Saunders NCLEX Postpartum Questions, 2 EVOLVE ANTEPARTUM/intra/post combined from other peoples stuff., Intrapartum, NEWBORN

A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply.

3. Increased efficiency of contractions 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

The nurse reviews the plan of care for a woman at 37 weeks' gestation who has sickle cell anemia. The nurse determines that which problem listed on the nursing care plan will receive the highest priority?

3. Insufficient fluid volume

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding?

3. The client is measuring normal for gestational age.

Which assessment following an amniotomy should be conducted first?

3. Fetal heart rate pattern

The nurse is taking a nutritional history from a 16-year-old pregnant adolescent. Which statement, if made by the adolescent, should alert the nurse to a potential psychosocial problem?

4. "I want to gain only 10 pounds because I want to have a small, petite baby."

The nurse encourages a pregnant client who is human immunodeficiency virus (HIV) positive to immediately report any early signs of vaginal discharge or perineal tenderness to the health care provider. The client asks the nurse about the importance of this action, and the nurse responds by making which statement to the client?

4. "This is necessary to assist in identifying potential infections that may need to be treated."

A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse plan to tell the client?

4. "You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed."

The nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing?

1. Hypotonic

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?

2. "The vaginal discharge may be bothersome, but is a normal occurrence."

The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued?

2. A fetal heart rate of 90 beats/minute

A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate?

2. Every 15 minutes

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?

2. Monitoring the fetal heart rate

The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement, if made by the client, indicates an understanding of the instructions?

3. "The iron is best absorbed if taken on an empty stomach."

The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions?

3. "The iron is best absorbed if taken on an empty stomach."

Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply.

3. It is the way the baby gets food and oxygen. 5. It provides an exchange of nutrients and waste products between the mother and developing fetus.

The result of a biophysical profile (BPP) of a 28-year-old client at 36 weeks' gestation after the ultrasound components is 8. Based on this result, the nurse should take which action?

3. Place the fetal heart monitor on the client in order to do a nonstress test (NST).

The nurse is preparing to care for a client in labor. The health care provider (HCP) has prescribed an intravenous (IV) infusion of oxytocin. The nurse should ensure that which is implemented before the beginning of the infusion?

3. Continuous electronic fetal monitoring

The nurse is providing instructions to a pregnant client visiting the antenatal clinic about foods that are rich in folic acid. Which food should the nurse encourage the client to consume because it is highest in folic acid?

4. Green leafy vegetables

The clinic nurse is teaching a pregnant woman about the warning signs in pregnancy. Which, if identified as a warning sign by the woman, should indicate a need for further education?

4. Presence of irregular, painless contractions

The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency?

3. Butorphanol tartrate

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. "You will need to bottle-feed your newborn." 2. "You will need to feed your newborn by nasogastric tube feeding." 3. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." 4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

1 Perinatal transmission of human immunodeficiency virus (HIV) can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV are advised not to breast-feed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.

The nurse is monitoring a postpartum client who is at risk of developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, would support a diagnosis of postpartum endometritis? 1. Abdominal tenderness and chills 2. Increased perspiration and appetite 3. Maternal oral temperature of 100.2° F 4. Uterus two fingerbreadths below midline and firm

1 Signs and symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104° F. This intrauterine infection may lead to further maternal complications, such as infections of the fallopian tubes, ovaries, and blood (sepsis). Options 2, 3, and 4 represent normal maternal physiological responses in the immediate postpartum period.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1. The diet should include additional fluids. 2. Prenatal vitamins should be discontinued. 3. Soap should be used to cleanse the breasts. 4. Birth control measures are unnecessary while breast-feeding.

1 The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraceptio

The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education? 1. "I should apply my antiembolism stockings after breakfast." 2. "I should avoid prolonged standing or sitting in one position." 3. "I should perform regularly scheduled exercise such as walking." 4. "I should avoid using pillows under my knees to prevent pressure in the back of my knee area."

1 The nurse should instruct the client to apply antiembolism stockings before the client rises in the morning to prevent the venous congestion that will begin as soon as the mother gets up. Circulation can be improved with a regular schedule of activity, preferably walking, and the mother should be instructed to avoid prolonged standing or sitting in one position and avoid placing pillows under the knees because of the risk venous stasis in the lower extremities. The mother also should be encouraged to maintain a fluid intake of at least 2500 mL/day to prevent dehydration and consequent sluggish circulation.

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume

1 The priority nursing consideration for a client who delivered 2 hours ago and who has a midline episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief? 1. "What can I do for you?" 2. "Now you have an angel in heaven." 3. "Don't worry, there is nothing you could have done to prevent this from happening." 4. "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

1 When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their health care provider or others on the health care team. It is important for the nurse to be with the parents at this time and to use therapeutic communication techniques. The nurse must also consider cultural and religious practices and beliefs. The correct option provides a supportive, giving, and caring response. Options 2, 3, and 4 are blocks to communication and devalue the parents' feelings.

The nurse is assessing a client in the postpartum period and suspects the presence of uterine atony. Which is the initial nursing action? 1. Massage the uterus until firm. 2. Take the client's blood pressure. 3. Contact the health care provider (HCP). 4. Assess the amount of drainage on the peripad.

1 When uterine atony occurs, the initial nursing action would be to massage the uterus until it is firm. If this does not assist in controlling blood loss, then the nurse would contact the HCP. Additionally, once bleeding is under control, the nurse would monitor the vital signs and estimate the amount of blood loss.

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breast-feed if the breasts are not too sore. 5. Take the prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breast-feeding or breast pump.

1, 2, 3, 4 Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.

The prenatal clinic nurse asks a nursing student to identify the physiological adaptations of the cardiovascular system that occur during pregnancy. The nurse determines that the student understands these physiological changes if the student makes which statement?

1. "An increase in pulse rate occurs."

The nurse is assisting in conducting a prenatal session with a group of expectant parents. One of the expectant parents asks, "How does the milk get secreted from the breast?" What should be the nurse's response?

1. "Prolactin stimulates the secretion of milk, which is called lactogenesis."

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply.

1. "The ductus arteriosus allows blood to bypass the fetal lungs." 2. "One vein carries oxygenated blood from the placenta to the fetus." 4. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta."

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider (HCP) prescribes a contraction stress test. The test is performed, and the nurse notes that the HCP has documented the results as negative. How should the nurse interpret this finding?

1. A normal test result

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?

1. A normal test result

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply.

1. Age 54 2. Body mass index of 28 3. Previous difficulty with fertility

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply.

1. Allows for fetal movement 2. Surrounds, cushions, and protects the fetus 3. Maintains the body temperature of the fetus 4. Can be used to measure fetal kidney function

A client calls the health care provider's office to schedule an appointment because she has missed 2 menstrual cycles and has always been very regular. The client receives an appointment for the next day. The nurse should expect which findings to be present at this prenatal visit if the client is pregnant? Select all that apply.

1. Chadwick's sign 3. Positive pregnancy test

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that which may be required during the second half of pregnancy?

1. Increased insulin

The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply.

1. Keep the room semi-dark. 2. Initiate seizure precautions. 3. Pad the side rails of the bed. 4. Avoid environmental stimulation.

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply.

1. Proteinuria 2. Hypertension

The purpose of a vaginal examination for a client in labor is to specifically assess the status of which findings? Select all that apply.

1. Station 2. Dilation 3. Effacement

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor?

1. The appearance of the fetal external genitalia

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data should alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? Select all that apply.

1. The client's last baby weighed 10 lb at birth. 5. The client has a history of gestational diabetes with her previous pregnancy.

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy?

1. The client's last baby weighed 10 pounds at birth.

The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply.

1. Uterine tenderness 2. Acute abdominal pain 3. A hard, "boardlike" abdomen 5. Increased uterine resting tone on fetal monitoring

The nurse is creating a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?

1. Monitoring fetal status

The nurse is providing emergency measures to a client in labor who has been diagnosed with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which client problem is most appropriate to address at this time?

1. The client's fear

A client in the prenatal clinic asks the nurse about the delivery date. The nurse notes that the client's record indicates that the client began her last menses on March 7, 2018, and ended the menses on March 14, 2018. Using Nägele's rule, the nurse should tell the client that the estimated date of delivery is what date? Fill in the blank. Record your answer using 6 digits (mmddyy).

121418

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity? 1. Ambulating 2. Breast-feeding 3. Taking sitz baths 4. Arriving home and activities are increased

2 Afterpains are a normal occurrence and result from contractions of the uterus as it reduces in size during involution. Afterpains may be especially noticeable during breast-feeding because oxytocin is released in response to the infant's sucking. The other options are incorrect.

A nurse is caring for a client who has just delivered a newborn following a pregnancy with a placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2 Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. The other options are not risks that are specifically related to placenta previa.

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client would be at the lowest risk for development of postpartum thromboembolic disorders? 1. A 39-year-old woman who reports that she smokes 2. A 26-year-old woman with a family history of thrombophlebitis 3. A 37-year-old woman in her fourth pregnancy who is overweight 4. A 22-year-old woman with a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

2 Certain factors create a risk for the development of thromboembolic disorders. These include smoking, varicose veins, obesity, a history of thrombophlebitis, women older than 35 years or who have had more than three pregnancies, and women who have had a cesarean birth. From the options presented, a 26-year-old woman with a family history of thrombophlebitis is least likely to develop thromboembolic disorders in the postpartum period

A nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which indicates an early sign of excessive blood loss? 1. A temperature of 100.4º F 2. An increased pulse rate of 88 to 102 beats/min 3. A blood pressure change from 130/88 to 124/80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/min

2 During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss, because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage.

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4° F 2. An increase in the pulse rate from 88 to 102 beats/minute 3. A blood pressure change from 130/88 to 124/80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/minute

2 During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.

The postpartum unit nurse is developing a plan of care for a first-time mother and identifies the need for measures that will promote parent-infant bonding. Which measure should the nurse include in the plan? 1. Use a low-pitched voice to speak to the infant. 2. Encourage the mother to hold the infant when the infant cries. 3. Encourage the parents to allow the infant to sleep in the parental bed. 4. Encourage the mother to allow the nursing staff to care for the infant during her hospital stay until she is discharged.

2 Holding the infant close and allowing the infant to feel the warmth will initiate a positive experience for the mother and will console the infant. The use of a high-pitched voice and participating in infant care are additional methods of promoting parental-infant attachment. Infants should not be allowed to sleep in the parental bed. The parents require time alone as a couple. Additionally, the danger of suffocation of the infant exists if the infant is allowed to sleep between parents.

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate? 1. Elevate the client's legs. 2. Massage the fundus until it is firm. 3. Ask the client to turn on her left side. 4. Push on the uterus to assist in expressing clots.

2 If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony.

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2 In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding. Options 1, 3, and 4 are not risks that are related specifically to placenta previa.

A pregnant woman who is infected with the human immunodeficiency virus (HIV) delivers a newborn infant, and the nurse provides instructions to help the mother regarding care of the infant. Which statement by the client would indicate the need for further instructions? 1. "I will be sure to wash my hands before and after bathroom use." 2. "I need to breast-feed, especially for the first 6 weeks postpartum." 3. "Support groups are available to assist me with understanding my diagnosis of HIV." 4. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."

2 Perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding. Therefore HIV-positive clients should be encouraged to bottle-feed their neonates. Frequent handwashing is encouraged. Support groups and community agencies can be identified to assist clients with home care of the newborn infant, the impact of the diagnosis of HIV infection, and finding available financial resources. It is recommended that newborn infants of HIV-positive clients receive antiviral medications for their first 6 weeks of life.

The nurse is collecting data on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client is least likely to be at risk for the development of thrombophlebitis in the postpartum period?

2. A 26-year-old client with a family history of thrombophlebitis

The clinic nurse is discussing nutrition with a pregnant client who has lactose intolerance. Which food should the nurse instruct the client to eat to supplement the dietary source of calcium?

2. Broccoli

The nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes of constipation. To help alleviate this problem, the nurse should instruct the client to take which measure?

2. Drink 8 glasses of water per day

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2018. Using Nägele's rule, which expected date of delivery should the nurse document in the client's chart?

2. July 26, 2019

The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client?

2. Breathe rapidly.

A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action?

2. Continue to monitor the client.

The nurse has collected the following data on a client in labor. The fetal heart rate (FHR) is 154 beats/min and is regular, and contractions have moderate intensity, occur every 5 minutes, and have a duration of 35 seconds. Using this information, what is the appropriate action for the nurse to take?

2. Continue to monitor the client.

The goal for a woman with partial premature separation of the placenta is: "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, indicates that this goal has been achieved?

2. Moderate variability present

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?

2. Obtain equipment for a manual pelvic examination.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

2. Rest between contractions

The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise?

2. The passage of meconium

The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Assess vital signs every 4 hours. 2. Measure fundal height every 4 hours. 3. Prepare an ice pack for application to the area. 4. Inform the health care provider of assessment findings.

3 A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 4 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the health care provider (HCP). 4. Place the client in Trendelenburg's position.

3 If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the HCP.

The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse should instruct the client that her calorie needs should increase by approximately how many calories a day? 1. 100 2. 300 3. 500 4. 1000

3 If the client is breast-feeding, her calorie needs increase by approximately 500 cal/day. The client should also be instructed regarding the need for increased fluids and the need for prenatal vitamins and iron supplements.

