Maternity Exam 2 Help

The nurse is caring for a client with placenta previa. The client asks about sexual activity. What is the best response from the nurse?

Intercourse is contraindicated in the presence of placenta previa.

The nurse is teaching new parents about umbilical cord care. The nurse knows more teaching is needing when the parents state:

It's ok for us to bathe our baby in a tub.

A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate?

"This is meconium stool and is normal for a newborn."

A postpartum woman who is bottle-feeding her newborn asks the nurse, "About how much should my newborn drink at each feeding?" The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding?

2 to 4 ounces

Which assessment finding 1 hour after birth should be reported to the health care provider?

Lochia rubra is saturating a pad every 45 to 60 minutes

A nurse is providing care to a newborn in the immediate newborn period. Which nursing intervention is priority?

Administer aquamephyton.

The nurse is assigned to clients who are having the following procedures: amniocentesis, fetal nonstress test, chorionic villus sampling, percutaneous umbilical blood sampling, and Doppler assessment of fetal heart rate. For which clients will the nurse ensure that signed informed consent has been given and is in the client's record?

Amniocentesis, chorionic villus sampling, percutaneous umbilical blood sampling

The nurse is caring for a client whose alpha-fetoprotein is elevated. The client asks the nurse what an elevated level means. The nurse's best response is:

An elevated level means you will need further testing.

The nurse is caring for a client in the third trimester of pregnancy. The client complains of swelling in her lower legs, hands, and feet. Which is the best response by the nurse?

Ask the client if she has headaches, blurred vision, or dizziness.

Which occurs as a result of contraction decrement? Select all that apply.

Blood flow to the fetus improves. Fetal heart rate should return to baseline.

The nurse is teaching a primigravida client how to measure the frequency of uterine contractions. The nurse should explain that the frequency of uterine contractions is measured by which of the following?

By timing from the beginning of one contraction to the beginning of the next contraction.

What is the correct interpretation of the fetal monitoring strip?

Category I requiring no intervention

A 36-hour-old newborn is ready for discharge from the hospital and the nurse notices that his skin looks yellow. What action will the nurse take?

Contact the health care provider to obtain a bilirubin level

The nurse is caring for a client who is having an NST (non-stress test). The nurse is evaluating the fetal monitoring strip for reactivity. She notes one heart rate acceleration 15 beats above baseline and 15 secs long within a 20-minute recording period. Which is the best action taken by the nurse?

Continue the NST for another 20 minutes observing for reactivity.

When preparing a woman for an amniocentesis, the nurse would instruct her to perform which action?

Empty the bladder

The nursery head nurse is conducting a staff in-service on prevention of hypoglycemia. What information would she share with this group? Select all that apply.

Encourage breastfeeding mothers to nurse immediately after delivery. Keep the newborns warm in the nursery and covered with a blanket. Initiate early feedings for all bottle-fed newborns.

A gravid client, G3P2, was examined 5 minutes ago, and her cervix was 8cm dilated and 90% effaced. She now states she needs to move her bowels. Which of the following actions should the nurse perform first?

Evaluate the progress of labor.

A nurse is assessing a woman during the first 24 hours after birth. Which assessment finding would the nurse determine as acceptable during this time? Select all that apply.

Fundus one finger-breadth below the umbilicus Moderate saturation of peri pad every 3 hours

A client in the first trimester of pregnancy presents with complaints of increased urinary frequency. What action should the nurse take?

Have the client give a urine sample to check for urinary tract infection.

The nurse is assessing a 1 day old newborn. Which of the assessment findings listed below would alert the nurse to a possible complication?

Head circumference is 2 cm less than the chest circumference.

Shortly after the birth of a newborn, the mother notices a gray patch across the baby's buttocks. She is immediately concerned that the baby has been bruised during the birth and asks the nurse about this. The nurse recognizes patch as a birth mark and explains this to the mother. Which type of birth mark is this most likely to be?

Mongolian spot

The nurse is teaching a new mother how to change a diaper. The mother clapped her hands, excitedly, as she successfully changed her first diaper. The nurse observed the baby stiffen, his arms extended then relaxed in an embrace gesture, in response to the clapping. The nurse recognizes this reflex as:

Moro reflex

The multigravida client is moving into the transition phase and asks for a narcotic, stating she doesn't remember the pain being this bad before. Which response from the nurse will be best?

