Unit 3
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?
"I should avoid exercise because of the negative effects on insulin production."
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?
"I will begin abdominal exercises immediately."
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?
"I will need to increase my insulin dosage during the first 3 months of pregnancy."
A newly pregnant client asks how she can best prepare her 3-year-old child for the upcoming birth of a sibling. Which appropriate response should the nurse make?
"Involve your child in planning and preparing for a sibling closer to the birth of the baby."
A client with acquired immunodeficiency syndrome (AIDS) is pregnant. The client is concerned that the baby will be born with AIDS and relays this information to the nurse. Which response by the nurse would be most appropriate?
"It is very important for you to take your medications to reduce the baby's risk."
A client who gave birth vaginally 16 hours ago states she doesn't need to void at this time. The nurse reviews the documentation and finds that the client hasn't voided for 7 hours. Which response by the nurse is indicated?
"It's common for you to have a full bladder even though you can't sense it."
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?
"My contractions will increase in duration and intensity."
A client in her first trimester of pregnancy notes that she is always tired. Which response by the nurse is best?
"Needs for rest and sleep typically increase during the first trimester of pregnancy."
The nurse notes that a neonate is pink with acrocyanosis at 5 minutes after birth; his knees are flexed, his fists are clenched, he has a whimpering cry, and his heart rate is 128 beats/minute. He withdraws his foot to a slap on the sole. What 5-minute Apgar score should the nurse record for this neonate? Record your answer using a whole number.
8
The nurse notes that a neonate is pink with acrocyanosis at 5 minutes after birth; knees are flexed, fists are clenched, a whimpering cry, and a heart rate of 128 beats/minute. The nurse withdraws the neonate's foot to slap on the sole and finds that the neonate responds well to this stimulation. What 5-minute Apgar score should the nurse record for this neonate? Record your answer using a whole number.
8
A client is 33 weeks' pregnant and has had diabetes since age 21. When checking the fasting blood glucose level, which value would indicate the client's disease is controlled?
85 mg/dL (4.7 mmol/L)
The charge nurse in a labor and delivery unit has one RN and one LPN caring for multiple clients at different stages of labor. Which client should be assigned to the LPN?
A client admitted 2 hours ago in the first stage of labor who is requesting to walk around the unit.
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.
A primigravida with abruptio placenta A gravida 2 who has just been diagnosed with dead fetus syndrome A primigravida at 29 weeks of gestation who was recently diagnosed with gestational hypertension
A primigravid client is admitted to the labor and delivery area in the early first stage of labor. She is breathing with each contraction. Which action taken by the nurse helps the client deal with the pain of labor?
Assist the client in performing effleurage.
When caring for a client during the second stage of labor, which action would be most appropriate?
Assisting the mother with pushing
The nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor. What information should the nurse provide to the parents? Select all that apply.
Be sure to keep the monitor on a flat surface away from other appliances. Develop a plan in case of a power failure. The parents should take a CPR course.
A client and her neonate have a blood incompatibility. The neonate has had a positive direct Coombs test. Which nursing intervention is appropriate?
Because the client has been sensitized, don't give Rho(D) immune globulin
A nurse is working with the team to develop a neonate's plan of care. Which action would be the highest priority in regulating the neonate's temperature?
Block sources of radiant, convective, conductive, and evaporative losses.
A client who's pregnant with her second child comes to the clinic reporting a pulling and tightening sensation over her pubic bone every 15 minutes. She reports no vaginal fluid leakage. Because she has just entered her 36th week of pregnancy, she's apprehensive about her symptoms. Vaginal examination discloses a closed, thick, posterior cervix. These findings suggest that the client is experiencing:
Braxton Hicks contractions
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 per minute for the past hour. What is the priority nursing action?
Discontinue the infusion of oxytocin.
The nurse has a client at 30 weeks gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when the client says that she wants to breastfeed her baby?
Discourage breastfeeding because HIV can be transmitted through breast milk.
During a routine assessment, a pregnant client tells the nurse that she hasn't had a bowel movement for "close to a week." What should the nurse do to help this client?
Discuss the client's diet, focusing on her fiber and water intake.
A client tells the nurse that she doesn't want to sign the hepatitis B vaccination consent form because she heard that, "vaccinations can cause autism." What's the most appropriate nursing interaction?
Discussing the purpose of the vaccine and providing the client with written information
A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action?
Explain that these are expected problems for the latter stages of pregnancy.
A client has progressed through the transition to the second stage of labor. The client says to the nurse, "I have so much pressure down there, it feels like I have to go the bathroom." What is the nurse's best response?
Explain to the client that the feeling is normal during this stage.
Which assessment finding after an amniotomy should be conducted first?
Fetal heart rate pattern
A nurse is evaluating a pregnant client's fundal height. In which way should the nurse stretch the measuring tape to measure it?
From the symphysis pubis notch to the highest level of the fundus
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?
G = 2, T = 1, P = 0, A = 0, L = 1
A neonate weighs 7 lb, 3 oz at birth. When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb and an axillary temperature of 98° F (36.7° C) and observes the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should provide what suggestions to the mother? Select all that apply.
Make sure that the newborn's temperature is maintained within normal range. Observe the stool for amount and characteristic. Encourage early and frequent feedings.
The 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 is appropriate?
Massage the fundus until it is firm.
The nurse is assessing a client whose membranes ruptured prematurely 12 hours ago. Which is the nurse's highest priority to evaluate when collecting data on this client?
