OB ATI Assessment B
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication?
Flaccid uterus is correct. Oxytocin increases the contractility of the uterus. Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding Wrong Cervical laceration is incorrect. Bleeding resulting from a cervical laceration continues even when the uterus is contracted and firm. It will require repair by the provider. Increased maternal temperature is incorrect. The use of oxytocin will have no effect on maternal temperature.
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.
The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.
A nurse is reviewing the laboratory report of a newborn who is 24hr old. Which of the following results should the nurse report to the provider?
Blood glucose 30 mg/dL MY ANSWER Newborns less than 24 hr old should have a blood glucose of 40 to 60 mg/dL. Newborns who are greater than 24 hr old should have a blood glucose of 50 to 90 mg/dL. A blood glucose level of 30 mg/dL is below the expected reference range for a newborn who is 24 hr old and should be reported to the provider. Wrong Hgb 20 g/dL This value is within the expected reference range of 14 to 24 g/dL for a newborn who is 24 hr old. Total bilirubin 5 mg/dL This value is within the expected reference range of 2 to 6 mg/dL for a newborn who is 24 hr old. WBC count 20,000/mm3 This value is within the expected reference range of 9,000 to 30,000/mm3 for a newborn who is 24 hr old.
A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching.
"You can share your room with your baby for the next few weeks." MY ANSWER The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome. Wrong "Cover your baby with a light blanket while sleeping." The nurse should instruct the parents to place the newborn in a sleep sack or a one-piece sleeper. Covering the newborn with a blanket or quilt increases the risk for sudden infant death syndrome. "Check the temperature of your baby's bath water with your hand." The nurse should instruct the parents to check the temperature of the newborn's bath water with their elbow, which is more sensitive to temperature than the hand. The hot water heater should be set at or below 49° C (120.2° F) to prevent burns. "Your baby can nap in the car seat during the daytime." The nurse should instruct the parents to lay the newborn in a bassinet or crib on her back to sleep. Sleeping in a supine position on a firm mattress decreases the risk of sudden infant death syndrome.
A nurse is teaching a client who is at 24 wks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?
"A blood glucose of 130 to 140 is considered a positive screening result." MY ANSWER The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus. Wrong "You will need to fast for 12 hours prior to the test." The nurse should instruct the client that fasting is not required for a 1-hr glucose tolerance test. "Limit your carbohydrate intake for 3 days prior to the test." The nurse should instruct the client that she should not limit her carbohydrate intake. "You will need to drink the glucose solution 2 hours prior to the test." The nurse should instruct the client to drink the glucose solution 1 hr prior to the test.
A nurse is teaching a client who is Rh negative about Rh0 (D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
"I will need this medication if I have an amniocentesis." MY ANSWER Rho(D) immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation. Wrong "I will need a second dose of this medication when my baby is 6 weeks old." Rho(D) immune globulin is administered at 28 weeks of gestation to clients who are Rh-negative and following the birth of a newborn who is Rh-positive. "I will receive this medication when I am in labor." Rho(D) immune globulin is administered at 28 weeks of gestation or after birth if the newborn is Rh-positive. "I will receive this medication if my baby is Rh-negative." Rho(D) immune globulin is administered to a client who is Rh-negative and gives birth to an Rh-positive newborn.
A nurse is teaching a client who is at 36 wks of gestation and has a rx for NST. Which of the following statements should the nurse include in the teaching?
"You will be offered orange juice to drink during the test." A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate fetal movements during the procedure, helping to obtain results. Wrong "You will receive IV fluids prior to this test." The nurse should state that IV fluids are initiated for an oxytocin-stimulated contraction test, rather than a nonstress test. "The procedure will take approximately 10 to 15 minutes." The nurse should instruct the client that the procedure will take 20 to 40 min. "You will need to sign an informed consent form each time you have this test." A nonstress test is a noninvasive procedure. Therefore, the client does not need to provide informed consent.
A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse include in the plan of care for lactation suppression?
Apply cabbage leaves to the breasts. MY ANSWER Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement. Wrong Place warm, moist packs on the breasts. The client can use cold compresses to decrease breast discomfort during lactation suppression. Wear a loose-fitting bra. A tight-fitting bra will provide support to the breasts during engorgement, which can decrease pain. Put green tea bags on the breasts. Tea bags are used to relieve nipple soreness in breastfeeding clients.
A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8cm and reports back pain. Which of the following actions should the nurse take?
Apply sacral counterpressure. MY ANSWER The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position. Wrong Perform transcutaneous electrical nerve stimulation (TENS). The nurse should perform TENS during the first stage of labor. Initiate slow-paced breathing. The nurse should transition a client to pattern-paced breathing during this stage of labor. Assist with biofeedback. The nurse should teach the client about biofeedback during the prenatal period for it to be effective during labor.
A nurse is reviewing lab results of a newborn who is 4hr old. Which fo the following findings should the nurse report to the provider?
Bilirubin 9 mg/dL MY ANSWER A bilirubin level of 9 mg/dL is above the expected reference range for a newborn who is 4 hr old. The expected reference range for a newborn who is less than 24 hr old is 2 to 6 mg/dL. The nurse should report this finding to the provider. Wrong Hemoglobin 18 g/dL This hemoglobin level is within the expected reference range of 14 to 24 g/dL for a newborn and does not require reporting. Platelets 175,0000/mm3 This platelet count is within the expected reference range of 150,000 to 300,000/mm3 for a newborn and does not require reporting. Hematocrit 45% This hematocrit level is within the expected reference range of 44% to 64% for a newborn and does not require reporting.
