Maternity 5
In evaluating the respiratory effort of a one-hour-old infant using the Silverman-Anderson Index, the nurse determines the infant has synchronized chest and abdominal movement, just visible lower chest retractions, just visible xiphoid retractions, minimal and transient nasal flaring, and an expiratory grunt heard only on auscultation. What Silverman-Anderson score should the nurse assign to this infant? (Enter numeral value only.)
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The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor.· a. Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x 3· b. Ampicillin 1 gram IV push q8h. c. Betamethasone (Celestone) 12 mg deep IM d. Butorphanol (Stadol) 1 mg IV push q2h PRN pain
c. Betamethasone (Celestone) 12 mg deep IM
The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? a. Respiratory rate of 22 breaths/min b. A large amount of lochia rubra c. Blood pressure 149/90 d. Positive Homan's sign
c. Blood pressure 149/90
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness? A. Wear a cotton bra. B. Increase nursing time gradually. C. Correctly place the infant on the breast. D. Manually express a small amount of milk before nursing.
C. Correctly place the infant on the breast.
A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain? A. Gravidity and parity. B. Time and amount of last oral intake. C. Date of last normal menstrual period. D. Frequency and intensity of contractions.
C. Date of last normal menstrual period.
A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement? A. Notify the healthcare provider. B. Move the newborn to an isolation nursery. C. Document the finding in the infant's record. D. Obtain a culture of the vesicles.
C. Document the finding in the infant's record.
The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement? A. Provide phototherapy for 30 minutes q8h. B. Feed the newborn sterile water hourly. C. Encourage the mother to breastfeed frequently. D. Assess the newborn's blood glucose level.
C. Encourage the mother to breastfeed frequently.
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? A. 3+ deep tendon reflexes. B. Periorbital edema. C. Epigastric pain. D. Decreased urine output.
C. Epigastric pain.
The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class? A. Begin as soon as your baby is born to establish a four-hour feeding schedule. B. Resting helps with milk production. Ask that your baby be fed at night in t nursery. C. Feed your baby every 2 to 3 hours or on demand, whichever comes first. D. Do not allow your baby to nurse any longer than the prescribed number of minutes.
C. Feed your baby every 2 to 3 hours or on demand, whichever comes first.
The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? A. Herpes. B. Staphylococcus. C. Gonorrhea. D. Syphilis.
C. Gonorrhea.
The nurse instructs a laboring client to use accelerated- blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? A. Administer oxygen by face mask. B. Notify the healthcare provider of the client's symptoms. C. Have the client breathe into her cupped hands. D. Check the client's blood pressure and fetal heart rate.
C. Have the client breathe into her cupped hands.
The nurse should encourage the laboring client to begin pushing when A. there is only an anterior or posterior lip of cervix left. B. the client describes the need to have a bowel movement. C. the cervix is completely dilated. D. the cervix is completely effaced.
C. the cervix is completely dilated.
A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited? A. Choking, coughing, and cyanosis. B. Projectile vomiting and cyanosis. C. Apneic spells and grunting. D. Scaphoid abdomen and anorexia.
A. Choking, coughing, and cyanosis.
Which nursing intervention is helpful in relieving "afterpains" (postpartum uterine contractions)? A. Using relaxation breathing techniques. B. Using a breast pump. C. Massaging the abdomen. D. Giving oxytocic medications.
A. Using relaxation breathing techniques.
A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 ml D W. How many ml of the solution should the nurse administer?
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A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best? A. A home pregnancy test can be used right after your first missed period. B. These tests are most accurate after you have missed your second period. C. Home pregnancy tests often give false positives and should not be trusted D. The test can provide accurate information when used right after ovulation
A. A home pregnancy test can be used right after your first missed period.
The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.) A. Admission weight of 4 pounds, 15 ounces (2244 grams). B. Head to heel length of 17 inches (42.5 cm). C. Frontal occipital circumference of 12.5 inches (31.25 cm). D. Skin smooth with visible veins and abundant vernix. E. Anterior plantar crease and smooth heel surfaces. F. Full flexion of all extremities in resting supine position.
