OB Passpoint Final

The nurse is developing a care plan for a client with an episiotomy. Which interventions would be included for the nursing diagnosis acute pain related to perineal sutures? Select all that apply. Apply an ice pack intermittently to the perineal area for 3 days. Avoid the application of topical pain gels. Administer sitz baths three to four times per day. Encourage the client to do Kegel exercises. Limit the number of times the perineal pad is changed.

Administer sitz baths three to four times per day. Encourage the client to do Kegel exercises.

The nurse is caring for a client who has just been admitted with suspected placenta previa and bloody discharge. After assessing vital signs and applying an external monitor, what is the priority action by the nurse? Insert an indwelling urinary catheter. Plan for an immediate cesarean birth. Place the client in Trendelenburg position. Draw bloodwork for complete blood count and typing.

Draw bloodwork for complete blood count and typing.

A client who is at 35 weeks' gestation arrives at a labor and delivery unit leaking clear fluid from her vagina. What is the most appropriate nursing intervention? Perform a cervical examination and check dilation. Obtain a catheterized urine specimen to rule out urinary tract infection. Encourage the client to ambulate in the hall. Obtain a sterile speculum sample of the fluid for culture.

Obtain a sterile speculum sample of the fluid for culture.

Following a cesarean birth, what should the nurse do first?

PALPATE THE FUNDUS!

A nurse observes several interactions between a client and her neonate. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply. She talks and coos to her neonate. She cuddles her neonate close to her. She does not make eye contact with her neonate. She requests that the nurse take the neonate to the nursery for feedings. She counts the fingers and toes of her neonate. She takes a nap when the neonate is also sleeping.

She talks and coos to her neonate. She cuddles her neonate close to her. She counts the fingers and toes of her neonate.

A 30-year-old multigravid client at 8 weeks' gestation has a history of insulin-dependent diabetes since age 20. When explaining about the importance of blood glucose control during pregnancy, the nurse should tell the client that what will occur regarding the client's insulin needs during the first trimester? They typically increase slightly. They may decrease. They will remain constant. They often double.

They will decrease

A client at 29 weeks' gestation who has been diagnosed with severe preeclampsia is noted to have a blood pressure of 170/112 mm Hg, 4+ proteinuria, and a weight gain of 10 lb (4.5 kg) over the past 2 days. Which instruction(s) from the healthcare provider would the nurse question? Select all that apply. Weigh the client weekly. Have the client eat a low-protein diet. Order labetalol 200 mg twice a day. Administer magnesium sulfate 2 g/hour. Maintain bed rest.

Weigh the client weekly. Have the client eat a low-protein diet.

A client comes to the healthcare provider's office for a routine prenatal visit. The client is G1 Para 0 and is 22 weeks' gestation. What assessments would the nurse perform on this client? Select all that apply. blood pressure urine dipstick measure fundal height 1-hour glucose tolerance test weight

blood pressure urine dipstick measure fundal height weight

During a home visit, a breastfeeding client asks the nurse what contraception method they should use until their 6-week postpartum examination. Which method would be most appropriate for the nurse to suggest? condom with spermicide oral contraceptives rhythm method abstinence

condom with spermicide

A pregnant client at 32 weeks' gestation has mild preeclampsia. She is discharged to home with instructions to remain on bed rest. She should also be instructed to call her healthcare provider if she experiences which symptoms? Select all that apply. headache increased urine output blurred vision difficulty sleeping epigastric pain severe nausea and vomiting

headache blurred vision epigastric pain severe nausea and vomiting

A client with gestational diabetes had a cesarean birth because the fetus was determined to be large for gestational age. The nurse should assess for which postsurgical complications? Select all that apply. wound-edge separation fever after the first 24 hours postpartum lochia odor purulent drainage from incision fever during the first 24 hours postpartum

wound-edge separation fever after the first 24 hours postpartum lochia odor purulent drainage from incision

A primigravid client at 10 weeks' gestation questions the nurse about the need for an ultrasound. The client states, "I feel fine, so why should I have the test?" The nurse should incorporate which statement(s) as the underlying reason for performing the ultrasound now? Select all that apply. "The test helps us view the gross anatomy of the fetus." "Early ultrasound helps verify gestational age." "The test will determine if the fetus is viable." "It is important to determine the fetal position." "The test helps verify that there is a sufficient nutrient supply for the fetus."

'The test helps us view the gross anatomy of the fetus." "Early ultrasound helps verify gestational age." Although ultrasounds are not considered part of routine care, the ultrasound is able to confirm the pregnancy, identify the major anatomic features of the fetus and possible abnormalities, and determine the gestational age by measuring the crown-to-rump length of the embryo during the first trimester. At this time, the ultrasound cannot confirm that the fetus is viable. The ultrasound will provide information about fetal position; however, this information would be more important later in the pregnancy, not during the first trimester. The ultrasound would provide no information about the nutrient supply for the fetus.

The nurse conducts the health assessment of a client who is a primigravida in the prenatal clinic. Which presumptive signs of pregnancy should the nurse expect to assess? amenorrhea and quickening uterine enlargement and Chadwick's sign a positive pregnancy test and a fetal outline Braxton Hicks contractions and Hegar's sign

Amenorrhea and Quickening

The nurse is caring for a postpartum client who states, "I feel so lightheaded when I stand up." Which immediate action(s) should the nurse take? Select all that apply. Ask the unlicensed assistive personnel to obtain orthostatic blood pressure measurement. Ask the client to sit or lie down with legs elevated, and reassess the client's symptoms. Compare the client's most recent hemoglobin laboratory results to baseline. Ask the unlicensed assistive personnel to assist the client to ambulate. Instruct client to move from sitting to standing often to improve tolerance. Instruct the client to use the call light when needing to void and to wait for assistance.

Ask the client to sit or lie down with legs elevated, and reassess the client's symptoms. Compare the client's most recent hemoglobin laboratory results to baseline. Instruct the client to use the call light when needing to void and to wait for assistance.

A 25-week gestation client is scheduled for amniocentesis. What should the nurse do to prepare the client for the procedure? Select all that apply. Ask the client to void. Instruct the client to drink 1 liter of fluid. Ask the client to lie on her left side. Assess fetal heart rate. Insert an IV catheter. Monitor maternal vital signs.

Ask the client to void. Assess fetal heart rate. Monitor maternal vital signs.

The nurse is caring for a client who is 30 weeks pregnant and in preterm labor who has been prescribed a magnesium sulfate infusion. Which will the nurse include in the client's plan of care? Select all that apply. Assess deep tendon reflexes (DTRs) every 4 hours. Evaluate urinary output every 24 hours. Assess temperature frequently. Monitor respiratory rate hourly and as needed. Ensure that calcium gluconate is on hand.

