Mother Baby Exam 1 Review w/Rationales P5

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?

"Baby powder will help prevent a diaper rash." Answer Rationale: Lotions, creams, oils, or powders can alter a newborn's skin and provide a medium for bacterial growth or cause an allergic response. Powders can be inhaled, leading to respiratory distress. This statement requires the nurse to clarify instruction on newborn care.

A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. Which of the following statements by the client indicates a need for further teaching?

"I should apply hot packs to my breasts during feeding." Answer Rationale: The application of heat promotes increased blood flow to the breasts, which are already engorged. This is not an appropriate intervention.

A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification?

"I should increase my calcium intake to 1,500 milligrams per day" Answer Rationale: A woman's dietary reference intake (DRI) of calcium for pregnancy and lactation is the same for a woman who is not pregnant. The DRI for a woman older than 19 years of age is 1,000 mg/day, which should supply enough calcium for fetal bone and tooth development and to maintain maternal bone mass.

A nurse is providing teaching to a client who is at 30 weeks of gestation and is to have a nonstress test (NST). Which of the following statements by the client indicates a need for further teaching?

"I will have to lie on my back during the test." Answer Rationale: The client is placed in a Semi-Fowler's position with one hip slightly elevated to promote uterine perfusion and prevent supine hypotension as a result of the uterus compressing the maternal vena cava.

A nurse is providing teaching about expected gestational changes to a client who is at 12 weeks of gestation. Which of the following statements by the client indicates a need for further teaching?

"I will use only nonprescription medications while pregnant." Answer Rationale: Both nonprescription and prescription medications can be harmful to the fetus. The client needs to understand the importance of disclosing all medications, supplements, and vitamins to the provider prior to use during pregnancy.

A nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching?

"My baby will be placed under special lights if the test result is positive." Answer Rationale: Phototherapy is used to reduce circulating unconjugated bilirubin in infants who have hyperbilirubinemia. Phototherapy for hyperbilirubinemia uses light energy to lower the bilirubin level in the newborn's blood. This would not be appropriate therapy for PKU.

A nurse is providing teaching about newborn care to a client who is 2 hr postpartum. Which of the following statements by the client indicates a need for further teaching?

"My baby's temperature will be checked rectally every hour." Answer Rationale: The newborn's axillary temperature should be checked every hour until the newborn's temperature stabilizes. Frequent rectal temperature checks are not recommended and can lead to rectal mucosal injury.

A nurse is preparing an in-service about St. John's wort. Which of the following information should the nurse include in the teaching?

"St. John's wort can cause photophobia." Answer Rationale: The nurse should teach the client that St. John's wort may cause photophobia; therefore, the client should wear protective clothing, sun screen, and sun-glasses when outside.

A nurse is teaching a client who is at 23 weeks of gestation about immunizations. Which of the following statements should the nurse include in the teaching?

"You can receive an influenza vaccination during pregnancy." Answer Rationale: It is recommended that pregnant women receive annual influenza vaccinations.

A nurse is providing teaching to a client who is planning on becoming pregnant about the changes she should expect. Identify the sequence of maternal changes. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

1)Amenorrhea 2) Goodell's sign 3) Quickening 4) Lightening

A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?

A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache Answer Rationale: These findings indicate that the client's condition is worsening and are signs of severe preeclampsia. They should be reported to the provider immediately. Other manifestations of severe preeclampsia include: blood pressure of 160/100 mm Hg or greater, proteinuria 3+ to 4+, oliguria, visual disturbances, such as blurred vision, hyperreflexia with clonus, nausea, vomiting, epigastric pain, and right upper-quadrant pain.

A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

A client who is at 28 weeks of gestation and reports of painless vaginal bleeding Answer Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should assess this client first. The nurse should suspect placenta previa when vaginal bleeding occurs after 24 weeks of gestation. A pregnant woman can lose up to 40% of blood before showing signs of shock.

A nurse is caring for a client who is in preterm labor with a current L/S ratio of 1:1. Which of the following actions should the nurse take?

Administer betamethasone 12 mg IM. Answer Rationale: Betamethasone is classified as a corticosteroid medication. Corticosteroids are often administered to the mother to assist in fetal lung maturity. These are usually administered by IM injection of 12 mg for the first two doses. The subsequent dosing should be 6 mg by IM every 12 hr x 4 doses.

A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.)

Administer magnesium sulfate IV. Provide a dark, quiet environment. Ensure that calcium gluconate is readily available.