A. Admission weight of 4 pounds, 15 ounces (2244 grams). B. Head to heel length of 17 inches (42.5 cm). C. Frontal occipital circumference of 12.5 inches (31.25 cm).
A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take? A. Apply cold compresses to both breasts for comfort. B. Instruct the client run warm water on her breasts. C. Wear a loose-fitting bra to prevent nipple irritation. D. Express small amounts of milk to relieve pressure.
A. Apply cold compresses to both breasts for comfort.
A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first? A. Bathe the infant with an antimicrobial soap. B. Measure the head and chest circumference. C. Obtain the infant's footprints. D. Administer vitamin K (AquaMEPHYTON).
A. Bathe the infant with an antimicrobial soap.
The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? A. Between the time the temperature falls and rises. B. Between 36 and 48 hours after the temperature rises. C. When the temperature falls and remains low for 36 hours. D. Within 72 hours before the temperature falls.
A. Between the time the temperature falls and rises.
A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A. Come to the clinic today for an ultrasound. B. Go immediately to the emergency room. C. Lie on your left side for about one hour and see if the bleeding stops. D. Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.
A. Come to the clinic today for an ultrasound.
A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client? A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue. B. We want your baby to be healthy, and this is the only way we can make sure that will happen. C. I know you're upset. Would you like to talk about some things you could d while in bed? D. Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties.
A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? A. Describe diet changes that can improve the management of her diabetes. B. Inform the client that oral hypoglycemic agents are teratogenic during pregnancy. C. Demonstrate self-administration of insulin. D. Evaluate the client's ability to do glucose monitoring.
A. Describe diet changes that can improve the management of her diabetes.
The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? A. Edema, basilar rales, and an irregular pulse. B. Increased urinary output and tachycardia. C. Shortness of breath, bradycardia, and hypertension. D. Regular heart rate and hypertension.
A. Edema, basilar rales, and an irregular pulse.
The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition? A. Gestational diabetes. B. Elevated blood pressure. C. Urinary tract infection. D. Swelling in lower extremities.
A. Gestational diabetes.
The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8- weeks gestation. What type of emotional response should the nurse anticipate? A. Grief related to her perceptions about the loss of this child. B. Relief of ambivalent feelings experienced with this pregnancy. C. Shock because she may not have realized that she was pregnant. D. Guilt because she had not followed her healthcare provider's instructions.
A. Grief related to her perceptions about the loss of this child.
Which action should the nurse implement when preparing to measure the fundal height of a pregnant client? A. Have the client empty her bladder. B. Request the client lie on her left side. C. Perform Leopold's maneuvers first. D. Give the client some cold juice to drink.
A. Have the client empty her bladder.
Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse perform next? A. Initiate positive pressure ventilation. B. Intervene after the one minute Apgar is assessed. C. Initiate CPR on the infant. D. Assess the infant's blood glucose level.
A. Initiate positive pressure ventilation.
When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.) A. Mood swings. B. Panic attacks. C. Tearfulness. D. Decreased need for sleep. E. Disinterest in the infant.
A. Mood swings. C. Tearfulness.
On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) is A. November 22. B. November 8. C. December 22. D. October 22.
A. November 22.
After feeding a newborn, how should the nurse position the infant in the crib? A. On the right side. B. Supine in a slight Trendelenburg. C. Supine with the head elevated. D. Prone with the foot of the crib elevated.
A. On the right side.
A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? A. Patellar reflex 4+. B. Blood pressure 158/80. C. Four-hour urine output 240 ml. D. Respiration 12/minute.
A. Patellar reflex 4+.
A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? A. Raise the foot of the bed. B. Assess for vaginal bleeding. C. Evaluate the fetal heart rate. D. Take the client's blood pressure.
A. Raise the foot of the bed.
The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do? A. Reduce activity level and notify the healthcare provider. B. Go to bed and assume a knee-chest position. C. Massage the uterus and go to the emergency room. D. Do not worry as this is a normal occurrence.
