ATI Custom: Missing clinicals day 2

Réussis tes devoirs et examens dès maintenant avec Quizwiz!

A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification?

"I should increase my calcium intake to 1,500 milligrams per day" Rationale: A woman's dietary reference intake (DRI) of calcium for pregnancy and lactation is the same for a woman who is not pregnant. The DRI for a woman older than 19 years of age is 1,000 mg/day, which should supply enough calcium for fetal bone and tooth development and to maintain maternal bone mass.

A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?

"I should remove extra blankets from my baby's crib." Rationale: Loose bedding such as sheets and blankets could cover the baby's head and lead to suffocation.

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

"I'll feed my baby every 2 hours." Rationale: Breast engorgement is relieved by emptying both breasts. The client might be able to accomplish this with more frequent feedings. Otherwise, she can pump her breasts after breastfeeding to ensure optimal emptying.

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?

"It sounds like you are feeling sad that things didn't go as planned." Rationale: This response uses the therapeutic communication technique of restating to encourage the client to continue to communicate her feelings.

A nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching?

"My baby will be placed under special lights if the test result is positive." Rationale: Phototherapy is used to reduce circulating unconjugated bilirubin in infants who have hyperbilirubinemia. Phototherapy for hyperbilirubinemia uses light energy to lower the bilirubin level in the newborn's blood. This would not be appropriate therapy for PKU.

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

"This could result in profound bleeding." Rationale: "Pelvic rest" is essential for clients who have placenta previa because any disruption of placental blood vessels in the lower uterine segment could cause premature separation of the placenta and life-threatening hemorrhage. This means no vaginal examinations, no douching, and no vaginal intercourse.

A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide?

"This infection is treated with one dose of azithromycin." Rationale: A single dose of azithromycin is an appropriate treatment for a chlamydial infection. An acceptable alternative is doxycycline twice a day for 7 days.

A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn's head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make?

"You should try to pant as the delivery proceeds." Rationale: Panting allows uterine forces to expel the fetus and permits controlled muscle expansion to avoid rapid expulsion of the fetal head.

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?

- Placenta previa Painless, bright red vaginal bleeding in the second or third trimester is a manifestation of placenta previa.

A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? (Select all that apply.)

- Apply breast milk to the nipples before each feeding is correct. The application of colostrum and breast milk to the nipples moistens them and prepares them for breastfeeding. This can prevent and reduce nipple tenderness. - Start breastfeeding with the nipple that is less sore is correct. The client who is breastfeeding should start with the nipple that is less sore, as the newborn's initial sucking motions are the strongest. - Change the infant's position on the nipples is correct. Changing the newborn's position on the nipples reduces discomfort and prevents nipple soreness. Repositioning of the mother can also prevent nipple discomfort.

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

- Assist the client to the bathroom to void. Rationale: A full bladder causes the uterus to be displaced above the umbilicus and off to one side. This prevents the uterus from contracting normally and increases the risk of hemorrhage.

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

- Changes in the cervix Rationale: Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor.

A nurse is caring for a client who is at 32 weeks of gestation. Which of the following provider prescriptions should the nurse plan to implement? For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

- Collecting a urine specimen for culture and sensitivity is nonessential. The nurse should collect a urine specimen for culture and sensitivity if the client presents with manifestations of a UTI. - Administer magnesium sulfate 4 g IV bolus is anticipated. This client is preeclamptic and has manifestations of CNS irritability including 3+ deep tendon reflexes, headache, and blurred vision. These manifestations place the client at a greater risk for seizure activity; therefore, the provider should prescribe a magnesium sulfate 4 g IV bolus, followed by a 2 g/hr maintenance dose. - Tell the client to lie in a supine position is contraindicated. The nurse should encourage the client to lay in a side-lying position. A side-lying position increases uteroplacental blood flow and decreases blood pressure. - Monitor blood pressure and respiratory status every 15 min is anticipated. To evaluate the effectiveness of therapy the nurse should anticipate the provider to prescribe monitoring the client's blood pressure every 15 to 30 min.

A nurse is providing preconception counseling for a client who is planning a pregnancy. Which of the following supplements should the nurse recommend to help prevent neural tube defects in the fetus?

- Folic acid Rationale: Adequate amounts of folic acid before conception and during the first trimester of pregnancy are necessary for fetal neural tube development. This vitamin helps prevent spina bifida and other neurological disorders.

