RN Maternal Newborn Online Practice 2023 A

A nurse is caring for a newborn. Which of the following actions should the nurse plan to implement? specify if the intervention is indicated or contraindicated for the newborn. Apgar score 9 at 1 min and 9 at 5 min Birth weight 4,706 g (10 lb 6 oz) Gestational age 40 weeks Difficult vaginal birth with shoulder dystocia. Absent Moro reflex noted in right arm. Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's palsy) paralysis.

indicated: - Educate the parents to begin range of motion exercises on the affected arm after 1 week. Passive ROM exercises of the arm are indicated to restore function of the extremity. The initiation of these exercises is delayed for approximately 1 week to prevent additional injury to the brachial plexus. - Assess for grasp reflex in the affected extremity. With Erb-Duchenne paralysis, only the upper arm is affected. The function of the wrists and fingers should be unaffected; the nurse should assess for a palmar grasp reflex. - Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved by pinning the sleeve to the shirt. Contraindicated - Instruct parents to limit physical handling for 2 weeks. Parents and guardians should participate in the physical care of their newborn to increase parental-infant attachment. Providing education and practice opportunities for the parents will decrease their fears of injuring the newborn and increase confidence and bonding.

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?

Assist the client to empty their bladder. Rationale: The nurse should assist the client to empty their 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.

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?

Blood pressure 105/64 mm Hg Rationale: The nurse should report decreased blood pressure to the provider since it can indicate dehydration. Other considerations: Testing the urine for ketones is the most important laboratory test for a client who has hyperemesis gravidarum. Urine testing positive for ketones is an indication of dehydration, which increases the risk of preterm labor. A negative test result is an expected finding. Therefore, the nurse does not need to report this finding to the provider.

A nurse is discussing with a newly licensed nurse gestational hypertension. Which of the following risk factors should the nurse include in the teaching for the condition?

Some risk factors for gestational hypertension include: Maternal age older than 40 years, and first pregnancy.

A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?

Substernal retractions Rationale: The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection or respiratory distress in the newborn. The nurse should report these findings to the provider for immediate intervention. Other considerations: - A head circumference of 33 cm is within the expected reference range for a newborn following birth. - Overlapping suture lines with molding are an expected variation for newborns who were delivered vaginally. - Acrocyanosis is an expected finding in the newborn for the first 24 hr following birth.

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?

Swelling of the face Rationale: 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. Other findings: - 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. - 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. - 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.

A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?

FHR 152/min Rationale: The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Other considerations: -The nurse should expect the client's DTR to be 2+ - From gestational weeks 18 to 32, the height of the fundus is approximately equal to the number of weeks of gestation plus or minus 2 cm. Therefore, the nurse should expect the fundal height for this client to be 16 to 20 cm. - An elevated blood pressure greater or equal to 140/90, may be an indication of preeclampsia.

A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"I should take 600 micrograms of folic acid each day." Rationale: A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects. Other indications: - A client who is pregnant should increase caloric intake by 340 cal during the second trimester and by 452 cal during the third trimester. - A client who is pregnant should consume 3 L of water each day. - A client who is pregnant should increase protein intake to 71 g each day during the second and third trimesters.

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? "I will need to increase my insulin doses during the first trimester" "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." "I will continue taking my insulin if I experience nausea and vomiting." "I will ensure that my bedtime snack is high in refined sugar."

"I will continue taking my insulin if I experience nausea and vomiting." Rationale: The nurse should teach the client to continue to take their insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes. Other interventions: - The nurse should teach the client to avoid snacks and foods that are high in refined sugar. To control hypoglycemic episodes, the nurse should instruct the client to consume a low-carbohydrate, high-protein diet, avoid fasting, and avoid simple sugars - The nurse should teach the client to avoid exercise during periods of hyperglycemia and when positive urine ketones are present. - The nurse should teach the client that their blood glucose levels are normally reduced and insulin response is enhanced during the first trimester of pregnancy which may require less insulin to control blood glucose levels.

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?

"I will eat foods that taste good instead of balancing my meals." Rationale: Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet. Other considerations: - 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. - 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. - The client should be encouraged to consume dairy products, because they are less likely to cause nausea than other foods.