A. Reduce activity level and notify the healthcare provider.
Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? A. The client's readiness to learn. B. The client's educational background. C. The order in which the information is presented. D. The extent to which the pregnancy was planned.
A. The client's readiness to learn.
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as A. a cephalhematoma, caused by forceps trauma and may last up to 8 weekS B. a subarachnoid hematoma, which requires immediate drainage to prevent further complications. C. molding, caused by pressure during labor and will disappear within 2 to 3 days. D. a subdural hematoma which can result in lifelong damage.
A. a cephalhematoma, caused by forceps trauma and may last up to 8 weekS
The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs A. two weeks before menstruation. B. immediately after menstruation. C. immediately before menstruation. D. three weeks before menstruation.
A. two weeks before menstruation.
During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Arrange in order.) A.Reposition the client. B.Call the healthcare provider. C.Increase IV fluid. D.Provide oxygen via face mask.
A.Reposition the client. C.Increase IV fluid. D.Provide oxygen via face mask. B.Call the healthcare provider.
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is started on an IV of ritodrine hydrochloride (Yutopar). What are the highest priority readings that the nurse should monitor frequently during the administration of this drug? A. Maternal blood pressure and respirations. B. Maternal and fetal heart rates. C. Hourly urinary output. D. Deep tendon reflexes.
B. Maternal and fetal heart rates.
A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nägele's rule, what is the estimated date of delivery? A. April 25, 2007. B. May 9, 2007. C. May 29, 2007. D. June 2, 2007.
B. May 9, 2007.
During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have A. lower Apgar scores. B. lower birth weights. C. respiratory distress. D. a higher rate of congenital anomalies.
B. lower birth weights.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take? A. Notify the healthcare provider or anesthesiologist immediately. B. Continue to assess the blood pressure q5 minutes. C. Place the woman in a lateral position. D. Turn off the continuous epidural.
C. Place the woman in a lateral position.
The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching? A. Cuddles the baby close to her. B. Rocks and soothes the infant in her arms. C. Places the infant prone in the bassinet. D. Wraps the baby in a warm blanket after bathing.
C. Places the infant prone in the bassinet.
The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention? A. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part. B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor. C. Urine specimens for glucose and protein must be obtained at certain intervals throughout labor. D. Frequent voiding minimizes the need for catheterization which increases t chance of bladder infection.
B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor.
A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurse's response should be based on what information? A. Males inherit the disorder with a greater frequency than females. B. Each pregnancy carries a 50% chance of inheriting the disorder. C. The disorder occurs in 25% of pregnancies. D. All children will be carriers of the disorder.
B. Each pregnancy carries a 50% chance of inheriting the disorder.
A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse implement? A. Massage the calf and foot. B. Extend the leg and dorsiflex the foot. C. Lower the leg off the side of the bed. D. Elevate the leg above the heart.
B. Extend the leg and dorsiflex the foot.
A client in active labor complains of cramps in her leg. What intervention should the nurse implement? A. Massage the calf and foot. B. Extend the leg and dorsiflex the foot. C. Lower the leg off the side of the bed. D. Elevate the leg above the heart.
B. Extend the leg and dorsiflex the foot.
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? A. She eagerly reaches for the infant, undresses the infant, and examines thE infant completely. B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. C. Her arms and hands receive the infant and she then cuddles the infant to her own body. D. She eagerly reaches for the infant and then holds the infant close to her own body.
B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.
A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin? A. Dehydration. B. Hyperstimulation. C. Galactorrhea. D. Fetal tachycardia.
B. Hyperstimulation.
A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? A. Length of labor and method of delivery. B. Infant's condition at birth and treatment received. C. Feeding method chosen by the parents. D. History of drugs given to the mother during labor.
B. Infant's condition at birth and treatment received.
A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? A. Supplementary iron is more efficiently utilized during pregnancy. B. It is difficult to consume 18 mg of additional iron by diet alone. C. Iron absorption is decreased in the GI tract during pregnancy. D. Iron is needed to prevent megaloblastic anemia in the last trimester.
