ATI Maternal Newborn 2019 B

A nurse is assessing a client who is at 35 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which of the following findings should the nurse report to the provider?

Urinary output 20 mL/hr Rationale: The nurse should report a urinary output of 20 mL/hr because this can indicate inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary output can also indicate a decrease in renal perfusion secondary to a worsening of the client's pre-eclampsia.

A nurse is assessing a client who is at 37 weeks of gestation and has suspected pelvic fracture due to blunt abdominal trauma. Which of the following findings should the nurse expect?

Uterine contractions Rationale: The nurse should expect the client to be experiencing uterine contractions due to abdominal trauma.

A nurse is teaching a client who is at 30 weeks of gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching?

Vaginal bleeding Rationale: Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a complication such as placental abruption, placenta previa, or preterm labor.

A nurse is teaching a client who is at 12 weeks of gestation and has HIV. Which of the following statements should the nurse include in the teaching?

"You should continue to take zidovudine throughout the pregnancy." Rationale: The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmission of HIV to her newborn.

A nurse is caring for a client who is at 35 weeks of gestation and has severe pre-eclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status?

Daily weight Rationale: Evidence-based practice indicates that daily weight is the most accurate assessment to determine a client's fluid and electrolyte status.

A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via continuous IV infusion. The nurse notes that the client is having contractions every 2 min which last 100 t o 110 seconds and that the fetal heart rate (FHR) is reassuring. Which of the following actions should the nurse take?

Decrease the dose of oxytocin by half. Rationale: The nurse should decrease the dose of oxytocin by half because the client is experiencing uterine tachysystole.

A nurse is reviewing laboratory results for a client who is 37 weeks of gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic streptococci, and has a blood type of O negative. Which of the following actions should the nurse take?

Instruct the client to obtain a rubella immunization after delivery. Rationale: This client is not immune to rubella and should receive this immunization after delivery.

A nurse is reviewing the medical record of a client who is at 33 weeks of gestation and has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider?

Perform a vaginal examination. Rationale: When a client has a placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta and increased bleeding.

discharge teaching to a newborn parent about car seat safety. which should include? Place the shoulder harness in the slots above the newborn's shoulders. Place the retainer clip at the level of the newborn's armpits. Place the newborn at a 60° angle in the car seat. Place the newborn in a blanket before securing them in the car seat.

Place the retainer clip at the level of the newborn's armpits. The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits. The nurse should instruct the parents to place the shoulder harness IN the slots that are at or just below the newborn's shoulders. The nurse should instruct the parents to position the newborn at a 45° angle to minimize the risk of airway obstruction from slumping forward. The nurse should instruct the parents to refrain from placing extra padding, including blankets, between the newborn and the straps of the car seat. Extra padding creates air pockets that decrease the effectiveness of the restraint and can lead to injuries.

A nurse is teaching a client who is at 12 weeks of gestation about the manifestations of potential complications that she should report to her provider. Which of the following information should the nurse include in the teaching?

Swelling of the face Rationale: The nurse should instruct the client to report swelling of the face because this can indicate a hypertensive disorder or preeclampsia.

A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority?

480 mL urine output in 24 hr Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is 480 mL of urine output in 24 hr because the minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of preeclampsia to preeclampsia with severe features, which requires immediate intervention. Therefore, this is the priority finding.

A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that which of the following laboratory tests will be used to confirm her pregnancy?

A urine test for the presence of human chorionic gonadotropin Rationale: Human chorionic gonadotropin is excreted by the placenta and promotes the excretion of progesterone and estrogen. This hormone is the basis for pregnancy testing.

A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take?

Apply pressure to the client's sacral area during contractions. Rationale: The nurse should provide counter pressure to the sacral area with a palm or a firm object, such as a tennis ball, during contractions. Counterpressure lifts the fetal head away from the sacral nerves, which decreases pain.

A nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following medications should the nurse plan to administer?

Betamethasone Rationale: The nurse should plan to administer betamethasone IM, a glucocorticoid, to stimulate fetal lung maturity and thereby prevent respiratory depression.

A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take?

