuria B. blood pressure 140/98 mm Hg C. nonreactive nonstress test D. fundal height 33 cm

C. nonreactive nonstress test A nonstress test measures FHR accelerations with normal movement. A fetal accelration is a positive sign present when the FHR increases 15/min and lasts 15 seconds. In a nonreactive nonstress test, there are no accelerations. Absence of FHR accelerations suggests that the fetus might be going into distress.

Pelvic floor exercises, also known as Kegel exercises, will help to strengthen the perineal muscles and encourage healing after childbirth. The nurse requests the client to repeat back instructions for this exercise. Which response by the client indicates successful learning? A) "I contract my thighs, buttocks, and abdomen." B) "I perform 10 of these exercises every day." C) "I stand while practicing this new exercise routine." D) "I pretend that I am trying to stop the flow of urine in midstream."

D) "I pretend that I am trying to stop the flow of urine in midstream."

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. What is the nurses highest priority in this situation? A. prepare the woman for imminent birth B. Notify the woman's provider C. Document the characteristics of the fluid D. Assess the fetal heart rate (FHR) and pattern

D. Assess the fetal heart rate (FHR) and pattern The umbilical cord may prolapse when the membranes rupture. The FHR and pattern should be closely monitored for several minutes immediately after the ROM to ascertain fetal well-being, and the findings should be documented. ROM may increase the intensity and frequency of the uterine contractions, but it does not indicate that birth is imminent. The nurse may notify the provider after ROM occurs and the fetal well being and response to ROM have been assessed. The nurse priority is to assess the fetal well being. The nurse should document the characteristics of the amniotic fluid, but the initial response is to assess fetal well being and the response to ROM.

A client is concerned that her breasts are engorged and uncomfortable. What is the nurses explanation for this physiological change? A. Overproduction of colostrum B. Accumulation of milk in the lactiferous ducts and glands C. Hyperplasia of mammary tissue D. Congestion of veins and lymphatic vessels

D. Congestion of veins and lymphatic vessels Breast engorgement is caused by the temporary congestion of veins and lymphatic vessels.

A hCG is an important biochemical marker for pregnancy and therefore the basis for many tests. Which statement regarding hCG is true? A. hCG can be detected as early as weeks after conception B. hCG levels gradually and uniformly increase throughout pregnancy C. Significantly lower than normal increases in the levels of hCG may indicate a postdate pregnancy D. Higher than normal levels of hCG may indicate an ectopic pregnancy or Down syndrome

D. Higher than normal levels of hCG may indicate an ectopic pregnancy or Down syndrome Higher hCG levels also could be a sign of a multiple gestation. hCG can detected as early as 7-10 days after conception. The hCG levels fluctuations during pregnancy, peaking, declining, stabilizing, and then increasing again. Abnormally slow increases may indicate impending miscarriage.

The nurse realizes that an FHR that is tachycardic ,bradycardic, has late decelerations or loss of variability is considered nonreassuring and is associated with which condition? A. Hypotension B. Cord compression C. Maternal drug use D. Hypoxemia

D. Hypoxemia Nonreassuring FHR patterns are associated with fetal hypoxemia. Fetal bradycardia may be associated with maternal hypotension. Variable FHR decelerations are associated with cord compression. Maternal drug use is associated with fetal tachycardia.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. What is the nurse highest priority at this time? A. Beginning an IV infusions of ringer's lactate solution B. Assessing the woman's vital signs C. Calling the woman's primary health care provider D. Massaging the woman's fundus

D. Massaging the woman's fundus The nurse should first assess the uterus for atony by massaging the woman's fundus. Uterine tone must must be established to prevent excessive blood loss. The nurse may begin an IV infusion restore circulatory volume, but this would not be the first action. Blood pressure is not reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurses first action. The physician would be notified after the nurse completes the assessment.

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? A. anemia B. frequent urinary tract infections C. previous c-section D. pelvic inflammatory disease (PID)

D. PID The most common site in ectopic pregnancies is within a fallopian tube, but can also occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery.