A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

Apply an ice pack to the affected area. Answer Rationale: During the first 24 hr, ice packs and cool water sitz baths are used. They reduce edema and promote comfort. The client may also apply witch hazel compresses to reduce edema. The nurse should instruct the client on the use of prescribed anesthetic creams, sprays, and ointments.

A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take?

Apply perineal pressure to the emerging fetal head. Answer Rationale: Using Maslow's hierarchy of needs, the priority intervention is to prevent injury to the fetus during the delivery by applying gentle perineal pressure to the emerging head. This avoids rapid expulsion of the fetal head. A change in pressure within the fetal skull due to a rapid delivery can cause neurologic damage (increased intracranial pressure and dural/subdural tearing). Rapid birth can also cause maternal injury, such as vaginal or perineal lacerations.

A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority?

Bilirubin 19 mg/dL Answer Rationale: Bilirubin 19 mg/dL is above the expected reference range for a newborn at 4 hr of age. A bilirubin level greater than 15 mg/dL or an increase by more than 6 mg/dL in 24 hr is pathologic or nonphysiologic jaundice. Pathologic jaundice is a result of an underlying disease and occurs before 24 hr of age; therefore, this is the nurse's priority finding.

A nurse is teaching a client about black cohosh. Which of the following information should the nurse include in the teaching?

Black cohosh should not be taken during pregnancy." Answer Rationale: Black cohosh has estrogenic properties and should not be taken during pregnancy.

A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?

Blood pressure 80/56 mm Hg Answer Rationale: When using the airway, breathing, circulation approach to client care, the nurse's priority finding is a blood pressure of 80/56, which indicates hypotension. The client's blood pressure is not adequate to sustain uteroplacental perfusion and oxygen to the fetus, which can lead to respiratory distress and possibly death.

A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)

Blot the perineal area dry after cleansing. Clean the perineal area from front to back. Perform hand hygiene before and after voiding. Wash the perineal area using a squeeze bottle of warm water after each voiding. Answer Rationale: Blot the perineal area dry is correct. Good perineal care is important to clean the skin folds, which often contain secretions that act as a medium for micro-organism growth. Therefore, the area should be thoroughly dried by blotting. Clean the perineal area from front to back is correct. Good perianal care is important to clean the skin folds, which often contain secretions that harbor microorganisms. Wiping from front to back decreases the chances of transmitting fecal organisms to other areas, such as the urinary meatus, episiotomy incision, or lacerations resulting from childbirth. Perform hand hygiene before and after voiding is correct. Hand hygiene is the primary method of reducing micro-organisms on the hands and thereby reducing the risk of transmission that can lead to infection. Wash the perineal area using a squeeze bottle of warm water after each voiding is correct. Rinsing with a solution of water is more effective at removing micro-organisms than wiping.

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

Change the client's position. Answer Rationale: The first action the nurse should take is to change the client's position in an attempt to increase blood flow to the fetus.

A nurse receives report about a client who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?

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

A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

Displaced fundus from the midline Answer Rationale: A distended bladder can cause uterine atony and lateral displacement of the fundus from the midline of the lower abdomen, usually to the right. This requires immediate intervention because the distended bladder pushes the uterus up and to the side, which prevents it from contracting firmly. Uterine atony results from the inability of the uterine muscle to contract adequately after birth. This can lead to postpartum hemorrhage.

A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)

Document fundal height. Observe the lochia during palpation of fundus. Determine whether the fundus is midline. Administer methylergonovine maleate if uterus is boggy.

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

Encourage the client to empty her bladder every 2 hr. Answer Rationale: A client in labor should be encouraged to empty her bladder every 2 hr. Bladder distention can impede the descent of the fetus and slow the progression of labor. It can also contribute to uterine atony after delivery, increasing the client's risk of postpartum hemorrhage.

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

Evaluate the firmness of the uterus. Answer Rationale: The first action the nurse should take using the nursing process is to assess the client. A blood pressure of 60/50 mm Hg can indicate postpartum hemorrhage; therefore, the first action the nurse should take is to evaluate the firmness of the uterus to determine if there is uterine atony.

A nurse is assessing a client who is in the third trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic change during pregnancy?

Gradual lordosis Answer Rationale: Clients who are pregnant can develop a gradual, forward curving of the spine as the growth of the fetus pulls the pelvis forward. This lordosis resolves after delivery.