Obtain blood samples for baseline laboratory values. Rationale: The nurse should obtain samples of the client's blood for baseline testing of hemoglobin and hematocrit levels.

teaching a new prescription for combined oral contraceptives about potential adverse effects of the med. tell pt to notify the HCP? Shortness of breath Breakthrough bleeding Vomiting Breast tenderness

Shortness of breath The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain. Breakthrough bleeding outside the menstrual period is a common adverse effect of combined oral contraceptives. Nausea and vomiting, Breast tenderness is a common adverse effect of combined oral contraceptives.

A nurse is teaching a client who is 13 weeks of gestation about the treatment of incompetent cervix with cervical cerclage. Which of the following statements by the client indicates an understanding of the teaching?

"I should go to the hospital if I think I may be in labor." Rationale: Cervical cerclage prevents premature opening of the cervix during pregnancy. The client should immediately go to a facility for evaluation if she experiences any manifestations of labor while the cerclage is in place. If the client experiences preterm uterine contractions she might require tocolytic therapy.

A nurse is teaching a client who is 8 weeks of gestation and has a uterine fibroid about the potential effects of the fibroid during pregnancy. Which of the following information should the nurse include in the teaching?

"The fibroid can increase the risk for postpartum hemorrhage." Rationale: Uterine fibroids can increase the risk for postpartum hemorrhage due to the increase in blood supply to the uterus, which supports the fibroid.

A nurse is caring for a client who is at 26 weeks of gestation and reports constipation. Which of the following responses by the nurse is appropriate?

"You should walk for at least 30 minutes every day." Rationale: The nurse should encourage the client to participate in moderate physical activity, such as walking or swimming, every day. This activity increases intestinal peristalsis, which will help alleviate constipation.

a diet teaching for hyperemesis gravidarum "I will eat foods that taste good instead of balancing my meals." "I will avoid having a snack before I go to bed each night." "I will have a cup of hot tea with each meal." "I will eliminate products that contain dairy from my diet."

"I will eat foods that taste good instead of balancing my meals." Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet. hyperemesis gravidarum should avoid going to bed with an empty stomach. The nurse should instruct the client to eat a healthy snack before going to bed. should alternate liquids and solids every 2 to 3 hr to avoid an empty stomach and over filling at each meal. do not need to eliminate dairy products from their diet. The client should be encouraged to consume dairy products, because they are less likely to cause nausea than other foods.

Teaching a client who is Rh negative about Rhimmune globin. understanding the teaching? "I will receive this medication if my baby is Rh-negative." "I will receive this medication when I am in labor." "I will need a second dose of this medication when my baby is 6 weeks old." "I will need this medication if I have an amniocentesis."

"I will need this medication if I have an amniocentesis." ***Rho(D) immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation. a. Rho(D) immune globulin is administered to a client who is Rh-negative and gives birth to an Rh-positive newborn. b. Rho(D) immune globulin is administered at 28 weeks of gestation or after birth if the newborn is Rh-positive.

teaching a new prescription of using diaphragm. include in the teaching? "You should replace the diaphragm every 5 years." "You should leave the diaphragm in place for at least 6 hours after intercourse." "You should use an oil-based product as a lubricant when inserting the diaphragm." "You should insert the diaphragm when your bladder is full."

"You should leave the diaphragm in place for at least 6 hours after intercourse." The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy. The client should replace the diaphragm every 2 years. The client should avoid using oil-based products because they can weaken the rubber in the diaphragm. The client should have an empty bladder prior to inserting the diaphragm.

A nurse is teaching a client who is at 10 weeks of gestation about an abdominal ultrasound in the first trimester. Which of the following information should the nurse include in the teaching?

"You will need to have a full bladder during the ultrasound." Rationale: The nurse should tell the client that a full bladder helps to lift the gravid uterus out of the pelvis during the examination. Therefore, it is important to ensure that the client has a full bladder to obtain the most accurate image of the fetus.

at 1800 reviewing the record for a 34 week gestation. What is the nursing care plan? ---------------- Diagnostic Results​: Lecithin/sphingomyelin (L/S) ratio 1.4:1 Phosphatidylglycerol (PG) absent ABO-Rh B-negative Medication Administration Record: Terbutaline 0.25 mg SQ every hr PRN contractions Rho(D) immune globulin 300 mcg IM once Nalbuphine 10 mg IV every 3 hr PRN pain Progress Report: 1655 - Amniocentesis completed, tocotransducer and external fetal monitor applied 1700 - Fetal heart rate 130/min with moderate variability Uterine contractions q 5 to 8 min lasting 30 to 60 sec duration Uterine contractions palpated at 1+ intensity Client reports uterine contraction pain of 2 on a scale of 0 to 10 ---------------- Administer terbutaline. Discuss possible genetic anomalies with the client. Administer nalbuphine. Discontinue external fetal monitoring.