In which clinical situation would the nurse most likely anticipate a fetal bradycardia? A. Tocolytic treatment using terbutaline B. Fetal anemia C. Intraamniotic infection D. Prolonged umbilical cord compression

D. Prolonged umbilical cord compression Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, prolonged compression of the umbilical cord, maternal hypothermia, and maternal hypotension. Intraamniotic infection, fetal anemia, and tocolytic treatment using terbutaline would most likely result in fetal tachycardia.

A nurse in a prenatal clinic is caring for a client who is within the recommended guideline 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? A. your provider can discuss an appropriate amount of weight gain with you B. a weight gain of about 14 pounds each trimester is suggested C. if you eat nutritious food when you feel hungry, the amount of weight gain is insignificant D. a weight gain of about 25-35 pounds is good

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

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? A. prolonged rupture of membranes at 38 weeks of gestation B. intrauterine growth restriction C. postterm pregnancy D. active genital herpes

D. active genital herpes The newborn can acquire genital herpes as they pass through the birth canal, so oxytocin is contraindicated. A c-section is recommended if genital herpes is active

A nurse is discussing anesthesia with a client who is receiving oxytocin for induction of labor. Which of the following statements should the nurse make? A. an epidural given too early in 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 to be slow. The medication depresses the CNS, so it takes longer for the cervix to dilate and efface

A nurse is planning care for a client who is pregnant and is Rh-. In which of the following situations should the nurse administer Rhogam? A. while the client is in labor B. following an episode of influenza during pregnancy C. prior to a blood transfusion D. at 28 weeks of gestation

D. at 28 weeks of gestation Rhogam 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 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? A. keep four side rails up while the client is in bed B. monitor FHR every hour C. insert indwelling urinary catheter D. check the cervix prior to analgesic administration

D. check the cervix prior to analgesic administration The nurse must know how many cm the cervix is dilated prior to analgesic administration during active labor. If administred too close to the time of delivery, the analgesic could cause resp. depression in the newborn

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? A. extended periods of sleep B. poor muscle tone C. respiratory rate 50/min D. exaggerated reflexes

D. exaggerated reflexes A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the CNS. Exaggerated reflexes are indicative of CNS irritability. Newborn would also have increased muscle tone, respiratory distress with rate greater than 60/min,

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? A. promoting maternal-newborn bonding B. tight swaddling of the newborn C. small frequent feedings D. frequent stimulation

D. 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 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? A. my ankles are swollen at the end of the day B. i can feel the baby kicking my ribs, and it is very uncomfortable C. i'm growing more and more worried every day D. my heart feels as if it is racing

D. my heart feels as if it is racing The primary action of terbutaline is to cause bronchodilation and relax smooth muscle. 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.

A nurse is caring for a client who is in labor. The client questions the application of an internal fetal scalp electrode. Which of the following responses should the nurse make? A. don't worry, your baby is fine B. you will need to ask your provider C. your provider feels it would be best D. we need to observe your baby more closely

D. we need to observe your baby more closely The client has asked an information-seeking question. This therapeutic response provides info to the client in an honest, nonthreatening manner.

A nurse is caring for newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following administration of synthetic surfactant? a. Oxygen saturation b. Body temperature c. Serum bilirubin d. Heart rate

a. Oxygen saturation Surfactant stabilizes the alveoli and helps increase oxygen saturation. It has no direct effect on body temperature, serum bilirubin and heart rate. ATI CH 27

Which medications are used to manage Postpartum hemorrhage(PPH)? Select all that apply a. Oxytocin (Pitocin) b. Methergine c. Terbutaline d. Hemabate e. Magnesium sulfate

a. Oxytocin b. Methergine d. Hemabate Oxytocin, Methergine (methylergonovine), Misoprostol (Cytotec), Hemabate (15-Methylprostaglandin F/prostin, 15 m carboprost), Dinoprostone (Prostin E2) are all used to mange PPH. Terbutaline and magnesium sulfate are tocolytic meds used to relax the uterus will which make PPH worse. Chart on Lowdermilk pg 725

A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The purpose of this pharmacologic treatment is to: a. Stimulate fetal surfactant production. b. Reduce maternal and fetal tachycardia associated with ritodrine administration. c. Suppress uterine contractions. d. Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.

a. Stimulate fetal surfactant production Antenatal glucocorticoids administered as IM injections to the mother accelerate fetal lung maturity. Propranolol is given to reduce effects of ritodrine administration. Betamethasone has no effect on uterine contractions. Calcium gluconate is given to reverse the respiratory depressive effects of magnesium sulfate therapy.