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." Rationale: 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. Other interventions: - The nurse should instruct the client that bed sharing is not a safe practice in the hospital or home environment because it can cause injury to the newborn. - The nurse should instruct the client that their newborn should sleep supine in a bassinet or crib. - The nurse should instruct the client that newborns will be transported in their bassinets and never carried outside the client's room in their arms to reduce the risk for falls. - 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.

A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?

"You should press the handheld button when you feel your baby move." Rationale: The nurse should instruct the client to press the handheld button when the fetus moves. This action will mark the fetal monitor tracing with the client's reports of fetal movement. This will assist in the interpretation of the nonstress test to determine if it is reactive or nonreactive. Other interventions: - The nurse should instruct the client to be positioned in a reclining chair or semi-Fowler's position with a slight lateral tilt to ensure optimal uterine perfusion. - The client is not required to be NPO before or during the procedure. The nurse can suggest the client drink orange juice to increase their blood glucose level which will stimulate fetal movements. - The nurse should instruct the client that the nonstress will take approximately 20 to 30 min, but more time might be required if the fetus is in a sleep state when the testing begins.

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." Rationale: 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. Levonorgestrel is an emergency contraceptive that prevents or delays ovulation. Therefore, the nurse should inform the client that they will not be protected from pregnancy if they have unprotected sexual intercourse in the days and weeks after receiving this medication. The adolescent should be evaluated for pregnancy if they do not menstruate within 21 days following administration of this medication.

For each finding, click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process.

- Abdominal pain is consistent with gonorrhea. Gonorrhea can present with reports of acute or chronic lower abdominal pain. - Greenish discharge is consistent with trichomoniasis and gonorrhea. Green-yellow discharge can occur in both trichomoniasis and gonorrhea. Candidiasis causes thick, white, lumpy discharge. Diabetes is consistent with candidiasis. Diabetes is a predisposing factor for yeast infections because high glucose levels provide an environment with enough glucose to allow the growth of yeast. -Pain on urination is consistent with trichomoniasis, gonorrhea, and candidiasis. Dysuria is a manifestation of trichomoniasis, gonorrhea, and candidiasis and can be the result of urine flowing over an irritated and inflamed vulva and surrounding skin. -Absence of condom use is consistent with trichomoniasis and gonorrhea. Sexual activity without the use of a condom can result in the transmission of STIs. Candidiasis is a vaginal infection that is not sexually transmitted.

The nurse suspects the adolescent is experiencing pelvic inflammatory disease and is planning care. Which of the following prescriptions should the nurse expect the provider to prescribe?

- Ceftriaxone and doxycycline. The nurse suspects that the adolescent is experiencing pelvic inflammatory disease (PID); Therefore, the nurse should anticipate a provider's prescription for ceftriaxone and doxycycline. The recommended treatment for PID in an outpatient setting is ceftriaxone administered as a single dose intramuscularly, along with doxycycline administered orally 2x/day for 14 days. The treatment regimen may change following the results of the cervical culture.

A nurse is caring for a newborn who is 70 hr old. Which of the following findings should the nurse report to the provider? Nurse notes: Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation. Increased muscle tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Several loose stools today. Heart rate 160/min Respiratory rate 60/min Temperature 37.3° C (99.2° F) Oxygen saturation 96% on room air

- Central nervous system findings. The newborn is displaying inconsolability, high-pitched cry, increased muscle tone, tremors, hyperactive Moro reflex, and excessive sucking. These findings are manifestations of NAS and should be reported to the provider. - Gastrointestinal findings is correct. The newborn is displaying poor feeding and loose stools. These findings are manifestations of NAS and should be reported to the provider Other considerations: - Newborn's oxygen saturation reference range of greater than 94%. - Newborn's temperature expected reference range of 36.5° to 37.5° C (97.7° to 99.5° F) - Newborn's respiratory rate reference range of 30 to 60/min. Report alteration in respiratory status - Neonatal Abstinence Syndrome (also called NAS) is a group of conditions caused when a baby withdraws from certain drugs he's exposed to in the womb before birth. NAS is most often caused when a woman takes drugs called opioids during pregnancy. - Hyperactive Moro reflex. The Moro reflex is a normal reflex for an infant when he or she is startled or feels like they are falling. The infant will have a startled look and the arms will fling out sideways with the palms up and the thumbs flexed. Absence of the Moro reflex in newborn infants is abnormal and may indicate an injury or disease.