Administer terbutaline. The nurse should administer terbutaline to stop contractions because the laboratory results indicate that the fetus's lungs are not mature enough for birth. There is no indication of genetic anomalies based on the results of the amniocentesis. Nalbuphine is an analgesic used for moderate to severe pain. A report of 2 on a scale of 0 to 10 is mild pain. The nurse should not discontinue external fetal monitoring. Because the client is exhibiting manifestations of preterm labor, fetal well-being and contraction patterns should be continuously monitored to continue to assess for preterm labor and provide necessary interventions to stop contractions.

performing a vaginal exam on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which following actions should take next? Place a rolled towel beneath one of the client's hips. Apply internal upward pressure to the presenting part using two gloved fingers. Administer oxygen to the client via a nonrebreather mask at 10 L/min. Increase the IV infusion rate.

Apply internal upward pressure to the presenting part using two gloved fingers. Using evidence-based practice, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand. The nurse should place a rolled towel under the client's left or right hip to alleviate some of the pressure; however, evidence-based practice indicates that the nurse should take a different action first. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. The nurse should administer oxygen via a nonrebreather mask at 10 L/min; however, evidence-based practice indicates that the nurse should take a different action first. The nurse should increase the IV infusion rate; however, evidence-based practice indicates that the nurse should take a different action first.

41 weeks gestation has a positive contraction stress test. Which diagnostic test should prepare? Percutaneous umbilical blood sampling Amnioinfusion Biophysical profile (BPP) Chorionic villus sampling (CVS)

Biophysical profile (BPP) The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. CVS is the assessment of a portion of the developing placenta, which is aspirated through a thin sterile catheter inserted through the abdominal wall or intravaginally through the cervix under ultrasound guidance. This procedure is done during the first trimester. This is not a diagnostic test used for clients who have a positive contraction stress test. An amnioinfusion of normal saline or lactated Ringer's is instilled into the amniotic cavity through a transcervical catheter introduced into the uterus to supplement the amount of amniotic fluid. The instillation reduces the severity of variable decelerations caused by cord compression for clients who are in labor. This is not a diagnostic test used for clients who have a positive contraction stress test. Percutaneous umbilical blood sampling, commonly called cordocentesis, is the most common method used for fetal blood sampling and transfusion. This is not a diagnostic test used for clients who have a positive contraction stress test.

under going phototherapy. Should take? Cover the newborn's eyes while under the phototherapy light. Keep the newborn in a shirt while under the phototherapy light. Apply a light moisturizing lotion to the newborn's skin. Turn and reposition the newborn every 4 hr while undergoing phototherapy.

Cover the newborn's eyes while under the phototherapy light. Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light. It is acceptable for the nurse to keep a diaper or other covering over the newborn's genitals and buttocks, but the nurse should remove all other clothing and blankets to expose as much body surface area as possible to the phototherapy light. The nurse should not apply any cream or moisture to the newborn's skin because it can absorb heat and cause burns. The nurse should turn and reposition the newborn every 2 to 3 hr to allow for maximum exposure of body surfaces to the phototherapy light.

A nurse is assessing a client who is at 34 weeks of gestation and has a mild placental abruption. Which of the following findings should the nurse expect?

Dark red vaginal bleeding Rationale: The nurse should expect the client who has a mild placental abruption to have minimal dark red vaginal bleeding.

planning care for a client who is 2hr postpartum. Which interventions should the nurse plan during the taking-hold phase of postpartum behavioral adjustment? Discuss contraceptive options with the client and her partner. Repeat information to ensure client understanding. Listen to the client and her partner as they reflect upon the birth experience. Demonstrate to the client how to perform a newborn bath.

Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new parent moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new parent confidence and promote maternal adjustment. The discussing of contraceptive options occurs during the letting-go phase. This phase focuses on moving forward as a family with interchanging members. The repeating of information to ensure client understanding occurs during the taking-in phase. During this phase, which is experienced on the first postpartum day, the client displays dependent and passive behaviors. Due to excitement and fatigue, the client is unable to retain information. Therefore, the nurse should repeat instructions to ensure that the client understands what is being said. Listening to the client and her partner reflect upon the birth experience occurs during the taking-in phase. During this phase, the new mother is focused on herself and meeting her basic needs. There is also much excitement about the newborn and the birth experience. Therefore, the nurse should allow the client to reflect, ensuring a healthy transition and a successful adaptation into the new family unit.