Preconception counseling is critical to the outcome of diabetic pregnancies because poor glycemic control before and during early pregnancy is associated with: a. Frequent episodes of maternal hypoglycemia. b. Congenital anomalies in the fetus. c. Polyhydramnios. d. Hyperemesis gravidarum.

b. Congenital anomalies in the fetus. Preconception counseling is particularly important since strict metabolic control before conception and in the early weeks of gestation is instrumental in decreasing the risk of congenital anomalies. Frequent episodes of maternal hypoglycemia may occur during the first trimester (not before conception) as a result of hormonal changes and effects on insulin production and use. Hydramnios occurs approximately 10 times more often in diabetic pregnancies than nondiabetic pregnancies. Typically, it is observed in the 3rd trimester. Hyperemesis gravidarum may exacerbate hypoglycemic events because the decreased food intake by mother and glucose transfer to the fetus contribute to hypoglycemia.

A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the Ilotycin ophthalmic ointment is to: a. Destroy an infectious exudate caused by Staphylococcus that could make the infant blind. b. Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal. c. Prevent potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes. d. Prevent the infant's eyelids from sticking together and help the infant see.

b. Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal.

What is the rationale for the administration of an oxytocic (e.g. Pitocin, Methergine) after expulsion of the placenta? a. To relieve pain b. To stimulate uterine contraction c. To prevent infection d. To facilitate rest and relaxation

b. To stimulate uterine contraction Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor. Oxytocics are not used to treat pain, do not prevent infection and do not facilitate rest and relaxation.

A nurse is caring for a client who is preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung maturity? a. Alpha-fetoprotein (AFP) b. Lecithin/sphingomyelin (L/S) ratio c. Kleihauer-Betke test d. Indirect Coombs' test

b.Lecithin/sphingomyelin (L/S) ratio L/s ratio test is done as part of amniocentesis for fetal lung maturity. AFP is also test done during amniocentesis but its to look at neural tubal defects or chromosome disorders.

Which options for saying goodbye would the nurse want to discuss with a woman who is diagnosed with having a stillborn girl? a. The nurse shouldn't discuss any options at this time; there is plenty of time after the baby is born. b. "Would you like a picture taken of your baby after birth?" c. "When your baby is born, would you like to see and hold her?" d. "What funeral home do you want notified after the baby is born?"

c. "When your baby is born, would you like to see and hold her?" Mothers and fathers may find it helpful to see their infant after delivery. The parent's wishes should be respected. Interventions and support from the nursing and medical staff after a prenatal loss are extremely important in the healing of the parents. The initial intervention should be directly related to the parents wishes concerning seeing or holding their dead infant. Although the info about funeral home notification may be relevant , its not appropriate neither is the burial arrangements.

The nurse is teaching a client with preterm premature rupture of membranes (PPROM) regarding self care activities. Which activities should the nurse include in her teaching? a. Report a temp higher than 40c b. Tampons are safe to use to absorb the leaking amniotic fluid c. Do not engage in sexual activity d. Taking frequent tub baths is safe

c. Do not engage in sexual activity Sexual activity should be avoided because it may induce preterm labor. A temperature higher than 38 C should be reported.

When a woman is diagnosed with postpartum depression (PPD) with psychotic features, one of the main concerns is that she may: a. Have outbursts of anger. b. Neglect her hygiene. c. Harm her infant. d. Lose interest in her husband.

c. Harm her infant. Thoughts of harm to herself or to the infant are among the most serious symptoms of PPD and require immediate assessment and intervention. Although outbursts of anger and neglecting personal hygiene are symptoms associated with PPD, the major concern remains the potential of harm to herself or her infant. Although this client is likely to lose interest in her spouse, it is not the nurse's primary concern

The nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. This intervention: a. Is adopted from classical British nursing traditions. b. Helps infants with motor and central nervous system impairment. c. Helps infants to interact directly with their parents and enhances their temperature regulation. d. Gets infants ready for breastfeeding.

c. Helps infants to interact directly with their parents and enhances their temperature regulation. Kangaroo care is skin to skin holding in which the infant, dressed only in a diaper, is placed directly on the parents bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits.