Assess deep tendon reflexes (DTRs) every 4 hours. Monitor respiratory rate hourly and as needed. Ensure that calcium gluconate is on hand.

The nurse plans to instruct the postpartum client who is breastfeeding about methods to prevent breast engorgement. Which measure(s) should the nurse include in the teaching plan? Select all that apply. Feed the neonate a maximum of 5 minutes per side on the first day. Wear a supportive brassiere with nipple shields. Breastfeed the neonate at frequent intervals. Keep the birth parent and baby together as much as possible. Express some milk with a breast pump at the beginning of feedings.

Breastfeed the neonate at frequent intervals. Keep the birth parent and baby together as much as possible.

The nurse enters the client's room to perform a postpartum assessment 1 hour after vaginal birth. The client's sheets are saturated in frank blood, and the client appears pale. Place the interventions in the order the nurse will perform them. All options must be used. Call for help. Perform fundal massage. Ensure patent intravenous access. Lower the head of bed, and reassure the client. Insert an indwelling urinary catheter. Delegate assessment of vital signs.

Call for help. Lower the head of bed, and reassure the client. Perform fundal massage. Delegate assessment of vital signs. Ensure patent intravenous access. Insert an indwelling urinary catheter.

As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. The nurse should do which in order of priority from first to last? All options must be used. Call for immediate assistance. Turn the client to their side. Clear airway secretions. Apply oxygen. Assess for ruptured membranes.

Call for immediate assistance. Turn the client to their side. Assess for ruptured membranes. Clear airway secretions. Apply oxygen.

The nurse is giving prenatal instructions to a 32-year-old primigravida who is 8 weeks' gestation. Which nutritional instructions would the nurse review? Select all that apply. Caloric intake should be increased by 300 cal/day. Protein intake should be increased by 30 g/day. Vitamin intake should not increase from prepregnancy requirements. Folic acid intake should be increased to 800 mg/day. Intake of all minerals, especially iron, should be increased. Water intake should be doubled.

Caloric intake should be increased by 300 cal/day. Protein intake should be increased by 30 g/day. Folic acid intake should be increased to 800 mg/day. Intake of all minerals, especially iron, should be increased.

The nurse is providing instruction to a woman who is 18 weeks pregnant. Which findings are expected at this time? Select all that apply. Fundal height of approximately 18 cm Quickening Insomnia Braxton-Hicks contractions Leg cramps

Fundal Height Quickening Between 18 and 30 weeks' gestation, fundal height in centimeters is approximately the same as the number of weeks' gestation. In this case, the client is 18 weeks pregnant, so fundal height should measure approximately 18 cm. Quickening, which is typically described as light fluttering and is usually felt between 16 and 22 weeks' gestation, is caused by fetal movement. Insomnia, Braxton-Hicks contractions, and leg cramps are common during the third trimester.

A pregnant client presents for a prenatal appointment and was told that she is positive for human immunodeficiency virus (HIV). The client asks the nurse about drug therapy. What information should the nurse teach the client about the medication therapy? It cannot start until the woman gives birth. It starts between 14 and 34 weeks gestation. It starts between 38 to 40 weeks. It starts between 8 and 10 weeks.

It starts between 14 and 34 weeks gestation.

A nurse is demonstrating umbilical cord care to a client who recently gave birth. Which actions should the nurse teach the client to perform? Select all that apply. Keep the diaper below the umbilical cord. Tug gently on the umbilical cord as it begins to dry. Apply antibiotic ointment to the umbilical cord twice daily. Only sponge bathe the neonate until the umbilical cord falls off. Allow the cord to be exposed to air. Wash the umbilical cord with mild soap and water.

Keep the diaper below the umbilical cord. Only sponge bathe the neonate until the umbilical cord falls off. Allow the cord to be exposed to air. The nurse should teach the client to position the diaper below the umbilical cord to allow it to air-dry and to prevent urine from getting on the cord. Soap and water shouldn't be used as a part of umbilical cord care. The nurse should instruct the parents to sponge bathe the neonate until the umbilical cord falls off. Parents should also be instructed to never pull on the umbilical cord but to allow it to fall off naturally. Antibiotic ointments are contraindicated unless there are signs of infection.

The parents of a young infant are exhausted and frustrated because their infant has colic and cries constantly. What intervention(s) should the nurse teach the parents to help console the infant? Select all that apply. Place the infant in a swing. Carry the infant in a carrier strapped to you. Offer the infant a pacifier. Administer simethicone. Feed the infant in an upright position.

Place the infant in a swing. Carry the infant in a carrier strapped to you. Offer the infant a pacifier. Colic is defined as inconsolable crying that lasts 3 hours or more and for which there is no physical cause. The crying and fussiness is most prevalent in the evenings. Although a cause has never been identified some contributing factors include gastrointestinal issues, neurological immaturity, temperament, and the parenting styles. To help the infant stop crying the parents should take a step-wise approach. First determine that all the infant's needs have been met. Then, one step at a time, use things like a swing, a car ride, different pacifier, or carrying the infant in a carrier strapped to the body. The infant should not be overstimulated in the process. Feeding in an upright position will increase the amount of air swallowed, which can worsen gastrointestinal upset. The infant should be fed in a vertical position and the parents should use a curved bottle, which may further reduce the swallowing of air. The use of simethicone is not advised because the safety for infants has not been established.

A 30-year-old multigravida client has missed three periods and now visits the prenatal clinic because they assume they are pregnant. The client is experiencing enlargement of the abdomen, a positive pregnancy test, and changes in the pigmentation on the face and abdomen. These assessment findings reflect this client is experiencing a cluster of which signs of pregnancy? positive probable presumptive diagnostic

Probable

A nurse is caring for a postpartum client suspected of developing postpartum psychosis. Which statements accurately characterize this disorder? Select all that apply. Symptoms appear at the 6-month screening. The disorder is common in postpartum women. Symptoms include delusions and hallucinations. Suicide and infanticide are uncommon in this disorder. The disorder rarely occurs without a psychiatric history.

Symptoms include delusions and hallucinations. The disorder rarely occurs without a psychiatric history.

A client asks the nurse if she is at risk for developing postpartum depression. Which of the following assessment data would further assist the nurse to identify a postpartum depression risk? Select all that apply. The client states she has a history of postpartum depression. The client has had multiple pregnancies. The client states she has a history of depression. The client's partner has stated the couple has financial problems. The client's pregnancy has had multiple complications.