A nurse is caring for a client who is at 41 wk of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client.
Biophysical profile (BPP) MY ANSWER The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. Wrong Amnioinfusion An amnioinfusion of normal saline or lactated Ringer's is instilled into the amniotic cavity through a transcervical catheter introduced into the uterus to supplement the amount of amniotic fluid. The instillation reduces the severity of variable decelerations caused by cord compression for clients who are in labor. This is not a diagnostic test used for clients who have a positive contraction stress test. Percutaneous umbilical blood sampling Percutaneous umbilical blood sampling, commonly called cordocentesis, is the most common method used for fetal blood sampling and transfusion. This is not a diagnostic test used for clients who have a positive contraction stress test. Chorionic villus sampling (CVS) CVS is the assessment of a portion of the developing placenta, which is aspirated through a thin sterile catheter inserted through the abdominal wall or intravaginally through the cervix under ultrasound guidance. This procedure is done during the first trimester. This is not a diagnostic test used for clients who have a positive contraction stress test.
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication the the newborn is experience pain.
Chin quivering MY ANSWER Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow. Wrong Decreased heart rate The heart rate will increase when a newborn is experiencing pain. Pinpoint pupils When experiencing pain, a newborn's pupils typically dilate. Slowed respirations When experiencing pain, a newborn's respirations are typically rapid and shallow.
A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's hx should the nurse recognize as a contraindication to oral contraceptives
Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives. Wrong Anxiety disorder is incorrect. The presence of an anxiety disorder is not a contraindication for the use of oral contraceptives. Human papillomavirus is incorrect. The presence of human papillomavirus is not a contraindication for the use of oral contraceptives.
A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?
Cover the newborn's eyes while under the phototherapy light. Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light. Wrong Keep the newborn in a shirt while under the phototherapy light. It is acceptable for the nurse to keep a diaper or other covering over the newborn's genitals and buttocks, but the nurse should remove all other clothing and blankets to expose as much body surface area as possible to the phototherapy light. Apply a light moisturizing lotion to the newborn's skin. The nurse should not apply any cream or moisture to the newborn's skin because it can absorb heat and cause burns. Turn and reposition the newborn every 4 hr while undergoing phototherapy.MY ANSWERThe nurse should turn and reposition the newborn every 2 to 3 hr to allow for maximum exposure of body surfaces to the phototherapy light.
A nurse is assessing a client who is 10 days postpartum and reports manifestations of mastitis. Which of the following findings should the nurse identify as a manifestation of this condition?
Erythema on the breast MY ANSWER Manifestations of mastitis include fever, aches, chills, headaches, and erythema. Erythema can be detected by palpating for warmth; in some clients the skin might appear reddened. Wrong A small white pearl visible on the tip of the nipple A small white pearl on the nipple tip is a manifestation of a plugged duct. This pearl is a curd of milk blocking the milk duct. Breast engorgement Breast engorgement is not a manifestation of mastitis. Temperature 37.7° C (99.9° F) A temperature of 37.7° C (99.9° F) is within the expected range for a client who is postpartum.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions the nurse take?
Have calcium gluconate readily available. MY ANSWER The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity. Wrong Restrict hourly fluid intake to 150 mL/hr. The nurse should restrict hourly fluid intake to no more than 125 mL/hr. The client's urine output should be 30 mL/hr or greater. Assess deep tendon reflexes every 6 hr. The nurse should assess deep tendon reflexes every 1 to 4 hr during continuous infusion of magnesium sulfate. Monitor intake and output every 4 hr. The nurse should monitor intake and output hourly for clients who are receiving a continuous infusion of magnesium sulfate.
A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider. Which of the following actions should the nurse take next?
Massage the client's fundus. MY ANSWER The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions. Wrong Insert an indwelling urinary catheter. The nurse should insert an indwelling urinary catheter to monitor perfusion of the kidneys. However, this is not the next action the nurse should take. Administer oxygen at 10 L/min. The nurse should administer oxygen at 10 L/min via rebreather face mask to enhance perfusion. However, this is not the next action the nurse should take. Administer oxygen at 10 L/min. The nurse should administer oxygen at 10 L/min via rebreather face mask to enhance perfusion. However, this is not the next action the nurse should take. Elevate the client's right hip. The nurse should elevate the client's right hip to enhance perfusion. However, this is not the next action the nurse should take.
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution. Wrong Place the client in a supine position for 30 min following the first dose of anesthetic solution. The nurse should plan to position the client upright to allow the anesthetic solution to flow downward. If additional pain management is needed for a cesarean birth, the nurse can place the client supine with her head and shoulders elevated and at a lateral tilt to increase perfusion to the fetus. Place the client in a supine position for 30 min following the first dose of anesthetic solution. The nurse should plan to position the client upright to allow the anesthetic solution to flow downward. If additional pain management is needed for a cesarean birth, the nurse can place the client supine with her head and shoulders elevated and at a lateral tilt to increase perfusion to the fetus. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution. The nurse should not plan to restrict the client's intake prior to the epidural placement and the first dose of anesthetic solution because NPO status is not indicated for this procedure.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following is an indication for fetal assessment using electronic fetal monitoring?
Oligohydramnios MY ANSWER The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis. Wrong Hyperemesis gravidarum Hyperemesis gravidarum is not an indication for further fetal assessment using electronic fetal monitoring unless complications occur. Leukorrhea Leukorrhea is a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring unless complications occur. Periodic tingling of the fingers Periodic tingling of the fingers is a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring.