A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about the expected adverse effects. Which of the following adverse effects should the nurse include in the teaching?

Feeling of warmth Rationale: The nurse should tell the client to expect the feeling of warmth all over her body while the magnesium sulfate is infusing.

A nurse is reviewing the medical record of a client who is at 39 weeks of gestation and has polyhydramnios. Which of the following findings should the nurse expect?

Fetal gastrointestinal anomaly Rationale: Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurologic disorders are expected findings for a fetus experiencing the effects of polyhydramnios.

assessing a newborn of a client who took a SSRI during pregnancy. Which shows an withdrawal from an SSRI? Large for gestational age Hyperglycemia Bradypnea Vomiting

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

antepartum unit which one is the priority? A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL A client who is at 34 weeks of gestation and reports epigastric pain A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL A client who is at 39 weeks of gestation and reports urinary frequency and dysuria

A client who is at 34 weeks of gestation and reports epigastric pain When using the urgent vs nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority. This finding is a manifestation of anemia in a client who is pregnant, which is a nonurgent condition. A fasting blood glucose of 120 mg/dL is above the expected reference range for a client who has gestational diabetes, which is a nonurgent finding. Dysuria can indicate a urinary tract infection, which can cause preterm labor. Dysuria in a client who is at 39 weeks of gestation is a nonurgent condition which will require antibiotics. Thereofre, another client is the nurse's priority.

A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. should take? Apply sacral counterpressure. Perform transcutaneous electrical nerve stimulation (TENS). Initiate slow-paced breathing. Assist with biofeedback.

Apply sacral counterpressure. The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position. The nurse should perform TENS during the first stage of labor. The nurse should transition a client to pattern-paced breathing during this stage of labor. The nurse should teach the client about biofeedback during the prenatal period for it to be effective during labor.

a newborn 24hr old. report to hcp? Hgb 20 g/dL Total bilirubin 5 mg/dL Blood glucose 30 mg/dL WBC count 20,000/mm3

Blood glucose 30 mg/dL Newborns less than 24 hr old should have a blood glucose of 40 to 60 mg/dL. Newborns who are greater than 24 hr old should have a blood glucose of 50 to 90 mg/dL. A blood glucose level of 30 mg/dL is below the expected reference range for a newborn who is 24 hr old and should be reported to the provider. This value is within the expected reference range of 9,000 to 30,000/mm3 for a newborn who is 24 hr old.

contraindication to oral contraceptives? Cholecystitis Hypertension Human papillomavirus Migraine headaches Anxiety disorder

Cholecystitis, HTN, Migraine ha. Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives. Human papillomavirus is incorrect. The presence of human papillomavirus is not a contraindication for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives. Anxiety disorder is incorrect.

A nurse is assessing a client who is at 12 weeks of gestation and has hyatidiform mole. Which of the following findings should the nurse expect?

Dark brown vaginal discharge Rationale: A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of the chorionic villi, which gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grapelike clusters.

in the anteroartum clinic, assessing a client's adaptation to pregn. she states "happy one minute and crying the next." indication of ... Emotional lability Focusing phase Cognitive restructuring Couvade syndrome

Emotional lability The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason. The focusing phase is the third phase of the father's emotional response to the pregnancy. It is characterized by his active involvement in the pregnancy and his relationship with the child. Cognitive restructuring is accepting the idea of pregnancy and assimilating it into the woman's life. The degree of acceptance is shown in the mother's emotional responses. Couvade syndrome is pregnancy-like manifestations experienced by the expectant father. Manifestations include nausea, weight gain, and other physical manifestations of pregnancy.

indication of adm oxytocin to a client who is postpartum? Flaccid uterus Cervical laceration Excess vaginal bleeding Increased afterbirth cramping Increased maternal temperature

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

magnesium sulfate is used for caring a client who has preeclampsia. Which action should the nurse take? Restrict hourly fluid intake to 150 mL/hr. Have calcium gluconate readily available. Assess deep tendon reflexes every 6 hr. Monitor intake and output every 4 hr.

