NURS 3610 Quiz 2
A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? (SATA) A. Apply breast milk to the nipples before each feeding. B. Place breast pads inside the nursing bra. C. Massage the breasts and nipples prior to feeding. D. Start breastfeeding with the nipple that is less sore. E. Change the infant's position on the nipple.
A D E
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take? A. Obtain blood glucose by heel stick. B. Initiate phototherapy. C. Monitor the newborn's blood pressure. D. Place the newborn in a radiant warmer.
A. Obtain blood glucose by heel stick. 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 providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition? A. Placental insufficiency B. Preterm delivery C. Fetal hyperinsulinemia D. Perinatal asphyxia
A. Placental insufficiency Placental insufficiency is a cause of small for gestational age. It can result from maternal infections, embryonic placental deficiency, teratogens, or chromosomal abnormalities.
A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding? A. Caput succedaneum B. Cephalhematoma C. Molding D. Pilonidal dimple
B. Cephalhematoma A cephalhematoma is a swelling, indicating bleeding under the subcutaneous tissues of the newborn's scalp. The collection of blood is beneath the periosteum of the cranial bone and therefore does not cross the suture line.
A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn's Apgar score.
6
A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (SATA) A. Cracked, peeling skin B. Positive Moro reflex C. Short, soft fingernails D. Abundant lanugo E. Vernix in the folds and creases
A B
A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make? A. Within 2 days B. In 3 to 5 days C. In 6 to 8 days D. In about 10 days
B. In 3 to 5 days By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milk.
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following? A. Uteroplacental insufficiency B. Maternal bradycardia C. Umbilical cord compression D. Fetal head compression
A. Uteroplacental insufficiency The pattern of the fetal heart rate during labor is an indicator of fetal well-being. Late decelerations are the result of uteroplacental insufficiency and the fetus becomes hypoxemic. They are an ominous sign if they cannot be corrected and place the fetus at risk for a low Apgar score.
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding on the circumcision care? (SATA) A. "I'll expect the plastic ring to fall off by itself within a week." B. "I'll apply petroleum jelly to his penis with diaper changes." C. "I'll wash his penis with warm water and mild soap each day." D. "I'll call the doctor if I see any bleeding." E. "I'll make sure his diaper is loose in the front."
A D E
A nurse is assessing a newborn for manifestations of a large patent ductus arteriosus. Which of the following findings should the nurse expect? A. Cyanosis with crying B. Systolic murmur C. Weak pulses D. Chronic hypoxemia
B. Systolic murmur A patent ductus arteriosus is failure of the artery connecting the aorta and pulmonary artery to close after birth, causing a left-to-right shunt. A systolic murmur is a clinical manifestation found in newborns who have a large patent ductus arteriosus.
A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute? A. "Newborns are abdominal breathers." B. "Newborns do not expand their lungs fully with each respiration." C. "Activity will increase the respiratory rate." D. "The rate and rhythm of breath are irregular in newborns."
D. "The rate and rhythm of breath are irregular in newborns." Newborns have an irregular respiratory rate and rhythm. Therefore, counting the respiratory rate for a complete minute is recommended to obtain an accurate rate.
A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and states she feels weak and light headed. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take next? A. Insert an indwelling urinary catheter. B. Administer oxytocin by continuous IV infusion. C. Tilt the client onto her right side with her legs elevated to at least 30. D. Massage the client's fundus to promote contractions.
D. Massage the client's fundus to promote contractions. A soaked perineal pad in less than 15 min, ashen skin color, and report of weakness and light headedness can indicate that the client is at greatest risk for hypovolemic shock. Therefore, the next action the nurse should take is to massage the client's fundus to expel blood clots and promote uterine contraction to stop the bleeding.
A nurse is preparing to administer 1 mg vitamin K to a newborn. The medication is available in 1 mg/0.5 mL. How much should the nurse administer?
0.5 mL
A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective? A. Fundus firm to palpation B. Increase in blood pressure C. Increase in lochia D. Report of absent breast pain
A. Fundus firm to palpation Methylergonovine is an oxytocic medication that is administered to promote uterine contractions. This medication is indicated for treatment of postpartum hemorrhage caused by uterine atony or subinvolution; the desired effect is an increase in uterine tone.
A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, "How will I know if my baby gets enough breast milk?" Which of the following responses should the nurse make? A. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding." B. "Your baby should wet 6 to 8 diapers per day." C. "Your baby should burp after each feeding." D. "Your baby should sleep at least 6 hours between feedings."