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding? 1. Scant 2. Light 3. Heavy 4. Excessive

3 Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (<1 inch) on menstrual pad in 1 hour; light = less than 10 cm (<4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (<6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes.

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, would indicate the need for further assessment related to this form of depression? 1. The mother is caring for the infant in a loving manner. 2. The mother demonstrates an interest in the surroundings. 3. The mother constantly complains of tiredness and fatigue. 4. The mother looks forward to visits from the father of the newborn.

3 Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating are also present. The mother would have little interest in food and would experience sleep disturbances.

A postpartum care unit nurse is reviewing the records of 4 new mothers admitted to the unit. The nurse determines that which mother would be least likely at risk for developing a puerperal infection? 1. A mother who had ten vaginal exams during labor 2. A mother with a history of previous puerperal infections 3. A mother who gave birth vaginally to a 3200 gram infant 4. A mother who experienced prolonged rupture of the membranes

3 Risk factors associated for puerperal infection include a history of previous puerperal infections, cesarean births, trauma, prolonged rupture of the membranes, prolonged labor, multiple vaginal exams, and retained placental fragments.

The rubella vaccine is prescribed to be administered to a client 2 days after delivery of her child. The nurse preparing to administer the vaccine develops a list of the potential risks associated with this vaccine. The nurse reviews the list with the client and cautions the client to avoid which situation? 1. Sunlight for 3 days 2. Scratching the injection site 3. Pregnancy for 2 to 3 months after the vaccination 4. Sexual intercourse for 2 to 3 months after the vaccination

3 Rubella vaccine is a live attenuated virus that evokes an antibody response, which provides immunity for 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects of this vaccine and the need to avoid becoming pregnant for 2 to 3 months after receiving the vaccine. Sunlight has no effect on the client who is vaccinated. The vaccine may cause local or systemic reactions, but all of these are mild and short-lived. Abstinence from sexual intercourse is not necessary unless another form of effective contraception is not being used.

The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis? 1. Elevate her legs. 2. Remain on bed rest. 3. Ambulate frequently. 4. Apply warm, moist packs to the legs.

3 Stasis is believed to be a predisposing factor in the development of thrombophlebitis. Because cesarean delivery is also a risk factor for thrombophlebitis, new mothers should ambulate early and frequently to promote circulation and prevent stasis. The other options may be interventions for the client diagnosed with thrombophlebitis. Additionally, bed rest promotes stasis.

A client with known cardiac disease has been admitted to the postpartum care unit after an uneventful delivery. The unit nurse instructs the client to use the call button for assistance whenever she needs to get out of bed or wishes to care for her infant. Which postpartum complication is the nurse most concerned about for this client? 1. Postpartum infection 2. Maternal attachment 3. Maternal overexertion 4. Postpartum newborn-mother bonding

3 The immediate postpartum period is associated with increased risks for the cardiac client. Hormonal changes and fluid shifts from extravascular tissues to the circulatory system cause additional stress on cardiac functioning. Although options 1, 2, and 4 are appropriate nursing concerns during the postpartum period, the primary concern for the cardiac client is to maintain a safe environment because of the potential for cardiac compromise.

The discharge nurse is discussing mastitis with a postpartum client. Which statement made by the client indicates a need for further instruction? 1. "If I develop a hot, reddened, triangle-shaped area on my breast, I should contact my health care provider." 2. "Antibiotics, rest, warm compresses, and adequate fluid intake are all important for the treatment of mastitis." 3. "If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately." 4. "I may develop mastitis if I wear underwire bras, experience excessive fatigue, or suddenly decrease the number of feedings."

3 The mother should not discontinue breast-feeding even if mastitis occurs. Mastitis, a breast infection, is best characterized by a sudden onset of flulike symptoms, localized breast pain and tenderness, and a hot, reddened area on the breast that often resembles the shape of a pie wedge. Treatment usually includes antibiotics, but the mother should be instructed to feed the baby or pump frequently to adequately empty the affected breast.

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3 Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is a normal finding.

The nursing student is assigned to care for a client in the postpartum unit. The coassigned nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method? 1. "I can estimate the amount of blood loss by gauging the amount of staining on a perineal pad." 2. "I should ask the client to keep a record and document every time the perineal pad is changed." 3. "I should weigh the perineal pad before and after use and note the amount of time between each pad change." 4. "I can look at the perineal pad and gauge the amount of staining and relate it to the amount of time between pad changes."

3 To gather accurate data for comparison, the perineal pads must be weighed both before and after use. Once these weights are gathered, the amount of lochia flow can be accurately determined. Noting the time frame between pad changes and the number of pads used also is an important factor. Gauging the amount of staining does not provide accurate data. Asking the client to obtain the information also may not provide accurate data.

A client who is a gravida III, para III had a cesarean section 1 day ago. She is being treated prophylactically for endometritis. She is complaining of abdominal cramping at a level of 6 on pain level scale of 1 to 10 (with 10 being the greatest amount of pain) and fears having her first bowel movement. These medications are prescribed and due now. Based on priority, in which order should the nurse administer the medications? Arrange the medications in the order that they should be administered. All options must be used. Drag the text in the left column to the correct order in the right column. Prenatal vitamin 1 tablet orally daily 1 Docusate sodium (Colace) 100 mg orally 2 Ketorolac (Toradol) 30 mg by intravenous push over 3 minutes 3 Ampicillin sodium (Ampicillin) 1 g intravenous (IV) piggyback over 60 minutes

3, 4, 2, 1 The client is complaining of abdominal cramping, which is the priority and should be treated first; an IV route (ketorolac) is used because it will alleviate the pain rapidly. The risk of infection is greater than the need for a stool softener or a multivitamin; therefore, the IV antibiotic is administered next. The client who has not had her first bowel movement and is afraid to do so is the next priority; therefore, the docusate sodium would be administered next. The multivitamin requires daily administration and works over time to assist in replenishing the nutrients lost during blood loss associated with the surgery; this would be administered last.

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus?

3. "It connects the umbilical vein to the inferior vena cava."

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response?

3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus."

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply.

3. A gravida II who has just been diagnosed with dead fetus syndrome 5. A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate?

3. Inform the client that these contractions are common and may occur throughout the pregnancy.

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action should the nurse implement?

3. Instruct the client that these are common and may occur throughout the pregnancy

The nurse is teaching a pregnant client about the physiological effects and hormonal changes that occur during pregnancy. The client asks the nurse about the role of estrogen in pregnancy. Which responses should the nurse give the client about the role of estrogen? Select all that apply.

3. It increases the blood flow to mucous membranes and causes them to swell and soften. 5. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply.

3. Tachycardia 4. Fetal hypoxia 5. Metabolic acidemia 6. Congenital anomalies

A pregnant primigravida is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse plans to base the response on which facts? Select all that apply.

3. The breast changes occur because of the secretion of estrogen and progesterone. 5. Blood vessels beneath the skin often appear as a blue, intertwining network, especially in a primigravida.

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply.

3. The cervix is dilated completely. 5. The spontaneous urge to push is initiated from perineal pressure.

The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment?

3. The client has a history of hypertension.

The nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion?

3. Continuous electronic fetal monitoring

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction? 1. "I need to urinate frequently throughout the day." 2. "The prescribed medication must be taken until it is finished." 3. "My fluid intake should be increased to at least 3000 mL daily." 4. "Foods and fluids that will increase urine alkalinity should be consumed."

4 A client with a urinary tract infection must be encouraged to take the medication for the entire time it is prescribed. The client should also be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that acidify the urine need to be encouraged.

The nurse is teaching a new mother how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and notes that this is the client's first child. Which nursing intervention is least appropriate in assisting the promotion of mother-infant interaction and bonding? 1. Accepting the client's feelings 2. Acknowledging the client's apprehension 3. Assisting the client with giving the baths to allow her to become more at ease 4. Leaving the infant with the client so that she will be required to provide the care

4 A client with no experience of handling infants may be fearful and reluctant to handle her newborn or to take on physical care on her own. Leaving the infant with the mother so that she will be required to provide the care will produce additional apprehension. Acceptance of her feelings and acknowledgment of the apprehension can help an unsure mother begin to participate in caring for her newborn. Assistance will help the client become more at ease.

After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement? 1. "I will probably need my mother to help me with housekeeping." 2. "Because I am so sore, I will nurse the baby while lying on my side." 3. "My husband and I will not have intercourse until the stitches are healed." 4. "The only medications I will take are prenatal vitamins and stool softeners."

4 A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. A vulvar hematoma is the most common type. The postoperative client will need an antibiotic because she is at increased risk for infection as a result of the break in skin integrity and collection of blood at the hematoma site. Stating that she will need only prenatal vitamins and stool softeners indicates that she requires further teaching. All other options indicate that the mother understands the home care measures after surgical evacuation and repair of a paravaginal hematoma.

A postpartum unit nurse is preparing to care for a client who has just delivered a healthy newborn. In the immediate postpartum period what is the recommended frequency for the nurse to assess the client's vital signs? 1. Every hour for the first 2 hours and then every 4 hours 2. Every 30 minutes during the first hour and then every hour for the next 2 hours 3. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours 4. Every 15 minutes during the first hour and then every 30 minutes for the next 2 hours

4 During the immediate postpartum period, the nurse takes vital signs every 15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. The nurse monitors vital signs thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay.

A nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis? 1. A primigravida with a normal spontaneous vaginal delivery 2. A gravida II who delivered vaginally following an 18-hour labor 3. A client experiencing an elective cesarean delivery at 38 weeks' gestation 4. An adolescent experiencing an emergency cesarean delivery for fetal distress

4 Endometritis is an acute infection of the uterine mucous lining immediately after delivery and is still a leading cause of mortality for childbearing women in the United States. Cesarean delivery is the primary risk factor for uterine infection, especially after emergency procedures. Other risk factors include prolonged rupture of membranes, multiple vaginal examinations, and an excessive length of labor. The other options do not describe the client most at risk to develop endometritis following delivery.

On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urinalysis is done, and the results indicate the presence of a urinary tract infection. The nurse instructs the new mother regarding measures to take for treatment of the infection. Which statement, if made by the mother, would indicate a need for further instructions? 1. "I need to urinate frequently throughout the day." 2. "The prescribed medication must be taken until it is finished." 3. "My fluid intake should be increased to at least 3000 mL daily." 4. "Foods and fluids that will increase urine alkalinity should be consumed."

4 Foods and fluids that acidify, not alkalinize the urine should be encouraged. The woman should be encouraged to urinate frequently throughout the day, instructed to take the medication for the entire time it is prescribed, and encouraged to drink at least 3000 mL of fluid each day to flush the infection from the bladder.

The nurse caring for a client with a diagnosis of subinvolution should understand that which is a primary cause of this diagnosis? 1. Afterpains 2. Increased estrogen levels 3. Increased progesterone levels 4. Retained placental fragments from delivery

4 Retained placental fragments and infections are the primary causes of subinvolution. When either of these processes is present, the uterus has difficulty contracting. The presence of afterpains is an expected finding following delivery. Options 2 and 3 are not causes of subinvolution.

A pregnant client asks the nurse, "What should I expect during a nonstress test?" Which information should the nurse provide to the client?

4. "An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."

The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instruction?

4. "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection."

The nurse provides home care instructions to a pregnant client with a history of cardiac disease. Which statement made by the client indicates a need for further teaching?

4. "During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection."

The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions?

4. "I should avoid eating foods that produce gas and fatty foods."

A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that she has a dilated cervix. Which statement, if made by the client, indicates that the client is interpreting the situation correctly?

4. "I will need to prepare myself and my family for the loss of this pregnancy."

A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse is most appropriate and supportive to the woman?

4. "You were wise to call. I will check your rubella titer screening results, and we can immediately identify whether future interventions are needed."

The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the mother asks if it is safe for her toddler to receive the vaccine. What is the nurse's best response?

4. "Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time."

The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain?

4. Calcium gluconate injection

The nurse is conducting a session about nutrition with a group of adolescents who are pregnant. Which measure is most appropriate to teach these adolescents?

4. Monitor for appropriate weight gain patterns.

Which is the priority nursing action for the client with an ectopic pregnancy?

4. Monitoring the pulse and blood pressure

A clinic nurse is explaining to a client the changes in the integumentary system that occur during pregnancy and should tell the client that which change may persist after she gives birth?

4. Striae gravidarum

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

4. "My contractions will increase in duration and intensity."

The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention?

4. Complaints of severe abdominal pain

The nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action?

4. Document the findings and continue to monitor fetal patterns.

The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes and she cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior?

4. Fear of losing control

The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia?

4. Monitoring the mother's blood pressure

A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and should suspect a diagnosis of placenta previa if which finding is noted?

4. Painless vaginal bleeding

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise?

4. Persistent nonreassuring fetal heart rate

The nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse should document these observations as signs of which condition?

4. Placental separation

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

4. Variable decelerations

The nurse is reviewing fetal development with a client who is at 36 weeks' gestation. Which statements describe the characteristics that are present in a fetus at this time? Select all that apply.