B. It is difficult to consume 18 mg of additional iron by diet alone.
The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? A. Elicit a positive scarf sign on the affected side. B. Observe for an asymmetrical Moro (startle) reflex. C. Watch for swelling of fingers on the affected side. D. Note paralysis of affected extremity and muscles.
B. Observe for an asymmetrical Moro (startle) reflex.
The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take? A. Ask the mother why she won't look at the infant. B. Observe the mother for other attachment behaviors. C. Examine the newborn's eyes for the ability to focus. D. Recognize this as a common reaction in new mothers.
B. Observe the mother for other attachment behaviors.
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is recommended for which purpose? A. Detect cardiovascular disorders. B. Screen for neural tube defects. C. Monitor the placental functioning. D. Assess for maternal pre-eclampsia.
B. Screen for neural tube defects.
Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?" A. Lying prone with a pillow on the abdomen. B. Using a breast pump. C. Massaging the abdomen. D. Giving oxytocic medications.
B. Using a breast pump.
A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation should the nurse provide? A. Weigh the baby daily, and if she is gaining weight, she is eating enough. B. Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 1 times a day. C. Offer the baby extra bottle milk after her feeding, and see if she is still hungry. D. If you're concerned, you might consider bottle feeding so that you can monitor her intake.
B. Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 1 times a day.
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved? A. 4+ reflexes. B. Urinary output of 50 ml per hour. C. A decrease in respiratory rate from 24 to 16. D. A decreased body temperature.
C. A decrease in respiratory rate from 24 to 16.
The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) A. Litmus paper. B. Fetal scalp electrode. C. A sterile glove. D. An amnihook. E. Sterile vaginal speculum. F. Lubricant.
C. A sterile glove. D. An amnihook. F. Lubricant.
A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective? A. Slowly increasing urinary output over the last week. B. Respiratory rate changes from the 40s to the 60s. C. Changes in apical heart rate from the 180s to the 140s. D. Change in indirect bilirubin from 12 mg/dl to 8 mg/dl.
C. Changes in apical heart rate from the 180s to the 140s.
A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first? A. Notify the pediatrician immediately. B. Suction the infant's nares, then the oral cavity. C. Check the infant's oxygen saturation rate. D. Position the infant on the right side.
C. Check the infant's oxygen saturation rate.
At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next? A. Check the hematocrit results. B. Administer pain medication. C. Increase the rate of IV fluids. D. Monitor client for contractions.
C. Increase the rate of IV fluids.
The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period is A. January 14-15. B. January 22-23. C. January 30-31. D. February 6-7.
C. January 30-31.
The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? A. Insert an internal fetal monitor. B. Assess for cervical changes q1h. C. Monitor bleeding from IV sites. D. Perform Leopold's maneuvers.
C. Monitor bleeding from IV sites.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? A. Wear support stockings. B. Reduce salt in her diet. C. Move about every hour. D. Avoid constrictive clothing.
C. Move about every hour.
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first? A. Provide oral hydration. B. Have a complete blood count (CBC) drawn. C. Obtain a specimen for urine analysis. D. Place the client on strict bedrest.
C. Obtain a specimen for urine analysis.
A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complaint indicates that the fallopian tubes are patent? A. Back pain. B. Abdominal pain. C. Shoulder pain. D. Leg cramps.
C. Shoulder pain.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate? A. Drowsiness and bradycardia. B. Depressed reflexes and increased respirations. C. Tachycardia and a feeling of nervousness. D. A flushed, warm feeling and a dry mouth.
C. Tachycardia and a feeling of nervousness.
A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best? A. This is not an unusual shaped head, especially for a first baby. B. It may look funny to you, but newborn babies are often born with heads like your baby's. C. That is normal; the head will return to a round shape within 7 to 10 days. D. Your pelvis was too small, so the baby's head had to adjust to the birth care
C. That is normal; the head will return to a round shape within 7 to 10 days.
The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? A. Two vessels: one artery and one vein. B. Two vessels: two arteries and no veins. C. Three vessels: two arteries and one vein. D. Three vessels: two veins and one artery.