B. "Your baby should wet 6 to 8 diapers per day." Newborns should wet 6 to 8 diapers per day. This is an indication that the newborn is getting enough fluids.
A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care? A. Hypoglycemia B. Hypomagnesemia C. Hyperbilirubinemia D. Hypocalcemia
A. Hypoglycemia Newborns of mothers who have diabetes are at high risk for hypoglycemia due to the loss of high levels of glucose after the umbilical cord is cut. This results in fetal hyperinsulinemia. It can take several days for the newborn to adjust to secreting appropriate amounts of insulin for the lower level of blood glucose. Because severe hypoglycemia can lead to cyanosis and seizures, prevention of hypoglycemia becomes the nurse's priority focus of care.
A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? A. Document the findings and continue to monitor the client. B. Notify the client's provider. C. Increase the frequency of fundal massage. D. Encourage the client to empty her bladder.
A. Document the findings and continue to monitor the client. These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. Small clots are common. The nurse should document the findings and continue to monitor the client.
A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make? A. "You should place your nipple and some of the areola into her mouth." B. "Babies know instinctively how much of the nipple to take into their mouth." C. "Your baby's mouth is rather small so she will only take part of the nipple." D. "Try to place the nipple, the areola, and some breast tissue beyond the areola into her mouth."
A. "You should place your nipple and some of the areola into her mouth." Placing the nipple and 2 to 3 cm of areolar tissue around the nipple into the baby's mouth aids in adequately compressing the milk ducts. This placement decreases stress on the nipple and prevents cracking and soreness.
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse? A. "Mongolian spots can be found on the skin of many newborns." B. "A caput succedaneum occurs due to compression of blood vessels." C. "This is a cephalhematoma, which can occur spontaneously." D. "This is erythema toxicum, which is a transient condition."
B. "A caput succedaneum occurs due to compression of blood vessels." A caput succedaneum is an area of edema on the newborn's occiput, often seen where the cup of the vacuum was applied. It is present at birth and will disappear within 3 to 4 days.
A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention? A. A newborn who is 24 hr post-delivery and has not voided. B. A newborn who is 18 hr post-delivery and has acrocyanosis C. A newborn who is 24 hr post-delivery and has not passed meconium D. A newborn who is 12 hr post-delivery and has a temperature of 37.5C (99.5F)
D. A newborn who is 12 hr post-delivery and has a temperature of 37.5C (99.5F) Hyperthermia in the newborn requires immediately intervention. Hyperthermia is typically caused by increased heat production related to sepsis or decreased heat loss.
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? A. Apply a fetal scalp electrode. B. Increase the rate of the IV infusion. C. Administer oxygen at 10 L/min via a nonrebreather mask. D. Change the client's position.
D. Change the client's position. 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 is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect? A. Copious vernix B. Scant scalp hair C. Increased subcutaneous fat D. Dry, cracked skin
D. Dry, cracked skin A newborn who is postmature has dry, cracked skin.
A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? (SATA) A. Vitamin K injection B. Hepatitis B immunization C. Antibiotic ointment to both eyes D. Lidocaine gel to the umbilical stump E. Haemophilus influenza type b immunization (Hib)
A B C
A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn? A. Clear the respiratory tract. B. Dry the infant off and cover the head. C. Stimulate the infant to cry. D. Cut the umbilical cord.
A. Clear the respiratory tract. Clearing the airway of the infant is the first action the nurse should take immediately following delivery.
A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn? A. Cold stress B. Shivering C. Basal metabolic rate reduction D. Brown fat production
A. Cold stress When an infant is stressed by cold exposure, oxygen consumption increases and pulmonary and peripheral vasoconstriction occurs. Metabolic demands for glucose increase. If the cold stress continues, hypoglycemia and metabolic acidosis can result.
A nurse is caring for a client who experienced a vaginal birth 12 hr ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase? A. Expressions of excitement B. Lack of appetite C. Focus on the family unit and its members D. Eagerness to learn newborn care skills
A. Expressions of excitement Expressing excitement and being talkative are characteristic of this phase.
A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. The finding indicates the newborn is experiencing a complication related to which of the following? A. Maternal/newborn blood group incompatibility B. Absence of vitamin K C. Physiologic jaundice D. Maternal cocaine abuse
A. Maternal/newborn blood group incompatibility Maternal/newborn blood group incompatibility is the most common form of pathologic jaundice and the jaundice appears within the first 24 hr of life.