The client states she has a history of postpartum depression. The client states she has a history of depression. The client's partner has stated the couple has financial problems. The client's pregnancy has had multiple complications.

A primigravid client has completed their first prenatal visit and blood work. Their laboratory test for the hepatitis B surface antigen (HBsAg) is positive. The nurse can advise the client that the plan of care for this newborn will include which intervention(s)? Select all that apply. administering hepatitis B immune globulin within 12 hours of birth beginning the hepatitis B vaccine series within 24 hours of birth testing the newborn for hepatitis B before discharge isolating the infant during hospitalization maintaining universal precautions for the client and the infant permitting breastfeeding if the nipples are not cracked

administering hepatitis B immune globulin within 12 hours of birth beginning the hepatitis B vaccine series within 24 hours of birth maintaining universal precautions for the client and the infant permitting breastfeeding if the nipples are not cracked

The nurse is assessing a client in the third trimester of pregnancy. What assessment findings does the nurse document as expected at this stage? Select all that apply. ankle edema shortness of breath nausea and vomiting hypertension increased vaginal discharge

ankle edema shortness of breath

The nurse is caring for a postpartum client who reports constipation. What foods would the nurse recommend to the client? Select all that apply. dairy foods like milk, cheese, and yogurt fruit juices like orange, apple, and grape beans and legumes such as kidney beans or chickpeas whole grain breads and cereals such as oatmeal red meat and other high iron foods such as liver

beans and legumes such as kidney beans or chickpeas whole grain breads and cereals such as oatmeal

The nurse assists with a precipitous birth in an outpatient setting. While waiting for more advanced care, the nurse places the infant skin to skin with the parent and encourages breastfeeding. What would be the desired outcome(s) of skin-to-skin care with early breastfeeding? Select all that apply. beginning the parent-infant bonding process preventing neonatal hypothermia providing glucose to the neonate contracting the client's uterus preventing maternal infection

beginning the parent-infant bonding process preventing neonatal hypothermia providing glucose to the neonate contracting the client's uterus

A client is admitted with suspected abruptio placentae. The nurse should assess the client for which sign(s) or symptom(s)? Select all that apply. bleeding that is concealed or apparent abdominal rigidity painful abdomen painless bleeding large placenta bleeding that stops spontaneously

bleeding that is concealed or apparent abdominal rigidity painful abdomen

During her first prenatal visit, a client asks a nurse what physiological changes she can expect during pregnancy. The nurse begins the discussion with the presumptive changes of pregnancy. Put the following presumptive changes in ascending chronological order according to when they occur. All options must be used. breast changes appearance of linea nigra, melasma, and striae gravidarum uterine enlargement in which the uterus can be palpated over the symphysis pubis quickening frequent urination

breast changes frequent urination uterine enlargement in which the uterus can be palpated over the symphysis pubis quickening appearance of linea nigra, melasma, and striae gravidarum

A client who is 15 weeks pregnant comes to the clinic for amniocentesis. The nurse knows that this test can be used to identify which characteristics or problems? Select all that apply. fetal lung maturity gestational diabetes chromosomal defects neural tube defects polyhydramnios sex of the fetus

chromosomal defects neural tube defects sex of the fetus

The nurse is caring for several postpartum clients. Which client(s) will the nurse anticipate to be at risk for experiencing strong contractions after birth? Select all that apply. client who experienced a rapid (precipitous) labor client who gave birth to a neonate weighing 12 lb (5.4 kg) client who is breastfeeding client who is a multipara client who is a primipara

client who gave birth to a neonate weighing 12 lb (5.4 kg) client who is breastfeeding client who is a multipara

A nurse is completing a prenatal assessment on a woman who is 28 weeks' pregnant with gestational hypertension. Which finding(s) should be reported to the primary health care provider? Select all that apply. dull headache weight gain of 1 lb (500 g) per week blurred vision 1+ urine protein fundal height of 28 cm

dull headache blurred vision 1+ urine protein

The nurse is discussing kangaroo care with the parents of a premature neonate. The nurse should tell the parents that the advantages of skin-to-skin care include which benefit(s)? Select all that apply. enhanced bonding increased IQ improved physiologic stability decreased length of stay in the neonatal intensive care unit improved breastfeeding

enhanced bonding improved physiologic stability decreased length of stay in the neonatal intensive care unit improved breastfeeding Holding a neonate skin to skin with a caregiver has been shown to enhance bonding, improve physiologic stability, decrease length of stay, and improve breastfeeding. Research has not shown an increase in IQ as a developmental outcome. The experience is usually limited to 1 to 2 hours, two to three times per day.

The nurse is assessing an hour-old newborn. Which observations would the nurse note as being abnormal? Select all that apply. respiratory rate of 56 heart rate of 135 expiratory grunting temperature of 97.4° F (36.3° C) nasal flaring

expiratory grunting temperature of 97.4 nasal flaring Respiratory rate for a newborn is 30-60 and the heart rate is 120-160. Expiratory grunting and nasal flaring are signs of respiratory distress in the newborn. Temperature for a newborn should be between 97.5° F (36.4° C) and 99° F (37.2° C).

A nurse is evaluating a client who is 34 weeks pregnant for premature rupture of the membranes (PROM). Which findings indicate that PROM has occurred? Select all that apply. fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry acidic pH of fluid when tested with nitrazine paper presence of amniotic fluid in the vagina cervical dilation of 6 cm alkaline pH of fluid when tested with nitrazine paper contractions occurring every 5 minutes

fernlike pattern when vaginal fluid is placed on a glass slide and allowed to dry presence of amniotic fluid in the vagina alkaline pH of fluid when tested with nitrazine paper

A client asks why she feels so much variability in fetal activity each day. The nurse explains that fetal movement is affected by which factors? Select all that apply. fetal sleep barometric pressure blood glucose time of day cigarette smoking

fetal sleep blood glucose time of day cigarette smoking

The nurse is teaching a woman who is 18 weeks' pregnant about normal findings. Which findings are expected at this time? Select all that apply. fundal height of approximately 18 cm quickening insomnia less urinary frequency leg cramps

fundal height of approximately 18 cm quickening less urinary frequency

A multigravid client in active labor at term is diagnosed with polyhydramnios. The health care provider (HCP) has instructed the client about possible neonatal complications related to polyhydramnios. The nurse determines that the client has understood the instructions when the client states that polyhydramnios is associated with which problem in the fetus or neonate? renal dysfunction intrauterine growth restriction pulmonary hypoplasia gastrointestinal disorders

gastrointestinal disorders

The nurse is caring for a client who has had a postpartum hemorrhage. The healthcare provider has prescribed methylergonovine maleate. What would be a contraindication for a client who has been prescribed this medication? Select all that apply. history of high blood pressure known drug sensitivity to methylergonovine maleate history of asthma or acute inflammatory disease allergy to prostaglandins cardiac disease

history of high blood pressure known drug sensitivity to methylergonovine maleate cardiac disease