5. The fetus is approximately 42 to 48 cm long. 6. The lecithin-sphingomyelin (L/S) ratio is greater than 2:1.

3.Thoroughly dry the newborn. An optimal thermal environment is essential to the effective care of a neonate. If a newborn is not thoroughly dried and placed in a warm environment immediately after delivery, cold stress may result. Infants respond to cold stress through an increased need for oxygen and depletion of glucose stores, resulting in an increased respiratory rate and possibly cyanosis. Although auscultating the heart rate is essential in the initial assessment of the newborn, palpating the heart rate via the umbilical cord can be done while drying the infant. Drying the infant should only take a few seconds and auscultating the heart rate can be done immediately afterward. The Apgar score is assessed at 1 and 5 minutes of life. Taking the temperature is not a priority immediately following delivery.

A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's priority is to perform which action? 1.Determine Apgar score. 2.Auscultate the heart rate. 3.Thoroughly dry the newborn. 4.Take the newborn's rectal temperature.

4.Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth Both HBIG and the vaccine are given to infants with perinatal exposure to prevent hepatitis and achieve lifelong prophylaxis; they are administered within 12 hours after birth. IG is given to prevent hepatitis A

An infant is born to a mother with hepatitis B. Which prophylactic measure would be indicated for the infant? 1.Hepatitis B vaccine given within 24 hours after birth 2.Immune globulin (IG) given as soon as possible after delivery 3.Hepatitis B immune globulin (HBIG) given within 14 days after birth 4.Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth

1.Elevates the gastrostomy tube In the immediate postoperative period, the gastrostomy tube is elevated, allowing gastric contents to pass into the small intestine and air to escape. This promotes comfort and decreases the risk of leakage at the anastomosis. The remaining options are incorrect. Taping the tube to the bed linens presents a risk of accidental removal. Attaching the tube to suction could disrupt the surgical repair site. Feedings are not initiated in the immediate postoperative period.

An infant returns to the nursing unit following surgery for a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous fluids and a gastrostomy tube is in place. Following assessment, the nurse positions the infant and performs which action? 1.Elevates the gastrostomy tube 2.Tapes the gastrostomy tube to the bed linens 3.Attaches the gastrostomy tube to low suction 4.Connects the gastrostomy to the feeding pump

1.Palpate the clavicles for a fracture. Because of the newborn infant's large size, there is an increased risk for shoulder dystocia. This may result in fractured clavicles or brachial plexus palsy or both. Other complications related to birth trauma include facial paralysis, phrenic nerve palsy, depressed skull fractures, hematomas, and bleeding. A cardiac defect would not be related to birth trauma, even though there is an increase in cardiac defects such as transposition of the great vessels in the LGA newborn infant. Jaundice would not be present initially. Hip dislocation is a congenital disorder and is not caused by birth trauma.

An initial assessment on a large-for-gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence of birth trauma? 1.Palpate the clavicles for a fracture. 2.Auscultate the heart for a cardiac defect. 3.Blanch the skin for evidence of jaundice. 4.Perform Ortolani's maneuver for hip dislocation.

4.90 to 150 mL The stomach capacity is 10 to 20 mL for a newborn infant, 30 to 60 mL for a 1-week-old infant, 75 to 100 mL for a 2- to 3-week-old infant, and 90 to 150 mL for a 1-month-old.

The mother of a 1-month-old infant is bottle-feeding her infant and asks the nurse about the stomach capacity of an infant. What should the nurse tell the client is the stomach capacity of a 1-month-old infant? 1.10 to 20 mL 2.30 to 90 mL 3.75 to 100 mL 4.90 to 150 mL

4.Phototherapy lights 5.Intravenous (IV) pump Given the fact that the newborn is 4 days old, accurate delivery and prevention of circulatory overload is a priority. The IV fluid rate must be maintained using an IV pump. Fluids by gravity would not be the safest mode of delivery in a newborn. The phototherapy lights must be used continually to be effective. The newborn can be fed via gravity using the gavage method if necessary. Vital signs may be obtained without powered equipment. The caregiver may require a call bell, but there are other options for a call device, such as a hand-held noisemaker or whistle.

The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only two red outlets in the room of a 4-day-old male newborn being treated for physiological jaundice and to rule out sepsis from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage? Select all that apply. 1.Call bell 2.Feeding pump 3.Vital sign machine 4.Phototherapy lights 5.Intravenous (IV) pump

The nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse should tell the woman that which will occur?

3. She will feel some pressure when the vaginal probe is moved.

A 25-year-old woman arrives on the maternity unit on February 2. She states that her estimated date of delivery (EDD) is March 22. She is verbalizing complaints of dull lower back pain, pelvic heaviness, and diarrhea for the past few days. On admission for observation, the client's blood pressure is 128/80 mm Hg, pulse is 100 beats/minute, respirations are 16 breaths/minute, and temperature is 99°F. The nurse plans care based on which interpretation?

1. The woman requires further evaluation for preterm labor.

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client?

1. Assess for signs and symptoms of labor.

The nurse assists the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure?

1. Assess the fetal heart rate.

The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations?

3. Encourage an upright or side-lying maternal position.

A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action?

3. Explain to the client why a cesarean delivery is necessary.

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and then teaches the client about proper nutrition to minimize this problem. Which statement, if made by the client, indicates an understanding of the proper nutritional measures to minimize this problem?

4. "I will eat fresh fruits and vegetables for snacks and for dessert each day."

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?

1. "I will need to increase my insulin dosage during the first 3 months of pregnancy."

The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response, if made by the student, indicates an understanding of this physiological process? Select all that apply.

1. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high." 5. "The release of the follicle-stimulating hormone and luteinizing hormone is inhibited by adaptations related to pregnancy."

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. Based on her last normal menstrual period, she is 8 weeks' gestation. Appropriate physical assessments are completed. Which findings are anticipated to be present at this time? Select all that apply.

1. A softening of the cervix 3. Bluish discoloration of the vaginal tissue 4. The presence of human chorionic gonadotropin in the urine

A pregnant client asks the nurse about the types of exercises that are allowed during pregnancy. Which exercise should the nurse instruct the client to engage in?

1. Swimming

The nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the documentation related to the results of the test. The nurse notes that the health care provider has documented the test results as reactive. How should the nurse interpret this result?

1. Normal findings

The nurse is conducting a routine screening to detect a client's risk for toxoplasmosis parasite infection during pregnancy. Which factor should the nurse ask the client about to determine this risk?

1. Presence of cats in the home

The nurse is assessing a client with a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse understands that which findings are associated with this condition? Select all that apply.

1. Vaginal bleeding 3. Excessive nausea and vomiting 4. Larger-than-normal uterus for gestational age 5. Elevated levels of human chorionic gonadotropin (hCG)

A pregnant woman tests positive for the hepatitis B virus (HBV). The woman asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which response by the nurse is most appropriate?

2. "Breast-feeding is allowed after the baby has been vaccinated with immune globulin."

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?

2. Uterine tenderness

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement by the client indicates a need for further teaching?

3. "I cannot exercise because of the negative effects on insulin production."

The nurse is providing instructions about treatment for hemorrhoids to a client in the second trimester of pregnancy. Which statement made by the client indicates a need for further teaching?

3. "I should apply heat packs to the hemorrhoids to help them shrink."

A health care provider has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy, and the client asks the nurse about the procedure. How should the nurse respond to the client?

3. "The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel."

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action?

3. Notify the health care provider (HCP).

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply.

4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age

The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amounts of folic acid if the client states that she will include which item in the daily diet?

4. Leafy green vegetables

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of which condition?

4. Placental separation

The nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily for which reason?

1. Reduce excessive maternal stress and fatigue.

A pregnant client asks the nurse about the types of exercises that are allowed during pregnancy. The nurse should tell that client that which exercise is safest?

1. Swimming

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply.

1. The client has a history of intravenous drug use. 2. The client has a significant other who is heterosexual. 3. The client has a history of sexually transmitted infections.

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The health care provider has documented the presence of first trimester pregnancy signs. Which signs should the nurse anticipate as being present during this time frame? Select all that apply.

1. Hegar's sign 4. Goodell's sign 5. Chadwick's sign

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require which treatment?

1. Increased insulin

During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be 180 beats/minute. What might the nurse suspect as the most likely cause of this tachycardia?

1. Maternal infection

The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. How should the nurse document this finding in the client's medical record? Refer to Figure. (Figure from McKinney et al. [2013], p. 310.)

1. Normal

The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation (DIC). Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply.

1. Petechiae 2. Hematuria 4. Prolonged clotting times 5. Oozing from injection sites

The nurse in the gynecology clinic is reviewing the record of a pregnant client after the first prenatal visit. The nurse notes that the health care provider has documented that the woman has a platypelloid pelvis. On the basis of this documentation, the nurse anticipates which possible outcomes? Select all that apply.

1. Places the client at risk for dystocia 2. Has an increased probability of cesarean section 5. Has a flat shape that may impede fetal descent

Which statement, if made by the laboring client, most likely indicates that the client is in the second stage of labor?

1. "I feel like I need to push."

The nurse is monitoring a client in labor whose membranes ruptured spontaneously. What is the initial nursing action?

1. Determine the fetal heart rate.

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate?

1. Notify the health care provider (HCP).

The nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which is the priority nursing intervention?

1. Provide pain relief measures.

The nurse is caring for a client who is receiving oxytocin for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first?

1. Stop the oxytocin infusion.

On March 10, the nurse performed an initial assessment on a client admitted to the labor and delivery unit for "rule out labor." The client has not received prenatal care but is certain that the first day of her last menstrual period (LMP) was July 7 the previous year. The nurse plans care based on which interpretation?

1. The client is possibly in preterm labor.

The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which nursing action is the priority?

3. Monitoring the apical pulse

The home care nurse is visiting a prenatal client who has a history of heart disease. The nurse provides instructions to the client regarding home care measures to promote a healthy pregnancy and includes which measure in that instruction?

3. Restrict visitors who may have an active infection.

A pregnant primigravida is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse plans to base the response on which facts? Select all that apply.

3. The breast changes occur because of the secretion of estrogen and progesterone. 5. Blood vessels beneath the skin often appear as a blue, intertwining network, especially in a primigravida.

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction?

2. "I will maintain strict bed rest throughout the remainder of the pregnancy."

The nursing instructor asks a nursing student who is preparing to assist with the assessment of an 18 weeks' gestation gravida 2, para 1 (G2P1) pregnant woman to describe expectations related to the process of quickening. Which statements, if made by the student, indicate an understanding of this process? Select all that apply.

2. "It is the fetal movement that is felt by the mother." 5. "It is typically experienced by the multigravida client between 16 and 18 weeks' gestation."

A pregnant client at 16 weeks' gestation reports to the health care clinic for a triple screen test. The nurse determines that the client understands the purpose of this test when the client makes which statements? Select all that apply.

2. "This test can be used as a screening for spina bifida." 3. "One of the purposes of this test is to determine the sex of my baby." 4. "This test is a screening test, and I will need other testing if I have abnormal results." 5. "This test can indicate if I may be at an increased risk for having a child with Down syndrome."

A client in labor is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which finding indicates that the rate of infusion needs to be decreased?

2. A fetal heart rate of 180 beats/min

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?

2. Assess the baseline fetal heart rate.

After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action?

2. Assess the vagina and cervix with a gloved hand.

The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action?

2. Clear and maintain an open airway.

4.Blood pressure cuff Methylergonovine is an oxytocic agent used to prevent or control postpartum hemorrhage by contracting the uterus. It causes constant uterine contractions and may cause the blood pressure to elevate. A priority assessment before administering this medication is obtaining a baseline blood pressure. The client's blood pressure also should be monitored during the administration of the medication. Methylergonovine is administered cautiously in the presence of hypertension, and the health care provider should be notified if hypertension occurs. The items in options 1, 2, or 3 are not priority items.

Methylergonovine (Methergine) has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside? 1.Peripads 2.Tape measure 3.Reflex hammer 4.Blood pressure cuff

A pregnant 39-week-gestation gravida 1, para 0 client arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that she has had a positive group B streptococcus (GBS) laboratory report during her prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which should be the nurse's first action?

3. Call the health care provider (HCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP).

A 39-week-gestation pregnant client calls the maternity unit, stating, "My baby has not moved very much in the past few days. Should I be concerned?" Which is the best response made by the nurse?

4. "Fetal movements do not decrease as a woman nears term; therefore, you should be seen by your health care provider for further evaluation."

The nurse is interviewing a 16-year-old client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation?

4. "I don't like my face anymore. I always look like I have been crying."

The nurse is providing instructions regarding the treatment of hemorrhoids to a client who is in the second trimester of pregnancy. Which statement by the client indicates a need for further instruction?

4. "I should apply heat packs to the hemorrhoids to help the hemorrhoids shrink."

A pregnant client tells the nurse that she frequently has a backache, and the nurse provides instructions regarding measures that will assist in relieving the backache. Which statement by the client indicates a need for further instruction?

4. "I should do more exercises to strengthen my back muscles."

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?

4. "I should drink adequate fluids and increase my intake of high-fiber foods."

A clinic nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse tells the client about the importance of an adequate daily fluid intake. Which client statement best indicates an understanding of the daily fluid requirement?