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? (Select all that apply.)

- Flaccid uterus. Oxytocin increases the contractility of the uterus. - Excess vaginal bleeding. Oxytocin enhances uterine contractility, decreasing vaginal bleeding. Other considerations: - The use of oxytocin will increase, rather than decrease, afterbirth cramping - Bleeding resulting from a cervical laceration continues even when the uterus is contracted and firm. It will require repair by the provider. - The use of oxytocin will have no effect on maternal temperature

A nursing is assisting with the care of a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected?

Calcium gluconate is the antidote for magnesium sulfate and should be readily available for client's who are receiving magnesium sulfate IV. Administer antidote calcium gluconate or calcium chloride.

The nurse is reviewing the adolescent's medical record. Which of the following conditions is the client most likely developing?

- Pelvic inflammatory disease. Pelvic inflammatory disease (PID) is an infection that involves the pelvic reproductive organs. There are several causative agents that lead to infection, including Neisseria gonorrhoeae and C. trachomatis. PID occurs as a result from untreated infections ascending from the vagina. Manifestations include fever, increased C-reactive protein, nausea, and vomiting; therefore, the nurse should suspect the adolescent is developing PID. - C-reactive protein. The adolescent's C-reactive protein is elevated, which is a manifestation of PID.

The nurse is reviewing the provider's prescriptions in the adolescent's medical chart.

- Providing education on medications . The nurse should first educate the adolescent regarding medications because clients have the right to know the purpose and potential adverse reactions of all prescribed medications before receiving them. An understanding of the prescribed medications will increase the likelihood that the adolescent will adhere to the prescribed therapy. - Administering ceftriaxone. Ceftriaxone is designated as a NOW prescription, which means it should be given within 90 min of the provider writing the prescription. The nurse should administer ceftriaxone after educating the adolescent about the purpose and potential adverse reactions of the medication.

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

- 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.

client is pregnant in an antepartum clinic. Which of the following findings should the nurse report? Temperature 36.6° C (97.9° F)Heart rate 88/min Respiratory rate 18/min BP 130/70 mm Hg O2 saturation 97% room air Heart rate 76/min Respiratory rate 20/min BP 138/68 mm Hg O2 saturation 98% room air 32 weeks of gestation Client reports cramping and lower back pain that started this morning. Client denies leaking fluid. Client placed on electronic fetal monitor. Client reports pain as 4 on a scale of 0 to FHR assessment 150/min. Average variability. No decelerations. Spontaneous accelerations noted. ​Uterine contractions occurring Q 2 min, 40 to 60 seconds in duration. Palpate as moderate intensity. Vaginal examination performed. Cervix 2 cm dilated and 50% effaced. Uterine contractions Fetal heart rate Gestational age Vaginal examination Maternal blood pressure

- Uterine contractions. The client is experiencing regular uterine contractions and cervical change, which are indicators of preterm labor; therefore, the nurse should notify the provider about this finding. - Gestational age. The client is at 32 weeks of gestation and is experiencing regular uterine contractions and cervical dilation, which indicates that the client is in preterm labor; therefore, the nurse should notify the provider about this finding. - Vaginal examination. The client's cervix is dilated to 2 cm and is 50% effaced, which indicate the client is in preterm labor; therefore, the nurse should notify the provider about this finding. The client's blood pressure is within the expected reference range . Blood pressure 130/70 mm Hg? what is normal.

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?

Chin quivering Rationale: Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow. When a newborn is experiencing pain: - The heart rate will increase - newborn's pupils typically dilate - newborn's respirations are typically rapid and shallow

A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1 g orally now." Available are 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?

A client who is at 11 weeks of gestation and reports abdominal cramping Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first. Other considerations: - Tingling and numbness of the right hand is nonurgent because it is a common discomfort related to pregnancy for a client who is at 15 weeks of gestation. - Constipation is nonurgent because it is a common discomfort related to pregnancy for a client who is at 20 weeks of gestation. - A client who is at 8 weeks of gestation and reports having three bloody noses in the past week (Epistaxis) is nonurgent because it is a common discomfort related to pregnancy for a client who is at 8 weeks of gestation.