The nurse is assessing a multigravid client at 12 weeks' gestation who has been admitted to the emergency department with sharp, right-sided abdominal pain and vaginal spotting. Which information should the nurse obtain about the client's history? Select all that apply. history of sexually transmitted infections number of sexual partners last menstrual period cesarean birth contraceptive use

history of sexually transmitted infections number of sexual partners last menstrual period contraceptive use

A postpartum client is experiencing thoughts and behaviors common to the taking-hold phase. Which items are characteristic of this phase? Select all that apply. prefers having the nurse care for her holds new child and breastfeeds without prompting rests to regain physical strength and calm her swirling thoughts expresses a strong interest in taking care of her child gives up fantasized image of her child and accepts the real one

holds new child and breastfeeds without prompting expresses a strong interest in taking care of her child

The health care provider (HCP) has informed the labor nurse that they believe the uterus has inverted in a primiparous client who has just given birth. Which finding(s) would help to confirm this diagnosis? Select all that apply. hypotension gush of blood from the vagina intense, severe, tearing type of abdominal pain uterus is hard and in a constant state of contraction inability to palpate the uterus diaphoresis

hypotension gush of blood from the vagina inability to palpate the uterus diaphoresis

A nurse is caring for a client with type I diabetes mellitus (DM) who is 39 weeks pregnant. Which of the following will the nurse include in the client's plan of care? Select all that apply. including a bedtime snack with protein administering glyburide 5 mg every morning performing twice-weekly fetal nonstress tests obtaining a fetal biophysical profile monitoring blood sugar 3 times a day

including a bedtime snack with protein performing twice-weekly fetal nonstress tests obtaining a fetal biophysical profile

A 17-year-old gravid client presents for a regularly scheduled 26-week prenatal visit. The client appears disheveled, is wearing ill-fitting clothes, and does not make eye contact with the nurse. Which item(s) should the nurse discuss with the client? Select all that apply. intimate partner violence substance abuse depression blood glucose screening hCG (human chorionic gonadotropin) levels

intimate partner violence substance abuse depression blood glucose screening

A menopausal woman is taking hormone replacement therapy. What warning sign of endometrial cancer should the nurse instruct the client to report to her health care provider? hot flashes irregular vaginal bleeding urinary urgency dyspareunia

irregular vaginal bleeding

A nurse completes postpartum assessments on every shift. Which parameters should the nurse include in the assessment? Select all that apply. lochia fundus appetite bowel sounds bladder complete blood count

lochia fundus bowel sounds bladder

The nurse is discussing dietary concerns with pregnant teens. Which choice(s) would be convenient for teens yet nutritious for both the birth parent and the fetus? Select all that apply. milkshake or yogurt with fresh fruit or granola bar chicken nuggets with tater tots cheese pizza with spinach and mushroom topping peanut butter with crackers and orange juice buttery light popcorn with diet cola cheeseburger, pickle, and ketchup

milkshake or yogurt with fresh fruit or granola bar cheese pizza with spinach and mushroom topping peanut butter with crackers and orange juice

During the initial assessment of a newborn, the nurse notes the presence of a cephalohematoma. Which is the primary nursing action? Select all that apply. monitor for jaundice assess the temperature every 8 hours ensure frequent feedings measure the abdominal size daily monitor output closely

monitor for jaundice ensure frequent feedings monitor output closely A cephalohematoma is a collection of blood and fluid that will need to be absorbed in the next few days. Due to the newborn's immature liver, the presence of a cephalohematoma increases the newborn's risk of jaundice. Treatment of jaundice includes monitoring for changes in the skin color, frequent feedings (expelling the bilirubin), and monitoring the output of the newborn. Assessment of temperature every 8 hours is too infrequent, and cold stress can increase the risk of jaundice. Measurement of the abdomen has nothing to do with jaundice.

Carboprost was injected into the uterus of a client to treat uterine atony during a cesarean birth. In preparing to care for this client after birth, the nurse should assess the client for which common adverse effect of the medication? vertigo and confusion nausea and diarrhea restlessness and increased vaginal bleeding headache and hypertension

nausea and diarrhea

A nurse is completing a physical assessment of a neonate following birth. When completing the musculoskeletal assessment, which findings would indicate developmental dysplasia of the hip (DDH)? Select all that apply. negative Ortolani test positive Barlow test asymmetrical leg skin folds limitation in adduction of the affected leg lengthening of the affected leg

negative ortolani test positive barlow test Developmental dysplasia (dislocation) of the hip is an abnormal formation of the hip joint in which the ball on the top of the femur is not held firmly in the socket. A neonate with DDH will have a positive Ortolani test, a positive Barlow test, and asymmetrical skin folds in the thigh. The affected leg has limited abduction and appears shorter than the unaffected leg in a neonate with DDH.

The nurse is interviewing a client with newly diagnosed syphilis. To prevent the spread of the disease, the nurse should focus the interview on which approach? motivating the client to undergo treatment obtaining a list of the client's sexual contacts increasing the client's knowledge of the disease reassuring the client that medical records are confidential

obtaining a list of the client's sexual contacts

The nurse cares for a client who had a cesarean birth 8 hours earlier. Which finding(s) suggest that the client is developing disseminated intravascular coagulation (DIC)? Select all that apply. petechiae on the arm where the blood pressure was taken heart rate of 126 bpm abdominal incision dressing with bright red drainage platelet count of 80,000/mm3 (80 × 109/L) urine output of 350 mL in the past 8 hours temperature of 98.4°F (36.9°C)

petechiae on the arm where the blood pressure was taken heart rate of 126 bpm abdominal incision dressing with bright red drainage platelet count of 80,000/mm3 (80 × 109/L)

A mother with a history of varicose veins has just delivered her first baby. The nurse suspects that the mother has developed a pulmonary embolus. Which data below would lead to this nursing judgment? Select all that apply. sudden dyspnea chills and fever diaphoresis cough confusion chest pain

sudden dyspnea diaphoresis cough confusion chest pain

The nurse is administering intravenous magnesium sulfate as prescribed for a client at 34 weeks' gestation with severe preeclampsia. Which outcome(s) of this therapy would be desired? Select all that apply. temperature, 98° F (36.7° C); pulse, 72 bpm; respiratory rate, 14 breaths/min urinary output less than 30 mL per hour fetal heart rate with late decelerations blood pressure of less than 140/90 mm Hg deep tendon reflexes 2+ absence of seizures

temperature, 98° F (36.7° C); pulse, 72 bpm; respiratory rate, 14 breaths/min deep tendon reflexes 2+ absence of seizures

The nurse is preparing to perform a fundal massage on a client who is 2 hours postpartum. Order the sequence of events for performing this procedure. All options must be used. Ask the client to void. Place the client in supine position. Place one hand around the top of the fundus. Place one hand on the abdomen just above the symphysis pubis. Gently press the fundus between the hands using slight downward pressure. Rotate the upper hand to massage the uterus until firm.