Pain medication can affect the baby's breathing; let's try to focus and breathe."

The nurse is caring for a 2 hour old newborn. The vital signs are as follows: temp 97.0, pulse 130, respirations 50, noted cyanosis to hands and feet. Which of the following is an appropriate response by the nurse?

Place the baby skin to skin with mother and cover with blankets.

Which of the following measures will the nurse implement to best ensure that a newborn is not misidentified in the hospital?

Placing ID bands on the mother and baby immediately after birth.

The nurse performs a nonstress test (NST) on a client at 36 weeks' gestation. What criteria does the nurse look for on the tracing to determine that the NST is reactive?

Presence of 2 accelerations in 20 minutes

The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?

Sudden infant death syndrome

A client has completed her first prenatal visit, and the nurse is reviewing the lab results. The nurse notes a nonimmune titer to Rubella. The nurse calls the client to discuss her lab results. What instructions should the nurse give to the client?

Tell the client she is not immune to rubella and will need to take the vaccine after delivery.

The nurse is caring for a 1 day old newborn. The mother of the baby is concerned because she has noticed tiny, white, pinpoint papules on the baby's nose and cheeks. What is the best response by the nurse?

The bumps are called milia and should disappear in a few days.

Which assessment findings of the fetus during labor are normal? Select all that apply.

Variability between 18-20 bpm Fetal heart baseline of 130 bpm

The nurse is in charge of a labor and delivery unit and receives a call from a client who states she is 32 weeks pregnant, and she has been having menstrual like cramping every 10 minutes for the past 2 hours. What is the best response by the nurse?

You should drink 2-3 glasses of water and lie on your side; call your MD if symptoms persist.

The nurse is discharging a mother and her newborn baby. The baby is less than 24 hours old. Which of the following is an accurate statement by the nurse?

Your baby's metabolic screening results may be inaccurate due to his age.

When assessing a postpartum woman, the nurse suspects the woman is experiencing a problem based on which finding?

acute decrease in hematocrit

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication?

an absence of lochia

The nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

are unable to shiver effectively to increase heat production.

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:

caput succedaneum

A nurse is conducting a refresher program for a group of nurses working in the newborn nursery. After teaching the group about variations in newborn head size and appearance, the nurse determines that the teaching was successful when the group identifies which variation as normal? Select all that apply.

cephalohematoma molding caput succedaneum

The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rh-positive newborn based on the understanding that this drug will prevent her from:

developing Rh sensitivity

A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor and notes a change from the earlier baseline FHR of 140 bpm to 168 bpm. The nurse is aware that which factors can result in fetal tachycardia? Select all that apply.

fetal movement fetal distress uteroplacental insufficiency maternal fever

When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartum day and how should it feel?

fundus two fingerbreadths below umbilicus and firm

A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that clients empty their bladders. A full bladder can lead to which complication?

increased lochia drainage

A group of nurses are reviewing information about the changes in the newborn's lungs that must occur to maintain respiratory function. The nurses demonstrate understanding of this information when they identify which event as occurring first?

initiation of respiratory movement

A client has not received any medication during her labor. She is having frequent contractions about every 1 to 2 minutes and has become irritable with her coach and no longer will allow the nurse to palpate her fundus during contractions. Her cervix is 8 cm dilated and 90% effaced. The nurse interprets these findings as indicating:

late active phase of the first stage of labor.

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?

nasal flaring

A nurse is reviewing the policies of a facility related to bonding and attachment with newborns. Which practice would the nurse identify as needing to be changed?

offering round-the-clock nursery care for all infants

The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which action would be a priority?

placing the call light within her reach

A nurse is preparing a presentation for a group of pregnant women about the labor experience. Which factors would the nurse include when discussing measures to promote coping for a positive labor experience? Select all that apply.

presence of a support partner low anxiety level participation in a pregnancy exercise program

During a nonstress test, when monitoring the fetal heart rate, the nurse notes that when the expectant mother reports fetal movement, the heart rate increases 15 beats or more above the baseline. This occurs about 4 or 5 times during the testing period. The nurse interprets this as:

reactive pattern

Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn's respiratory status. What would the nurse expect to assess?

respiratory rate 45 breaths/minute, irregular