A nurse is reviewing the medical history of a client who is at 30 weeks of gestation and has a prescription for terbutaline. Which of the following conditions should the nurse identify as a contraindication for the administration of terbutaline?
Preeclampsia Preeclampsia, cardiac disease, gestational diabetes, and severe gestational hypertension are all contraindications for the administration of terbutaline. The nurse should notify the provider of the client's condition. Wrong Hypothyroidism MY ANSWER Hypothyroidism is not a contraindication for the administration of terbutaline. Hypothyroidism MY ANSWER Hypothyroidism is not a contraindication for the administration of terbutaline. Rheumatoid arthritis Rheumatoid arthritis is not a contraindication for the administration of terbutaline.
A nurse is calculating a client's expected DOB using Nageles rule. The client tells the nurse that her last menstrual cycle started on Nov. 27th. Which of the following dates is the client's expected DOB.
September 3rd When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd. Wrong September 20th When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. Therefore, the correct date is September 3rd. August 3rd When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. Therefore, the correct date is September 3rd. August 20th MY ANSWER When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. Therefore, the correct date is September 3rd.
A nurse is caring for a newborn who was transferred to the nursery 30 min after brith because of mild respiratory distress. Which of the following actions should the nurse take first?
Verify the newborn's identification. MY ANSWER When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery. Wrong Confirm the newborn's Apgar score. The Apgar score is a physiological assessment that occurs 1 min following birth and again at 5 min. The nurse should confirm the score when the newborn arrives in the nursery. However, there is another action the nurse should take first. Administer vitamin K to the newborn. The nurse should administer IM vitamin K to the newborn soon after birth to increase clotting factors and prevent bleeding. However, the injection can be delayed until after initial bonding time and the first breastfeeding if necessary. Therefore, there is another action the nurse should take first. Determine obstetrical risk factors. The nurse should identify obstetrical risk factors to determine if interventions are required for the newborn. However, there is another action the nurse should take first.
A nurse is preparing to administer medroxyprogresterone to a client. Which of the following actions should the nurse plan to take?
Vigorously shake the contents of the vial before drawing up the dosage of medication The vial of medication should be vigorously shaken before drawing up the dose to ensure a uniform suspension of the medication. Wrong Massage the injection site for 15 seconds after administration Massaging the site after administration can hasten the absorption of the medication and decrease the length of effectiveness of the contraception. Administer the medication every 4 to 6 weeks after a menstrual cycle The medication should be administered every 11 to 13 weeks during the first five days of the menstrual cycle. Teach the client that fertility returns within one month of stopping this medication MY ANSWER Fertility can be impaired for up to 18 months after stopping this medication.
A nurse is teaching a client who is 2 hr postpartum and had a midline episiotomy. Which of the following instructions should the nurse include in the teaching?
"Fill the sitz bath half full with water." The nurse should instruct the client to fill the sitz bath one-half to one-third full with water. Wrong "Use the sitz bath once daily." The nurse should instruct the client to use the sitz bath at least twice daily for 20 min. "Cleanse your perineum with an iodine solution after voiding." MY ANSWER The nurse should instruct the client to cleanse the perineum with warm water and mild soap at least twice daily. "Change your perineal pad three times per day." The nurse should instruct the client to change the perineal pad after voiding or defecation or at least four times daily.
A nurse is teaching a client who has pre-gestational type 1 DM about management during pregnancy. Which of the following statements by the client indicates and understanding of the teaching.
"I will continue taking my insulin if I experience nausea and vomiting." The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes. Wrong "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." The nurse should teach the client to avoid exercise during periods of hyperglycemia and when positive urine ketones are present. "I should have a goal of maintaining my fasting blood glucose between 100 and 120." MY ANSWER The nurse should teach the client to maintain her fasting blood glucose level between 60 and 99 mg/dL. "I will ensure that my bedtime snack is high in refined sugar." The nurse should teach the client to avoid snacks and foods that are high in refined sugar.
A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicated an understanding of the teaching?
"I will have blood tests because my potassium might decrease." An adverse effect of terbutaline is hypokalemia. Wrong "I will get injections of the medication once daily until my labor stops." MY ANSWER Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr. "My blood sugar may be low while I'm on this medication." An adverse effect of terbutaline is hyperglycemia. "My blood pressure may increase while I'm on this medication." An adverse effect of terbutaline is hypotension.
A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?
"Staff members who take care of your baby will be wearing a photo identification badge." MY ANSWER The nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs. Wrong "Your baby will stay in the nursery while you are asleep." The nurse should instruct the client to place the baby in the bassinet on the side of the bed furthest from the door while she is sleeping. "We will document the relationship of visitors in your medical record."The nurse should instruct the client that they can have anyone visit them on the unit. There is no documentation of a visitor's relationship to the client entered into the medical record. "The nurse will carry your newborn to the nursery for procedures." The nurse should instruct the client that newborns will be transported in their bassinets and never carried outside the client's room to reduce the risk for falls.
A nurse is providing teaching for a postpartum client who has a new prescription for carboprost thromethamine. Which of the following statements should the nurse make?
"This medication can cause diarrhea." Carboprost tromethamine is a medication given to control postpartum bleeding and prevent hemorrhage by causing uterine contractions and vasoconstriction. Adverse effects include diarrhea, nausea, vomiting, headache, tachycardia, hypertension, fever, and chills. Wrong "This medication will make you sleepy." MY ANSWER Carboprost tromethamine is a medication given to control postpartum bleeding and prevent hemorrhage by causing uterine contractions and vasoconstriction. Adverse effects include diarrhea, nausea, vomiting, headache, tachycardia, hypertension, fever, and chills. "This medication will be given by mouth." Carboprost tromethamine is a medication given that is administered intramuscularly or intrauterine. "This medication can cause a decrease in your blood pressure." Carboprost tromethamine is a medication given to control postpartum bleeding and prevent hemorrhage by causing uterine contractions and vasoconstriction. Adverse effects include diarrhea, nausea, vomiting, headache, tachycardia, hypertension, fever, and chills.