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse's priority? A. Respiratory distress B. Hypothermia C. Accidental lacerations D. Acrocyanosis
A. Respiratory distress Shortly before labor, there is a decreased production of fetal lung fluid and a catecholamine surge that promotes fluid clearance from the lungs. Newborns born by cesarean, in which labor did not occur, can experience lung fluid retention, which leads to respiratory distress. The priority assessment when using the airway, breathing, circulation (ABC) approach to client care is to monitor the newborn for respiratory distress.
A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make? A. "You need to take pain medications so you are more comfortable." B. "We can time your pain medication so that you have an hour or two before the next feeding." C. "All medications are found in breast milk to some extent." D. "You have the option of not taking pain medication if you are concerned."
B. "We can time your pain medication so that you have an hour or two before the next feeding." This answer provides the client an option that allows for administration of pain medication but minimizes the effect it will have on the newborn while breastfeeding.
A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take? A. Ask another nurse to verify the heart rate. B. Document this as an expected finding. C. Call the provider to further assess the newborn. D. Prepare the newborn for transport to the NICU.
B. Document this as an expected finding. The expected reference range for an apical pulse in a newborn who is awake is 120 to 160/min. The nurse should document this as an expected finding.
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mmHg. Which of the following is the priority action for the nurse to take? A. Notify the provider of the findings. B. Position the client with one hip elevated. C. Ask the client if she needs pain medication. D. Have the client void.
B. Position the client with one hip elevated. Based on Maslow's hierarchy of needs, the client's need for an adequate blood pressure to perfuse herself and her fetus is a physiological need that requires immediate intervention. Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By turning the client on her side and retaking her blood pressure, the nurse is attempting to correct the low blood pressure and reassess.
A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform? A. Bladder distention B. Pulse rate C. Respiratory rate D. Color of lochia
B. Pulse rate A sitz bath causes vasodilation; therefore, the nurse should monitor the client's pulse rate. Orthostatic hypotension can occur upon standing causing the client to feel faint.
A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch? A. Babinski B. Rooting C. Moro D. Stepping
B. Rooting The rooting reflex is elicited when the client strokes the newborn's lips, cheek, or corner of the mouth with her nipple. The newborn will turn his head while making sucking motions with his mouth and latch onto the nipple.
A nurse is providing teaching about comfort measure 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? A. "I will breastfeed every 2 hours." B. "I will apply ice packs to my breasts after feeding." C. "I should apply hot packs to my breasts during feeding." D. "I should crush cabbage leaves and place them on my breasts."
C. "I should apply hot packs to my breasts during feeding." The application of heat promotes increased blood flow to the breasts, which are already engorged. This is not an appropriate intervention.
A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn? A. Placing the newborn on a warm surface B. Preventing air drafts C. Drying the newborn's skin thoroughly D. Maintaining ambient room temperature at 24C / 75F
C. Drying the newborn's skin thoroughly Heat loss through evaporation occurs when moisture on the skin is converted to a vapor. This process is the most significant cause of heat loss in the first few days of life but is minimized by quickly and thoroughly drying the infant
A nurse is caring for a client who is 6 hours postpartum and asks the nurse to feed her newborn. Which of the following responses should the nurse provide? A. "I'll feed him today. Maybe tomorrow you can try it." B. "Oh, this isn't difficult. You'll be fine doing this." C. "You can learn to feed him; I wasn't comfortable the first time I fed a baby either." D. "Feedings an infant can feel a little intimidating at first, but I'll stay and help you."
D. "Feedings an infant can feel a little intimidating at first, but I'll stay and help you." The nurse, while recognizing and acknowledging the client's apprehension, offers assistance and a sense of presence, with the intention of boosting client confidence.
A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include? A. Wash the cord daily with mild soap and water. B. Cover the cord with the diaper. C. Apply petroleum jelly to the cord stump. D. Give a sponge bath until the cord stump falls off.
D. Give a sponge bath until the cord stump falls off. Immersing the umbilical cord stump in water can delay the process of drying, separation, and healing. Sponge baths are appropriate until the stump falls off.
A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication? A. Orthostatic hypotension B. Fundus palpable at the umbilicus C. Urine output of 3,000 mL in 12 hr D. Heart rate 110/min
D. Heart rate 110/min A rapid or increasing heart rate can be a manifestation of fluid volume depletion related to hemorrhage. The nurse should further evaluate the client for evidence of postpartum hemorrhage.