Maternal vital signs and fetal heart rate (FHR)
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 per minute. Which nursing action is most appropriate?
Notify the primary health care provider (PHCP).
A licensed practical nurse (LPN) who typically works in the nursery is being cross-trained to work with postpartum clients. The charge nurse is busy with a delivery and assigns her to complete hourly rounds on the unit. As she enters a client's room, the LPN notices that a client looks pale and shaky. Which action should she take?
Obtain a set of vital signs, check the client's fundus and flow, and compare the findings to baseline data.
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 primary health care provider's prescriptions and should question which prescription?
Obtain equipment for a manual pelvic examination.
On her third postpartum day, a client says she has chills and aches. Her chart shows that she has had a temperature of 38.1° C (100.6° F) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What should the nurse do first?
Obtain vagina swab for culture.
A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Which action should the nurse take?
Place the client on her left side and start supplemental oxygen, as ordered, to maximize fetal oxygenation.
A client with a high-risk pregnancy is admitted in the labor and delivery area. Internal fetal monitoring is to be initiated. Which action(s) should the nurse take before starting internal fetal monitoring? Select all that apply.
Prepare for manual rupture of the membrane. Check dilation of the cervix. Obtain baseline fetal heart rate and maternal vital signs. Explain the procedure to the client.
A nurse is assisting with the education of a client who receives a dose of human Rho(D) immune globulin at 28 weeks' gestation to prevent Rh isoimmunization. What should the nurse inform the client regarding the reason for administering the medication?
Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies.
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?
Supine position with a wedge under the right hip
After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery?
Support the mother in her reaction to the newborn infant.
During a bath, a neonate has a nursing diagnosis of Risk for injury related to slippage while bathing. Which intervention best addresses this nursing diagnosis?
Support the neonate's head and back with the forearm.
The mother of a neonate expresses concern about how she will continue to breastfeed when she returns to work in 6 weeks. Which response by the nurse would be best?
Tell me what you would like to do when you return to work
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.
The cervix is dilated completely. The Ferguson reflex is initiated from perineal pressure.
The home care nurse visits a pregnant client who has a diagnosis of preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the primary health care provider (PHCP)?
The client complains of a headache and blurred vision.
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?
The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.
A nurse is gathering neurological data on a 1-day old neonate in the nursery. Which findings would indicate possible asphyxia in utero? Select all that apply.
The neonate's toes do not curl downward when the soles of the feet are touched. The neonate does not respond when the nurse claps hands. The neonate displays weak, ineffective sucking.
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?
Variable decelerations
Meconium aspiration syndrome is suspected in a neonate. What's the most accurate diagnostic tool used to confirm the diagnosis?
Vocal cord examination using a laryngoscope
The nurse is assessing clients at full-term gestation to determine if admission to the labor and delivery unit is necessary. Which client(s) does the nurse prioritize as being safe to send home? Select all that apply.
a client with irregular contractions between 3 and 7 minutes and whose cervix is 2 cm dilated with no effacement a client with mild contractions every 7 minutes and whose cervix is 3 cm dilated compared to 2 cm one week prior
A client is admitted to the facility with a suspected ectopic pregnancy. When reviewing the client's health history for risk factors for this abnormal condition, the nurse expects to find:
a history of pelvic inflammatory disease
A nurse is collecting data on a client who believes she is pregnant. The nurse would suspect a hydatidiform mole based on which finding?
abnormally high hCG levels
Which of the following behaviors would cause the nurse to suspect that a client's labor is moving quickly and that the physician should be notified?
an increased sense of rectal pressure
A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should complete which of the following tasks?
ask her to void
The nurse is developing a teaching plan for a client who's 2 months pregnant. The nurse should tell the client that she can expect to feel the fetus move at which time?
between 16 and 22 weeks gestation
A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client's history, which finding would the nurse identify as placing the client at increased risk for fetal distress?
blood pressure 146/94
The health care practitioner uses nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes are ruptured, the nurse expects the paper will turn which color?
blue
Which findings would be considered positive signs of pregnancy?
fetal heartbeat and fetal movement on palpation
A client who is 12 weeks pregnant attends a class on fetal development as part of a childbirth education program. The nurse provide which information that at 16 weeks' gestation the client's fetus will most likely present?
have audible heart sounds
The nurse is caring for a primigravid client in the labor and delivery area who developed disseminated intravascular coagulation (DIC) due to abrupt placenta. Which intervention should the nurse expect the health care provider to implement first?
infusion of heparin drip
Which medication is considered safe during pregnancy?
insulin
Two days after a cesarean birth, a client is diagnosed with deep vein thrombosis. Which complication is this client at greatest risk for?
pulmonary embolism
A client in labor has been receiving oxytocin to aid her progress. The nurse caring for her notes that a contraction has remained strong for 60 seconds. Which action should the nurse take first?
stop the oxytocin infusion
A nurse is caring for a neonate and suspects the development of early-onset sepsis. Which finding would indicate to the nurse that this is occurring? Select all that apply.
tachypnea hypoglycemia lethargy
A 3-day-old neonate needs phototherapy for hyperbilirubinemia. The nurse is reviewing the plan of care for this neonate. Which interventions would the nurse most likely find?
use of eye patches to prevent retinal damage
A multiparous client has given birth vaginally to a healthy neonate. It is now her first postpartum day. Which factor would the nurse identify as putting this client at risk for developing hemorrhage?
uterine atony
A nursing student is surprised that a young couple is seeking treatment for Infertility. When asked by the nursing instructor to define it in a 25-year-old couple, how does the student respond?