A nurse is caring for a client who is experience preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration?
"This medication stimulates fetal lung maturity." MY ANSWER The nurse should inform the client that betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of enzymes that release lung surfactant. Wrong "This medication will stop your labor." Betamethasone is not a tocolytic and does not stop labor. "This medication will decrease your risk for uterine infections." Betamethasone is not given to decrease the client's risk for uterine infections. "This medication will increase your baby's weight." Betamethasone does not increase fetal weight.
A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, "What effects will this procedure have on my sex life?"
"This procedure should have no effect on your sexual performance or adequacy." MY ANSWER The nurse is giving the client the information she is seeking. Sexual function depends on various hormonal and psychological factors. Therefore, tubal occlusion should have no physiological effect on sexual function. Wrong "I think that is something you should discuss with your doctor." The nurse is dismissing the client's question, providing no information to help the client make an informed decision. "You'll be fine. I can't imagine you and your partner will have any problems with sexual function." The nurse is giving the client unwarranted reassurance without addressing the information the client is seeking. "If this concerns you, perhaps you should reconsider and use another form of contraception." The nurse is giving the client unwarranted advice which might imply that there is a reason to be concerned about the effect of the procedure on sexual function.
A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following response should the nurse make?
"You can miss your period for several other reasons. Describe your typical menstrual cycle." Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions. Wrong "If you have been sexually active and haven't used protection, it is likely that you are pregnant." The nurse's response is assuming and confirming that the client is pregnant based only on the client's statement, which can increase the client's anxiety level. "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" MY ANSWER The nurse's response is making a false assumption that the client is pregnant based only on the client's statement. The nurse should gather more information from the client before making any false assumptions. "Because you have missed your period, you should try taking a home pregnancy test before you start worrying." The nurse's response dismisses the client's concerns and does not answer or address the client's question, which can increase the client's anxiety level.
A nurse is teaching a client who is at 8wks of gestation about nutrition during pregnancy. Which of the following statements should the nurse include in the teaching?
"You should consume 6 ounces of protein foods daily." MY ANSWER The nurse should instruct the client to consume 5.5 to 6.5 oz of protein foods each day. The client should select high-protein foods, such as legumes, nuts, eggs, and lean meat or poultry. Wrong "You should consume 6 ounces of protein foods daily." MY ANSWER The nurse should instruct the client to consume 5.5 to 6.5 oz of protein foods each day. The client should select high-protein foods, such as legumes, nuts, eggs, and lean meat or poultry. "You should consume 4 ounces of grains each day." The nurse should instruct the client to consume 6 to 8 oz of grains. The client should consume at least half of the servings as whole grains. "You should consume 2 cups of milk daily." The nurse should instruct the client to consume 3 cups of dairy daily. It is best to select fat free or low fat dairy products.
A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching?
"You should leave the diaphragm in place for at least 6 hours after intercourse." MY ANSWER The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy. Wrong "You should replace the diaphragm every 5 years." The client should replace the diaphragm every 2 years. "You should use an oil-based product as a lubricant when inserting the diaphragm." The client should avoid using oil-based products because they can weaken the rubber in the diaphragm. "You should insert the diaphragm when your bladder is full." The client should have an empty bladder prior to inserting the diaphragm.
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
"You should take the medication within 72 hours following unprotected sexual intercourse." MY ANSWER Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse. Wrong "You should avoid taking this medication if you are on an oral contraceptive." Levonorgestrel, an emergency contraceptive, has no effect on the other oral contraceptive the adolescent might be taking. To prevent pregnancy, this medication should be taken if an adolescent misses a dose of oral contraception. "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test." The adolescent should be evaluated for pregnancy if she does not menstruate within 21 days following administration of this medication. "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it." Levonorgestrel is an emergency contraceptive that prevents or delays ovulation. Therefore, the nurse should inform the client that she will not be protected from pregnancy if she has unprotected sexual intercourse in the days and weeks after receiving this medication.
A nurse is discussing prenatal care with a primigravida client at her fist prenatal visit. Which fo the following statements should the nurse make?
"You will have a group B streptococcus culture at 35 weeks of your pregnancy." The nurse should instruct the client to expect a culture of the vagina and rectum to test for group B streptococcus (GBS) between 35 and 37 weeks of pregnancy. Wrong "You should feel your baby moving at 12 weeks." MY ANSWER The nurse should inform the client that quickening, or feeling fetal movement, occurs between 16 and 20 weeks of gestation. "You should expect your blood glucose level to be checked during each visit." The nurse should inform the client that screening for gestational diabetes will occur between 24 and 28 weeks of gestation. "You will have an appointment every other week starting at 36 weeks of gestation." The nurse should instruct the client to expect weekly scheduled appointments with the provider from 36 weeks of gestation until the birth of the baby.
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching.