A nurse on 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 Rationale: 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. Non urgent findings: - A fasting blood glucose of 120 mg/dL is above the expected reference range for a client who has gestational diabetes - A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL (11 to 16 g/dL) This finding is a manifestation of anemia in a client who is pregnant - 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.

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? A newborn who is 26 hr old and has erythema toxicum on their face A newborn who is 32 hr old and has not passed a meconium stool A newborn who is 12 hr old and has pink-tinged urine A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)

A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F) Rationale An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range of 36.5 - 37.5 ° C for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider. other considerations: - A newborn should pass the first meconium stool within the first 24 to 48 hr following birth. Failure to pass a meconium stool can indicate a bowel obstruction or congenital disorder. - Pink-tinged urine is an indication of uric acid crystals and is an expected finding for a newborn during the first week following birth. - Erythema toxicum is a transient rash that can appear anywhere on a newborn's body during the first 24 to 72 hr following birth and can last up to 3 weeks. This finding requires no treatment.

A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take prior to leaving the newborn with their parent?

Ensure that the parent's identification band number matches the newborn's identification band number. Rationale: The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the number on the parent's identification band to the number on the newborn's identification band.

A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?

Active Rationale: The nurse should identify that the client is in the active phase of labor. This phase is characterized by a cervical dilatation of 6 to 10 cm and contractions every 1.5 to 5 min, each lasting 40 to 90 seconds. Other considerations: - The early phase of labor is characterized by cervical dilation of 0 to 5 cm and contractions every 2 to 30 min, each lasting 30 to 40 seconds. - The passive descent phase of labor is in the second stage of labor and is characterized by a period of calm and rest. The fetus continues to descend and rotate through the birth canal. - 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 admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurse's priority?

Begin FHR monitoring. Rationale The greatest risk to the client and their fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take. Other interventions: - The nurse should perform a Nitrazine test to determine the pH of the fluid. An alkaline pH can indicate rupture of membranes. - The nurse should observe the characteristics of the fluid to document color, odor, and amount. - The nurse should check the client's cervical dilation to assess progress of labor.

A nurse is caring for a client who is at 41 weeks 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) Rationale: 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. Other tests: - 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. - 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. - 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.

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 history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)

Contraindication for the use of oral contraceptives. - Cholecystitis - Hypertension - Migraine

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 Rationale: A client who has ITP has an autoimmune response that results in a decreased platelet count. Other considerations: - An increased ESR is an indication of chronic renal failure. - An increased WBC is an indication of infection.

A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?

Depression Rationale: The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, breast tenderness, hypertension, abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain. Report to PCP shortness of breath.

A nurse is preparing to teach a client who is at 20 weeks of gestation and is scheduled to undergo a prophylactic cervical cerclage. What information should the nurse include in the teaching?

Description of Procedure: Surgical reinforcement of the cervix with a heavy ligature (suture) that is placed submucosally around the cervix to strength it and prevent premature cervical dilation. Potential Complications - Uterine contractions - Rupture of membranes - Infection Client Education - Remain on activity restrictions/bed rest as prescribed. - Increase hydration to promote a relaxed uterus. - Refrain from sexual intercourse. = Findings to report to the provider include preterm labor, rupture of membranes, manifestations of infection, strong contractions less than 5 min apart, perineal pressure, and the urge to push. - Plan for removal of the cerclage between 37 and 38 weeks of gestation.

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. Rationale: The first 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. Other interventions: - The nurse should increase the IV fluid rate to maintain circulation. - The nurse should access emergency medications from cart to assist in resuscitative efforts - The nurse should collect a maternal blood sample in preparation for a blood transfusion

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that they are "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following?

Emotional lability Rationale: 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.

A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?

Frequent vomiting with weight loss of 3 lb in 1 week Rationale: The nurse should recognize that frequent vomiting with a weight loss of 3 lb in 1 week may indicate hyperemesis gravidarum and should be reported to the provider. The client could experience electrolyte imbalances due to hyperemesis gravidarum. Common findings during the first trimester of pregnancy: - emotional lability and mood swings - Nosebleeds occurring approximately 3 times per week. (epistaxis) - increased vaginal discharge, or leukorrhea

A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? Fundal height 30 cm

Fundal height measurement Rationale A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. In this case fundal height should be 24-28 cm.