"It is the couple's inability to conceive after 1 year of unprotected attempts."
A pregnant client comes to the clinic after missing several scheduled prenatal appointments. During the initial assessment, the client states, "I haven't been coming to some of my appointments because I go to a homeopathic specialist who takes great care of me." Which response by the nurse is best?
"You should mention the homeopathic specialist to your health care provider so he can help devise the best care plan for you."
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?
"You will need to bottle-feed your newborn."
A client's neonate was delivered by cesarean. Which management strategy should be implemented regarding breast-feeding after this type of delivery?
Use the football hold to avoid incisional discomfort
During her first prenatal visit, a client expresses concern about gaining weight. Which action should be the nurse's next step?
Ask the client how she feels about gaining weight and provide instructions about expected weight gain and diet.
A nurse checks the fundus of a postpartum client and notes that the fundus is situated in the client's left abdomen. What is the priority action by the nurse?
Ask the client to empty her bladder.
The nurse determines that a postpartum client's perineal pad weighs 100 g. The nurse should document this client's blood loss as:
100 mL
A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding?
A normal test result
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?
Administer oxygen via face mask.
Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action?
Administer oxygen, 8 to 10 L/minute, via face mask.
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.
Administration of subcutaneous heparin postdelivery as prescribed. An overbed lift may be necessary if the client requires a cesarean section. Thromboembolism stockings or sequential compression devices may be prescribed.
A breast-feeding client is diagnosed with mastitis. Which nursing intervention would be most helpful to her?
Advising her to massage the effected area while breast feeding.
The nurse is preparing to perform a fundal massage on a client who is 2 hours postpartum. In what order, from first to last, should the nurse perform the listed steps? All options must be used.
Ask the client to void. Place the client in a supine position. Place one hand on the abdomen just above the symphysis pubis and the other on top of the fundus. Rotate the upper hand to massage the uterus until firm. Document the findings.
A client has received dinoprostone to help ripen her cervix. What should the nurse do to determine effectiveness of the drug?
Assess the rippening and softening of the cervix
The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.
Ballottement Chadwick's sign Uterine enlargement Braxton Hicks Contractions
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.
Bright red vaginal bleeding Soft, relaxed, nontender uterus Fundal height may be greater than expected for gestational age
The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?
Change the client's position
The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?
Client pain level
A client in labor, who attended natural birth classes, is asking for something to relieve the pain. What is the most appropriate action for the nurse to take?
Contact the health care provider, supporting the client until an analgesic is prescribed.
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 15 minutes. How should the nurse respond to this finding initially?
Contact the obstetrician (OB) and inform him or her of this finding.
An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?
Delivery of the fetus
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?
Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.
The nurse-midwife determines that a client is in the second stage of labor and the presenting part is descending rapidly. What action should the nurse take to prevent complications?
Encourage the client to practice breathing exercises to decrease the urge to push.
During the sixth month of pregnancy, a client reports intermittent earaches and a constant feeling of fullness in the ears. What would the nurse expect is the likely cause of these symptoms?
Eustachian tube vascularization
The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?
Evidence of bleeding, such as in the gums, petechiae, and purpura
The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia?
Hypertension
A pregnant client tells the nurse that she dreads coming to her prenatal examinations. She states, "The health care provider is constantly reminding me that many women keep weight on after having children, and it really depresses me." How should the nurse respond?
Have you discussed this with your healthcare provider?
A client in the first stage of labor is agitated, upset, and crying. The client expressed concern about being in labor for 32 hours the last time she gave birth. Based on this information, the nurse should expect which nursing diagnosis in the client's plan of care?
Fear related to a potentially difficult childbirth
A primipara is being evaluated in the client during her second trimester of pregnancy. Which occurrence indicates an abnormal physicals findings that necessitates further testing?
Fetal heartrate of 180 beats per minute
The nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client indicates an understanding of the nurse's teaching?
I can lie in any comfortable position, but I should stay off my back.
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?
Increase hydration by encouraging oral fluids.
A client arrives at a birthing center in active labor. After examination, it is determined that her membranes are still intact and she is at a −2 station. The primary 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.
Increased efficiency of contractions The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord
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 is most appropriate?
Instruct the client to request help when getting out of bed.
The nurse explains to new parents the importance of maintaining their infant's safety during hospitalization. Which action best ensures the infant's safety?
Instructing the mother to notify staff when she showers to avoid leaving the infant unattended
The nurse is caring for a pregnant client in the third trimester of pregnancy. The client is concerned about being dizzy when lying down on her back. The nurse would suggest which intervention to eliminate the dizziness?
Lie on the left side when lying down
A nurse observes a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown). Which terms best identifies the discharge?
Lochia rubra.
The nurse is providing care to a pregnant adolescent client in the first trimester. Which intervention would the nurse identify as the highest priority?
Make sure the client receives nutritional counseling and reinforce the education.
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?
Monitoring the fetal heart rate
The nurse is obtaining information from a pregnant client who is at 38 weeks' gestation and believes that she is going into labor. Which statement made by the client should be immediately reported to the health care provider?
My membrane ruptured 2 days ago.
A client with a full-term, uncomplicated pregnancy comes into the labor and delivery unit in early labor states, "I think my water has broken." Which action by the nurse would be the priority?
Note the color, amount and odor of the fluid
When performing a postpartum assessment on a client, the 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?