"Your baby can nap in the car seat during the daytime." The nurse should instruct the parents to lay the newborn in a bassinet or crib on her back to sleep. Sleeping in a supine position on a firm mattress decreases the risk of sudden infant death syndrome. Wrong "I will avoid having a snack before I go to bed each night." MY ANSWER Clients who have hyperemesis gravidarum should avoid going to bed with an empty stomach. The nurse should instruct the client to eat a healthy snack before going to bed. "I will have a cup of hot tea with each meal." Clients who have hyperemesis gravidarum should alternate liquids and solids every 2 to 3 hr to avoid an empty stomach and over filling at each meal. "I will eliminate products that contain dairy from my diet." Clients who have hyperemesis gravidarum do not need to eliminate dairy products from their diet. The client should be encouraged to consume dairy products, because they are less likely to cause nausea than other foods.
A nurse is caring for a client who is active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make?
"Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions." MY ANSWER Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, frequency, and duration which will identify whether the contractions are adequate for progression of labor. Wrong "I will give you some IV pain medicine to strengthen your contractions." Administering IV pain medication can decrease the intensity of uterine contractions. "I am going to call the doctor to get a prescription for medication to ripen your cervix."A cervical ripening agent is not used during the active stage of labor. "Let me help you into a comfortable pushing position so you can begin bearing down." The nurse should not instruct the client to start bearing down until the second stage of labor.
A nurse an an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
A client who is at 34 weeks of gestation and reports epigastric pain When using the urgent vs nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority. Wrong A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL A fasting blood glucose of 120 mg/dL is above the expected reference range for a client who has gestational diabetes, which is a nonurgent finding. Therefore, another client is the nurse's priority. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL MY ANSWER This finding is a manifestation of anemia in a client who is pregnant, which is a nonurgent condition. Therefore, another client is the nurse's priority. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria Dysuria can indicate a urinary tract infection, which can cause preterm labor. Dysuria in a client who is at 39 weeks of gestation is a nonurgent condition which will require antibiotics. Thereofre, another client is the nurse's priority.
A nurse is reviewing lab results for a client who is at 10wk of gestation which of the following labs should the nurse report to the provider?
A hemoglobin level of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this laboratory finding to the provider. Wrong WBC count 15,000/mm3MY ANSWERThis white blood cell count is within the expected reference range of 5,000 to 15,000/mm3 for a client who is pregnant. This finding is does not require reporting. RBC count 5.8 million/mm3 This red blood cell count is within the expected reference range of 5 to 6.25 million/mm3 for a client who is pregnant and does not require reporting. This count increases by 20% to 30% during pregnancy. Hematocrit 34% This hematocrit is within the expected reference range of greater than 33% for a client who is pregnant and does not require reporting.
A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking hold phase of postpartum behavioral adjustment?
A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking hold phase of postpartum behavioral adjustment? Wrong Listen to the client and her partner as they reflect upon the birth experience. MY ANSWER Listening to the client and her partner reflect upon the birth experience occurs during the taking-in phase. During this phase, the new mother is focused on herself and meeting her basic needs. There is also much excitement about the newborn and the birth experience. Therefore, the nurse should allow the client to reflect, ensuring a healthy transition and a successful adaptation into the new family unit. Repeat information to ensure client understanding. The repeating of information to ensure client understanding occurs during the taking-in phase. During this phase, which is experienced on the first postpartum day, the client displays dependent and passive behaviors. Due to excitement and fatigue, the client is unable to retain information. Therefore, the nurse should repeat instructions to ensure that the client understands what is being said. Discuss contraceptive options with the client and her partner. The discussing of contraceptive options occurs during the letting-go phase. This phase focuses on moving forward as a family with interchanging members.
A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chard findings and documentation, the nursing plan of care should include which of the following actions.
Administer terbutaline. MY ANSWER The nurse should administer terbutaline to stop contractions because the laboratory results indicate that the fetus's lungs are not mature enough for birth. Wrong Discuss possible genetic anomalies with the client. There is no indication of genetic anomalies based on the results of the amniocentesis. Administer nalbuphine. Nalbuphine is an analgesic used for moderate to severe pain. A report of 2 on a scale of 0 to 10 is mild pain. Discontinue external fetal monitoring. The nurse should not discontinue external fetal monitoring. Because the client is exhibiting manifestations of preterm labor, fetal well-being and contraction patterns should be continuously monitored to continue to assess for preterm labor and provide necessary interventions to stop contractions.
A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take?
Apply internal upward pressure to the presenting part using two gloved fingers. MY ANSWER Using evidence-based practice, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand. Wrong Place a rolled towel beneath one of the client's hips. The nurse should place a rolled towel under the client's left or right hip to alleviate some of the pressure; however, evidence-based practice indicates that the nurse should take a different action first. Administer oxygen to the client via a nonrebreather mask at 10 L/min. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. The nurse should administer oxygen via a nonrebreather mask at 10 L/min; however, evidence-based practice indicates that the nurse should take a different action first. Increase the IV infusion rate. The nurse should increase the IV infusion rate; however, evidence-based practice indicates that the nurse should take a different action first.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions?
Assist the client to empty her bladder. MY ANSWER The nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage. Wrong Administer simethicone. The nurse should administer simethicone to reduce bloating, discomfort, or pain caused by excessive gas. Reassess the client in 2 hr. The nurse should assess the client more frequently after birth to determine the position of the uterus and to intervene as soon as possible if necessary. Instruct the client to lie on her right side. Lying on her right side will not resolve the client's displaced uterus.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
Decreased platelet count MY ANSWER A client who has ITP has an autoimmune response that results in a decreased platelet count. Wrong Increased erythrocyte sedimentation rate (ESR) An increased ESR is an indication of chronic renal failure. Decreased megakaryocytes A client who has ITP will have megakaryocytes within the expected reference range. Increased WBC An increased WBC is an indication of infection.