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

- Hypotension Rationale: Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of the epidural catheter to decrease the likelihood of this complication.

A nurse is admitting a client who is pregnant. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

- IV fluid therapy - Administer metoclopramide - Hyperemesis gravidarum - Intake and output - Weight Rationale: The nurse should initiate IV fluid therapy and administer metoclopramide because the client is most likely experiencing hyperemesis gravidarum as evidence by increased nausea and vomiting and weight loss. The client's laboratory results are indications of dehydration and electrolyte imbalances. The nurse should plan to manage this condition by providing the client with IV fluids and antiemetics. The nurse should monitor the client's intake and output and weight because these provide assessment information regarding overall fluid balance and the client's response to therapy.

A nurse is caring for a client who is in labor. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

- Initiate an infusion of oxytocin. - Change client's position hourly. - Dysfunctional labor - Cervical dilation - Frequency of uterine contractions The nurse should initiate an infusion of oxytocin and change the client's position hourly because the client is most likely experiencing dysfunctional labor as evidenced by the client's cervical assessment findings not changing during an 8 hr period. The nurse should monitor the frequency of uterine contractions and cervical dilation because dysfunctional labor can increase the risk for uterine rupture and fetal distress, leading to emergency cesarean birth.

A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization?

- Shortly after giving birth Rationale: The rubella immunization should be offered to the client following birth, preferably prior to discharge from the hospital. This prevents the client from contracting rubella during the current or subsequent pregnancies, which would put her fetus at risk for rubella syndrome.

A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what to do when her newborn cries persistently. Which of the following strategies should the nurse suggest? (Select all that apply.)

- Swaddle the newborn in a receiving blanket. - Carry the newborn in a front or back pack. - Take the newborn for a ride in the car. Rationale: Take the newborn for a ride in the car is correct. Movement and rhythmic noise are soothing to newborns.Keep the newborn in the center of a large crib is incorrect. Newborns prefer small, warm, close spaces similar to the intrauterine environment.Carry the newborn in a front or back pack is correct. Carrying the newborn in a front or back carrier provides the comfort of close contact and gentle movement that is soothing to newborns.Swaddle the newborn in a receiving blanket is correct. Swaddling simulates the intrauterine environment, position-wise, and provides security to the newborn.Allow the newborn to continue crying is incorrect. Responsiveness to crying fosters trust as the newborn associates comfort with the caregiver.

A nurse is caring for a newborn 2 hr following birth. Select the 4 findings the nurse should report to the provider.

- Temperature - Respiratory assessment - Serum glucose level -Hematocrit Rationale: Temperature is correct. The newborn's temperature is below the expected reference range. Therefore, the nurse should report the finding to the provider. Respiratory assessment is correct. The newborn is exhibiting tachypnea, grunting, nasal flaring, and intermittent retractions, which are findings associated with respiratory distress syndrome. Therefore, the nurse should report the findings to the provider. Serum glucose is correct. The newborn's serum glucose is below the expected reference range. Therefore, the nurse should report this finding to the provider. White blood cell count is incorrect. The newborn's white blood cell count is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. Hematocrit is correct. The newborn's hematocrit is 40%, which is below the expected reference range. Therefore, the nurse should report this finding to the provider. Heart rate is incorrect. The newborn's heart rate is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider.

A nurse on a labor and delivery unit is caring for a client who is at 39 weeks of gestation and is in the first stage of labor. Complete the diagram by dragging from the choices below to specify what complication the client is most likely experiencing, 2 actions the nurse should take to address that complication, and 2 parameters the nurse should monitor to assess the client's progress.

- Turn the client to their left side. - Administer oxygen at 10 L/min via non-rebreather facemask. - Variable fetal heart rate decelerations - Fetal heart rate baseline - Fetal heart rate variability The nurse should turn the client to their left side and administer oxygen at 10 L/min via non-rebreather facemask to promote intrauterine blood flow, cardiac output, and maternal oxygenation because the client is most likely experiencing variable fetal heart rate decelerations because, at 1200, the Nurses' Note documents a FHR of 140 to 145/min with average variability and FHR decreases to 100/min with contractions, lasts 15 seconds, returning to baseline within 30 seconds. The nurse should monitor the fetal heart rate baseline and fetal heart rate variability because recurrent variable decelerations indicate repetitive disruption in the oxygen supply of the fetus, resulting in hypoxemia, hypoxia, metabolic acidosis, and eventually, metabolic acidemia.