Have calcium gluconate readily available. The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity. The nurse should restrict hourly fluid intake to no more than 125 mL/hr. The client's urine output should be 30 mL/hr or greater. The nurse should assess deep tendon reflexes every 1 to 4 hr during continuous infusion of magnesium sulfate. The nurse should monitor intake and output HOURLY for clients who are receiving a continuous infusion of magnesium sulfate.

a preterm labor about terbutaline. Understanding the teaching? "I will get injections of the medication once daily until my labor stops." "My blood sugar may be low while I'm on this medication." "I will have blood tests because my potassium might decrease." "My blood pressure may increase while I'm on this medication."

I will have blood tests because my potassium might decrease." An adverse effect of terbutaline is hypokalemia. Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr. An adverse effect of terbutaline is hyperglycemia. An adverse effect of terbutaline is hypotension. An adverse effect of terbutaline is hypokalemia.

A nurse is caring for a client who is at 35 weeks of gestation and is experiencing placenta previa. Which should take? Perform a vaginal exam to determine cervical dilation every 2 hr. Instruct the client to ambulate in the hallway once every 4 hr. Administer betamethasone to the client via IM injection. Initiate continuous external fetal monitoring.

Initiate continuous external fetal monitoring. The nurse should identify that a client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor laboratory values. Also, the nurse should implement interventions to prepare for an emergency birth. Betamethasone is given to enhance fetal lung maturity for clients who are experiencing preterm labor. It is given to clients between 24 and 34 weeks of gestation. A client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. Ambulating frequently could potentially stimulate labor and increase vaginal bleeding. Therefore, the nurse should place the client on bed rest with bathroom privileges. A client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should place the client on pelvic rest and should not perform vaginal or rectal examinations.

hypoglycemia of nb, expect? Jitteriness Hypertonia Abdominal distention Mottling

Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia. Hypotonia, rather than hypertonia, is a manifestation of hypoglycemia. Hypertonia is a manifestation of opioid withdrawal. Abdominal distention is not a manifestation of hypoglycemia. Abdominal distention is a finding in newborns who have hypocalcemia. Mottling is not a manifestation of hypoglycemia. It can be a normal variation seen in newborns. Also, it is a manifestation of opioid withdrawal.

a client has an amniocentesis 18 weeks of gestation, which report to HCP as a potential complication? Increased fetal movement Leakage of fluid from the vagina Upper abdominal discomfort Urinary frequency

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

assessing fetal heart tones for a client. the fetal position as left ocipital anterior. To which of the following areas of the client' abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart? Left upper quadrant Right upper quadrant Left lower quadrant Right lower quadrant

Left lower quadrant The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant. The fetal heart tones of a fetus in the right occipital anterior position are best heard in the right lower quadrant. The fetal heart tones of a fetus in the left sacrum anterior position are best heard in the left upper quadrant. The fetal heart tones of a fetus in the right sacrum anterior position are best heard in the right upper quadrant.

a postpartum unit, pt is experiencing hypovolemic shock.after noticing the provider, which of the following actions should the nurse take next? Massage the client's fundus. Insert an indwelling urinary catheter. Administer oxygen at 10 L/min. Elevate the client's right hip.

Massage the client's fundus. The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions. The nurse should insert an indwelling urinary catheter to monitor perfusion of the kidneys.The nurse should administer oxygen at 10 L/min via rebreather face mask to enhance perfusion.The nurse should elevate the client's right hip to enhance perfusion. However, this is not the next action the nurse should take.

the client is in labor and requesting epidural anesthesia for pain control. Take an action? Place the client in a supine position for 30 min following the first dose of anesthetic solution. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution.

Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution. b. The nurse should plan to administer 500 to 1,000 mL of lactated Ringer's or 0.9% sodium chloride 15 to 30 min prior to the administration of the first dose of anesthetic solution to decrease the maternal risk for hypotension. The nurse should NOT administer dextrose because it can cause maternal hyperglycemia and neonatal hypoglycemia. a. The nurse should plan to position the client upright to allow the anesthetic solution to flow downward. If additional pain management is needed for a cesarean birth, the nurse can place the client supine with her head and shoulders elevated and at a lateral tilt to increase perfusion to the fetus. d.The nurse should not plan to restrict the client's intake prior to the epidural placement and the first dose of anesthetic solution because NPO status is not indicated for this procedure.