A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz (4252g). The nurse should recognize that this client is at risk for which of the following postpartum complications? A. Puerperal infections B. Retained placental fragments C. Thrombophlebitis D. Uterine atony
D. Uterine atony A uterus that is over distended, such as from a macrosomic fetus, has an increased risk of uterine atony.
A nurse is discussing postpartum depression with newly licensed nurse. Which of the following statements indicates an understanding of this disorder? A. "Postpartum depression usually begins 48hr after childbirth." B. "It's common for client's who have postpartum depression to exhibit psychotic behavior." C. "The most common manifestation of postpartum depression is harming the infant." D. "Postpartum depression is most often seen in women who have a history of depression."
B. "It's common for client's who have postpartum depression to exhibit psychotic behavior." Psychotic behavior is a common finding in clients who have postpartum psychosis.
A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse? A. Assist the family to identify prior use of positive coping skills in family crises. B. Ask the client if she has considered harming her newborn. C. Anticipate a prescription by the provider for an antidepressant. D. Reinforce postpartum and newborn care discharge teaching.
B. Ask the client if she has considered harming her newborn. When using the nursing process in caring for a client, the first action should focus on assessment of the client's mood, ability to concentrate, thought processes, and if the client has had thoughts of self-harm or of injuring her newborn.
A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action? A. Elevate the client's legs B. Position the client on her side. C. Administer oxygen via face mask. D. Increase the infusion rate of the IV fluid.
B. Position the client on her side. Late decelerations stem from decreased blood perfusion to the placenta or compression of the placenta. A position change should increase perfusion or decrease compression, and it is the first intervention the nurse should try. The greatest risk to the client is fetal hypoxia, so the priority action is the one that has the best chance of improving fetal perfusion.
A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority? A. Suction the nose with a bulb syringe. B. Suction the mouth with a bulb syringe. C. Use a suction catheter with low negative pressure. D. Turn the newborn on his side.
B. Suction the mouth with a bulb syringe. The greatest risk to the newborn is aspiration of secretions. Removing the secretions from the mouth first is the priority action.
A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make? A. "Preterm newborns have a smaller body surface area than normal newborns." B. "The added brown fat layer in a preterm newborn reduces his ability to generate heat." C. "Preterm newborns lack adequate temperature control mechanisms." D. "The heat in the incubator rapidly dries the sweat of preterm newborns."
C. "Preterm newborns lack adequate temperature control mechanisms." Preterm newborns have poor body control of temperature and need support to avoid losing heat. They require an external heat source, such as an incubator.
A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care? A. Monitor I & O. B. Monitor axillary temperature. C. Monitor blood glucose levels. D. Monitor weight.
C. Monitor blood glucose levels. Decreased stores of glycogen and a lower rate of gluconeogenesis place newborns who are SGA at higher risk for hypoglycemia. Monitoring of blood glucose levels is a priority intervention.
A nurse is caring for a client who is breastfeeding her newborn and asks the nurse about the changes she should make in her diet. Which of the following dietary changes should the nurse suggest? A. Increase her caloric intake by 600 kcal/day. B. Increase her fluid intake to 2.5 L/day. C. Reduce her intake of iron. D. Avoid shellfish.
C. Reduce her intake of iron. Recommendations for some nutrients, such as iron and folic acid, are less during lactation than during pregnancy. Because maternal blood volume decreases after childbirth, the client's need for these nutrients also diminishes.
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns? A. Early decelerations B. Accelerations C. Late decelerations D. Variable decelerations
D. Variable decelerations Variable decelerations occur when the umbilical cord becomes compressed and disrupts the flow of oxygen to the fetus. * Think VEALCHOP
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? (SATA) A. Document fundal height. B. Massage a firm fundus. C. Observe the lochia during palpation of fundus. D. Determine whether the fundus is midline. E. Administer methylgonovine maleate if uterus is boggy.
A C D E
A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rho (D) immunoglobulin. Which of the following should be included in the teaching? A. It prevents the formation of Rh antibodies in mothers who are Rh negative. B. It destroys Rh antibodies in mothers who are Rh negative. C. It destroys Rh antibodies in newborns who are Rh positive. D. It prevents the formation of Rh antibodies in newborns who are Rh positive.