Ask the client to void. Place the client in supine position. Place one hand on the abdomen just above the symphysis pubis. Place one hand around the top of the fundus. Rotate the upper hand to massage the uterus until firm. Gently press the fundus between the hands using slight downward pressure.

The client is one day postpartum with an episiotomy. Teaching includes medications commonly used for the local relief of perineal pain due to episiotomy and/or laceration. Which medications does the nurse include in the client's teaching concerning pain? Select all that apply. oxycodone/acetaminophen benzocaine witch hazel aspirin NSAIDs

Benzocaine Witch Hazel

During her first prenatal visit, a pregnant client admits to the nurse that she uses cocaine at least once per day. What is the nurse's priority implementation? Obtain urine and serum drug screens. Refer the client for drug counseling. Report the client to child protective services. Explain why the pregnancy is at risk.

Obtain urine and serum drug screens.

A 19-year-old primigravid client is being discharged home after hospitalization for hyperemesis gravidarum and is being referred to home health care. The nurse should develop a discharge plan that includes which interventions? Select all that apply. Refer client to a nutritionist for the following day. Ensure that the client has a prescription for an antiemetic. Ask the health care provider for an anxiolytic prescription. Encourage return to normal routine when client feels ready. Coordinate follow-up appointment with provider in 6 weeks. Discuss plan of care and discharge instructions with client.

Refer client to a nutritionist for the following day. Ensure that the client has a prescription for an antiemetic. Encourage return to normal routine when client feels ready. Discuss plan of care and discharge instructions with client.

When developing a teaching plan for a client who is 8 weeks' pregnant, the nurse would suggest which food(s) to meet the client's need for increased folic acid? Select all that apply. spinach bananas seafood yogurt beans

Spinach Beans

A nurse on a postpartum unit is teaching a new mother about babies using cues to communicate needs. What action suggests that the mother understands a newborn's cues? Select all that apply. The mother looks for nonverbal and behavioral cues. The mother states that cues could be communicating, "I need something different." The mother states that the cues will be lessened after the first month of life. The mother states that she will look for cues around feeding times. The mother states she will seek cues when the infant is in an awake state.

The mother looks for nonverbal and behavioral cues. The mother states that cues could be communicating, "I need something different."

The nurse is making a home visit to assess a client who delivered vaginally 6 days ago. Which finding(s) should the nurse report immediately to the health care provider (HCP)? Select all that apply. foul-smelling lochia engorged breasts bilaterally client who cries easily soaking one peripad every 3 to 4 hours temperature of 100.8°F (38.2°C)

foul-smelling lochia temperature of 100.8°F (38.2°C)

A client comes to the office for a routine prenatal visit at 26 weeks gestation. The urine dipstick is negative for protein but 2+ for glucose. The nurse would teach the client about what testing that needs to be performed? 1-hour glucose tolerance test glycated hemoglobin level 3-hour glucose tolerance test 24-hour urine collection

1-hour glucose tolerance test

The nurse finds that a client who gave birth 3 hours ago has completely saturated a perineal pad within 15 minutes. Which of the following actions should the nurse take? Select all that apply. Begin an intravenous infusion of lactated Ringer's solution. Assess the client's vital signs. Palpate the client's fundus. Place the client in high Fowler's position. Place client on bedrest.

Assess the client's vital signs. Palpate the client's fundus.

A multiparous client at 33 weeks gestation is admitted to the labor and birth area with painless vaginal bleeding. Ultrasonography shows marginal placenta previa. Which nursing interventions should be included in the plan of care for this client? Select all that apply. Institute bed rest. Assess the cervix hourly. Establish intravenous (IV) access. Apply continuous fetal heart monitoring. Administer oxygen as ordered.

Institute bed rest. Establish intravenous (IV) access. Apply continuous fetal heart monitoring. Administer oxygen as ordered.

Which findings in a newborn would require the nurse to notify the primary healthcare provider? Select all that apply. Epstein's pearls milia on the nose positive Ortolani's sign positive Babinski's sign absence of Moro's reflex

positive ortolani's sign absence of moro's reflex The nurse would be concerned about a positive Ortolani's sign, which could indicate congenital hip dysplasia and the absence of Moro's reflex. The rest of the findings are to be expected.

What information should the nurse include in a teaching plan for first-time parents of a bottle-feeding term newborn? Select all that apply. Fill the entire nipple of the bottle with formula. All term babies have well-developed sucking skills. Burp the baby after 2 oz (60 ml) of formula have been taken. Do not prop the bottle. The other parent can feed the baby the bottle whenever possible.

Fill the entire nipple of the bottle with formula. Do not prop the bottle. The other parent can feed the baby the bottle whenever possible.

The antenatal clinic nurse is educating a client with gestational diabetes soon after diagnosis. Evaluation for this client session will include which outcome(s)? Select all that apply. The client states the need to maintain blood glucose levels between 70 and 110 mg/dL (3.9 to 6.2 mmol/L). The client describes a planned walking program while pregnant. The client will strive to maintain a hemoglobin A1C less than 6%. The client verbalizes the need to maintain a dietary intake of fewer than 1500 calories a day to prevent hyperglycemia. The client will continue taking prenatal vitamins, iron, and folic acid.

The client states the need to maintain blood glucose levels between 70 and 110 mg/dL (3.9 to 6.2 mmol/L). The client describes a planned walking program while pregnant. The client will strive to maintain a hemoglobin A1C less than 6%. The client will continue taking prenatal vitamins, iron, and folic acid.