C. Three vessels: two arteries and one vein.
When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation? A. Milia are red marks made by forceps and will disappear within 7 to 10 day B. Meconium is the first stool and is usually yellow gold in color. C. Vernix is a white, cheesy substance, predominantly located in the skin fold D. Pseudostrabismus found in newborns is treated by minor surgery.
C. Vernix is a white, cheesy substance, predominantly located in the skin fold
A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is: A. shortness of breath. B. joint pain. C. a persistent cold. D. organomegaly.
C. a persistent cold.
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full- term baby, and has had no abortions. Which GTPAL should the nurse document in this client's record? A. 3-1-2-0-3. B. 4-1-2-0-3. C. 2-1-2-1-2. D. 3-1-1-0-3.
D. 3-1-1-0-3.
The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure? A. A gravida 6, para 5 who is 38 years of age and in early labor. B. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilatation, and a -1 station. C. A gravida 2, para 1 who is at 1 cm cervical dilatation and a 0 station admitted for induction of labor due to post dates. D. A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.
D. A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.
A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? A. Cervical dilation of 5 cm with 90% effacement. B. White blood cell count of 12,000/mm3. C. Hemoglobin of 12 mg/dl and hematocrit of 38%. D. A platelet count of 67,000/mm3.
D. A platelet count of 67,000/mm3.
The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take? A. Check the client for urinary bladder distention. B. Notify the healthcare provider of the nonreactive results. C. Have the mother stimulate the fetus to move. D. Ask the client if she has felt any fetal movement.
D. Ask the client if she has felt any fetal movement.
When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. At 16-weeks gestation. B. At 20-weeks gestation. C. At 24-weeks gestation. D. At 30-weeks gestation
D. At 30-weeks gestation
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse take immediately? A. Give the medication as prescribed and monitor for efficacy. B. Encourage the client to breastfeed rather than bottle feed. C. Have the client empty her bladder and massage the fundus. D. Call the healthcare provider to question the prescription.
D. Call the healthcare provider to question the prescription.
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client? A. Which symptom did you experience first? B. Are you eating large amounts of salty foods? C. Have you visited a foreign country recently? D. Do you have a history of rheumatic fever?
D. Do you have a history of rheumatic fever?
The nurse is planning preconception care for a new female client. Which information should the nurse provide the client? A. Discuss various contraceptive methods to use until pregnancy is desired. B. Provide written or verbal information about prenatal care. C. Ask the client about risk factors associated with complications of pregnancy D. Encourage healthy lifestyles for families desiring pregnancy.
D. Encourage healthy lifestyles for families desiring pregnancy.
A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide? A. Herbs are a cornerstone of good health to include in your treatment. B. Touch is also therapeutic in relieving discomfort and anxiety. C. Your healthcare provider should direct treatment options for herbal therapy D. It is important that you want to take part in your care.
D. It is important that you want to take part in your care.
An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse. B. Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed. C. Ask him to observe his wife's behavior carefully for the next few weeks an report any similar behavior to the nurse at the next prenatal visit. D. Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.
D. Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.
A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? A. Encourage the mother to provide total care for her infant. B. Provide privacy so the mother can develop a relationship with the infant. C. Encourage the father to provide most of the infant's care during hospitalization. D. Meet the mother's physical needs and demonstrate warmth toward the infant.
D. Meet the mother's physical needs and demonstrate warmth toward the infant.
Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first? A. Assess the husband's feelings about his wife's decision to breastfeed their baby. B. Ask the client to describe why she was unsuccessful with breastfeeding her last child. C. Encourage the client to develop a positive attitude about breastfeeding to help ensure success. D. Provide assistance to the mother to begin breastfeeding as soon as possibility after delivery.
D. Provide assistance to the mother to begin breastfeeding as soon as possibility after delivery.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A. Use a thread to tie off the umbilical cord. B. Provide as much privacy as possible for the woman. C. Reassure the husband and try to keep him calm. D. Put the newborn to breast.