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
Determine respiratory function. MY ANSWER The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation. Wrong Increase the IV fluid rate. The nurse should increase the IV fluid rate to maintain circulation. However, this is not the first action the nurse should take. Access emergency medications from cart. The nurse should access emergency medication to assist in resuscitative efforts. However, this is not the first action the nurse should take. Collect a maternal blood sample for coagulopathy studies. The nurse should collect a maternal blood sample in preparation for a blood transfusion. However, this is not the first action the nurse should take.
A nurse is administering oxytocin to a client for augmentation of labor. The nurse observers uterine contractions every 1 to 2 minutes with a duration of 70 to 80 seconds. Which of the following actions should the nurse take?
Discontinue the oxytocin infusion. The nurse should discontinue the oxytocin infusion because more than five contractions in 10 min is indicative of uterine hyperstimulation. This pattern does not allow adequate fetal oxygenation and can cause fetal distress. Wrong Check the client's cervix. MY ANSWER Vaginal examinations are for determining the dilatation and effacement of the cervix, as well as the station of the presenting part of the fetus. There is no indication for the nurse to perform a vaginal examination. Administer misoprostol. The nurse should not administer misoprostol because it is a cervical ripening agent that stimulates uterine contractions. If the client has uterine hyperstimulation requiring tocolysis, the nurse can administer terbutaline subcutaneously. Ambulate the client. The nurse should not ambulate the client during uterine hyperstimulation. During uterine hyperstimulation, placental perfusion can be decreased, resulting in fetal bradycardia. The nurse should assist the client to a side-lying position to increase blood flow to the placenta.
A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, ''happy one min and crying the next.'' The nurse should interpret the client's statement as an indication of which of the following?
Emotional lability MY ANSWER The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason. Wrong Focusing phase The focusing phase is the third phase of the father's emotional response to the pregnancy. It is characterized by his active involvement in the pregnancy and his relationship with the child. Cognitive restructuring Cognitive restructuring is accepting the idea of pregnancy and assimilating it into the woman's life. The degree of acceptance is shown in the mother's emotional responses. Couvade syndrome Couvade syndrome is pregnancy-like manifestations experienced by the expectant father. Manifestations include nausea, weight gain, and other physical manifestations of pregnancy.
A nurse is discussing discomforts that may occur during the first trimester of pregnancy with a client who is at 6 weeks of gestation. Which of the following manifestations should the nurse include?
Epistaxis Nasal stuffiness and epistaxis are common manifestations during the first trimester. Epistaxis is related to increased levels of estrogen. Wrong Pruritus Pruritus is a common manifestation during the second trimester of pregnancy. The cause is unknown but is possibly due to stretching of the skin. Periodic tingling of the fingers Drooping of the shoulders during pregnancy can cause brachial plexus traction syndrome, which results in periodic tingling of the fingers. This is a common manifestation during the second trimester of pregnancy. Heartburn MY ANSWER Heartburn, or pyrosis, is a common manifestation during the second trimester of pregnancy. It is caused by progesterone slowing the motility of the gastrointestinal tract and relaxing of the cardiac sphincter.
A nurse is assessing the newborn of a client who took a SSRI during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI
Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days. Wrong Large for gestational age Low birth weight is an expected manifestation of fetal exposure to SSRIs. Hyperglycemia Hypoglycemia is an expected manifestation of fetal exposure to SSRIs. Bradypnea Tachypnea is an expected manifestation of fetal exposure to SSRIs.
A nurse is caring for a client who is at 22 wks gestation and reports concern about the blotchy hyper pigmentation of her forehead. Which of the following actions should the nurse take?
Explain to the client this is an expected occurrence.MY ANSWER Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery. Wrong An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an increase in the pigmentation of the skin during pregnancy. Treatment by a dermatologist will not affect the client's condition. Instruct the client to increase her intake of vitamin D. An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an increase in the pigmentation of the skin during pregnancy. Increasing her vitamin D intake will not affect the client's condition. Inform the client she might have an allergy to her skin care products. An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an increase in the pigmentation of the skin during pregnancy. Changing skin care products will not affect the client's condition.
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication.
Increased fetal movement Decreased fetal movement is a potential complication that should be reported to the provider. Wrong Leakage of fluid from the vagina MY ANSWER Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider. Upper abdominal discomfort Upper abdominal discomfort is not a potential complication associated with an amniocentesis. Urinary frequency Urinary frequency is not a potential complication associated with an amniocentesis.
A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include?
Place the retainer clip at the level of the newborn's armpits. MY ANSWER The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits. Wrong Place the shoulder harness in the slots above the newborn's shoulders. The nurse should instruct the parents to place the shoulder harness in the slots that are at or just below the newborn's shoulders. Place the newborn at a 60° angle in the car seat. The nurse should instruct the parents to position the newborn at a 45° angle to minimize the risk of airway obstruction from slumping forward. Place the newborn in a blanket before securing them in the car seat. The nurse should instruct the parents to refrain from placing extra padding, including blankets, between the newborn and the straps of the car seat. Extra padding creates air pockets that decrease the effectiveness of the restraint and can lead to injuries.
A nurse is reviewing the electronic medical record for a client who is at 39 weeks of gestation and has a prescription for oxytocin. Which of the following findings is a contraindication for the medication?
Placenta previa MY ANSWER Placenta previa, acute fetal distress, previous uterine incisions that prohibits a trial of labor, and uncontrolled hemorrhaging are contraindications for the administration of oxytocin. Wrong Bishop score of 10 A bishop score is assigned by the provider to evaluate a client's readiness for labor induction. The best predictors for a successful induction is a ripe cervix. A bishop score of 8 or greater indicates the cervix is more favorable for a labor induction. Vertex presentation The fetus should be in the vertex presentation. Fetal heart rate of 120/min A fetal heart rate of 120/min is within the expected reference range and is not a contraindication for the use of oxytocin to induce labor.