A nurse is discussing with a newly licensed nurse gestational diabetes mellitus. Which of the following risk factors should the nurse include in the teaching for the condition?

Gestational diabetes mellitus has some of the following as risk factors for the condition which includes: Maternal age older than 25 years old, and a previous birth of an infant who was large or stillborn.

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 should the nurse take?

Have calcium gluconate readily available. Rationale: The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity. Other interventions: - The nurse should assess deep tendon reflexes every 1 to 4 hr during continuous infusion of magnesium sulfate. - 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. - The nurse should monitor intake and output hourly for clients who are receiving a continuous infusion of magnesium sulfate.

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 Rationale: A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider. 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 - Swelling of feet and ankles at the end of the day. Swelling of feet and ankles is due to the enlarging uterus sitting at the pelvic area and interfering with blood return to the heart. - Braxton Hicks contractions. Braxton Hicks contractions are an indication that the uterus is preparing for labor

A nurse is caring for a newborn, specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis. Decreased temperature Poor feeding Lethargy Ecchymotic caput succedaneum Yellow sclera and oral mucosa Respiratory distress

Hypoglycemia: Decreased temperature, poor feeding, respiratory distress, and lethargy Hyperbilirubinemia: . Yellow sclera and oral mucosa, and poor feeding. Sepsis: decreased temperature, yellow sclera and oral mucosa, poor feeding, respiratory distress, and lethargy Notes: - Caput succedaneum is swelling of the scalp in a newborn. It is most often brought on by pressure from the uterus or vaginal wall during a head-first (vertex) delivery. Swelling and bruising usually occur on the top of the scalp where the head first enters the cervix during birth. - hypoglycemia is a cause for delayed bilirubin elimination along with hypoxia, hypothermia, and sepsis. - A newborn with an ecchymotic caput succedaneum is at higher risk for hyperbilirubinemia.

A nurse on an antepartum unit is caring for a client. Specify if the intervention is indicated or contraindicated for the client. 0900: Temperature 36.2°C (97.2° F) Pulse rate 78/min Respiratory rate 20/min Blood pressure 112/64 mm Hg Fetal heart rate 132/min 0930: Pulse rate 82/min Blood pressure 116/60 mm Hg Fetal heart rate 160/min Client passed large amount of bright red blood from vagina. Denies pain. Uterine tone soft and nontender to palpation. Contraction pattern: no contractions noted. Fetal heart rate pattern: Fetal heart rate baseline 135/min. Moderate variability. No decelerations noted. 30 weeks gestation Previous pregnancies delivered via cesarean section

Indicated: - Insert a large bore intravenous catheter.. Clients who have third trimester vaginal bleeding may experience a sudden hemorrhage and require fluid resuscitation or the administration of blood products. - Weigh perineal pads. The nurse should weigh perineal pads. Weighing perineal pads after use will provide a more accurate assessment of the volume of blood loss that the client is experiencing. Contraindicated: - Administer methotrexate. The nurse should not administer methotrexate. Methotrexate is an antimetabolite and folic acid antagonist which destroys rapidly dividing cells. It can be administered during pregnancy to medically resolve an ectopic pregnancy during the first trimester. - Assess cervical dilation. The nurse should not assess for cervical dilation. Assessing cervical dilation is contraindicated for any pregnant client who is experiencing vaginal bleeding. Manipulation of the cervix during the examination may result in further damage to the placenta and compromise the well-being of the client and fetus.

The nurse has just reviewed discharge instructions with the adolescent. Which of the following indicates whether the adolescent understands the teaching or requires further education?

Indicates understanding: - "I should continue taking all my medications even if I don't show any symptoms" - "If I continue to get this type of infection, it can affect my ability to have kids in the future" repeated instances of PID can cause infertility. - "I'm more likely to get a sunburn while taking these medications" The nurse informed the adolescent that they might experience increased sensitivity to sunlight while using doxycycline and that they should use sunscreen and wear protective clothing while taking the medication. Requires further education: - "I should go to the emergency department if my urine turns dark" The nurse informed the adolescent that while taking metronidazole their urine might turn dark, they should not be alarmed because dark urine is an adverse effect of taking this medication. - "As long as I keep my IUD, I don't need to use condoms" The nurse informed the adolescent that they should use a condom to decrease the risk of contracting an STI; IUDs effectively prevent pregnancy, not STIs.