The nurse is admitting a client with a suspected diagnosis of abruptio placentae. When assessing client symptoms, which symptoms require healthcare provider notification of this medical emergency? Select all that apply. overt vaginal bleeding white creamy vaginal discharge rigid abdomen gastrointestinal upset Increased blood pressure rapid uterine contractions

overt vaginal bleeding rigid abdomen Increased blood pressure rapid uterine contractions

The nurse caring for a postpartum client recalls which of the following are appropriate instructions for the prevention of a urinary tract infection (UTI)? Select all that apply. "Drink at least eight 8-ounce glasses of water daily" Talk with your health care provide about which antibiotic therapy is best for you" "Set your phone alarm to remind you to change your peri-pad every one to two hours" "Be sure to include lots of probiotics in your diet" "Remember to empty her bladder completely every 2-4 hours"

"Drink at least eight 8-ounce glasses of water daily" "Set your phone alarm to remind you to change your peri-pad every one to two hours" "Remember to empty her bladder completely every 2-4 hours"

The nurse is caring for a client who is 32 weeks pregnant. The client is started on nifedipine for preterm labor. Which of the following statements made by the client demonstrate an understanding of the plan of care? Select all that apply. "I will check my blood pressure prior to taking my scheduled nifedipine." "I will move about frequently to keep my contractions regular." "I will avoid sexual intercourse until my physician says otherwise." "I will drink 2 to 3 quarts (1.9 to 2.8 liters) of water per day." "I will not take my scheduled nifedipine if I have a headache."

"I will check my blood pressure prior to taking my scheduled nifedipine." "I will avoid sexual intercourse until my physician says otherwise." "I will drink 2 to 3 quarts (1.9 to 2.8 liters) of water per day."

A client at 28 weeks' gestation presents to the emergency department with a "splitting headache." What action(s) would be indicated by the nurse at this time? Select all that apply. Assess for the presence of urine ketones. Assess the client for vision changes or epigastric pain. Obtain a nonstress test. Assess the client's reflexes and presence of clonus. Determine if the client has a documented ultrasound for this pregnancy.

Assess the client for vision changes or epigastric pain. Obtain a nonstress test. Assess the client's reflexes and presence of clonus.

While instructing the client about breast-feeding, which instructions should the nurse include to help the mother prevent mastitis? Select all that apply. Wash your nipples with soap and water. Change the breast pads frequently. Expose your nipples to air part of the day. Wash your hands before handling your breast and breast-feeding. Make sure the baby grasps only one nipple. Release the baby's grasp on the nipple before removing the baby from the breast.

Change the breast pads frequently. Expose your nipples to air part of the day. Wash your hands before handling your breast and breast-feeding. Release the baby's grasp on the nipple before removing the baby from the breast.

The nurse is caring for a client in the first trimester of pregnancy with a threatened miscarriage. The client is ordered to bed rest with bathroom privileges. The client is experiencing muscle cramps and pain in her legs while on bed rest. What is an appropriate recommendation from the nurse? Select all that apply. Have support persons do passive ROM exercises. Do gentle exercises of the legs. Frequently walking around the room. Roll side to side in bed a few times an hour. Do mild stretching exercises.

Do gentle exercises of the legs. Roll side to side in bed a few times an hour. Do mild stretching exercises.

A client is a 43-year-old G2 P1 at 16 weeks' gestation that has completed prenatal testing for chromosomal abnormalities. The results reveal the infant is a female with Down syndrome. The parents are seeking information about this syndrome. What should the nurse tell the parents? Select all that apply. Down syndrome can occur in mothers of any age. Down syndrome is correlated with autosomal dominant traits carried by the parents. Down syndrome is a result of autosomal recessive traits carried by the parents. Down syndrome depends upon maternal prenatal care since pregnancy began. Down syndrome occurs more frequently with advanced maternal age. Down syndrome results from a trisomy of chromosome 21.

Down syndrome can occur in mothers of any age. Down syndrome occurs more frequently with advanced maternal age. Down syndrome results from a trisomy of chromosome 21.

During prenatal screening of a client with diabetes, the nurse should keep in mind that the client is at increased risk for which complications? Select all that apply. stillbirth Rh incompatibility pregnancy-induced hypertension placenta previa spontaneous abortion

Stillbirth Pregnancy-Induced Hypertension Spontaneous Abortion

A multigravida client gave birth vaginally 2 hours ago. A family member notifies the nurse that the client is pale and shaky. Which are the priority assessments for the nurse to make? blood glucose and vital signs temperature and level of consciousness uterine infection and pain fundus and lochia

fundus and lochia

A nurse is explaining the risk factors associated with a client's postpartum depression. Which statements from the nurse are accurate about postpartum depression? Select all that apply. "Symptoms often begin around 4 weeks postpartum." "Symptoms present for two weeks or more." "The incidence is infrequent, happening in less than 5% of pregnancies." "It is more common with primiparas." "A risk factor is an unplanned pregnancy."

"Symptoms often begin around 4 weeks postpartum." "Symptoms present for two weeks or more." "A risk factor is an unplanned pregnancy."

After the nurse reinforces the danger signs to report with a gravida 2 client at 32 weeks' gestation with an elevated blood pressure, which client statement(s) would demonstrate understanding of when to call the primary health care provider's (HCP's) office? Select all that apply. "if I feel dizzy when I get up quickly" "if I see any bleeding, even if I have no pain" "if I have a pounding headache that will not go away" "if I notice the veins in my legs getting bigger" "if the leg cramps at night are waking me up" "if the baby seems to be more active than usual"

"if I see any bleeding, even if I have no pain" "if I have a pounding headache that will not go away" "if the baby seems to be more active than usual"

A nurse is assessing a newborn with the following findings: respiratory rate of 40 breaths per minute, heart rate of 145 beats per minute, and a temperature of 97.3° F (36.2° C). Which are appropriate nursing interventions? Select all that apply. Double wrap the newborn with blankets. Place a hat on the newborn. Assess the oxygenation saturation. Auscultate lung sounds. Reduce the newborn's exposure to drafts.

Double wrap the newborn with blankets. Place a hat on the newborn. Reduce the newborn's exposure to drafts. Temperature for a newborn should be between 97.5° F (36.4° C) and 99° F (37.2° C). The respiratory rate of the newborn should be 30-60 per minute. The heart rate of the newborn should be 120-160 per minute. Double wrapping and applying a hat to the newborn are appropriate interventions for a newborn with a low temperature. Reducing the newborn's exposure to drafts would also be an appropriate intervention for a newborn with a low body temperature. Assessment of the oxygenation saturation and auscultation of the lung sounds would not help with the newborn's temperature.

An adolescent girl is being treated for anogenital warts caused by the human papillomavirus (HPV). What is the nurse's priority intervention for this client? Educate the client about the need to adhere to antibiotic therapy. Educate the client about the accompanying risk of cervical cancer. Assess the client's knowledge of hormonal contraceptives. Assess the client for signs and symptoms of systemic infection.

Educate the client about the accompanying risk of cervical cancer.