4. "I should drink at least 8 to 10 glasses of fluid each day, of which at least 6 glasses should be water."

The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instruction?

4. "I should wear knee-high hose, but I should not leave them on longer than 8 hours."

A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures?

4. "I should wear underwear with a cotton panel liner."

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem?

4. "I will eat fresh fruits and vegetables for snacks and for dessert each day."

The nurse is caring for a pregnant woman who has herpes genitalis. The nurse provides instructions to the woman about treatment modalities that may be necessary for this condition. Which statement made by the woman indicates an understanding of these treatment measures?

4. "It may be necessary to have a cesarean section for delivery."

A pregnant client who is anemic tells the nurse that she is concerned about her infant's condition after delivery. Which nursing response would best support the client?

4. "The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."

A nursing student is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of Kegel exercises. Which response made by the student indicates an understanding of the purpose? Select all that apply.

4. "The exercises will help strengthen the pelvic floor in preparation for delivery." 5. "The exercises will help strengthen the muscles that support the bladder and urethra."

A couple is seen in the fertility clinic. After several tests it has been determined that the husband is not sterile and that the wife has nonpatent fallopian tubes. The nurse is preparing the woman and her husband for an in vitro fertilization. Which statement by the woman or her spouse indicates a need for further information about the procedure?

4. "The procedure is performed using artificial insemination of sperm instilled through the vagina."

The nurse provides teaching on how to relieve discomfort to a client in her second trimester of pregnancy who is having frequent low back pain and ankle edema at the end of the day. Which statement made by the client indicates an understanding of the teaching?

4. "When I get home I should lie on the floor, with my legs elevated on a couch, and turn my hips and knees at right angles."

A client who has just been told that she is pregnant wants to know when the baby's heart will be completely developed and beating. The nurse reads in the client's chart that the health care provider has determined the client to be at 6 weeks' gestation. What is the nurse's best response?

4. "Your baby's heart right now has double heart chambers and has begun to beat, so we should be able to see it beat using an ultrasound machine."

The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instruction should the nurse provide to the client?

4. A cesarean section will be necessary if vaginal lesions are present at the time of labor.

A pregnant client asks the nurse in the clinic, "When will I begin to feel fetal movement?" Which response should the nurse make?

4. Between 16 and 20 weeks

The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the lightheadedness?

4. Compression of the vena cava

The nurse in the prenatal clinic is providing nutritional counseling to a pregnant client. The nurse instructs the client to increase the intake of folic acid and tells the client that which food item is highest in folic acid?

4. Dried peas

A client who is 8 weeks' pregnant calls the prenatal clinic and tells the nurse that she is experiencing nausea and vomiting every morning. The nurse should suggest which measure that will best promote relief of the signs and symptoms?

4. Eating dry crackers before arising

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

4. Evidence of bleeding, such as in the gums, petechiae, and purpura

A pregnant woman seen in the health care clinic has tested positive for human immunodeficiency virus (HIV). What can the nurse determine based on this information?

4. HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test.

The health care provider (HCP) is assessing the client for the presence of ballottement. To make this determination, the HCP should take which action?

4. Initiate a gentle upward tap on the cervix.

The nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if she states that she will take the supplements with which item?

4. Orange juice

The nurse is providing instructions about taking iron supplements to a pregnant client. The nurse determines that the client understands the instructions if the client states that she will take the supplements with which drink?

4. Orange juice

The nurse is counseling a pregnant woman diagnosed with gestational diabetes at 29 weeks' gestation. Which information should the nurse discuss with the client? Select all that apply.

4. Plan for weekly nonstress tests at 32 weeks. 5. Obtain nutritional counseling with a dietitian.

A primigravida is receiving magnesium sulfate for the treatment of gestational hypertension. The nurse who is caring for the client is performing assessments every 30 minutes. Which finding would be of most concern to the nurse?

4. Respiratory rate of 10 breaths/minute

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider (HCP)?

4. The client complains of a headache and blurred vision.

Shortly after receiving epidural anesthesia, a laboring woman's blood pressure drops to 95/43 mm Hg. Which immediate actions should the nurse take? Select all that apply.

4. Turn the woman to a lateral position. 5. Increase the rate of the intravenous infusion. 6. Administer oxygen by face mask at 10 L/minute.

The nurse is instructing a pregnant client on measures to increase iron in the diet. The nurse should tell the client to consume which food that contains the highest source of dietary iron?

4. Whole-grain cereal

The nurse is describing cardiovascular system changes that occur during pregnancy to a client. Which findings are normal for a client in the second trimester? Select all that apply.

1. Increase in pulse rate 4. Increase in red blood cell production

The prenatal client asks the nurse about substances that can cross the placental barrier and potentially affect the fetus. The nurse most appropriately explains that which substances can cross this barrier? Select all that apply.

1. Viruses 3. Nutrients 4. Antibodies 5. Medications

A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client?

1. Measure fundal height.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?

1. Provide pain relief measures.

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. What is the initial nursing action?

1. Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min.

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action?

1. Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min.

The nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings should the nurse expect to note if abruptio placentae is present? Select all that apply.

2. Abdominal pain 4. Firm uterus by palpation

A pregnant client is seen in the health care clinic. During the prenatal visit, the client informs the nurse that she is experiencing pain in her calf when she walks. Which is the most appropriate nursing action?

2. Assess for signs of venous thrombosis.

A pregnant client calls the clinic and tells the nurse that she is experiencing leg cramps and is awakened by the cramps at night. Which activity should the nurse tell the client to perform when the cramps occur?

2. Dorsiflex the foot while extending the knee.

The nurse is discussing nutrition with a pregnant client who has lactose intolerance. The nurse should instruct the client to supplement the dietary source of calcium by eating which food?

2. Dried fruits

Which medication, if present in the client's history, indicates a need for teaching related to the woman's potential risk for carrying a fetus with a congenital cleft lip or cleft palate?

2. Phenytoin

A rubella titer is performed on a client who has just been told that she is pregnant. The results of the titer indicate that the client is not immune to rubella. Which should the nurse anticipate to be prescribed for this client? 2. Retesting rubella titer during pregnancy

2. Retesting rubella titer during pregnancy

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply.

2. Routine administration of subcutaneous heparin may be prescribed. 3. An overbed lift may be necessary if the client requires a cesarean section. 4. Less frequent cleansing of a cesarean incision, if present, may be prescribed. 5. Thromboembolism stockings or sequential compression devices may be prescribed.

On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies which category of decelerations?

2. Periodic, early decelerations that indicate fetal head compression

A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan?

2. Reduce external stimuli.

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis?

2. "Your type of pelvis is the most favorable for labor and birth."

The nurse is assisting the health care provider to perform Leopold's maneuvers on a pregnant client. Which action should the nurse perform before the procedure?

1. Ask the client to urinate.

A prenatal clinic nurse is providing instructions to a group of pregnant women regarding measures to prevent toxoplasmosis. Which client statement indicates a need for further instruction?

2. "I should drink unpasteurized milk only."

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action?

2. Place the client in Trendelenburg's position.

The nurse in a health care clinic is instructing a client on how to perform kick counts. Which statement made by the client indicates a need for further teaching?

1. "I should lie on my back to perform the procedure."

A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps?

1. Apply heat to the affected area

The nurse is reviewing the medical record of a woman scheduled for her weekly prenatal appointment. The nurse notes that the woman has been diagnosed with mild preeclampsia. Which interventions should the nurse include in planning nursing care for this client? Select all that apply.

1. Assess blood pressure. 2. Check the urine for protein. 3. Assess deep tendon reflexes. 5. Teach the importance of keeping track of a daily weight.

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply.

1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Positive pregnancy test

The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse should report which abnormal findings to the health care provider (HCP)? Select all that apply.

1. Clear, dark amber amniotic fluid 3. Light green amniotic fluid with no odor 4. Thick white amniotic fluid with no odor

The nurse is performing an assessment on a client seen in the health care clinic for a first prenatal visit. The client reports February 9 as the first day of the last menstrual period (LMP). Using Nägele's rule, what date later that same year will the nurse relay as the client's due date? Fill in the blank. Record your answer using 4 digits (mmdd).

1116

The nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by taking which action? 1. Monitoring the vital signs 2. Palpating the uterine fundus 3. Auscultating the bowel sounds 4. Assessing the amount of drainage on the peripad

2 To assess uterine involution, the nurse would palpate the fundal height. Fundal height is measured in fingerbreadths or centimeters in relation to the umbilicus, and this measurement is used to assess the rate of uterine involution. Vital signs and the amount of drainage on the peripad do not indicate uterine involution. Bowel sounds, although they may be diminished in the postpartum period, are not helpful in assessing uterine involution.

The nurse is conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by doing which action?

2. Massaging the abdomen during contractions, using both hands in a circular motion

A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 90 beats/minute. Which nursing action is appropriate?

2. Notify the health care provider (HCP).

A pregnant client has been diagnosed with a vaginal infection from the organism Candida albicans. Which finding should the nurse expect to note when assessing this client?

2. Pain, itching, and vaginal discharge

The nurse is caring for a client with a diagnosis of placenta previa. The nurse collects data knowing that which are characteristic of placenta previa? Select all that apply.

2. Painless, bright red vaginal bleeding 3. Location in the lower uterine segment

The nurse provides dietary instructions to a pregnant woman regarding food items that contain folic acid. Which food item should the nurse recommend as a good source of folic acid?

2. Spinach

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor?

2. The client has a history of cardiac disease.

A pregnant client who is at 30 weeks' gestation comes to the clinic for a routine visit, and the nurse performs an assessment on her. Which observations made by the nurse during the assessment indicates a need for further teaching? Select all that apply.

2. The client is wearing knee-high nylon stockings. 5. The client is wearing sweatpants with snug elastic ankle bands.

A pregnant client calls the nurse at the health care provider's office and reports that she has noticed a thin, colorless vaginal drainage. Which information is most appropriate for the nurse to provide to the client?

2. The vaginal discharge may be bothersome but is a normal occurrence.

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?

2. Discontinue the infusion of oxytocin.

During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome?

2. Prevent dehydration and hypoxemia.

The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area? Click on the image to indicate your answer.

3

The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse should plan to provide which instruction to the client? 1. Apply a heating pad to breasts for comfort. 2. Wear a breast shield to correct nipple inversion. 3. Wear a supportive brassiere continuously for 72 hours. 4. Use the manual breast pump provided to express milk.

3 Wearing a supportive brassiere continuously for 72 hours postpartum will minimize breast engorgement. Any stimulation of the breasts (expression of milk, infant sucking) or increase in circulation (heating pad) will increase milk production or cause the blood vessels and lymphatics to engorge. Correction of nipple inversion will not be necessary if the mother chooses not to breast-feed her infant.

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?

3. "I should avoid exercise because of the negative effects on insulin production."

The nurse is teaching a woman in her first trimester measures to alleviate nausea and vomiting. Which statement by the woman indicates that further teaching is required?

3. "I will eat dry crackers for breakfast after I get up."

A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to the chart below. History and Physical Laboratory and Diagnostic Results Medications Gravida, Term Births, Preterm Births, Abortions, Living Children (GTPAL) 1,0,0,0,0 Venereal Disease Research Laboratory (VDRL) nonreactive Prenatal vitamins Weight 135 lb (61 kg) Rubella immune Positive Goodell and Chadwick Rh positive, Type O

3. "You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk."

The nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the sex of the fetus and asks the nurse when she will be able to know. The nurse should respond to the client knowing that the sex of the fetus is determined by which weeks?

3. 12 to 16

The nurse is collecting data from a client who is at 32 weeks' gestation. The nurse measures the fundal height in centimeters and expects the findings to be how many centimeters (cm)?

3. 32 cm

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client?

3. A private room 2 doors away from the nurses' station

A 35-week-gestation pregnant woman is transferred to the maternity unit from the emergency department, where she was treated for minor injuries sustained in a motor vehicle crash. The maternity nurse's priority will be to assess for which complication?

3. Abruptio placentae

A contraction stress test is scheduled for a pregnant woman, and she asks the nurse to describe the test. What should the nurse include in the teaching? Select all that apply.

3. An external monitor is attached in order to view fetal heart rate response to an established contraction pattern. 4. The uterus is stimulated to contract by the administration of small amounts of oxytocin or by nipple stimulation.

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?

3. An informed consent needs to be signed before the procedure.

The nurse is reviewing the record of a pregnant woman and notes that the health care provider has documented the presence of Chadwick's sign. Which assessment finding supports the presence of Chadwick's sign?

3. Bluish discoloration of cervix and vagina

The nurse is collecting data on a pregnant client in the first trimester of pregnancy diagnosed with iron deficiency anemia. The nurse should monitor the client to detect which manifestation indicating that this problem has not yet resolved?

3. Complaints of daily headaches and fatigue

During a woman's 20-week prenatal visit, the nurse is measuring fundal height. The nurse locates the fundus at the level of the umbilicus. What should be the nurse's next intervention?

3. Document findings in the electronic health record.

The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which findings concern the nurse and indicate the need for follow-up? Select all that apply

3. Fetal heart rate of 180 beats/minute 5. Elevated level of maternal serum alpha-fetoprotein (MSAFP)

The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which findings concern the nurse and indicate the need for follow-up? Select all that apply.