Notify the obstetrician (OB).
A client in active labor is sweating profusely and has minimal urine output. Which of the following is how the nurse should intervene?
Offer the client ice chips and ask the charge nurse to notify the physician of the low urine
A neonate has been placed on cardiac and apnea monitoring in the neonatal nursery. The nurse notes that the apnea alarm repeatedly triggers. In what order, from first to last, should the nurse perform the listed steps when responding to the alarm? All options must be used.
Perform a focused assessment on the neonate. Count the respiratory rate for 60 seconds. Reset the monitor to a 20-second alarm. Check all connections on the apnea monitor. Document the assessment findings, interventions, and neonate's response.
The nurse is reviewing the primary health care provider's (PHCP'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?
Perform a vaginal examination every shift.
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?
Persistent nonreassuring fetal heart rate
The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding?
Place the client in Trendelenburg's position.
A neonate born at 32 weeks' gestation is taken to the neonatal intensive care unit (NICU). When caring for this neonate, what are the most important nursing actions to prevent and control infection?
Practice meticulous hand washing.
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.
Pregnancy needs to be avoided for 1 to 3 months. The vaccine is administered by the subcutaneous route. Exposure to immunosuppressed individuals needs to be avoided. A hypersensitivity reaction can occur if the client has an allergy to eggs.
After a client enters the second stage of labor, the nurse notes that her amniotic fluid is port-wine colored. What should the nurse do next?
Prepare for immediate delivery of the baby
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?
Provide pain relief measures.
A client who is breast-feeding her infant is experiencing breast engorgement. The nurse suggests breast pumping to relieve the breast engorgement. Which instruction should the nurse provide?
Pump each breast for at least 10 minutes every 3 to 4 hours; pump at night only if she's awake.
A nurse is attempting to interact with a neonate experiencing drug withdrawal. The nurse determines that the neonate is willing to interact based on which behavior?
Quiet, Alert State
A 41-year-old multipara client had a spontaneous vaginal delivery of an 8-lb (3,629-g) baby 3 hours ago. The nurse collects the following data: "Fundus firm, three fingerbreadths above the umbilicus and deviated to the right. Perineal pad saturated after 20 minutes." Which nursing intervention by the licensed practical nurse (LPN) is best?
Reminding the client to void and helping her to the bathroom.
A client treated with terbutaline for preterm labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan?
Report a heart rate greater than 120 beats/minute to the health care provider.
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?
Rest between contractions
While preparing a client for a postpartum tubal ligation, a nurse overhears the client tell her husband that they can always have reversal surgery if they decide they want more children in the future. Which intervention by the nurse would be best?
Review the client's understanding of the procedure in private.
A client who's 12 weeks pregnant is reporting severe left lower quadrant pain and vaginal spotting. She's admitted for treatment of an ectopic pregnancy. Which nursing diagnosis should the nurse should give the highest priority to?
Risk for deficient fluid volume.
During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into his or her mouth. Which of the following actions would enhance latching on to the nipple?
Stroke the neonate's lip with the nipple
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.
The client has a history of intravenous drug use. The client has a history of sexually transmitted infections.
A postpartum client recovering from spinal anesthesia with morphine reports that her nose itches. Which would the nurse suspect as the cause?
The client is experiencing a common effect due to a morphine-based anesthetic.
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?
The client is measuring normal for gestational age.
The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up?
The client with lochia that is red and has a foul-smelling odor
The nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if her gestational diabetes will affect her delivery. The nurse should know that:
The delivery may need to be induced early
The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?
The diet should include additional fluids.
A client is 2 days postpartum and is experiencing bleeding. She asks the nurse, "Will it always be like this?" Which statement by the nurse would be the most accurate?
This is lochia rubra and will last 3 to 4 days.
The nurse is discussing posture with a client who's 18 weeks pregnant. The clients asks why should she avoid the supine position. How does the nurse respond?
This position impedes blood flow to the fetus
A client who comes to the labor and delivery area tells the nurse she believes her membranes have ruptured. When obtaining her history, what should the nurse ask about first?
Time of the membrane rupture
A client who is 9 days postpartum and breastfeeding her baby reports pain, redness, swelling of her left breast and is diagnosed with mastitis. The nurse is reviewing information with the client about how to care for her infected breast. Which information should the nurse most likely reinforce?
Use warm, moist compress over the painful area
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?
Uterine tenderness
Which sign indicates respiratory distress in a neonate?
nasal flaring
A client comes to the clinic for her first prenatal visit. While the nurse is obtaining the client's vital signs, the client asks, "When will you be able to hear my baby's heart beat?" Which response by the nurse would be most appropriate?
"At about 11 weeks, we'll be able to hear them with an ultrasound device."
A client comes to the labor unit reporting contractions. After gathering data, it is determined the client is having Braxton Hicks contractions, and education regarding the difference between true and false labor is given. Which statement by the client indicates the teaching has been effective?
"Braxton Hicks contractions begin in the abdomen and remain irregular."
A client in active labor has severe second-degree burns on her buttocks. When questioned about the burns, the client replies, "I was trying to use that hot water thing to help my hemorrhoids." Which statement made by the nurse is therapeutic?
"Did I hear you say you sustained this burns from hot water application to the buttocks?"
A client is expecting her second child in 6 months. During the psychosocial assessment, she says, "I've been through this before. Why are you asking me these questions?" What is an appropriate response by the nurse?
"Each pregnancy has a unique psychosocial meaning."