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. Rationale: Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when they detect fetal movement will ensure that the fetal movement is noted. Other considerations: - 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. - There is no indication for the client to be NPO. Sometimes clients are encouraged to drink liquids to promote adequate hydration. - To stimulate fetal movement use a buzzer or give the client orange juice to wake up the baby

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?

Jaundice Rationale: Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider. Other manifestations: - Acrocyanosis is a bluish discoloration of the hands and feet and is an expected finding in a newborn 24 to 48 hr after birth. - Caput succedaneum is a benign, edematous area of the scalp and is commonly found on the occiput. - Transient strabismus is a normal variation in the newborn's eyes that can persist until the third or fourth month of age.

A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?

Late decelerations Rationale: Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider. Other considerations: - Cessation of uterine dilation and a prolonged active phase of labor are indications for the initiation of an oxytocin infusion to augment the client's labor progression. - Moderate variability of the FHR is an expected assessment finding associated with normal fetal acid-base balance. It is not a contraindication to the administration of oxytocin.

A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?

Lays the newborn across their lap and gently sways Rationale: This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn. Other considerations: - The guardian should place the infant in the supine position, not a prone position, in the bassinet or crib because of the risk of sudden infant death syndrome. - Rice cereal should not be added to the bottle of a newborn because solids should not be introduced until 4 to 6 months of age. - Pacifiers may be used for a newborn who needs extra sucking for self-soothing. However, formula should not be placed on the tip of the pacifier because the newborn might become accustomed to it and refuse to take the pacifier in the future without added supplement.

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 Leakage of fluid from the vagina Upper abdominal discomfort Urinary frequency

Leakage of fluid from the vagina Rationale: Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider. Other considerations: - Decreased fetal movement is a potential complication that should be reported to the provider. - Upper abdominal discomfort is not a potential complication associated with an amniocentesis. - Urinary frequency is not a potential complication associated with an amniocentesis.

A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?

Maintain the client on bed rest. Rationale: The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended. Other considerations: - A client receiving anticoagulant therapy, such as heparin, should not receive aspirin because it can lead to prolonged clotting times and increased risk of bleeding. - The nurse should avoid massaging the affected leg to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. - The nurse should apply warm compresses to the affected area to promote circulation and decrease edema.

A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?

Minimal arm recoil Rationale: The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil. What is the New Ballard Score.?????? -Raised areolas with 3 to 4 mm buds is an indicator of physical maturity with increasing gestational age after 26 weeks. - Creases over the entire sole of a newborn's foot are an indicator of physical maturity with increasing gestational age after 26 weeks. - A popliteal angle of 90° is an indicator of physical maturity with increasing gestational age after 26 weeks.

A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?

Monitor the FHR. Rationale: The greatest risk to this client and their fetus is fetal death due to blood mixing. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis. Other considerations: - The nurse should check the client's temperature to monitor for infection following an amniocentesis. - The nurse should administer Rho(D) immune globulin following an amniocentesis to prevent Rh sensitization. - The nurse should observe for uterine contractions to identify preterm labor following an amniocentesis.

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. Rationale: 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. Other considerations: - The nurse should plan to administer 500 to 1,000 mL of lactated Ringer's or 0.9% sodium chloride 15 to 30 min prior to the administration of the first dose of anesthetic solution to decrease the maternal risk for hypotension. The nurse should not administer dextrose because it can cause maternal hyperglycemia and neonatal hypoglycemia - 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 their head and shoulders elevated and at a lateral tilt to increase perfusion to the fetus. - 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 conditions is an indication for fetal assessment using electronic fetal monitoring?

Oligohydramnios Rationale: The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further fetal assessment using electronic fetal monitoring include: hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.

A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?

Perform Leopold maneuvers. Rationale: The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer. Note: The nurse should determine the client's dilation and effacement prior to applying an internal monitor. This action is not required prior to applying an external transducer for fetal monitoring.

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?