3. Fetal heart rate of 180 beats/minute t 5. Elevated level of maternal serum alpha-fetoprotein (MSAFP)

A pregnant client tells the nurse that she has been craving "unusual foods." The nurse gathers additional assessment data and discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Laboratory studies are performed and the nurse determines that which finding indicates a physiological consequence of the client's practice?

3. Hemoglobin 9 g/dL (90 mmol/L)

A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply.

3. Increase in fundal height 4. Hard, boardlike abdomen 5. Persistent abdominal pain

The home care nurse's assignment is to visit a new mother at home 24 to 48 hours after discharge. What should the nurse expect to note in a healthy mother who is breast-feeding her newborn infant? 1. The mother has cracked nipples and feeds the infant with a supplemental bottle. 2. The mother complains of breast engorgement, and the infant demonstrates difficulty in latching onto the breast. 3. The mother is breast-feeding the infant with the infant's head turned toward her breast and the body flat in her arms; the mother has sore nipples, and the infant has a suck blister. 4. The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow.

4 The infant should be positioned completely facing the mother with head, neck, and spine aligned. Poor positioning increases the number of attempts for latching on. The infant's head turned toward the breast and the body flat in the mother's arms is incorrect because it demonstrates improper positioning. Breast engorgement, sore nipples, and cracked nipples are all complications that are the result of improper positioning.

A nonstress test is prescribed for a pregnant client, and she asks the nurse about the procedure. How should the nurse respond?

4. "A round, hard plastic disk called an ultrasound transducer picks up and marks the fetal heart activity on the recording paper and is secured over the abdomen."

Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement?

4. Administer oxygen at 8 to 10 L/min via face mask.

2.Indicates the presence of maternal infection A positive antibody test in a child younger than 18 months of age indicates only that the mother is infected because maternal immunoglobulin G antibodies persist in infants for 6 to 9 months and, in some cases, as long as 18 months. A positive ELISA does NOT indicate true HIV infection or the development of AIDS, nor does it indicate that the newborn will develop AIDS later in life.

A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results? 1.Positive for HIV 2.Indicates the presence of maternal infection 3.Indicates that the newborn will develop AIDS later in life 4.Positive for acquired immunodeficiency syndrome (AIDS)

4.A bottle of sterile normal saline Spina bifida is a central nervous system defect that results from failure of the neural tube to close during embryonic development. The newborn with spina bifida is at risk for infection before the closure of the sac, which is done soon after birth. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents. This prevents tearing or breakdown of the skin integrity at the site. A thermometer will be needed to assess temperature, but in this newborn the priority is to maintain sterile normal saline dressings over the sac. Blood pressure may be difficult to assess during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development.

A nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside? 1.A rectal thermometer 2.A blood pressure cuff 3.A specific gravity urinometer 4.A bottle of sterile normal saline

2.Periodic well-baby examinations Primary prevention activities are actions that are designed to prevent a disease from occurring or to reduce the probability of occurrence of a specific illness. Periodic well-baby examinations focus on health education, nutrition, concerns related to adequate housing, recreation, and genetics. Selective placement of the infant is vague and does not provide any specific information. PKU testing at birth is an example of secondary prevention because it relates to early diagnosis and treatment. Option 4 identifies an actual treatment.

A nurse is teaching the mother of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant? 1.Selective placement of the infant 2.Periodic well-baby examinations 3.Phenylketonuria (PKU) testing at birth 4.Administration of an antibiotic for an umbilical cord staphylococcal infection

4.A copper-colored skin rash Signs and symptoms of congenital neonatal syphilis may be nonspecific initially, including poor feedings, slight hyperthermia, and "snuffles." By the end of the first week of life, a copper-colored maculopapular dermal rash typically is observed on the palms of the hands, on the soles of the feet, in the diaper area, and around the mouth and anus. Options 1, 2, and 3 are not associated signs of this disorder.

The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which finding? 1.Loose stools 2.High-pitched cry 3.Vigorous feeding habits 4.A copper-colored skin rash

1.Bring the infant to the clinic. Symptoms of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If symptoms of infection occur, the client should be instructed to notify a health care provider (HCP). If these symptoms occur, antibiotics may be necessary. Options 2, 3, and 4 are inappropriate nursing interventions for the description given in the question

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1.Bring the infant to the clinic. 2.This is a normal occurrence. 3.Increase the number of times that the cord is cleaned per day. 4.Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

2.Maintaining standard precautions at all times while caring for the newborn An infant born to a mother infected with human immunodeficiency virus (HIV) must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn. Mothers infected with HIV should not breast-feed. Options 1 and 3 are not associated specifically with the care of a potentially HIV-infected newborn.

The nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse should include which intervention in the plan of care? 1.Monitoring the newborn's vital signs routinely 2.Maintaining standard precautions at all times while caring for the newborn 3.Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4.Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment

3.Two arteries The umbilical cord is made up of two arteries to carry blood from the embryo to the chorionic villi and one vein that returns blood to the embryo. There should be no odor noted from the umbilical cord. Options 1, 2, and 4 are incorrect.

The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse should expect to observe which finding? 1.One artery 2.Two veins 3.Two arteries 4.One artery and one vein

3.Conduction Heat loss occurs by four different mechanisms. In conduction, heat loss occurs when the infant is on a cold surface, such as a table. Radiation occurs when heat from the body surface radiates to the surrounding environment. In convection, air moving across the infant's skin transfers heat to the air. Evaporation of moisture from a wet body surface dissipates heat along with the moisture.

The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method? 1.Radiation 2.Convection 3.Conduction 4.Evaporation

4.Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane Omphalocele is an abdominal wall defect. It involves a large herniation of the gut into the umbilical cord. The viscera are outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane. Options 1 and 2 describe an umbilical hernia.Option 3 describes a gastroschisis.

The nurse is admitting a newborn infant to the nursery and notes that the health care provider has documented that the newborn has an omphalocele. While performing an assessment, where should the nurse document the location of the viscera in this condition? 1.Inside the abdominal cavity and under the skin 2.Inside the abdominal cavity and under the dermis 3.Outside the abdominal cavity and not covered with a sac 4.Outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane

4.Coughing, wheezing, and short periods of apnea Clinical manifestations associated with hiatal hernia specifically include vomiting, coughing, wheezing, short periods of apnea, and failure to thrive. Excessive oral secretions are a clinical manifestation of esophageal atresia and tracheoesophageal fistula. Bowel sounds heard over the chest is a clinical manifestation associated with congenital diaphragmatic hernia. Hiccups and spitting up after a meal is a clinical manifestation of gastroesophageal reflux.

The nurse is assessing a newborn infant with a diagnosis of hiatal hernia. Which findings would the nurse most specifically expect to note in the infant? 1.Excessive oral secretions 2.Bowel sounds heard over the chest 3.Hiccups and spitting up after a meal 4.Coughing, wheezing, and short periods of apnea

3.Constant crying A newborn of a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held.

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn? 1.Lethargy 2.Sleepiness 3.Constant crying 4.Cuddles when being held

1.A normal value total calcium levels are 7.0 to 12.0 mg/dL in a term infant younger than 1 week and 8.0 to 10.5 mg/dL in a child. Neonatal hypocalcemia is defined as a total serum calcium level of less than 7.0 mg/dL. If a newborn baby's calcium level is abnormal, the nurse should notify the health care provider.

The nurse is caring for a newborn. Blood samples for serum chemistries are drawn, and the total calcium level is reported as 8.0 mg/dL. How should the nurse interpret this laboratory value? 1.A normal value 2.Lower than normal 3.Higher than normal 4.Requiring health care provider notification

1.Presence of a cephalhematoma Enclosed hemorrhage, such as with cephalhematoma, predisposes the newborn to jaundice by producing an increased bilirubin load as the cephalhematoma resolves and the blood is absorbed into the circulatory system. The classic Rh incompatibility situation involves an Rh-negative mother with an Rh-positive fetus or newborn. The birth weight in option 3 is within the acceptable range for a term newborn and therefore does not contribute to an increased bilirubin level. A negative direct Coombs' test result indicates that no maternal antibodies are present on fetal erythrocytes

The nurse is caring for a term newborn. Which assessment finding would alert the nurse to suspect the potential for jaundice in this infant? 1.Presence of a cephalhematoma 2.Infant blood type of O negative 3.Birth weight of 8 pounds 6 ounces 4.A negative direct Coombs' test result

1.Clap hands or slap the mattress. The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The newborn should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs and then by flexion and adduction of the limbs. This reflex disappears at 6 months of age. The rooting reflex is elicited by stimulating the perioral area with the finger. The plantar grasp reflex is elicited by stimulating the ball of the foot with firm pressure and the palmar grasp reflex is elicited by stimulating the palm of the hand with firm pressure.

The nurse is checking the reflexes of a newborn. Which action should the nurse perform in eliciting the Moro reflex? 1.Clap hands or slap the mattress. 2.Stimulate the perioral cavity with a finger. 3.Stimulate the ball of the infant's foot with firm pressure. 4.Stimulate the pads of the infant's hands with firm pressure.

2.A soft and flat anterior fontanel The anterior fontanel is diamond-shaped and located on the top of the head. It should be soft and flat and may range in size from almost nonexistent to 4 to 5 cm across. It normally closes by 18 to 24 months of age. A depressed fontanel may indicate dehydration.

The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely finding? 1.A depressed anterior fontanel 2.A soft and flat anterior fontanel 3.An anterior fontanel measuring 1 cm 4.An anterior fontanel measuring 7 cm

2.Place the paper tape under the newborn's head, wrap around the occiput, and measure just above the eyes. to measure head circumference, the nurse should place the paper tape under the newborn's head and wrap the tape around the newborn's head, measuring just above the eyebrows so that the largest area of the occiput is included. Therefore the remaining options are incorrect.

The nurse is performing an assessment on a newborn. The nurse is preparing to measure the head circumference of the newborn. Which procedure should the nurse use to perform this procedure? 1.Wrap the paper tape around the newborn's head, and measure just above the eyebrows. 2.Place the paper tape under the newborn's head, wrap around the occiput, and measure just above the eyes. 3.Place the paper tape at the back of the head, wrap across the ears, and measure across the newborn's mouth. 4.Place the paper tape under the newborn's head at the base of the skull, and wrap around to the front, just above the eyes.

3.Notify the health care provider. Low or oddly placed ears are associated with various congenital defects and should be reported immediately. Although the findings should be documented, the most appropriate action would be to notify the health care provider. Options 2 and 4 are inaccurate and inappropriate nursing actions.

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? 1.Document the findings. 2.Arrange for hearing testing. 3.Notify the health care provider. 4.Cover the ears with gauze pads.

.Maintaining safety because of low blood glucose levels The newborn of a diabetic mother is at risk for hypoglycemia, so maintaining safety because of low blood glucose levels would be a priority. The newborn would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. Developmental delays, choking, and an elevated body temperature are not expected problems.

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1.Developmental delays because of excessive size 2.Maintaining safety because of low blood glucose levels 3.Choking because of impaired suck and swallow reflexes 4.Elevated body temperature because of excess fat and glycogen

4.The lateral aspect of the middle third of the vastus lateralis muscle The preferred injection site for vitamin K in the newborn infant is the lateral aspect of the middle third of the vastus lateralis muscle in the infant's thigh. This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication.

The nurse is preparing to administer an injection of vitamin K to a newborn. Which injection site should the nurse select? 1.The gluteal muscle 2.The lower aspect of the rectus femoris muscle 3.The medial aspect of the upper third of the vastus lateralis muscle 4.The lateral aspect of the middle third of the vastus lateralis muscle

2.40 to 60 breaths/min If the newborn is apneic or has gasping respirations after stimulation, or the heart rate is below 100 beats/min, positive pressure ventilation by bag and mask can be given. The anesthesia bag used for neonatal resuscitation should have a pressure gauge. Ventilations should be given at a rate of 40 to 60 breaths/min at pressures of 15 to 20 cm H2O.

The nurse is preparing to assist in administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic, gasping, and has a heart rate below 100 beats/min. The nurse should understand that how many ventilations per minute should be delivered to this neonate? 1.20 to 40 breaths/min 2.40 to 60 breaths/min 3.70 to 80 breaths/min 4.80 to 100 breaths/min

2.Abnormal palmar creases Fetal alcohol syndrome is caused by maternal alcohol use during pregnancy. Features of newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal assessment findings in the full-term newborn infant.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1.Length of 19 inches 2.Abnormal palmar creases 3.Birth weight of 6 lb, 14 oz 4.Head circumference appropriate for gestational age

2.Hypoglycemia 3.Fractured clavicle 5.Congenital heart defect Any newborn weighing more than 4000 g at birth is defined as being large for gestational age (LGA). Because of their size, LGA infants are also at risk for hypoglycemia. LGA infants also have a higher incidence of birth injuries (fractured clavicle), asphyxia, and congenital anomalies (heart defect). Retinopathy is a disorder that affects the developing vessels of preterm infants. Hyperbilirubinemia is not an immediate risk related to LGA. Preterm birth is the most prominent risk factor in the development of necrotizing enterocolitis.