A nurse is caring for a client who is 32 weeks gestation and being monitored in the antepartum unit for pre-eclampsia. The client suddenly reports continuous abdominal pain and vaginal bleeding. Which nursing interventions are priorities? Select all that apply. Evaluate maternal vital signs. Prepare for vaginal birth. Reassure the client that she will be able to continue the pregnancy. Auscultate fetal heart tones. Monitor the amount of vaginal bleeding. Monitor intake and output.

Evaluate maternal vital signs. Auscultate fetal heart tones. Monitor the amount of vaginal bleeding. Monitor intake and output.

The nurse palpates a client's fundus, and notes it is 1 in. (3 cm) above the umbilicus and displaced to the right. What would be priority nursing actions? Select all that apply. Assist to semi-Fowler's position and reassess the fundus. Carefully observe the client for any discomfort. Massage the fundus and express clots. Have the client void and reassess the fundus. Ask the client how many pads she is soaking per hour.

Have the client void and reassess the fundus. Ask the client how many pads she is soaking per hour.

A client is in the first hour of her recovery after a vaginal birth. During an assessment, the lochia is moderate, bright red, and trickling from the vagina. The nurse locates the fundus at the umbilicus; it is firm and midline with no palpable bladder. The client's vital signs remain at their baseline. Based on this information, the nurse would implement which action? Massage the fundus and expel clots. Recheck the admission hematocrit and hemoglobin levels. Request that the health care provider (HCP) assess the client. Document the findings as normal.

Request that the health care provider (HCP) assess the client.

A nurse is caring for a client who is 3 days postpartum and breastfeeding their baby. The nurse assesses that the episiotomy area is red and edematous; the breasts are firm and tender on palpation; and the fundus is firm and 2 fingerbreadths below the umbilicus. Which nursing action(s) would be indicated? Select all that apply. Suggest that the client apply cool compresses to the breasts. Encourage the client to sit on a supportive device. Ask the client how often the baby feeds. Suggest the client take cool sitz baths twice a day. Obtain a specimen for culture and sensitivity from the episiotomy site.

Suggest that the client apply cool compresses to the breasts. Ask the client how often the baby feeds.

The nurse is caring for a family that is grieving the loss of their newborn. Which tokens of remembrance would be appropriate to provide? Select all that apply. a picture of the newborn a certificate of death the footprints a lock of hair an invitation to an annual remembrance service

a picture of the newborn the footprints a lock of hair an invitation to an annual remembrance service Tokens of remembrance are offered to the family as a remembrance of their newborn. It is most commonly taken directly from the newborn such as a lock of hair or footprint. A picture of the neonate is taken and a picture of the family unit is offered. Many hospital photographers have specialized training in taking pictures of a stillborn newborn. Many facilities have remembrance services annually and invite all families. This service allows the staff to reconnect with the family in their grief journey. The death certificate will be provided from the state.

A graduate nurse is explaining to the nurse mentor how to assess newborn jaundice and the effects of phototherapy in a dark skinned neonate. Which statement made by the graduate nurse would need clarification? Select all that apply. "It is best to observe for jaundice in the conjunctival sac or oral mucosa." "I will monitor the unconjugated bilirubin carefully as it is the dangerous one." "I will carefully record the neonate's intake as limiting fluids is helpful." "The neonate will be irritable from the elevated bilirubin in the system." "Phototherapy treatment can increase the risk of dehydration."

"I will carefully record the neonate's intake as limiting fluids is helpful." "The neonate will be irritable from the elevated bilirubin in the system." The nurse mentor must clarify a graduate nurse's statement relating to limiting fluids. Hydration is crucial for all neonates as they are already at risk for imbalance due to increased body surface area. Intravenous fluids in addition to oral feeding may be necessary. Newborns are typically not irritable due to the bilirubin. Many sleep comfortably throughout their phototherapy treatment. It is correct to observe for the yellowish discoloration of jaundice in the conjunctival sac or oral mucosa in a dark skinned neonate. In light skinned neonate, applying pressure with the thumb over a bony prominence to blanch the skin reveals the yellowish tone. The dangerous bilirubin is the unconjugated, indirect bilirubin. It is measured by subtracting the direct bilirubin level from the total bilirubin level.

The nurse working on the mother-baby unit teaches the client about the facility's measures to prevent infant abduction. What precaution(s) does the nurse discuss? Select all that apply. "Carry your baby in your arms back to the nursery if you plan to nap." "Infant footprints and a color photograph are taken soon after birth." "Only let staff wearing an appropriate identification (ID) badge transport your baby." "Notify the staff about anyone who appears unusual." "Make sure the staff compares your ID bracelets with your baby's daily."

"Infant footprints and a color photograph are taken soon after birth." "Only let staff wearing an appropriate identification (ID) badge transport your baby." "Notify the staff about anyone who appears unusual." Infants should always be transported in a bassinette or crib in the hallways. A baby in arms outside of a parent room should trigger activation of infant abduction protocols. Footprints and a photograph taken by 2 hours after birth serve as ID should there be an unforeseen separation from the parent. Clients should only let staff wearing appropriate ID take their baby from their room. Clients should notify staff if they see anyone who looks suspicious on the unit. ID badges should be matched each and every time an infant is taken from or returned to the parent not just on a daily basis.

The nurse must administer erythromycin ophthalmic ointment 0.5% to a neonate born 30 minutes ago. How should the nurse proceed? Select all that apply. Clean the eyes before administration. Put on gloves. Apply a 4-cm ribbon of ointment to the lower conjunctival sac of each eye. Open the eyes by putting a thumb and finger at the corner of each lid and gently pressing on the periorbital ridges. Spread the ointment from the inner canthus of the eye to the outer canthus. Wipe excess ointment from the eyes after waiting 1 minute.

Clean the eyes before administration. Put on gloves. Open the eyes by putting a thumb and finger at the corner of each lid and gently pressing on the periorbital ridges. Spread the ointment from the inner canthus of the eye to the outer canthus. Wipe excess ointment from the eyes after waiting 1 minute. Before administering erythromycin ophthalmic ointment, the nurse should put on gloves and clean the eyes (if necessary). Then the nurse should open the eyes by putting a thumb and finger at the corner of each lid and gently pressing on the periorbital ridges. Next, the nurse should apply a 1- to 2-cm ribbon of ointment to the lower conjunctival sac of each eye, spreading the ointment from the inner canthus to the outer canthus. After 1 minute, the nurse should wipe the excess ointment from the eye.

The nurse is caring for a postterm newborn. What interventions will the nurse include in the client's plan of care? Select all that apply. Encourage early feedings. Assess for respiratory distress. Assess for hypoglycemia. Double-wrap the infant in blankets. Examine the indirect Coombs test.