A client who's planning a pregnancy asks the nurse about ways to promote a healthy pregnancy. Which statement would be the nurse's best response?
"Folic acid supplements improve pregnancy outcomes by preventing certain complications."
When collecting data on a neonate, which finding would the nurse identify as expected?
positive babinski sign
The nurse prepares to administer an I.M. injection of prophylactic vitamin K to a normal, full-term neonate. Which needle should the nurse use?
25G, 5/8" needle
The nurse is collecting data from a pregnant client who is currently at 28 weeks gestation. At her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in centimeters and should expect which finding?
26 cm
The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?
3 days postpartum
A client delivers a full-term neonate who weighed 7 lb, 8 oz. (3,402 g) at birth 2 days ago. When weighing the neonate, which weight would the nurse expect?
6 lb, 12 oz. (3,061 g)
A client with preeclampsia is prescribed magnesium sulfate to prevent seizure activity. The nurse is reviewing the results of the client's serum magnesium level and determines that the client's level is therapeutic based on which result?
6.8 mEq/L (3.4 mmol/L)
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.
Age 54 years Body mass index of 28 Previous difficulty with fertility
A client concerned about the pinkish "stretch marks" on her abdomen asks the nurse about them. Which response by the nurse would be most appropriate?
Although they will fade, they won't disappear
The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?
An informed consent needs to be signed before the procedure.
A pregnant client with diabetes is admitted to the labor unit. Which action by the nurse would be most appropriate for this situation?
Ask the client about her most recent blood glucose level
The nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Although not a normal finding, it's an expected finding of physiologic jaundice and is caused by which of the following?
large immature liver
A client, who is 11 weeks' pregnant and admitted to the facility with hyperemesis gravidarum, is being cared for by a nursing student. The nursing instructor asks the nursing student to discuss hyperemesis gravidarum. How does the student respond appropriately? Select all that apply.
"The cause is unknown." "It is characterized by severe nausea and vomiting during the first half of pregnancy."
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?
"I need to lie flat on my back to perform the procedure."
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?
"I should drink adequate fluids and increase my intake of highfiber foods."
A postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. After assisting with the discharge teaching plan, the nurse determines that the client has understood the information when what statement is made?
"I should not take any over-the-counter (OTC) salicylates."
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.
"I should wear a bra that provides support." "Drinking alcohol can affect my milk supply." "The use of caffeine can decrease my milk supply." "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."
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?
"I will maintain strict bed rest throughout the remainder of the pregnancy."
A pregnant client concerned about gaining weight during pregnancy questions the nurse about dietary intake. Which response by the nurse is best?
"I'll ask the dietitian to speak with you about normal weight gain during pregnancy."
The night before discharge, a client expresses guilt that she'll have to return to work in 3 weeks and leave her infant with a nanny. The client asks the nurse for an opinion about using a nanny. What should the nurse say first?
"It's difficult to be a working parent, but having a nanny will provide your baby with a consistent caregiver while you're gone."
A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond?
"No, it can initiate premature uterine contractions."
The nurse is providing care for a pregnant 16-year-old client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying:
"Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems."
The nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client?
"The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment."
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?
"The vaginal discharge may be bothersome, but is a normal occurrence."
A 30-year-old primiparous client at 34 weeks' gestation comes to the prenatal facility concerned about the reddish streaks she has increasingly developed on her breasts and abdomen. She asks what these skin changes are and whether they're permanent. What is the best response by the nurse?
"These streaks are called striae gravidarum, or stretch marks; they'll grow lighter after delivery."
During an initial prenatal visit, a client reports increased clear, watery vaginal drainage. When responding to the client about this report, which statement would be most appropriate?
"This is normal during pregnancy. Just be sure to wash daily with soap and water."
The nurse in a maternity unit is providing emotional support to a client and her significant other 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?
"We want to attend a support group."
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 assist the family in their period of grief?
"What can I do for you?"
The nurse is caring for a client suspected of having a hydatidiform mole. Which signs and symptoms would confirm this diagnosis?
"snowstorm" pattern on ultrasound with no fetus or gestational sac
A nurse is to administer 1,000 ml of normal saline over 6 hours to a client in labor. The drip factor of the IV administration set is 15 drops/ml. What is the rate of the infusion?
42 drops/min
The nurse is reviewing the record of a client who was just told that her pregnancy test was positive. The nurse notes the healthcare provider documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which change that occurs with pregnancy?
A softening of the cervix
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.
Ballottement Chadwick's sign Uterine enlargement Positive pregnancy test
The nurse is about to give a full-term neonate his first bath. Which of the following should the nurse do first?
Bathe the neonate only after his vital signs have stabilized
A pregnant client tells the nurse that she doesn't like milk and can't possibly drink three to four glasses per day as recommended by her health care provider. What is the best response by the nurse?
Are there any dairy products that you do like?
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?
Assess the baseline fetal heart rate.
A postpartum client has given birth to a healthy newborn by cesarean. Which information would the nurse most likely reinforce?
Coughing and deep-breathing exercises
The nurse observes that a 2-hour-old neonate has acrocyanosis. Which nursing action is a priority?
Do nothing because acrocyanosis is normal in a neonate.
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 primary health care provider (PHCP)?
Fetal heart rate of 180 beats per minute
The nurse is informed that a client hospitalized for premature labor is having occasional contractions. Which nursing intervention would be most appropriate?
Give IV and oral fluids, encouraging the client to empty the bladder.