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring? Oligohydramnios Hyperemesis gravidarum Leukorrhea Periodic tingling of the fingers

Oligohydramnios The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis. Hyperemesis gravidarum is not an indication for further fetal assessment using electronic fetal monitoring unless complications occur. Leukorrhea is a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring unless complications occur. Periodic tingling of the fingers is a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring.

teach a new mother how to use a bulb syringe to suction her newborn's secretions. teaching include? Insert the syringe tip before compressing the bulb. Suction each of the nares before suctioning the mouth. Insert the tip of the syringe into the center of the newborn's mouth. Stop suctioning when the newborn's cry sounds clear.

Stop suctioning when the newborn's cry sounds clear. The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus. The client should insert the tip of the syringe into the SIDE of the newborn's mouth. Inserting it into the center of the newborn's mouth can trigger the gag reflex. The client should suction the mouth before suctioning the nares. Otherwise, the newborn could gasp and inhale pharyngeal secretions when the syringe tip touches the nares.

assessing a 30 weeks of gestation during a routine prenatal visit. which should report to the provider? Swelling of the face Varicose veins in the calves Nonpitting 1+ ankle edema Hyperpigmentation of the cheeks

Swelling of the face Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema. Varicose veins are an expected finding in the second trimester. The increase in hormones during pregnancy causes the relaxation of the smooth muscle of the vascular system, leading to vessel dilation and vasocongestion. Additionally, the weight of the enlarging uterus on the pelvic veins decreases the return of blood from the lower extremities. Nonpitting edema of the lower extremities is an expected finding in the third trimester. Warm weather, sitting or standing for prolonged periods of time, and tight clothing can increase edema. Hyperpigmentation of the cheeks, areola, vulva, and linea nigra are expected findings in the second trimester. The anterior pituitary increases the production of melanocyte-stimulating hormone, which leads to hyperpigmentation of the skin.

performing Leopold maneuvers steps?

The first step- palpate the client's fundus to identify the FETAL part. Second, determine the location of the fetal BACK. Third, palpate for the fetal part presenting at the INLET. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.

Which image shows a spina bifida occulta?

The nurse should identify this as an image of spina bifida occulta. External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or Hairy Patch above the area. The nurse should identify this as an image of spina bifida manifesta in the form of a myelomeningocele that is open. External indications of this neural tube defect include an open area over the defect that allows for leakage of cerebrospinal fluid and entry of microorganisms.

teaching to promote the security and safety of the client's newborn. should do? "The nurse will carry your newborn to the nursery for procedures." "We will document the relationship of visitors in your medical record." "Your baby will stay in the nursery while you are asleep." "Staff members who take care of your baby will be wearing a photo identification badge."

The nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs. a.The nurse should instruct the client that newborns will be transported in their bassinets and Never carried outside the client's room to reduce the risk for falls. b. The nurse should instruct the client that they can have anyone visit them on the unit. There is no documentation of a visitor's relationship to the client entered into the medical record. c. The nurse should instruct the client to place the baby in the bassinet on the side of the bed furthest from the door while she is sleeping.

discharge teaching to a client who is postpartum. which manifestations report to the provider? Persistent abdominal striae Temperature 37.8° C (100° F) Unilateral breast pain Brownish-red discharge on day 5

Unilateral breast pain Sudden onset of chills, fever, malaise, body aches, headaches, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this manifestation to the provider. Brownish-red discharge is an expected manifestation during days 3 to 10. The client should report a large amount of lochia and large clots to the provider. The nurse should instruct the client to report a temperature of 38° C (100.4° F) or higher because it could be an indication of infection. Persistent abdominal striae are caused by the separation of the underlying connective tissue and are an expected postpartum finding.

A nurse is caring for a client who is at 37 weeks of gestation and is undergoing a nonstress test. The fetal heart rate is 130/min without accelerations for the past 10 min. Which of the following actions should hte nurse

Use vibroacoustic stimulation on the client's abdomen for 3 seconds. Rationale: The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR.

A nurse is caring for a client who is at 39 weeks of gestation and is in the active phase of labor. The nurse observes late decelerations in the fetal heart rate. Which of the following findings should the nurse identify as the cause for late decelerations?