A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?
Platelets 50,000/mm3 MY ANSWER A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider. Wrong WBC 9,000/mm3 A WBC of 9,000/mm3 is within the expected reference range and does not indicate a postpartum complication. WBC 9,000/mm3 A WBC of 9,000/mm3 is within the expected reference range and does not indicate a postpartum complication. Hct 39% An Hct of 39% is within the expected reference range and does not indicate a postpartum complication.
A nurse is caring for a client who is at 39 weeks of gestation and is in labor. The fetal monitor tracing reveals a series of late decels. After placing the client in a lateral position, which of the following actions should the nurse take?
Heartburn MY ANSWER Heartburn, or pyrosis, is a common manifestation during the second trimester of pregnancy. It is caused by progesterone slowing the motility of the gastrointestinal tract and relaxing of the cardiac sphincter. Wrong Prepare the client for an amnioinfusion. The nurse should implement an amnioinfusion for a client who is having variable decelerations. This therapeutic procedure is not used for a client who is having late decelerations. Administer oxygen at 2 L/min via nasal cannula. The nurse should administer oxygen at 8 to 10 L/min via nonrebreather face mask to assist with improving fetal oxygenation. Apply fundal pressure. The nurse should not apply fundal pressure, which is gentle steady pressure against the fundus used to facilitate a vaginal birth. Late decelerations indicate fetal hypoxia, and applying fundal pressure does not increase oxygenation to the fetus.
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
Headache that is unrelieved by analgesia MY ANSWER A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider. Wrong Swelling of feet and ankles at the end of the day Swelling of feet and ankles is due to the enlarging uterus interfering with blood return to the heart and is an expected manifestation at 35 weeks of gestation. Shortness of breath when climbing stairs Shortness of breath is related to the enlarging uterus interfering with the expansion of the diaphragm and is an expected manifestation at 35 weeks of gestation. Braxton Hicks contractions Braxton Hicks contractions are an indication that the uterus is preparing for labor and is an expected manifestation at 35 weeks of gestation.
A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa? Which of the following actions should the nurse take?
Initiate continuous external fetal monitoring. MY ANSWER The nurse should identify that a client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor laboratory values. Also, the nurse should implement interventions to prepare for an emergency birth. Wrong Administer betamethasone to the client via IM injection. Betamethasone is given to enhance fetal lung maturity for clients who are experiencing preterm labor. It is given to clients between 24 and 34 weeks of gestation. Instruct the client to ambulate in the hallway once every 4 hr. A client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. Ambulating frequently could potentially stimulate labor and increase vaginal bleeding. Therefore, the nurse should place the client on bed rest with bathroom privileges. Perform a vaginal exam to determine cervical dilation every 2 hr. A client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should place the client on pelvic rest and should not perform vaginal or rectal examinations.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
Instruct the client to press the provided button each time fetal movement is detected. MY ANSWER Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted. Wrong Instruct the client to massage the abdomen to stimulate fetal movement. Massaging the abdomen does not stimulate fetal movement. Place the client in a supine position. The client should be placed in a semi-Fowler's or sitting position and tilted to the right or left to promote uterine perfusion and prevent supine hypotension. Maintain the client NPO throughout the procedure. There is no indication for the client to be NPO. Sometimes clients are encouraged to drink liquids to promote adequate hydration.
A nurse in a woman health clinic is providing teaching about nutritional intake to a client who is at 8wks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients?
Iron MY ANSWER The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old. Wrong Vitamin E The recommendation for vitamin E intake during pregnancy is 15 mg/day, the same as that for women who are not pregnant. Calcium The recommendation for calcium intake during pregnancy is the same as that for women who are not pregnant: 1,300 mg/day for women younger than 19 years old and 1,000 mg/day for women between the ages of 19 and 50 years old. Vitamin D The recommendation for vitamin D intake during pregnancy is 600 IU/day, the same as that for women who are not pregnant.
A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following should the nurse expect?
Jitteriness MY ANSWER Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia. Wrong Hypertonia Hypotonia, rather than hypertonia, is a manifestation of hypoglycemia. Hypertonia is a manifestation of opioid withdrawal. Abdominal distention Abdominal distention is not a manifestation of hypoglycemia. Abdominal distention is a finding in newborns who have hypocalcemia. Mottling Mottling is not a manifestation of hypoglycemia. It can be a normal variation seen in newborns. Also, it is a manifestation of opioid withdrawal.
A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the doppler ultrasound stethoscope in which fo the following locations to being assessing the fetal heart tones?
Just above the symphysis pubis At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis. Wrong Just above the umbilicus MY ANSWER The nurse should assess FHT using the Doppler stethoscope just above the umbilicus if the fetus is in a transverse or breech presentation and the client is at a minimum of 22 weeks of gestation. The right lower quadrant At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse might not hear FHT in the right lower quadrant. The left lower quadrant At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse might not hear FHT in the left lower quadrant.
A nurse is assessing FHR for a client who is preg. The nurse has determined as left occipital anterior (LOA). To which of the following areas of the clients abdomen should the nurse apply the ultrasound transducer in order to assess the PMI of the fetal heart?
Left lower quadrant MY ANSWER The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant. Wrong Right upper quadrant The fetal heart tones of a fetus in the right sacrum anterior position are best heard in the right upper quadrant. Left upper quadrant The fetal heart tones of a fetus in the left sacrum anterior position are best heard in the left upper quadrant. Right lower quadrant The fetal heart tones of a fetus in the right occipital anterior position are best heard in the right lower quadrant.