D. Put the newborn to breast.
A 30-year-old multiparous woman who has a 3-year-old boy and an newborn girl tells the nurse, "My son is so jealous of my daughter, I don't know how I'll ever manage both children when I get home." How should the nurse respond? A. Tell the older child that he is a big boy now and should love his new sister. B. Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him. C. Let the older child stay with his grandparents for the first six weeks to allow him to adjust to the newborn. D. Regression in behaviors in the older child is a typical reaction so he needs attention at this time.
D. Regression in behaviors in the older child is a typical reaction so he needs attention at this time.
The nurse is calculating the estimated date of confinement (EDC) using Nägele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? A. August 1. B. August 10. C. September 3. D. September 8.
D. September 8.
A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client? A. Elevate lower legs while resting. B. Increase caloric intake by 200 to 300 calories per day. C. Increase water intake to 8 full glasses per day. D. Take prescribed multivitamin and mineral supplements.
D. Take prescribed multivitamin and mineral supplements.
While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother? A. The infant should be positioned to reduce the swelling. B. The swelling is a subperiosteal collection of blood. C. The pediatrician will aspirate the blood if it gets larger. D. The scalp edema will subside in a few days after birth.
D. The scalp edema will subside in a few days after birth.
A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client? A. Some care is required when touching the large soft area on top of your baby's head until the bones fuse together. B. That's just an 'old wives' tale' so don't worry, you can't harm your baby's head by touching the soft spot. C. The soft spot will disappear within 6 weeks and is very unlikely to cause a problems for your baby. D. There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.
D. There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.
A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child? A. Exercise regimen of both partners includes running four miles each morning. B. History of having sexual intercourse 2 to 3 times per week. C. The woman's menstrual period occurs every 35 days. D. They use lubricants with each sexual encounter to decrease friction.
D. They use lubricants with each sexual encounter to decrease friction.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity? A. Deep tendon reflexes 2+. B. Blood pressure 140/90. C. Respiratory rate 18/minute. D. Urine output 90 ml/4 hours.
D. Urine output 90 ml/4 hours.
In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the A. anterior fontanel closes at 2 to 4 months and the posterior by the end of t first week. B. anterior fontanel closes at 5 to 7 months and the posterior by the end of t second week. C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.
D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.
One day after vaginal delivery of a full term baby, a postpartum client's white blood cell count is 15.000/mm. What action should the nurse take first? a. Check the differential, since the WBC is normal for this client b. Assess the client's temperature, pulse, and respirations q4h c. Assess the client's perineal area for signs of a perineal hematoma d. Notify the healthcare provider, since this finding is indicative of infection
a. Check the differential, since the WBC is normal for this client
A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? a. Discuss the need for cortisol and aldosterone replacement therapy after discharge b. Support the parents in their decision to assign sex of their child according to their preference c. Offer information about ultrasonography and genotyping to determine sex assignment d. Explain that corrective surgical procedures consistent with sex assignment can be delayed
a. Discuss the need for cortisol and aldosterone replacement therapy after discharge
A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 mg/dl and a hematocrit of 25.1 %. What food should the nurse encourage this client to include in her diet? a. Carrots b. Chicken c. Yogurt d. Cheese
b. Chicken
A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? a. Alert the neonatal team and prepare for neonatal resuscitation b. Notify the healthcare provider from the client's bedside c. Obtain written consent for an emergency cesarean section d. Draw a blood sample for stat hemoglobin and hematocrit
b. Notify the healthcare provider from the client's bedside
A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? a. Turn the client to her left side b. Contact the healthcare provider c. Assess the fetal heart rate d. Check the cervical dilation
c. Assess the fetal heart rate
A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? a. Pain level b. Blood pressure c. Infusion site d. Contraction pattern
d. Contraction pattern
A client whose labor is being augmented with an oxytocin(Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a 2-station. What action should the nurse implement first? a. Decrease the oxytocin infusion rate b. Determine current cervical dilation c. Request placement of the epidural d. Give a bolus of intravenous fluids
d. Give a bolus of intravenous fluids