A nurse is preparing to evaluate a client who gave birth 6 hours ago. Which statement best explains the use of gloves during the postpartum evaluation?
Gloves are an essential part of standard precautions
The nurse receives a report on a client who delivered a healthy neonate 1 hour ago. What should the nurse monitor during the immediate postpartum period of this client?
Height of the fundus
A client in the early stages of labor who is admitted to the labor and delivery unit is noted to have not recently bathed or changed her clothes. Which action should the nurse take to help this client?
Help the client to undress and suggest a quick bath to freshen up.
The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?
Hemorrhage
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?
Inform the client that these contractions are common and may occur throughout the pregnancy.
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?
Isoniazid plus rifampin will be required for 9 months.
A mother asks the nurse why her neonate is getting an injection of vitamin K. Which response by the nurse would be most appropriate?
It helps with coagulation.
A neonate has been diagnosed with caput succedaneum. Which information would the nurse reinforce with the parent about this condition?
It is tissue swelling over the presenting part of the fetal scalp.
A pregnant client's last menstrual period began on October 12. The nurse calculates the estimated date of delivery (EDD) as:
July 19
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, 2020. Using Näegele's rule, which expected date of delivery should the nurse document in the client's chart?
July 26, 2021
When bathing a neonate who is one hour old, which nursing action is most important?
Keep under a radiant warmer, and give a sponge bath.
The nurse is providing care to a postpartum client with mastitis. As part of the client's teaching plan, the nurse is reinforcing information about the condition. Which information should the nurse emphasize?
Symptoms include fever, chills, malaise, and localized breast tenderness.
The nurse is caring for a client on the fourth postpartum day. The nurse is expecting to observe which behavior in the client on the fourth postpartum day?
The client asks many questions about the baby's care
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?
The client has a history of cardiac disease.
A nurse is obtaining data on a 1-day-old neonate in the nursery. Which findings would indicate possible asphyxia in utero? Select all that apply.
The neonate's toes do not curl downward when the soles of the feet are touched. The neonate does not respond when the nurse claps hands. The neonate displays weak, ineffective sucking.
The nurse is working as part of multidisciplinary team in developing the plan of care for a premature neonate. Breast milk is being encouraged as part of the plan. The nurse understands that the use of breast milk for this neonate would help prevent which condition?
necrotizing enterocolitis
An adolescent client in her first trimester of pregnancy continues to smoke cigarettes. The client tells the nurse that she'd like to quit but she doesn't want to gain any more weight. What should the nurse do for this client?
ask permission to further discuss smoking
The nurse is collecting data on a pregnant woman in the clinic. In the course of the data collection, the nurse learns that this woman smokes one pack of cigarettes per day. The first step the nurse should take to help the woman stop smoking is to:
assess the client's readiness to stop
An adolescent prenatal client asks about getting fat while pregnant. To prevent which condition, the nurse says, "Because of your age, you need to gain enough weight to be in the upper portions of your recommended weight"?
birth of a low-birth-weight neonate
A pregnant client is receiving heparin. While the client is receiving this drug, which data would the nurse immediately report to the supervising nurse?
bleeding from an orifice
A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client's history, which finding would the nurse identify as placing the client at increased risk for fetal distress?
blood pressure of 146/94
A nurse is reviewing the instructions given to a new mother on how to feed her infant who was born with a cleft lip and palate. When observing the interaction between the mother and infant, which action by the mother would indicate to the nurse that the teaching has been successful?
burping the baby frequently
A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation?
by positioning the neonate so that the head stays still
A client with active genital herpes is admitted to the labor and birth area during the first stage of labor. What intervention specific to the client's condition should the nurse anticipate?
cesarean delivery
A 2-day-old boy is scheduled for circumcision without anesthesia. When reviewing the neonate's plan of care, which measure would the nurse likely find as most important after the procedure?
charting the time of the neonate's voiding
A nurse caring for a client during the fourth stage of labor observes that the client has changed pads four times in the past hour and is reporting dizziness. What initial actions should the nurse take? Select all that apply.
check fundal height check vital signs notify RN
A nurse is caring for a primigravida client who is in labor. When does the nurse suspect the client has progressed to the second stage of labor?
client has an uncontrollable urge to bear down
The nurse is caring for a client in labor and notes that the fetal heart rate (FHR) slows to 100 beats per minute (bpm) during contractions and increases to 120 when the uterus relaxes. The nurse would take which appropriate intervention?
continue to monitor and document
Which intervention takes priority when caring for a neonate immediately after birth?
covering the neonate's head with a cap
A nurse is preparing a lecture for a prenatal class. Which hormone would the nurse include in the presentation as being responsible for maintaining pregnancy during the first 3 months?
hCG
A nurse is assisting with assigning an Apgar score for a neonate who was delivered at 40 weeks' gestation. The nurse would expect to gather data about which areas when determining the neonate's score?
heart rate, respiratory effort, reflex irritability, and color
A pregnant client comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic?
danger signs during pregnancy
A multiparous client admitted to the labor unit has not received prenatal care for this pregnancy. When collecting information from this client, which data would be most important to obtain?
date of last menstrual period
A client who's 24 weeks pregnant has sickle cell anemia. When preparing the plan of care, the nurse should identify which factor as a potential trigger for a sickle cell crisis during pregnancy?
dehydration
A diabetic client in labor tells the nurse she has been feeling nauseous since her labor started and did not take her insulin even after eating some soup and crackers. One hour later, she reports increased nausea and feeling flushed. The nurse notes a fruity odor to her breath. What do these findings suggest?