Encourage early feedings. Assess for respiratory distress. Assess for hypoglycemia. Double-wrap the infant in blankets. Postterm newborns are at risk for hypoglycemia, meconium aspiration, and hypothermia, so the nurse should assess for all these disorders. Respiratory distress can occur after meconium aspiration, so the infant should be monitored closely for increased respiratory rates, grunting, retractions, and nasal flaring. Encouraging early feedings helps prevent hypoglycemia. Double-wrapping infants in blankets after they have been removed from the radiant warmer is done to prevent hypothermia. An indirect Coombs test would be related to jaundice.

A nurse is caring for a full-term neonate who is 24 hours old. Assessment findings include axillary temperature of 96.8° F (36° C), apical heart rate of 188 beats/minute, and respiratory rate of 48 breaths/minute. The mother reports that the neonate is lethargic when she tries to breast-feed and looks "like a rag doll." The mother also has a low-grade fever. Pulse oximetry reveals saturation of 89% on room air, and the neonate has dusky mucous membranes. What are the most appropriate nursing interventions? Select all that apply. Encourage the mother to breast-feed because the neonate is becoming dehydrated. Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis. Provide blow-by oxygen and monitor the neonate's respiratory status. Inform the parents that she wants to monitor the neonate closely.

Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis. Provide blow-by oxygen and monitor the neonate's respiratory status. Inform the parents that she wants to monitor the neonate closely. The neonate's symptoms are consistent with early-onset neonatal sepsis. The oxygen saturation, respiratory rate, and cyanosis (evidenced by dusky mucous membranes) indicate that the neonate needs immediate oxygen support. The nurse should contact the physician immediately and continue to monitor the neonate closely. The tachycardia and tachypnea also indicate that the neonate is compromised and may deteriorate rapidly. Keeping the parents informed at this time is important and supports the mother by acknowledging her concerns. There's no evidence that the cause of the neonate's problem is dehydration. The neonate's condition warrants taking vital signs more often than every 2 hours.

A client who is 7 weeks' pregnant comes to the clinic for her first prenatal visit. She reports smoking 20 to 25 cigarettes per day. The nurse should include what priority implementation in this client's plan of care? Measure the fundal height. Implement a smoking cessation program. Reduce the number of cigarettes smoked. Have the client switch to vaping.

Reduce the number of cigarettes smoked. With the number of cigarettes this client smokes, she is considered a heavy smoker. Intrauterine growth retardation (IUGR) increases with the number of cigarettes a woman smokes per day. Babies born to smokers are smaller than in mothers who do not smoke. The infants are at risk for many problems, including congenital heart defects. Smoking increases the risk of placental abruption. Smoking cessation is the ultimate goal for this mother, but realistically it will be difficult for her to abruptly stop. The most immediate goal is to reduce the number of cigarettes smoked per day after explaining all the risks associated with smoking. Vaping carries the same risk as cigarettes because nicotine is still present, but it also increases other risks from other ingredients in the product. Because IUGR can be significant, the fundal height should be measured regularly to assess for fetal growth.

The newborn nurse has just received the shift report about a group of newborns and is to receive another admission in 30 minutes. To provide the safest care and plan for the new admission, the nurse should do which tasks in order of first to last? All options must be used. Review notes from the shift report, and prioritize all clients; make rounds on the most critical first. Check the room to which the new client will be admitted to ensure all supplies and equipment are available. Move quickly from room to room, and assess all clients. Log on to the clinical information system, and determine if there are new prescriptions.

Review notes from the shift report, and prioritize all clients; make rounds on the most critical first. Move quickly from room to room, and assess all clients. Log on to the clinical information system, and determine if there are new prescriptions. Check the room to which the new client will be admitted to ensure all supplies and equipment are available. Based on the report given by the preceding nurse, the nurse should plan to prioritize all clients and first make rounds on the client needing the highest level of nursing care. The nurse can then make rounds on all other clients. The nurse can then check for new prescriptions and, finally, inspect the room in which the next client will be admitted to be sure all of the equipment is available.

The nurse is discharging a newborn to home. Which discharge instructions will the nurse give to the newborn's parents? Select all that apply. "Sponge bathe as needed until the umbilical cord comes off." "Clean the umbilical cord with soap and water." "Apply hydrogen peroxide to the circumcision after each diaper change." "Ensure that feedings occur every 3 to 4 hours." "Place newborn in a rear-facing car seat."

Sponge bathe as needed until the umbilical cord comes off ensure that feedings occur every 3-4 hours place newborn in a rear-facing car seat The newborn should be sponge bathed until the umbilical cord comes off because if the cord gets wet or moist, that is an ideal area for microbes to grow. The circumcision should be cleaned with wet wipes or sponge bathed until healed. Feedings should occur every 3 to 4 hours until a schedule or pattern has been established. Newborns should be in a rear-facing car seat.

What information would the nurse include in discharge instructions for post-circumcision care to the parents of a neonate? Select all that apply. The parents must note that the neonate has voided. Petroleum jelly or antibiotic ointment should be applied to the glans of the penis with each diaper change. The infant can have tub baths while the circumcision heals. Any amount of blood noted on the front of the diaper should be reported. The circumcision will require care for 2 to 4 days after discharge.

The parents must note that the neonate has voided. Petroleum jelly or antibiotic ointment should be applied to the glans of the penis with each diaper change. The circumcision will require care for 2 to 4 days after discharge. Circumcision is a common surgical procedure involving the removal of the foreskin of the penis. Parents must note the first void after circumcision, since this helps verify that the urethra is not obstructed. A lubricating or antibiotic ointment would be applied with each diaper change. Typically, the penis heals within 2 to 4 days, and circumcision care is needed for that period only. To prevent infection, the infant would not have tub baths until the circumcision is healed; sponge baths are appropriate. A small amount of bleeding is expected following a circumcision; parents would report only a large amount of bleeding.

Following the admission assessment of a neonate born at 42 weeks of gestation, the nurse documents which findings as normal? Select all that apply. a three-vessel umbilical cord peeling skin on the feet absence of sole creases absence of vernix caseosa cyanosis of the hands and feet large amounts of frothy oral secretions

a three-vessel umbilical cord peeling skin on the feet absence of vernix caseosa cyanosis of the hands and feet All of the answers are expected findings in a healthy infant at 42 weeks of gestation except for absence of sole creases (creases will be present) and large amounts of frothy oral secretions. Frothy oral secretions are indicative of a tracheoesophageal fistula; it is an abnormal finding in any neonate, regardless of gestational age at the time of birth.