A. It prevents the formation of Rh antibodies in mothers who are Rh negative. Rho (D) immunoglobulin prevents the immune system of a client who is Rh negative from reacting to accidental exposure to fetal blood during pregnancy or delivery. If the client has another Rh positive fetus in the future, these antibodies can destroy the blood cells of the fetus. Rho (D) immunoglobulin is administered routinely to Rh negative mothers at 28 weeks of gestation and following any pregnancy outcome (including birth or any planned or unintentional fetal loss).
A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first? A. Place the client in the lateral position. B. Increase the rate of maintenance IV infusion. C. Elevate the client's legs. D. Administer oxygen using a nonrebreather mask.
A. Place the client in the lateral position. This is a late deceleration and is associated with fetal hypoxemia due to insufficient placental perfusion. Placing the client in the lateral position is the first action the nurse should take.
A nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP? A. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. B. Observe an area of redness on the breast of a client who is 1 day postpartum. C. Monitor vital signs during admission of a client who has gestation hypertension. D. Change the perineal pad of a client who just transferred from labor and delivery.
A. Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. Providing comfort measures is an appropriate task that can be delegated to the AP since it does not require nursing judgment.
A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemmia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons? A. The client's blood does not contain the Rh factor, she she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. B. The client' blood contains the Rh factor and the newborn's does not and antibodies that destroy red blood cells are formed in the fetus. C. The client has a history of receiving a transfusion with Rh-negative blood. D. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells.
A. The client's blood does not contain the Rh factor, she she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. If the Rh-negative client has been exposed to Rh-positive fetal blood, she will produce antibodies against Rh factor. These antibodies can cross the placenta and destroy the red blood cells of the Rh-positive fetus. This accelerated rate of red blood cell destruction results in the increased release of bilirubin. The newborn's serum bilirubin level can rise quickly.
A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which is a correct interpretation of this finding? A. Variable decelerations are due to umbilical cord compression B. Variable decelerations are caused by uteroplacental insufficiency C. Variable decelerations are a result of the administration of IV narcotic analgesics. D. Variable decelerations are related to fetal head compression.
A. Variable decelerations are due to umbilical cord compression Variable decelerations are decreases in the fetal heart rate with an abrupt onset, followed by a gradual return to baseline. Variable decelerations coincide with umbilical cord compression, which decreases the oxygen supply to the fetus.
A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles? A. Vastus lateralis B. Ventrogluteal C. Dorsogluteal D. Deltoid
A. Vastus lateralis The nurse should administer vitamin K, or phytonadione, into the vastus lateralis muscle in the thigh. This medication prevents and treats hemorrhagic disease of the newborn, as newborns are born with vitamin K deficiency.
A nurse is on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take? A. Decrease the rate of infusion of the maintenance IV solution. B. Discontinue the infusion of the IV oxytocin. C. Increase the rate of infusion of the IV oxytocin. D. Slow the client's rate of breathing.
B. Discontinue the infusion of the IV oxytocin. Discontinue the oxytocin infusion immediately if a client is experiencing late decelerations due to uterine hyperstimulation.
A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate? A. Moderate lochia rubra B. Fundus three fingerbreadths above the umbilicus C. Moderate swelling of the labia D. Blood pressure 130/84 mmHg
B. Fundus three fingerbreadths above the umbilicus A full bladder can raise the level of uterine fundus and possibly deviate it to the side.
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? A. Begin phototherapy B. Initiate early feeding C. Suction excess mucus with bulb syringe D. Prepare for an exchange blood transfusion
B. Initiate early feeding 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 nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make? A. "There is no need to worry about that. Most forms of hearing loss are not inherited." B. "Look at how she looks at you when you speak. That's a good sign." C. "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." D. "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles."
C. "We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." Most states mandate hearing screening for all newborns. The two tests in use do not diagnose hearing loss, but determine whether or not a newborn requires further evaluation.
A nurse is caring for a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis? A. Swelling in both breasts B. Cracked and bleeding nipples C. Red and painful area in one breast D. A white patch on a nipple
C. Red and painful area in one breast 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 12hr postpartum and received spinal anesthesia for a cesarean birth. Which of the following findings requires immediate intervention by the nurse? A. Blood pressure 100/70 mmHg B. Headache pain rated 6 on a scale of 0 to 10 C. Respiratory rate 10/min D. Urinary output 30mL/hr
C. Respiratory rate 10/min 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.