A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which of the following findings should the nurse instruct the client to notify provider?
Shortness of breath The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain. Wrong Breakthrough bleeding MY ANSWER Breakthrough bleeding outside the menstrual period is a common adverse effect of combined oral contraceptives. Vomiting Nausea and vomiting are common adverse effects of combined oral contraceptives. Breast tenderness Breast tenderness is a common adverse effect of combined oral contraceptives.
A nurse is teaching a new mother how to use a bulb syringe to suctio her newborn's secretions. Which of the following instructions should the nurse take?
Stop suctioning when the newborn's cry sounds clear. MY ANSWER The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus. Wrong Insert the tip of the syringe into the center of the newborn's mouth. The client should insert the tip of the syringe into the side of the newborn's mouth. Inserting it into the center of the newborn's mouth can trigger the gag reflex. Suction each of the nares before suctioning the mouth. The client should suction the mouth before suctioning the nares. Otherwise, the newborn could gasp and inhale pharyngeal secretions when the syringe tip touches the nares. Insert the syringe tip before compressing the bulb. The client should compress the bulb before inserting the syringe tip. Compressing the bulb after it is in the newborn's nares or mouth could push the secretions and mucus further inside.
A nurse is assessing a newborn who is 12hr old. Which of the following clinical s/s requires intervention by the nurse?
Substernal chest retractions while sleeping MY ANSWER Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This manifestation requires further assessment and intervention by the nurse. Wrong Acrocyanosis of the extremities Acrocyanosis of the extremities is an expected manifestation in newborns. Acrocyanosis is a bluish discoloration of the newborn's hands and feet. Murmur at the left sternal border An audible murmur heard at the left sternal border is an expected manifestation in newborns. Positive Babinski reflex A positive Babinski reflex is an expected manifestation in newborns. This reflex is elicited when a newborn's sole is stroked with a finger upward along the lateral aspect of the sole and then across the ball of the foot and, in response, the toes hyperextend, and the large toe dorsiflexes.
A nurse is assessing a client who is at 30 wks gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
Swelling of the face MY ANSWER Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema. Wrong Varicose veins in the calves Varicose veins are an expected finding in the second trimester. The increase in hormones during pregnancy causes the relaxation of the smooth muscle of the vascular system, leading to vessel dilation and vasocongestion. Additionally, the weight of the enlarging uterus on the pelvic veins decreases the return of blood from the lower extremities. Nonpitting 1+ ankle edema Nonpitting edema of the lower extremities is an expected finding in the third trimester. Warm weather, sitting or standing for prolonged periods of time, and tight clothing can increase edema. Hyperpigmentation of the cheeks Hyperpigmentation of the cheeks, areola, vulva, and linea nigra are expected findings in the second trimester. The anterior pituitary increases the production of melanocyte-stimulating hormone, which leads to hyperpigmentation of the skin.
A nurse is planning care for a client who is in labor and is to have an aminotomy following assessment the nurse identify as the priority?
Temperature The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature. Wrong O2 saturation Assessing the client's O2 saturation is important during labor. However, another assessment is the nurse's priority. Blood pressure MY ANSWER Assessing the client's blood pressure is important. However, another assessment is the nurse's priority. Blood pressure MY ANSWER Assessing the client's blood pressure is important. However, another assessment is the nurse's priority.
A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of spina bifida occulta?
The nurse should identify this as an image of spina bifida occulta. External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area. Wrong The nurse should identify this as an image of spina bifida manifesta in the form of a myelomeningocele that is closed. External indications of this neural tube defect include a herniated sac over the site of the defect that is covered with skin. The nurse should identify this as an image of spina bifida manifesta in the form of a myelomeningocele that is open. External indications of this neural tube defect include an open area over the defect that allows for leakage of cerebrospinal fluid and entry of microorganisms. The nurse should identify this as an image of Mongolian spots. These bluish-black pigmented areas are most commonly found on the buttocks and back of newborns of Mediterranean, Asian, African, and Latin American ethnicity and can be incorrectly identified as areas of ecchymosis.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. She has experience contractions 2 to 3 minutes apart, each lasting 80 to 90 seconds, and a a vaginal examination reveals that her cervix is dilated to nine centimeters. The nurse should identify that the client is in which of the following phases of Labor?
Transition MY ANSWER The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds. Wrong Active The active phase of labor is characterized by a cervical dilatation of 4 to 7 cm and contractions every 3 to 5 min, each lasting 40 to 70 seconds. LatentThe latent phase of labor is characterized by cervical dilation of 0 to 3 cm and contractions every 5 to 30 min, each lasting 30 to 45 seconds. Descent The descent phase of labor is characterized by active pushing with contractions every 1 to 2 min, each lasting for 90 seconds.
A nurse is providing discharge teaching to a client who is postpartum. For which of the following manifestations should the nurse instruct the client to monitor and report to the provider?
Unilateral breast pain Sudden onset of chills, fever, malaise, body aches, headaches, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this manifestation to the provider. Wrong Temperature 37.8° C (100° F) MY ANSWER The nurse should instruct the client to report a temperature of 38° C (100.4° F) or higher because it could be an indication of infection. Persistent abdominal striaePersistent abdominal striae are caused by the separation of the underlying connective tissue and are an expected postpartum finding. Brownish-red discharge on day 5 Brownish-red discharge is an expected manifestation during days 3 to 10. The client should report a large amount of lochia and large clots to the provider.