The nurse weighing a term newborn during the initial newborn assessment determines the infant's weight to be 4325 g. The nurse determines that this infant may be at risk for which complications? Select all that apply. 1.Retinopathy 2.Hypoglycemia 3.Fractured clavicle 4.Hyperbilirubinemia 5.Congenital heart defect 6.Necrotizing enterocolitis

2.Irritability Characteristic behaviors of the newborn infant with fetal alcohol syndrome (FAS) are similar to those of the drug-exposed newborn infant. These behaviors include irritability, tremors, poor feeding, and hypersensitivity to stimuli. Newborn infants with FAS are smaller at birth and present with failure to thrive. Head circumference and weight are most affected (smaller head circumference and decreased weight).

The nursery room nurse is assessing a newborn infant who was born to a mother who abuses alcohol. Which assessment finding should the nurse expect to note? 1.Lethargy 2.Irritability 3.Higher-than-normal birth weight 4.A greater-than-normal appetite when feeding

1.The mother bathes the newborn infant after a feeding. It is not advisable to bathe a newborn infant after a feeding because handling may cause regurgitation. Because bathing is thought to be relaxing to the infant, bathing before feeding may be the best time. All other options are appropriate interventions in teaching the mother how to bathe a newborn.

The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which observation indicates a lack of understanding of the instructions? 1.The mother bathes the newborn infant after a feeding. 2.The mother states that she would gather all supplies before the bath is started. 3.The mother states that she would never leave the newborn infant in the tub of water alone. 4.The mother fills a clean basin or sink with 2 to 3 inches of water and then checks the temperature with her wrist.

4.Measles-mumps-rubella vaccination Vitamin K is administered intramuscularly into the vastus lateralis muscle. Tetracycline 1% and erythromycin are prescribed for prophylaxis against gonorrhea and are administered into the eye. The measles-mumps-rubella vaccination is not given to a newborn.

Which medication should the nurse plan to administer to a newborn by the intramuscular (IM) route? 1.Erythromycin 2.Tetracycline 1% 3.Phytonadione (Vitamin K) 4.Measles-mumps-rubella vaccination

1.Grunting respirations 3.Heart rate of 190 beats/minute 6.A yellow discoloration of the sclera and body Grunting respirations is a sign of possible respiratory distress. The normal newborn heart rate is 100 to 160 beats/minute. The presence of a yellow discoloration could indicate newborn jaundice. Options 2, 4, and 5 are normal findings. The anterior fontanelle should measure 5 cm wide by 2-3 cm long.

Which would be considered abnormal findings in a newborn less than 12 hours old? Select all that apply. 1.Grunting respirations 2.Presence of vernix caseosa 3.Heart rate of 190 beats/minute 4.Anterior fontanelle measuring 5.0 cm 5.Bluish discoloration of hands and feet 6.A yellow discoloration of the sclera and body

1.Make a loud, abrupt noise to startle the newborn. The Moro reflex is elicited by placing the newborn on a flat surface and striking the surface or making a loud, abrupt noise to startle the newborn. The newborn assumes sharp extension and abduction of the arms with the thumbs and forefingers in a C position; this is followed by flexion and adduction to an "embrace" position (legs follow a similar pattern). The Moro reflex is present at birth and is absent by 6 months of age if neurological maturation is not delayed. A persistent response lasting more than 6 months may indicate a neurological abnormality. The rooting reflex is elicited by stimulating the perioral area with the finger. The palmar grasp reflex is elicited by stimulating the palm of the hand by firm pressure, and the plantar grasp reflex is elicited by stimulating the ball of the foot by firm pressure.

he nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action? 1.Make a loud, abrupt noise to startle the newborn. 2.Stimulate the ball of the foot of the newborn by firm pressure. 3.Stimulate the perioral cavity of the newborn infant with a finger. 4.Stimulate the pads of the newborn infant's hands by firm pressure.

3.Blood glucose levels The most common metabolic complication in the SGA newborn infant is hypoglycemia, which can produce central nervous system abnormalities and mental retardation if not corrected immediately. Urinary output, although important, is not the highest-priority action, because the post-term SGA infant is typically dehydrated as a result of placental dysfunction. Hemoglobin and hematocrit levels are monitored because the post-term SGA infant exhibits polycythemia, although this also does not require immediate attention. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery.

the nurse is caring for a post-term, small-for-gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority? 1.Urinary output 2.Total bilirubin levels 3.Blood glucose levels 4.Hemoglobin and hematocrit levels

3.Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat The skin of a newborn infant plays a significant role in thermoregulation and as a barrier against infection. The skin of a preterm newborn infant is immature in comparison with that of a term newborn infant. The skin of a preterm newborn is thin and gelatinous, with decreased amounts of subcutaneous fat, brown fat, and glycogen stores. In addition, preterm newborn infants lose heat because of their large body surface area in relation to their weight and because their posture is more relaxed, with less flexion. Therefore preterm newborn infants are less able to generate heat, which places them at risk for increased heat loss and increased fluid requirements.

the nurse is developing a plan of care for a preterm newborn infant. The nurse develops measures to provide skin care, knowing that the preterm newborn infant's skin appears in what way? 1. Thin and gelatinous, with increased subcutaneous fat 2.Thin and gelatinous, with increased amounts of brown fat 3.Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat 4.With fine downy hair on thin epidermal and dermal layers, with increased amount of brown fat

4.Edema resulting from bleeding below the periosteum of the cranium A cephalohematoma indicates edema resulting from bleeding below the periosteum of the cranium. It does not cross the suture line. It is most likely to be caused by ruptured blood vessels from head trauma during birth. The lesion develops within 24 to 48 hours after birth and may take 2 to 3 weeks to resolve. Option 1 may indicate increased intracranial pressure. Option 2 may be associated with premature closure or craniosynostosis and should be investigated further. Option 3 identifies a caput succedaneum.

the nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant? 1.A suture split greater than 1 cm 2.A hard, rigid, immobile suture line 3.Swelling of the soft tissues of the head and scalp 4.Edema resulting from bleeding below the periosteum of the cranium

The nurse is assessing the deep tendon reflexes of a client with severe preeclampsia who is receiving intravenous magnesium sulfate. The nurse should perform which procedure to assess the brachioradialis reflex? Click on the image to indicate your answer.

1

During a prenatal visit, the nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement?

1. "Diet and insulin needs change during pregnancy."

A home care nurse is monitoring a 16-year-old primigravida who is at 36 weeks' gestation and has gestational hypertension. Her blood pressure during the past 3 weeks has been averaging 130/90 mm Hg. She has had some swelling in the lower extremities and has had mild proteinuria. Which statement by the woman should alert the nurse to the worsening of gestational hypertension?

1. "My vision for the past 2 days has been really fuzzy."

The nurse is performing a physical assessment on a client during her first prenatal visit to the clinic. The nurse takes the client's temperature and notes that it is 99.2°F. Based on this finding, which nursing action is most appropriate?1. Document the temperature.

1. Document the temperature.

In the prenatal clinic, the nurse is interviewing a new client and obtaining health history information. Which action should the nurse plan to elicit the most accurate responses to the questions that refer to sexually transmitted infections?

1. Establish a therapeutic relationship.

The client is being seen at 24 weeks' gestation at the prenatal clinic. At her last routine visit, the fundus was located at the umbilicus. Today, the fundus is measured and found to be 23 cm. How should the nurse interpret this finding?

1. Fundus is at the appropriate level.

A home care nurse is visiting a pregnant client with a diagnosis of mild preeclampsia. What is the priority nursing intervention during the home visit?

1. Monitor for fetal movement.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

1. Administer oxygen via face mask.

The nurse is caring for a client in the active stage of labor. The nurse notes that the fetal pattern shows a late deceleration on the monitor strip. Based on this finding, the nurse should prepare for which appropriate nursing action?

1. Administering oxygen via face mask

An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention should the nurse prepare the client for?

1. Delivery of the fetus

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be most appropriate?

2. "Do you plan to have any other children?"

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis? 1. Palpate for pedal pulses. 2. Ask the client about pain in the calf area. 3. Assess for the presence of vaginal hematoma. 4. Ask the client to ambulate and assess for the presence of pain.

2 Thrombophlebitis is a potential complication in the postpartum period. The client with thrombophlebitis may experience pain in the calf. The remaining options would not determine the presence of thrombophlebitis. Palpating pulses assesses circulation. The presence of a hematoma does not indicate thrombophlebitis. The nurse should not ask the client to ambulate if thrombophlebitis is suspected.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)?

2 .Fetal heart rate of 180 beats/minute

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart?

2. G = 2, T = 1, P = 0, A = 0, L = 1

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for a spontaneous abortion?

2. History of syphilis

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan?

2. Isoniazid plus rifampin will be required for 9 months

The charge nurse on a labor and delivery unit has numerous admissions of laboring clients and must transfer 1 of the clients to the postpartum/gynecological unit, where the nurse-to-client ratio will be 1:4. Which antepartum client is the most appropriate one to transfer?

2. The 26-year-old, gravida I, para 0 client who is at 10 weeks' gestation and is experiencing vaginal bleeding

A client in week 35 of her pregnancy is placed on the fetal heart monitor for a nonstress test (NST) as a result of her complaints of decreased fetal movement. Twenty minutes after placing the client on the monitor, the nurse sees the following monitor strip and makes which conclusion regarding the NST? Refer to Figure. (From McKinney et al. [2013], p. 319.)

2. The FHR is reactive, with a baseline of 130 beats/minute, moderate variability, and no decelerations.

The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply.

2. Use of fertility medications 3. History of Chlamydia 4. Use of an intrauterine device 5. History of pelvic inflammatory disease (PID)

The nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. Which instruction should the nurse provide?

2. Wash the breasts with warm water and keep them dry.

A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the health care provider (HCP). The nurse should tell the woman to call the HCP if which occurs?

3. Weight increases by more than 1 pound in a week.

The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation?

3. "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus."

The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately?

3. Palpating the maternal radial pulse while listening to the FHR

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?

3. Perform a vaginal examination every shift.

The postpartum unit nurse has provided information regarding performing a sitz bath to a new mother after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that the sitz bath will promote which action? 1. Numb the tissue. 2. Stimulate a bowel movement. 3. Reduce the edema and swelling. 4. Assist in healing and provide comfort.

4 Warm, moist heat is used after the first 24 hours after tissue trauma from a vaginal birth to provide comfort and promote healing and reduce the incidence of infection. This warm, moist heat is provided via a sitz bath. Ice is used in the first 24 hours to reduce edema and numb the tissue. Promoting a bowel movement is best achieved by ambulation.

A postpartum client is attempting to breast-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action should the nurse take to assist the client in breast-feeding the newborn infant? 1. Massage the breasts, applying gentle pressure on the areolas with the thumb and forefinger. 2. Have the mother grasp her areola between the thumb and forefinger and tug firmly to get the nipple to protrude. 3. Encourage taking a cool shower, allowing the water to run over the breasts, because this will encourage the nipples to protrude. 4. Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp.

4 Wearing breast shells and using a breast pump before each feeding will make it easier for the newborn infant to grasp the nipple. Massaging the breast is an appropriate instruction for the mother with engorgement but will not help with resolving inverted nipples. True inverted nipples will retract if the areola is pressed between the thumb and forefinger. Having the client take a cool shower will only make the mother cold, and it has no effect on inverted nipples.

1."The medication provides pain relief during labor." Butorphanol tartrate is an opioid analgesic that provides systemic pain relief during labor. It does not relieve nausea, increase uterine contractions, or prevent respiratory depression in the newborn infant.

Butorphanol tartrate (Stadol) is prescribed for a woman in labor, and the woman asks the nurse about the purpose of the medication. The nurse should make which most appropriate response? 1."The medication provides pain relief during labor." 2."The medication will help prevent any nausea and vomiting." 3."The medication will assist in increasing the contractions." 4."The medication prevents respiratory depression in the newborn infant."

1.At 1 minute after birth and 5 minutes after birth One of the earliest indicators of successful adaptation of the newborn is the Apgar score. This test is performed 1 minute after birth and again 5 minutes after birth.

On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score? 1.At 1 minute after birth and 5 minutes after birth 2.Immediately at birth, 3 minutes after birth, and 10 minutes after birth 3.At 1 minute after birth, 5 minutes after birth, and 10 minutes after birth 4.At 1 minute after birth, after the cord is cut, and after the mother delivers the placenta

A primigravida asks the nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?

4. 18 and 20

A nulliparous woman asks the nurse when she will begin to feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately how many weeks of gestation?

4. 18 weeks

The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1. "We want to attend a support group." 2. "We never want to try to have a baby again." 3. "We are going to try to adopt a child immediately." 4. "We are okay, and we are going to try to have another baby immediately."

1 A support group can help the parents work through their pain by nonjudgmental sharing of feelings. The correct option identifies a statement that would indicate positive, normal grieving. Although the other options may indicate reactions of the client and significant other, they are not specifically a part of the normal grieving process.

A nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching? 1. "I can begin abdominal exercises immediately." 2. "I need to notify the health care provider if I develop a fever." 3. "I can't lift anything heavier than my newborn for at least 2 weeks." 4. "I need to turn on my side and push up with my arms to get out of bed."

1 Abdominal exercises should not start immediately following abdominal surgery until 3 to 4 weeks postoperatively to allow for healing of the incision. The other options are appropriate instructions for the client following a cesarean delivery.