A nurse in an antepartum clinic is caring for a client who is pregnant. A nurse reviews the assessments findings. For each assessment finding, click to specify if the assessment findings is consistent with urinary tract infection or preterm labor. Each finding may support more than one disease process.

- Vaginal examination is consistent with preterm labor. The client who is at 33 weeks of gestation should have not have cervical dilation. However, the client is dilated 2 cm, is 100% effaced and at 0 station, which should indicate to the nurse that the client is experiencing preterm labor. - Pain is consistent with preterm labor and urinary tract infection. Clients who have preterm labor frequently have constant, low dull back pain and mild, low abdominal cramping. Clients who have a urinary tract infection can have back pain, urinary frequency, burning with urination, and lower abdominal and suprapubic pain. - Type of vaginal discharge is consistent with preterm labor. The nurse had bloody mucous noted on the sterile glove after checking the client's cervical dilation. This type of discharge is consistent with preterm labor and occurs as a result of cervical dilation. - Temperature is consistent with a urinary tract infection. This client has a temperature of 38.1 °C (100.5 °F). The nurse should identify that fever, frequency, urgency, and burning with urination are findings associated with a urinary tract infection.

A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings is associated with this condition?

- Wide skull sutures Rationale: Newborns who are SGA have wide skull sutures due to inadequate bone growth. Head circumference is smaller than in a normal newborn and there is reduced brain capacity.

A nurse is caring for a newborn who is 30 min old. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? The condition that poses the greatest risk to the newborn is (Condition) due to (Finding).

- meconium aspiration syndrome - color of amniotic fluid Rationale: Meconium aspiration syndrome is correct. The nurse should identify that meconium aspiration syndrome is the complication that poses the greatest risk to the newborn because this can result in both a mechanical obstruction in the airways and a chemical pneumonitis. The presence of meconium-stained amniotic fluid at birth increases the risk that the fetus could inhale the meconium into their lungs while in utero or during the birth process. The nurse should monitor the newborn for signs of respiratory distress frequently and intervene if there are any unexpected findings. - Color of amniotic fluid is correct. The presence of meconium in the amniotic fluid at delivery increases the risk for meconium aspiration syndrome and meconium ileus.

A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on July 27. What is the client's EDB? (State the date in MMDD. For example, July 27 is 0727)

0504 Rationale: Using Nägele's rule, the nurse subtracts three months from the date of the last menstrual period, then adds 7 days. July minus 3 months equals April. There are 30 days in April, so 27 + 7 = May 4. The client's EDB is May 4, which would be written as 0504 in the MMDD format.

A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

48/min Rationale: The expected reference range for a newborn's resting respiratory rate is 30 to 60/min.

A nurse in an antepartum unit is triaging clients. Which of the following clients should the nurse see first?

A client who is at 28 weeks of gestation and reports of painless vaginal bleeding Rationale: Using the urgent vs. nonurgent approach to client care, the nurse should assess this client first. The nurse should suspect placenta previa when vaginal bleeding occurs after 24 weeks of gestation. A pregnant woman can lose up to 40% of blood before showing signs of shock.

A nurse is instructing a male client about a semen analysis to be done for suspected infertility. Which of the following should be included in the teaching?

Abstain from ejaculation for at least 2 to 5 days prior to the test. Rationale: The client should be instructed to abstain from ejaculation for at least 2 to 5 days prior to the test.

A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alpha-fetoprotein (MSAFP) screening for which of the following clients?

All of the clients Rationale: MSAFP is a screening tool to detect open spinal and abdominal wall defects in the fetus. This maternal blood test is recommended for all pregnant woman.

A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

Apply an ice pack to the affected area. Rationale: During the first 24 hr, ice packs and cool water sitz baths are used. They reduce edema and promote comfort. The client may also apply witch hazel compresses to reduce edema. The nurse should instruct the client on the use of prescribed anesthetic creams, sprays, and ointments.

A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure?

Assess the fetal heart rate. Rationale: The fetal heart rate should be assessed before and immediately after the amniotomy to detect any changes.

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action?

Assess the odor of the amniotic fluid. Rationale: Chorioamnionitis is an infection of the amniotic cavity that presents with maternal fever, tachycardia, increased uterine tenderness, and foul-smelling amniotic fluid.