Uteroplacental insufficiency Rationale: A late deceleration in the FHR is a nonreassuring FHR pattern resulting from fetal hypoxemia due to insufficient placental perfusion. The nurse should reposition the client, initiate oxygen, and increase the infusion rate of IV fluid to enhance placental perfusion.

teaching an adolescent about Levonorgestrel contraception. which should teach? "You should take the medication within 72 hours following unprotected sexual intercourse." "You should avoid taking this medication if you are on an oral contraceptive." "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test." "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it."

You should take the medication within 72 hours following unprotected sexual intercourse." Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse. Levonorgestrel, an emergency contraceptive, has no effect on the other oral contraceptive the adolescent might be taking. To prevent pregnancy, this medication should be taken if an adolescent misses a dose of oral contraception. The adolescent should be evaluated for pregnancy if she does not menstruate within 21 days following administration of this medication. Levonorgestrel is an emergency contraceptive that prevents or delays ovulation. Therefore, the nurse should inform the client that she will not be protected from pregnancy if she has unprotected sexual intercourse in the days and weeks after receiving this medication.

24 weeks of gestation regarding a 1hr glucose tolerance test. teaching? "You will need to drink the glucose solution 2 hours prior to the test." "Limit your carbohydrate intake for 3 days prior to the test." "A blood glucose of 130 to 140 is considered a positive screening result." "You will need to fast for 12 hours prior to the test."

"A blood glucose of 130 to 140 is considered a positive screening result." The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus. The nurse should instruct the client to drink the glucose solution 1 hr prior to the test. the nurse should instruct the client that she should not limit her carbohydrate intake. The nurse should instruct the client that fasting is not required for a 1-hr glucose tolerance test.

speaking with a client who is trying to make a decision about tubal ligation. The client asks, "what effects will this procedure have on my sex life?" which statement should make? "I think that is something you should discuss with your doctor." "This procedure should have no effect on your sexual performance or adequacy." "You'll be fine. I can't imagine you and your partner will have any problems with sexual function." "If this concerns you, perhaps you should reconsider and use another form of contraception."

"This procedure should have no effect on your sexual performance or adequacy." The nurse is giving the client the information she is seeking. Sexual function depends on various hormonal and psychological factors. Therefore, tubal occlusion should have no physiological effect on sexual function. a. The nurse is dismissing the client's question, providing no information to help the client make an informed decision. c The nurse is giving the client unwarranted reassurance without addressing the information the client is seeking. d. The nurse is giving the client unwarranted advice which might imply that there is a reason to be concerned about the effect of the procedure on sexual function.

in a prenatal visit, her menstrual period is 2 weeks late. she appears anxious and ask the nurse if she is pregnant. response is "You can miss your period for several other reasons. Describe your typical menstrual cycle." "If you have been sexually active and haven't used protection, it is likely that you are pregnant." "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" "Because you have missed your period, you should try taking a home pregnancy test before you start worrying."

"You can miss your period for several other reasons. Describe your typical menstrual cycle." Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions.

Which should include in the teaching for a 36 weeks of gestation has a prescription for a nonstress test? "You will receive IV fluids prior to this test." The procedure will take approximately 10 to 15 minutes." "You will be offered orange juice to drink during the test." "You will need to sign an informed consent form each time you have this test."

"You will be offered orange juice to drink during the test." A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate fetal movements during the procedure, helping to obtain results. A nonstress test is a noninvasive procedure. Therefore, the client does not need to provide informed consent. The nurse should state that IV fluids are initiated for an oxytocin-stimulated contraction test, rather than a nonstress test. The nurse should instruct the client that the procedure will take 20 to 40 min.

a client is in active labor and has had no cervical change in the last 4 hr. should make? Let me help you into a comfortable pushing position so you can begin bearing down." "I am going to call the doctor to get a prescription for medication to ripen your cervix." "I will give you some IV pain medicine to strengthen your contractions." "Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions."

"Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions." Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, frequency, and duration which will identify whether the contractions are adequate for progression of labor. a.The nurse should not instruct the client to start bearing down until the second stage of labor. b.A cervical ripening agent is not used during the active stage of labor. c. Administering IV pain medication can decrease the intensity of uterine contractions.

A nurse is caring for a client whose last menstrual period began July 8. Using Nagele's rule, the nurse should identify the clients estimates date of birth as which of the following?

April 15 Rationale: Using Nagele's rule, the nurse determines the EDB by counting back 3 months from the first day of the LMP and adding 7 days.