The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of delivery 4. Within 2 weeks postpartum

1 After birth, the nurse should auscultate the client's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. 1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 4. "I will start my estrogen birth control pills again as soon as I get home." 5. "I know if my breasts get engorged I will limit my breast-feeding and supplement the baby." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

1, 2, 3, 6 The postpartum client should wear a bra that is well-fitted and supportive. Breasts may leak between feedings or during coitus, and the client is taught to place a breast pad in the bra. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding, but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or other medications.

Which instructions should a nurse provide to a client following delivery regarding care of the episiotomy site to prevent infection? Select all that apply. 1. Report a foul-smelling discharge. 2. Take a warm sitz baths three times a day. 3. Change the perineum pads three times a day. 4. Use warm water to rinse the perineum after elimination. 5. Wipe the perineum from front to back after voiding and defecation.

1, 2, 4, 5 Warm sitz baths and cleansing with warm water are helpful for relieving pain, and these measures will promote cleanliness in the perineal area to prevent infection. The client should also be instructed to wipe the perineum from front to back after voiding and defecation to decrease the risk for contamination with microorganisms from the anus to the vagina. Warm water should be used to rinse the perineum after elimination. The client also should be instructed that the perineal pad should be changed after each elimination and may be changed in between.

A nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and is not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply. 1. Massaging the uterus 2. Pushing gently on the uterus 3. Assisting the woman to urinate 4. Rechecking the uterus in 1 hour 5. Checking for a distended bladder 6. Calling the delivery room to schedule an abdominal hysterectomy

1, 3, 5 If the uterus is soft and spongy and is not firmly contracted, the initial nursing action is to massage the fundus gently until it is firm; this will express clots that may have accumulated in the uterus. If the uterus does not remain contracted as a result of massage, the problem may be a distended bladder, which lifts and displaces the uterus and prevents effective contraction of the uterine muscles. The nurse would then check for a distended bladder and assist the woman to urinate. Pushing on an uncontracted uterus could invert the uterus, potentially causing massive hemorrhage and rapid shock. Waiting for 1 hour without intervention could result in bleeding. The health care provider will need to be notified if uterine massage is not helpful. Pharmacological measures may be necessary to maintain firm contraction of the uterus. An abdominal hysterectomy may need to be performed for massive hemorrhage that is uncontrollable. The question presents no data indicating that hemorrhage is a problem. Additionally, the nurse would not schedule an operative procedure.

The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred?

1. Forceps delivery

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment? 1. Ask the client to turn on her side. 2. Ask the client to urinate and empty her bladder. 3. Massage the fundus gently before determining the level of the fundus. 4. Ask the client to lie flat on her back, with her knees and legs flat and straight.

2 Before fundal assessment is started, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. The nurse can then assess the bladder for complete emptying and accurately assess uterine involution. When performing fundal assessment, the woman is asked to lie flat on her back, with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy or soft, and then it should be massaged gently until firm.

A nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement made by the client indicates a need for further teaching? 1. "I need to wear a supportive bra to relieve the discomfort." 2. "I need to stop breast-feeding until this condition resolves." 3. "I can use analgesics to assist in alleviating some of the discomfort." 4. "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

2 In most cases, the client can continue to breast-feed with both breasts. If the affected breast is too sore, the client can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery? 1. Encourage the mother to breast-feed soon after birth. 2. Support the mother in her reaction to the newborn infant. 3. Tell the mother that it is important to hold the newborn infant. 4. Document a complete account of the mother's reaction on the birth record.

2 Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the client's feelings.

The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned with the presence of subinvolution if which occurs? 1. The presence of afterpains 2. Retained placental fragments from delivery 3. An oral temperature of 99.0° F following delivery 4. Increased estrogen and progesterone levels as noted on laboratory analysis

2 Retained placental fragments and infection are the primary causes of subinvolution. When either of these processes is present, the uterus will have difficulty contracting. An oral temperature of 99.0° F after delivery and the presence of afterpains are expected findings following delivery. Option 4 is not a cause of subinvolution and is unrelated to the subject of the question.

The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client? 1. "You should avoid sexual intercourse for 2 weeks after administration of the vaccine." 2. "You should not become pregnant for 2 to 3 months after administration of the vaccine." 3. "You should avoid heat and extreme temperature changes for 1 week after administration of the vaccine." 4. "You must sign an informed consent because anaphylactic reactions can occur with the administration of this vaccine."

2 Rubella vaccine is a live attenuated virus that provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as a virus and is potentially harmful to the organogenesis phase of fetal development. Informed consent for rubella and varicella vaccination in the postpartum period includes information about possible side effects and the risk of teratogenic effects. The client should be informed about the potential effects of this vaccine and the need to avoid becoming pregnant for 2 to 3 months (or as indicated by the health care provider) after administration of the vaccine. Abstinence from sexual intercourse is unnecessary. Heat or extreme changes in temperature have no effect on the person who has been vaccinated. The vaccine is not known to cause anaphylactic reactions.

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breast-feeding needs to be stopped for 3 months. 2. Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. 6. The area of the injection needs to be covered with a sterile gauze for 1 week.

2, 3, 4, 5 Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. The live attenuated rubella virus is not communicable in breast milk; breast-feeding does not need to be stopped. The client is counseled not to become pregnant for 1 to 3 months after immunization as specified by the health care provider because of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at the time of the immunization. The client should avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or necessary reason for covering the area of the injection with a sterile gauze.

After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients should be assessed. How would the nurse plan assessments? Arrange the clients in the order that they should be assessed. All options must be used. Drag the text in the left column to the correct order in the right column. An 8-hour post-vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV) solution of 5% dextrose in lactated Ringer's solution (D5LR) with 20 milliunits of oxytocin (Pitocin) infusing at 125 mL/hr. 1 A 12-hour post-cesarean section delivery of a gravida 3, para 3, who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks. 2 A 48-hour post-cesarean section delivery of a gravida 1, para 1, who reports not yet having a bowel movement since delivery and requests a stool softener. 3 A 24-hour post-vaginal delivery of a gravida 4, para 4, who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen (Motrin).

2, 4, 1, 3 The 12-hour post-cesarean section delivery client should be assessed first because she is reporting a sensation of wetness; this could be excessive bleeding. The 24-hour post-vaginal delivery client is complaining of pain, which can be treated easily with oral medications; therefore this client should be assessed next. The 8-hour post-vaginal delivery client who is scheduled for a bilateral tubal ligation has an IV infusing of oxytocin, which will facilitate uterine involution, thereby promoting uterine contractions and minimal bleeding. A baseline assessment must be conducted preoperatively for a bilateral tubal ligation; however, the scheduled operative time is 5 hours away. The client who had cesarean section delivery 48 hours ago is assessed last as she is the farthest out from delivery, and the effectiveness of a stool softener will be achieved over time with continued administration.

A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure? 1. Pump both breasts and discard the milk. 2. Bottle-feed the infant on a temporary basis. 3. Breast-feed from the left breast and gently pump the right breast. 4. Stop breast-feeding from both breasts until this condition resolves.

3 In most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. If an abscess forms and ruptures into the ducts of the breast, breast-feeding will need to be discontinued and a pump should be used to empty the breast (but the milk should be discarded). Options 1, 2, and 4 are incorrect.

A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action would be appropriate? 1. Massage the fundus. 2. Contact the health care provider. 3. Cover the client with a warm blanket. 4. Place the client in Trendelenburg's position.

3 In the postpartum period, a woman may experience a shaking, uncontrollable chill immediately after birth. The exact cause of this fairly common event is not known; however, it is thought to be associated with a nervous system reaction such as a vasovagal response. If the chill is not associated with an elevated temperature, it is of no clinical significance. The appropriate nursing action would be to provide a warm blanket to the client and a warm drink if this is not contraindicated.

A nurse is monitoring the client for signs of postpartum depression. Which would indicate the need for further assessment related to this form of depression? 1. The client is caring for the infant in a loving manner. 2. The client demonstrates an interest in the surroundings. 3. The client constantly complains of tiredness and fatigue. 4. The client looks forward to visits from the father of the newborn.

3 Postpartum depression is not the normal depression that many new mothers experience from time to time. The client experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The client also is unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The client often expresses a sense of loss of self. Generalized fatigue, complaints of ill health and difficulty in concentrating also are present. The client would have little interest in food and experience sleep disturbances.

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated in blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action? 1. Call the health care provider. 2. Assess the client's vital signs. 3. Gently message the uterine fundus. 4. Administer a 300-mL bolus of a 20 units/L oxytocin (Pitocin) solution.

3 The most frequent cause of excessive bleeding after childbirth is uterine atony. A major intervention to restore adequate tone is stimulation of the uterine muscle via gently massaging the uterine fundus. Options 1, 2, and 4 may be necessary but they are not initial actions. The initial action is to alleviate the problem. Additionally a health care provider's prescription is needed to administer a medication.

The nurse in an obstetrical clinic is reviewing current prenatal laboratory results of a pregnant client who is being seen for a routine prenatal visit. The nurse discovers that the client's 1-hour oral glucose tolerance test (OGTT) result was 163 mg/dL (9.3 mmol/L). Which is the nurse's best response to the client?

3. "The OGTT is a screening tool for gestational diabetes, and you will need further testing to confirm a diagnosis owing to your results being elevated."

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? 1. The mother requests that the window be closed before feeding. 2. The mother holds the newborn properly during feeding and burping. 3. The mother tests the temperature of the formula before initiating feeding. 4. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

4 Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce maternal complications. The correct option provides the best evaluation of maternal understanding of disease transmission. Option 1 will not affect disease transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding, but do not minimize disease transmission for hepatitis B.

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/minute, by face mask.

4 If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.

The nursing instructor is reviewing the plan of care with a student regarding care of a postpartum client. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which response made by the student indicates an understanding of this phase? 1. "The client would be independent." 2. "The client initiates activities on her own." 3. "The client participates in mothering tasks." 4. "The client is self-focused and talks to others about labor."

4 Rubin has identified three phases of regeneration during the postpartum period. The taking-in phase occurs in the first 3 days postpartum, and the taking-hold phase occurs between days 3 to 10. During the taking-in phase, the new mother is attempting to integrate her labor and birth experience. She tends to need sleep and feels fatigued, talks about labor, and is self-focused and dependent. In the taking-hold phase, the client is more active, independent, initiates activities, and partakes in mothering tasks. In the letting-go phase, the mother may grieve over the separation of the baby from part of her body.

The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions? 1. "If I experience any sweating during the night, I should call the health care provider." 2. "If I have uterine cramping while breast-feeding, I should contact the health care provider." 3. "If I'm still having bloody vaginal drainage in a week, I should contact the health care provider." 4. "If I notice any pain, redness, or swelling in my breasts, I should contact the health care provider."

4 Signs of infection include pain, redness, heat, and swelling of a localized area of the breast. If these symptoms occur, the client needs to contact the HCP. Options 1, 2, and 3 are normal changes that occur in the postpartum period.

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take? 1. Provide oral fluids and begin fundal massage. 2. Begin hourly pad counts and reassure the client. 3. Elevate the head of the bed and assess vital signs. 4. Assess for hypovolemia and notify the health care provider (HCP).

4 Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the HCP. Providing oral fluids and beginning fundal massage and beginning hourly pad counts and reassuring the client will delay necessary treatment. Also, the question gives no indication of the cause of the hypovolemia or that the client is hemorrhaging and that fundal massage is needed. The head of the bed is not elevated in a hypovolemic condition.

The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A primiparous client who delivered 6 hours ago and had epidural anesthesia 4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

4 The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than the other clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 3 that present the risk for hemorrhage.

A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time? 1. Lack of power about the situation 2. Grieving because of the loss of the baby 3. Lack of knowledge regarding what occurred 4. Concern about the loss of the baby and personal health

4 The client expresses that there is no way out of the situation except for death; therefore the client exhibits concern about the loss of the baby and personal health. The data given do not support lack of power. Grieving is a possible client problem at a later time; however, at this time, the concern over the loss should take priority. Lack of knowledge is a possible problem later, but not enough data support it at this point, and it is not the priority.

The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction? 1. The mother is observed talking to the newborn. 2. The mother performs cord care for the newborn. 3. The mother verbalizes discomfort with the new role of motherhood. 4. The mother requests that the nurse feed the newborn because she is feeling fatigued.

4 The nurse should be alert to maladaptive interaction in the maternal-infant bonding processes. If the nurse notes that the mother is avoiding interaction with the newborn or is avoiding caring for the newborn, the nurse should suspect the potential for a maladaptive interaction. Talking to the newborn or willingness to perform cord care does not indicate a maladaptive response. Expressing discomfort with the new role of motherhood is a normal, expected process, and it is important for the mother to verbalize concerns.

An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse should identify which findings as normal?

4. Pale straw in color, with flecks of vernix

3."I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." In male newborn infants, the prepuce is continuous with the epidermis of the glans and is not retractable. If retraction is forced, this may cause adhesions to develop. The mother should be told to allow separation to occur naturally, which usually occurs between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently at this time for cleaning. Options that identify actions that address retraction of the foreskin are therefore incorrect.