A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

Initiate early feeding. Answer Rationale: Prevention of jaundice can be facilitated best by early and frequent feeding, which stimulates intestinal activity and passage of meconium. Jaundice occurs due to elevated serum bilirubin, which is excreted primarily in the newborn's stool. Physiologic jaundice manifests after 24 hr and is considered benign. However, bilirubin may accumulate to hazardous levels and lead to a pathologic condition.

A charge nurse observes a nurse checking fetal heart tones (FHT) for a client who is at 12 weeks of gestation. Which of the following actions by the nurse indicates a need for intervention by the charge nurse?

Listens with a fetoscope Answer Rationale: A fetoscope is not able to detect FHT this early in the pregnancy. The nurse should use a Doppler or ultrasound stethoscope. Typically at 12 weeks, the heart tones will be heard midline just above the symphysis pubis with a Doppler or ultrasound device. A fetoscope can be used to assess FHT later in the pregnancy, around 16 to 20 weeks.

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction. Answer Rationale: The nurse should obtain a 20 to 30 min EFM strip before induction of the spinal anesthesia. The strip should be evaluated as baseline information. After induction, fetal heart rate and pattern is assessed and documented every 5 to 10 min and emergency care is provided for fetal distress, such as bradycardia or late decelerations.

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?

Obtain blood glucose by heel stick. Answer Rationale: The newborn is exhibiting early signs of hypoglycemia. The nurse should obtain blood by heel stick to check glucose. A therapeutic serum glucose level for a newborn is 40 to 60 mg/dL. Less than 40 mg/dL indicates hypoglycemia. Other findings of hypoglycemia include poor feeding, tremors, hypothermia, flaccid muscle tone, irregular respirations, apnea, cyanosis, and a weak, shrill cry. Early breastfeeding also should be encouraged to prevent hypoglycemia.

A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider?

Poor sucking Answer Rationale: Vacuum-assisted birth involves attaching a vacuum cup to the fetal head and using negative pressure to assist in the birth of the head, placing the newborn at risk for a subdural hematoma. The nurse should report manifestations of cerebral irritation, such as listlessness and poor sucking to the provider.

A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?

Red and painful area in one breast Answer Rationale: Mastitis often appears as a red, hard, and painful area on the breast, commonly in the upper outer quadrant. Although mastitis can occur in both breasts, it is usually unilateral. A client who has mastitis can also influenza-like manifestations, such as fever, chills, headache, and myalgia. After delivery, the nurse should instruct the client to observe the breasts for indications of mastitis and to notify her provider if they occur.

A nurse is assessing a client who is 12 hr postpartum and received spinal anesthesia for a cesarean birth. Which of the following findings requires immediate intervention by the nurse?

Respiratory rate 10/min Answer Rationale: A client who has received spinal anesthesia is at risk for respiratory depression and hypotension. A respiratory rate of 10/min indicates bradypnea and requires immediate intervention.

A nurse is reinforcing teaching about contraceptive methods with a client. Which of the following should the nurse recognize as a contraindication for diaphragm use?

The client has pelvic relaxation. Answer Rationale: Pelvic relaxation and large cystocele are contraindications for diaphragm use.

A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse?

The mother applies lotion to the newborn's skin. Answer Rationale: Lotions and ointments should not be applied as they can absorb heat and cause burns.

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

Turn the client onto her side. Answer Rationale: When using the urgent vs non-urgent approach to client care, the nurse determines that the priority action is to turn the client onto her left side. Late decelerations indicate that the client might have uteroplacental insufficiency, maternal hypotension, uterine tachysystole form oxytocin administration, or several other complicating factors. The client might be exerting pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to the fetus. Turning the client onto her side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply.

A nurse is assessing a client who is receiving magnesium sulfate to treat preeclampsia. Which of the following findings should the nurse report to the provider?

Urinary output 40 mL in 2 hr Answer Rationale: Urinary output is critical for the excretion of magnesium from the body. The nurse should report an hourly output below 30 mL/hr to the provider immediately and discontinue the medication.

A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? (Select all that apply.)

Vitamin K injection Hepatitis B immunization Antibiotic ointment to both eyes

A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. Which of the following findings should the nurse expect?

Weakened uterine contractions Answer Rationale: Terbutaline is a beta2-adrenergic agonist that acts to relax uterine smooth muscles. Terbutaline is used to stop contractions in a client who is experiencing preterm labor.