A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority?

Bilirubin 19 mg/dL Rationale: Bilirubin 19 mg/dL is above the expected reference range for a newborn at 4 hr of age. A bilirubin level greater than 15 mg/dL or an increase by more than 6 mg/dL in 24 hr is pathologic or nonphysiologic jaundice. Pathologic jaundice is a result of an underlying disease and occurs before 24 hr of age; therefore, this is the nurse's priority finding.

A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record?

Breech Rationale: An RSA position indicates that the body part of the fetus that is closest to the cervix is the sacrum. Therefore, the buttocks or feet are the presenting part, which is classified as a breech presentation.

A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn?

Cold stress Rationale: When an infant is stressed by cold exposure, oxygen consumption increases and pulmonary and peripheral vasoconstriction occurs. Metabolic demands for glucose increase. If the cold stress continues, hypoglycemia and metabolic acidosis can result.

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

Deep tendon reflexes of +1 Rationale: Deep tendon reflexes of +1 are decreased. In a client who has preeclampsia, the nurse should expect to find an increased, rather than a decreased, deep tendon reflex.

A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?

Discontinue the infusion of the IV oxytocin. Rationale: Discontinue the oxytocin infusion immediately if a client is experiencing late decelerations due to uterine hyperstimulation.

A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?

Document this as an expected finding. Rationale: The expected reference range for an apical pulse in a newborn who is awake is 120 to 160/min. The nurse should document this as an expected finding.

A nurse is caring for a client who experienced a vaginal birth 12 hr ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase?

Expressions of excitement Rationale: Expressing excitement and being talkative are characteristic of this phase.

A nurse in a prenatal clinic is caring for a client who asks what her estimated date of delivery will be if her last menstrual period was May 4, 2015. Which of the following is the appropriate response by the nurse?

Feb 11 2016 Rationale: Subtracting 3 calendar months and adding 7 days plus one year will result in this estimated date of delivery.

A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?

Hypertension Rationale: Maternal hypertension, either chronic or related to pregnancy, is the most common risk factor for placental abruption.

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take?

Have the client pant during the next contractions. Ratioanle: Panting is rapid, continuous, shallow breathing. It helps a client in labor refrain from pushing before her cervix reaches full dilation. Observe for hyperventilation and have the client exhale slowly through pursed lips.

A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

Maternal/newborn blood group incompatibility Rationale: Maternal/newborn blood group incompatibility is the most common form of pathologic jaundice and the jaundice appears within the first 24 hr of life.

A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action?

Place the client in a lateral position Rationale: Based on Maslow's hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client's hips to relieve pressure on the inferior vena cava and improve the blood pressure.

A nurse is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition?

Placental insufficiency Rationale: Placental insufficiency is a cause of small for gestational age. It can result from maternal infections, embryonic placental deficiency, teratogens, or chromosomal abnormalities.

A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider?

Respiratory depression Rationale: Magnesium sulfate toxicity can cause life-threatening adverse effects, including respiratory and CNS depression. The nurse should report a respiratory rate slower than 12/min immediately to the provider and stop the infusion.

A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch?

Rooting Rationale: The rooting reflex is elicited when the client strokes the newborn's lips, cheek, or corner of the mouth with her nipple. The newborn will turn his head while making sucking motions with his mouth and latch onto the nipple.

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

Suction the mouth with a bulb syringe. Rationale: The greatest risk to the newborn is aspiration of secretions. Removing the secretions from the mouth first is the priority action.

A nurse is reinforcing teaching about contraceptive methods with a client. Which of the following should the nurse recognize as a contraindication for diaphragm use?

The client has pelvic relaxation Rationale: Pelvic relaxation and large cystocele are contraindications for diaphragm use.

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

Uteroplacental insufficiency Rationale: The pattern of the fetal heart rate during labor is an indicator of fetal well-being. Late decelerations are the result of uteroplacental insufficiency and the fetus becomes hypoxemic. They are an ominous sign if they cannot be corrected and place the fetus at risk for a low Apgar score.


Ensembles d'études connexes

Micro Econ Final Exam Module 1 and 2

View Set

Chapter 3 World Population and Global Inequality

View Set

Civil Rights and Civil Liberties

View Set

AP Human Geography: Agriculture Vocabulary

View Set

5 M's & "S" of the Industrial Revolution

View Set

Key Events of the American Revolution

View Set