The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis? 1."I should retract the foreskin and clean the penis every time I change the diaper." 2."I need to retract the foreskin and clean the penis every time I give my infant a bath." 3."I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." 4."I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."

2.5 One of the earliest indicators of successful adaptation of the newborn is the Apgar score. Scores range from 0 to 10. Five criteria are used to measure the infant's adaptation. Heart rate: absent = 0; less than 100 = 1; greater than 100 = 2. Respiratory effort: absent = 0; slow or irregular weak cry = 1; good, crying lustily = 2. Muscle tone: limp or hypotonic = 0; some extremity flexion = 1; active, moving, and well flexed = 2. Irritability or reflexes (measured by bulb suctioning): no response = 0; grimace = 1; cough, sneeze, or vigorous cry = 2. Color: cyanotic or pale = 0; acrocyanotic, cyanosis of extremities = 1; pink = 2. Newborn infants with an Apgar score of 5 to 7 often require resuscitative interventions. Scores of less than 5 indicate that the newborn infant is having difficulty adjusting to extrauterine life and requires more vigorous resuscitation.

The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. The nurse should most appropriately document which Apgar score for the newborn? 1.3 2.5 3.7 4.10

4.Stimulating for reflex responses in the extremities A subdural hematoma can cause pressure on a specific area of the cerebral tissue. Especially if the infant is actively bleeding, such pressure can cause changes in the stimuli responses in the extremities on the opposite side of the body. Options 1 and 2 are incorrect. An infant after delivery normally would be incontinent of urine. Blood in the urine would indicate abdominal trauma and would not be a result of the hematoma. Option 3 is incorrect because contractures would not occur this soon after delivery.

The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique would assist to support the newborn's diagnosis? 1.Monitoring the urine for blood 2.Monitoring the urinary output pattern 3.Testing for contractures of the extremities 4.Stimulating for reflex responses in the extremities

4.Monitor skin temperature closely. 5.Reposition the newborn every 2 hours. 6.Cover the newborn's eyes with eye shields or patches. Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment (done with a special device known as a photometer), monitors skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued.

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1.Avoid stimulation. 2.Decrease fluid intake. 3.Expose all of the newborn's skin. 4.Monitor skin temperature closely. 5.Reposition the newborn every 2 hours. 6.Cover the newborn's eyes with eye shields or patches.

3.A large for gestational age infant with a history of shoulder dystocia at delivery Brachial plexus injuries, a fractured clavicle, or a fractured humerus are all possible risks during a delivery of an infant with shoulder dystocia and must be considered during the immediate newborn assessment. Stretching or pulling away of the shoulder from the head may occur during a difficult delivery such as one involving shoulder dystocia. This positioning may cause damage to the upper plexus. Larger infants are more likely to be involved in a delivery in which inadequate space is a concern. In most cases, option 4 would result in an infant of smaller size, so shoulder dystocia would not be a priority risk. Shoulder dystocia does not occur during cesarean section, which eliminates option 2. Option 1 can be eliminated because with a forceps delivery, priority concern is for facial or head injuries more than shoulder, arm, or clavicle injuries.

Which newborn is most at risk for a brachial plexus injury? 1.A term infant with a history of a forceps-assisted delivery 2.A term infant delivered via primary cesarean section for malpresentation 3.A large for gestational age infant with a history of shoulder dystocia at delivery 4.A 36-week preterm infant delivered vaginally after preterm rupture of membranes

The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the health care provider's prescriptions and should expect to note which prescribed treatment for this condition?

1. Oxytocin infusion

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? 1. "I will begin abdominal exercises immediately." 2. "I will notify the health care provider if I develop a fever." 3. "I will turn on my side and push up with my arms to get out of bed." 4. "I will lift nothing heavier than my newborn baby for at least 2 weeks."

1 A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery.

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation

1 Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood coll

A woman infected with the human immunodeficiency virus (HIV) has given birth to a normal-appearing infant, and the nurse provides instructions about newborn infant care. Which statement by the mother indicates a need for further instruction? 1. "I'm going to breast-feed my baby starting right away." 2. "I need to wash my hands before and after bathroom use." 3. "My baby needs to be on antiviral medications for the next 6 weeks." 4. "I am going to contact some support groups listed in my take-home material to help me with everything I'll have to deal with when I get home."

1 Perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding; therefore HIV-positive clients should be encouraged to bottle-feed their neonates. Frequent hand washing is encouraged. Support groups and community agencies can be identified to assist the parents with the newborn's home care, the impact of the diagnosis of HIV infection, and available financial resources. It is recommended that newborn infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life.

A woman in active labor has requested a regional anesthetic. She is currently 5 cm dilated. The health care provider has prescribed an epidural block. Which nursing intervention should be implemented after the epidural block has been placed?

1. Palpate the bladder at frequent intervals.

A nurse visits a client at home who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast engorgement. Which instructions should the nurse provide to the client regarding relief of the engorgement? Select all that apply. 1. Wear a supportive bra between feedings. 2. Avoid breast-feeding during the time of breast engorgement. 3. Feed the infant at least every 2 hours for 15 to 20 minutes on each side. 4. Apply moist heat to both breasts for about 20 minutes before a feeding. 5. Massage the breasts gently during a feeding, from the outer areas to the nipples.

1, 3, 4, 5 During breast engorgement, the client should be advised to feed the infant frequently, at least every 2 hours, for 15 to 20 minutes on each side. The infant will have an easier time latching on if the client softens her breast and expresses her milk before a feeding. Instruct the client to apply moist heat to both breasts for about 20 minutes before a feeding. This can be done in the shower or with warm wet towels. During a feeding, it is helpful to massage the breast gently from the outer area to the nipple. This helps stimulate the let-down and flow of milk. The client should also be instructed to wear a supportive bra between feedings.

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position?

1.Supine position with a wedge under the right hip

The nurse is collecting data from a client seen in the health care clinic for a first prenatal visit. The nurse asks the client when the first day of her last menstrual period was and the client reports February 9, 2018. Using Nägele's rule, the nurse determines that what is the estimated date of delivery? Fill in the blank. Record your answer using 6 digits (mmddyy).

111618

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels

2 Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.

When planning care for a postpartum client that plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis? 1. Offer only one breast at each feeding. 2. Massage distended areas as the infant nurses. 3. Cleanse nipples with a mild antibacterial soap before and after infant feedings. 4. Express and discard milk from the affected breast at the first signs of mastitis.

2 Massaging the distended areas as the infant nurses will encourage complete emptying of the breast and prevent milk stasis. Each breast should be offered at each feeding to prevent milk stasis and ensure adequate milk supply. Soap should not be used on the nipples because of the risk of drying or cracking. If early signs of mastitis occur, the client usually will be instructed to nurse the infant more frequently, because infant sucking is thought to empty the breast more completely.

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement, if made by the client, indicates a need for further instructions? 1. "I need to wear a supportive bra to relieve the discomfort." 2. "I need to stop breast-feeding until this condition resolves." 3. "I can use analgesics to assist in alleviating some of the discomfort." 4. "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

2 Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breast-feeding. In most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy newborn infant. The mother is complaining that she feels as though she has the flu and complains of fatigue and aching muscles. On further assessment the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse about the condition. The nurse should make which response? 1. "Mastitis usually involves both breasts." 2. "Mastitis can occur at any time during breast-feeding." 3. "Mastitis usually is caused by wearing a supportive bra." 4. "Mastitis is most common for women who have breast-fed in the past."

2 Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breast-feeding. Mastitis is more common in mothers nursing for the first time and usually affects one breast. A supportive bra will not cause mastitis; however, constriction of the breasts from a bra that is too tight may interfere with the emptying of all the ducts and may lead to infection.

The nurse is developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed? 1. Administration of anticoagulants 2. Elevation of the affected extremity 3. Ambulation eight to ten times daily 4. Application of ice packs to the affected area

2 Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the affected lower extremity to improve venous return also may be recommended. Warm packs may be prescribed to be applied to the affected area to promote healing. There is usually no need for anticoagulants or anti-inflammatory agents unless the condition persists. Bed rest or limited activity may be prescribed depending on health care provider preference.

A pregnant client calls a clinic and tells the nurse that she is experiencing leg cramps that awaken her at night. What should the nurse tell the client to provide relief from the leg cramps?

2. "Bend your foot toward your body while extending the knee when the cramps occur."

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction?

2. "I need to lie flat on my back to perform the procedure."

A prenatal woman with a history of heart disease has been instructed on care at home. Which statement, if made by the woman, indicates that she understands her needs?

2. "I should avoid stressful situations."

A nursing instructor asks a nursing student to describe the process of quickening. Which statements by the student indicate an understanding of this term? Select all that apply.

2. "It is the fetal movement that is felt by the mother." 5. "It is a process that occurs in the pregnant woman as early as 16 weeks but definitely by week 20."

A pregnant client in the prenatal clinic is scheduled for a biophysical profile (BPP). The client asks the nurse what this test involves. The nurse should make which appropriate response?

2. "This test measures amniotic fluid volume and fetal activity."

A nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on this data, the nurse should make which interpretation? 1. The client is hemorrhaging. 2. The client needs to increase oral fluids. 3. The client is experiencing normal lochia discharge. 4. The client's health care provider needs to be notified of the finding.

3 Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the first 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochial flow should steadily decrease, and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, options 1, 2, and 4 are incorrect.

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings. 2. Reassess the client in 2 hours. 3. Notify the health care provider. 4. Encourage increased oral intake of fluids.

3 Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the HCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate? 1. Raise the head of the client's bed. 2. Obtain hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the client until the mother's symptoms have subsided.

3 Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a health care provider's prescription. Option 4 is unnecessary.

A pregnant client reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. A sputum culture is obtained, and Mycobacterium tuberculosis is identified in the sputum. Which instruction should the nurse provide to the client regarding therapeutic management of tuberculosis?

3. Isoniazid plus rifampin will be required for a total of 9 months

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, would indicate a complication related to a laceration of the birth canal? 1. Presence of dark red lochia 2. Palpation of the uterus as a firm contracted ball 3. The saturation of more than one peripad per hour 4. Palpation of the fundus at the level of the umbilicus

3 Saturation of more than one peripad per hour is considered excessive even in the early postpartum period. In the first 24 hours after birth, the uterus will feel like a firmly contracted ball, roughly the size of a large grapefruit. One easily can locate the uterus at the level of the umbilicus. Lochia should be dark red and moderate in amount.

The nurse is administering an intravenous analgesic to a laboring woman. The woman inquires as to why the nurse is waiting for a contraction to begin before she infuses the medication into the intravenous line. Which is the nurse's most appropriate response?

3."Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication."

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum her systolic blood pressure has dropped 20 points, her diastolic blood pressure has dropped 10 points, and her pulse is 120 beats/min. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, what is the nurse's next action? 1. Reassure the client. 2. Monitor fundal height. 3. Apply perineal pressure. 4. Prepare the client for surgery.

4 A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. A vulvar hematoma is the most common type . The use of an epidural, prolonged second-stage labor, and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 mL of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action is to prepare the client for surgery to stop the bleeding.

The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action? 1. The client with mild afterpains 2. The client with a pulse rate of 60 beats/minute 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foul-smelling odor

4 Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client.

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? 1. "I should breast-feed every 2 to 3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breast-feeding." 4. "I should wash my nipples daily with soap and water."

4 Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand-washing and that she should breast-feed every 2 to 3 hours.

Which nursing intervention would be most appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care? 1. Limit fluid intake. 2. Maintain the client in a supine position. 3. Ask family members to care for the newborn. 4. Encourage the client to take pain medication as prescribed.

4 Nursing responsibilities for the care of the client with endometritis include maintaining adequate hydration (3000 to 4000 mL/day), bed rest in Fowler's position to facilitate drainage and lessen congestion, providing appropriate analgesia to lessen the pain, and administering antibiotics as prescribed. If the client's pain is relieved, she will be more likely to participate in newborn care. Asking family members to care for the newborn will not facilitate client participation in newborn care.

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? 1. Document the findings. 2. Retake the temperature in 15 minutes. 3. Notify the health care provider (HCP). 4. Increase hydration by encouraging oral fluids.

4 The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the HCP is not necessary.

The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instructions? 1. "I need to take the antibiotics as prescribed." 2. "I need to take warm sitz baths to promote healing." 3. "I need to apply warm compresses to provide comfort." 4. "I need to isolate the infant for 48 hours after beginning the antibiotics."

4 The infant is not isolated routinely from the mother with a wound infection, but the mother must be taught good hand washing techniques and how to protect the infant from contact with contaminated articles. If the mother has a wound infection, broad-spectrum antibiotics will be prescribed for the mother, and she should be instructed to take the antibiotics as prescribed. Analgesics are often necessary, and warm compresses or sitz baths may be used to provide comfort in the area.

A postpartum client with deep vein thrombosis is being treated with anticoagulant therapy. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for which symptoms? 1. Dysuria, ecchymosis, and vertigo 2. Epistaxis, hematuria, and dysuria 3. Hematuria, ecchymosis, and vertigo 4. Hematuria, ecchymosis, and epistaxis

4 The treatment for deep vein thrombosis is anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with bleeding.

A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/minute and the umbilical cord protruding from the vagina. The client tells the nurse that her "water broke" before coming to the hospital. What is the appropriate nursing action?

4. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.