A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to: a. Apply an oil-based lotion to the newborn's skin to prevent dying and cracking. b. Limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea. c. Place eye shields over the newborn's closed eyes. d. Change the newborn's position every 4 hours.

c. Place eye shields over the newborn's closed eyes. The infants eyes must be protected by an opaque mask to prevent overexposure to the light. Eye shields should completely cover the eyes but no occlude the nares. Lotions and ointments should NOT be applied to the infant because they absorb heat and can cause burns. The light increase insensible water loss, placing the infant at risk for dehydration/fluid loss. So adequate hydration is important for newborn. The infant should also be turned every 2 hours to expose all body surfaces to light.

A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn? a. Conjunctivitis b. Bronze skin discoloration c. Sunken fontanels d. Maculopapular skin rash

c. Sunken fontanels Using the safety and risk reduction framework, sunken fontanels is the priority finding. Infants receiving phototherapy are at risk for dehydration from loose stools due to increased bilirubin excretion. The rest are important findings but not the priority. ATI CH 27

Which outcome might occur if the interventions for maternal hypotension are inadequate? a. Early FHR decelerations b. Fetal arrhythmias c. Uteroplacental insufficiency d. Spontaneous rupture of membranes

c. Uteroplacental insufficiency Low maternal bp reduces placental blood flow during uterine contractions, resulting in fetal hypoxemia. Maternal hypotension does not result in FHR decelerations nor is it associated with fetal arrhythmias. Spontaneous rupture of membranes is not a result of maternal hypotension.

The nurse is cognizant of which information related to the administration of vitamin K? a. Vitamin K is important in the production of red blood cells. b. Vitamin K is necessary in the production of platelets. c. Vitamin K is not initially synthesized because of a sterile bowel at birth. d. Vitamin K is responsible for the breakdown of bilirubin and the prevention of jaundice.

c. Vitamin K is not initially synthesized because of a sterile bowel at birth. The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food introduced in the bowl. Vitamin K is necessary to activate blood-clotting factors. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other blood clotting factors.

A client is in early labor, and her nurse is discussing the pain relief options she is considering. The client states that she wants an epidural "no matter what!" What is the nurse's best response? a. "I'll make sure you get your epidural." b. "You may only have an epidural if your physician allows it." c. "You may only have an epidural if you are going to deliver vaginally." d. "The type of analgesia or anesthesia used is determined, in part, by the stage of your labor and the method of birth."

d. "The type of analgesia or anesthesia used is determined, in part, by the stage of your labor and the method of birth." To avoid suppressing the progress of labor, pharm measures for pain relief are generally not implemented until labor has advanced to the active phase of the first stage and the cervix is dilated approximately is dilated approximately 4-5 cm (class measurement varies). A plan of care is developed for each woman that addresses her particular clinical and nursing problems. The nurse collaborates with the primary provider and the laboring woman in selecting features of cate relevant to the woman and her family. The decision whether to use an epidural to relieve labor pain is multifactorial. The nurse should not make a blanket statement guaranteeing the client one pharmacologic option over another until a complete history and physical exam has been obtained. A physician's order is required for pharm options for pain management. However expressing this requirement is not is not the nurse's best response. An epidural is an effective pharm pain management for many laboring women. It can also be used for anesthesia control if the woman undergoes an operative delivery.

A 25 yr old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As the nurse prepare her for discharge, she begins to cry. The nurse's next action should be what? a. Assess her for pain b. Point out how lucky she is to have a healthy baby c. Explain that she is experiencing postpartum blues d. Allow her time to express her feelings

d. Allow her time to express her feelings The client needs the opportunity to express feelings first; teaching will occur later.

A nurse is planning care for a newly admitted client who reports, "I am in labor and have been bleeding for 2 weeks." Which of the following should the nurse include in the plan of care? a. Inspect the introitus for prolapsed cord b. Perform a test to identify the ferning pattern c. Monitor station of the presenting part d. Defer vaginal examination

d. Defer vaginal examination Vaginal examinations should not be performed until placenta previa or abruptio placentae has been ruled out as cause of bleeding.