diabetic ketoacidosis
A nurse is reinforcing teaching with a client at 24 weeks of gestation regarding a glucose tolerance test to screen for gestational diabetes. The client asks, "What will be done if I have this disorder?" The nurse is correct to state that gestational diabetes is managed by which therapy?
dietary control of carbohydrates, fats, and proteins
A client who is 36 weeks pregnant appears anxious and tells the nurse that she will never be able to handle labor and delivery. What is the appropriate action by the nurse?
document the common concern during the third trimester
A 2-week-old neonate is admitted to the hospital with a diagnosis of possible sepsis. The neonate weighs 3.2 kg. The health care provider writes the following orders for the neonate and signs the order sheet. Which order should the nurse question?
draw blood culture x3 in am
Which intervention would the nurse recommend to a client having severe heartburn during pregnancy?
eat several small meals a day
When determining maternal and fetal well-being, which data collection finding is most important?
fetal heart rate and activity
A client with preeclampsia is scheduled to undergo a nonstress test (NST) and asks the nurse why this test is being performed. When responding to the client, which condition would the nurse most likely include as the reason?
fetal well-being
The nurse is caring for a postpartum client after giving birth to a healthy neonate. When checking the client's fundus, which finding would the nurse most likely note?
fundus 1 cm above the umbilicus 1 hour postpartum
When collecting data on a pregnant client with diabetes mellitus, the nurse stays alert for signs and symptoms of a vaginal or urinary tract infection (UTI). The nurse recognizes which condition makes this client more susceptible to such infections?
glycosuria
A client makes a routine visit to the prenatal clinic. Although she believes that she is 14 weeks pregnant, the size of her uterus approximates that in an 18- to 20-week pregnancy. The health care provider diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal:
grape-like clusters
A neonate develops significant respiratory distress about 14 hours after birth. After reviewing the neonate's medical record, the nurse finds that the neonate's mother experienced prolonged rupture of membranes. Based on the nurse's knowledge of this condition, the nurse suspects that which organism most likely contributed to this problem?
group B beta-hemolytic streptococci
A 29-week gestation client arrives in the labor and delivery suite for an emergency cesarean section. The neonate is born and exogenous surfactant is administered. Which action best explains the main function and goal of surfactant use?
helps lungs remain expanded after the initiation of breathing improving oxygenation
The nurse is caring for a neonate whose mother is infected with hepatitis B. The nurse would inform the mother that her child will receive which treatment?
hepatitis B immune globulin within 12 hours of birth, and hepatitis B vaccine at birth, age 1 month, and age 6 months
When teaching a group of pregnant adolescents about reproduction and conception, where does the nurse states that fertilization occurs?
in the first third of the Fallopian tube
A client is 22 weeks pregnant and reports constipation. Which initial recommendation would the nurse reinforce with the client?
increase intake of high fiber foods
Which of the following options best describes the anticipated actions in the taking-hold phase of the maternal attachment process?
kissing, embracing and caring for the infant
When questioned, a pregnant client admits she sometimes has several glasses of wine with dinner. The nurse expects the health care practitioner to explain the client that her alcohol consumption puts her fetus at risk for which condition?
learning disability
A client in the first stage of labor is being monitored using an external fetal monitor. After the nurse reviews the monitoring strip from the client's chart (shown), into which position should the nurse assist the client?
left lateral
A client is in the 8th month of pregnancy. Which body position does the nurse advise the client to assume to enhance cardiac output and renal function when laying down?
left lateral
The neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is:
lethargy
The nurse is caring for a neonate of a diabetic mother. For which condition should the nurse monitor the neonate?
macrosomia
A pregnant client in the latent stage of labor begins reporting pain in the epigastric area, blurred vision, and a headache. The client has a history of hypertension during pregnancy. The nurse anticipates the administration of which medication?
magnesium sulfate
Which intervention should be included in the safety plan for the maternal- infant unit?
making sure the spouse or significant other wears and identification band
A client in the third stage of labor delivers the placenta and the fundus is noted at 1 to 2 cm above the umbilicus. Which initial nursing action should the nurse take next?
massage the fondus
A nurse is caring for a client during the fourth stage of labor. Which intervention by the nurse can prevent uterine atony?
massage the fundus
The nurse is participating in the care of a client who has given birth to a 7 pound, 4 ounce baby. The nurse observes bleeding saturating the pad. What is the priority intervention at this time to control the bleeding?
massage the fundus
A neonate was diagnosed as having cystic fibrosis. When reviewing a neonate's medical record, the nurse would most likely find which condition?
meconium ileus
The nurse is caring for a client who is in the fourth stage of labor. How can the nurse assist with maintaining the primary focus of care at this time?
monitor vital signs and client responses
When caring for a client who has had a cesarean section, which of the following actions is appropriate?
monitoring pain status and providing relief
A nurse who is part of the multidisciplinary team is assigned to care for four neonates and is reviewing each neonate's plan of care. The nurse would closely monitor which neonate considered to be at highest risk for developing hyperbilirubinemia?
neonate with ABO incompatibility
When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should take which of the following actions?
notify the obstetrician
A neonate of a diabetic mother was born full-term and weighing 10 lb, 1 oz (4.6 kg). While caring for this large-for-gestational age (LGA) neonate, the nurse checks the clavicles for which reason?