A nurse is caring for a client who is at 38 weeks of gestation and reports no fetal movement for 24 hr. Which of the following actions should the nurse take?

Auscultate for a fetal heart rate. Rationale: Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The nurse should auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action.

3 days postpartum. what is the plan of care for lactation suppression? Place warm, moist packs on the breasts. Apply cabbage leaves to the breasts Wear a loose-fitting bra. Put green tea bags on the breasts.

Apply cabbage leaves to the breasts. Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement. The client can use cold compresses to decrease breast discomfort during lactation suppression. A tight-fitting bra will provide support to the breasts during engorgement, which can decrease pain. Tea bags are used to relieve nipple soreness in breastfeeding clients.

show newborn experiences pain when he is undergo a circumcision?

Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow. Increased HR, dilating pupils, rapid and shallow respi.

A nurse is providing teaching to a client who is at 8 weeks of gestation about the manifestations to report to the provider during pregnancy. Which of the following information should the nurse include in the teaching?

Blurred or double vision Rationale: A client who is pregnant should report experiencing blurred or double vision as these could be a manifestation of gestation hypertension or pre-eclampsia.

A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy?

Palpable fetal movement rationale: Palpable fetal movements are a positive sign of pregnancy. Quickening, the client's report of fetal movement, is a presumptive sign of pregnancy. Chadwick's sign

8 weeks of gestation. increase daily intake of which? Calcium Vitamin E Iron Vitamin D

Iron The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old. The recommendation for calcium intake during pregnancy is the same as that for women who are not pregnant: 1,300 mg/day for women younger than 19 years old and 1,000 mg/day for women between the ages of 19 and 50 years old. The recommendation for vitamin E intake during pregnancy is 15 mg/day, the same as that for women who are not pregnant. The recommendation for vitamin D intake during pregnancy is 600 IU/day, the same as that for women who are not pregnant.

assessing a pregnant is at the end of the first trimester. Place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones FHT? Just above the umbilicus Just above the symphysis pubis The right lower quadrant The left lower quadrant

Just above the symphysis pubis At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis. Therefore, the nurse might not hear FHT in the right or left lower quadrant. The nurse should assess FHT using the Doppler stethoscope just above the umbilicus if the fetus is in a transverse or breech presentation and the client is at a minimum of 22 weeks of gestation.

A nurse is caring for a client who is n active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following action should the nurse take?

Prepare equipment needed for newborn resuscitation. Rationale: The nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.

A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect?

Renal agenesis Rationale: Oligohydramnios is a volume of amniotic fluid less than 300 mL during the third trimester of pregnancy and occurs when there is a renal system dysfunction or obstructive uropathy. Absence of fetal kidneys will cause oligohydramnios.

planning care for a client who is in labor and is to have amniotomy. what is the priority? O2 saturation Temperature Blood pressure Urinary output

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

gave a vaginally 12 hr ago and palpate her uterus to the right above the umbilicus. interventions? Reassess the client in 2 hr. Administer simethicone. Assist the client to empty her bladder. Instruct the client to lie on her right side.

The nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage. Instruct the client to lie on her right side.

is in labor and reports increasing rectal pressure. contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and dilated to 9 cm. Which stage of labor? Active Transition Latent Descent

Transition The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds. The active phase of labor is characterized by a cervical dilatation of 4 to 7 cm and contractions every 3 to 5 min, each lasting 40 to 70 seconds. The latent phase of labor is characterized by cervical dilation of 0 to 3 cm and contractions every 5 to 30 min, each lasting 30 to 45 seconds. The descent phase of labor is characterized by active pushing with contractions every 1 to 2 min, each lasting for 90 seconds.

teaching a newborn safety?

You can share your room with your baby for the next few weeks." The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome. The nurse should instruct the parents to place the newborn in a sleep sack or a one-piece sleeper. Covering the newborn with a blanket or quilt increases the risk for sudden infant death syndrome. not Cover your baby with a light blanket while sleeping." The nurse should instruct the parents to check the temperature of the newborn's bath water with their ELBOW not hand, which is more sensitive to temperature than the hand. The hot water heater should be set at or below 49° C (120.2° F) to prevent burns. The nurse should instruct the parents to lay the newborn in a bassinet or crib on her back to sleep. Sleeping in a supine position on a firm mattress decreases the risk of sudden infant death syndrome. Should NOT nap in the car seat during the daytime."