Remove all clothing from the newborn except the diaper. Rationale: The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin. Other considerations: - The nurse should not discontinue phototherapy if the newborn develops a rash. A temporary, fine rash can occur during therapy. This rash requires no treatment. - The nurse should not apply lotion, ointments, or creams to a newborn who is undergoing phototherapy. Lotions, ointments, and creams can absorb heat and lead to burns. - The nurse should not feed the newborn any water or glucose water. Hydration can be maintained through regular breastfeeding or formula feeding. Water and glucose water do not increase the excretion rate of bilirubin in the stool or provide nutritional value.

A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?

Report the client's condition to the local health department. Rationale: The nurse should report the condition to the local health department. HIV is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is required to be reported. Other considerations: The nurse should tell the client that treatment for HIV will be during the prenatal and perinatal periods. Treatment with antiretroviral prophylaxis such as zidovudine, triple-drug antiretroviral therapy (ART), or highly active antiretroviral therapy (HAART) during pregnancy have been reported to decrease the transmission of the virus to the newborn.

A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?

Respiratory distress Rationale: Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include hypothermia, poor feeding behaviors, hypotonia, an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.

Extra questions from review A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. The nurse should identify that which of the following are risk factors for the client?

Risk factors for hyperemesis gravidarum which include: - diabetes - multifetal pregnancy. - Gestational trophoblastic disease - Clinical hyperthyroid disorders - Maternal age younger than 30 years - Psychosocial issues and high levels of emotional stress - Gastrointestinal disorders - Family history of hyperemesis

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

Temperature Rationale: The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.

A nurse is assisting with the care of a client who has severe preeclampsia who is receiving magnesium sulfate IV. Which of the following findings should the nurse identify and report as magnesium sulfate toxicity?

The following findings the nurse should report as magnesium sulfate toxicity: - Absence of patellar deep tendon reflexes - Urine output less than 30 mL/hr - Respirations less than 12/min - Decreased level of consciousness - Cardiac dysrhythmias Flushing and sweating are adverse effects of magnesium sulfate but are not manifestations of toxicity.

A nurse in a clinic is caring for a 16-year-old adolescent. Which of the following findings should the nurse report to the provider?

The nurse should report these findings to the provider. - Abdominal assessment. Abdominal tenderness with palpation is not an expected finding with an abdominal assessment - Vaginal discharge. Greenish vaginal discharge indicates that the adolescent has an infection, which is not an expected finding - Temperature is correct. The client's temperature of 38.3° C (101° F) is above the expected reference range. An elevated temperature could signal infection or inflammation Dyspareunia. Dyspareunia is painful intercourse, which can be associated with STIs - Condom usage. Sexual activity without the use of condoms increases the risk of contracting STIs

A nurse is caring for a newborn who is 48 hr old. Specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Heart rate 174/min Respiratory rate 88/min Temperature 36.1° C (97.0° F) Oxygen saturation 97% on room air Total bilirubin 10 mg/dL (1.0 to 12.0 mg/dL) Blood glucose: 38 mg/dL (expected value greater than 40 to 45 gm/dL Newborn awake, alert, and crying. Loosely wrapped in one blanket. Mild tremors noted. Yellow discoloration of mucus membranes and sclera noted. Respirations 88/min, no retractions, grunting, or nasal flaring noted. Diaper changed for small amount of urine and transitional stool.

Upon recognizing and analyzing newborn findings of temperature below the expected range, respiratory rate above the expected range, and hypoglycemia, the nurse's priority hypothesis is that this newborn is most likely experiencing cold stress. 2 actions the nurse should take are: Place newborn skin to skin on birthing parent's chest, and Encourage birthing parent to breastfeed. It is important to generate solutions and take actions that address cold stress. Therefore, the nurse should monitor the newborn's temperature and glucose levels because a newborn experiencing cold stress is at risk for developing metabolic acidosis. To evaluate the client's response to these interventions, the nurse should monitor the newborn's temperature and glucose levels.

A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

Verify the newborn's identification. Rationale: 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. Other considerations: - 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. - 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. - The nurse should identify obstetrical risk factors to determine if interventions are required for the newborn.

A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?

Vomiting Rationale: Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days. Manifestations of fetal exposure to SSRIs. include: Low birth weight, Hypoglycemia, Tachypnea.