one of the neonates clavicles may have been broken during delivery
The nurse is admitting a client with suspected diagnosis of abruptio placentae. When gathering data, which symptoms require health care provider notification of this medical emergency? Select all that apply.
overt vaginal bleeding rigid abdomen increased blood pressure rapid uterine contractions
A nurse is caring for a neonate whose mother was abusing drugs. The nurse anticipates that the neonate may experience drug withdrawal. Which intervention would be the priority?
place the isolette in a quiet area of the nursery
A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note, which postpartum complication has the client developed?
postpartum hemmorhage
Which of the following health conditions makes it necessary for the nurse to check blood pressure frequently during labor?
preeclampsia
A nurse is part of a team providing care to a neonate with a myelomeningocele. When implementing the neonate's plan of care, what is the priority action by the nurse?
preventing infection
A client has just been diagnosed with having a hydatidiform mole. When reviewing the client's medical record, what is the most significant risk factor?
prior molar gestation
A client with pregnancy-induced hypertension (PIH) is admitted to the hospital. The nurse would expect this client to probably exhibit which of the following symptoms?
proteinuria, headaches, and double vision
To ensure that the breast-feeding neonate's weight loss remains within the expected parameter of 5% to 10%, the nurse should initially establish which of the following types of feeding schedules?
provide feeding on demand
A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the plan of care for the neonate during the first 24 hours?
provide frequent early feedings with formula
A 23-year-old primigravida client is in the active stage of labor. She and her husband have been using breathing techniques. The husband asks whether he can do anything more to help his wife during labor. What should the nurse suggest?
provide helpful distractions
A client who is 27 weeks' pregnant arrives at the health care provider's office reporting fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness. About which condition does the nurse anticipate reinforcing education?
pyelonephritis
A nurse is providing care to a postpartum client on her second day. What appearance does the nurse anticipate the lochia will have on the second postpartum day?
red moderate flow
A client gives birth to a neonate prematurely, at 28 weeks' gestation. To obtain the neonate's Apgar score, the nurse assesses the neonate's:
respiration
Which symptom would indicate the neonate was adapting normally to extrauterine life without difficulty?
respiratory rate of 40 to 60
Just after birth, the nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do?
rewarm the neonate gradually
A client has just given birth to her first child. The client is Rho(D)-negative and her baby is Rh-positive. At which time would the nurse most likely expect Rho(D) immune globulin IM to be given to the mother to reduce the risk of Rh incompatibility?
within 72 hours
The nurse on the labor and delivery unit is starting a quality improvement initiative. After reviewing current routine practices on the unit, which one(s) does the nurse identify as not complying with current best practice? Select all that apply.
routine artificial rupturing of amniotic membranes maintaining lithotomy position during the second stage of labor removal of the support person during epidural insertion
A client is diagnosed with disseminated intravascular coagulation (DIC) postpartum. The nurse recognizes that DIC may be related to which antepartum complication?
severe pre-eclampsia
The nurse is providing dietary teaching to a pregnant client. To help meet the client's iron needs, the nurse should advise her to eat:
spinach and beef
A nurse is caring for a neonate who was born at 34 weeks' gestation and has a surfactant deficit. Which condition would the nurse most likely find while collecting data on this neonate?
sternal retractions
A multiparous client with pelvic thrombophlebitis is being treated with bed rest and anticoagulant therapy. The nurse should call for assistance immediately if the client experiences which symptom?
sudden onset of shortness of breath
A client who has just given birth to a full-term neonate is handed the neonate by the nurse. Which factor is most likely to promote attachment between parents and their neonate?
sustained physical contact with the neonate immediately after birth
To minimize the amount of a drug received by an infant through breast- feeding, the nurse should tell the mother to:
take the medication immediately after breastfeeding
A client with hyperemesis gravidarum is on a clear liquid diet. The nurse instructs the unlicensed assistive personnel (UAP) to observe her tray for which food selections?
tea and gelatin dessert
The nurse is caring for a neonate that was born to a mother with gestational diabetes. What site will be used to puncture the neonate's foot in order to monitor the neonate's glucose level?
the lateral aspect of the heel
A client plans to breast-feed her healthy, full-term neonate. The nurse encourages her to start breast-feeding within 30 minutes of the neonate's birth because:
the neonate will be responsive and eager to suck at this time
During an examination, a pregnant client at 32 weeks' gestation becomes dizzy, light-headed, and pale while supine. Which action would the nurse do first?
turn the client to the left side
A client with painless vaginal bleeding is suspected of having placenta previa. The nurse will assist in preparing the client for which procedure?
ultrasound
A neonate was born at 36-weeks' gestation weighing 4 pounds (1,800 g). The neonate also has microcephaly and microphthalmia. The nurse is reviewing the maternal history in preparation for care. Which risk factor would the nurse most likely expect to find?
use of alcohol
A nurse is assisting with the care of neonate immediately after birth. The neonate is to receive vitamin K intramuscularly. The new parents asks the nurse, "Where are you going to give it?" Which site would the nurse include in the response to the parents?
vatus lateralis
A neonate is born at 38 weeks' gestation. The parent asks what the thick, white, cheesy coating is on the skin. What does the nurse document related to this finding?
vernix
A 10-hour-old neonate appears exceptionally irritable, crying easily and startling when touched. A drug screen test indicates that the neonate is positive for cocaine. When assisting with developing the plan of care for this neonate, which action would be most helpful in soothing the neonate?
wrapping the neonate snugly in a blanket