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The heart rate of the newborn in the first few minutes after birth will be in which range? 180 to 220 bpm 80 to 120 bpm 110 to 160 bpm 120 to 130 bpm
110 to 160 bpm During the first few minutes after birth, the newborn's heart rate is approximately 110 to 160 bpm. Thereafter, it begins to decrease to an average of 120 to 130 bpm.
A pregnant client with type 1 diabetes is in labor. The client's blood glucose levels are being monitored every hour and she has a prescription for an infusion of regular insulin as needed based on the client's blood glucose levels. Her levels are as follows: 1300: 105 mg/dL (5.83 mmol/L) 1400: 100 mg/dL (5.55 mmol/L) 1500: 120 mg/dL (6.66 mmol/L) 1600: 106 mg/dl (5.88 mmol/L) Based on the recorded blood glucose levels, at which time would the nurse likely administer the regular insulin infusion? 1500 1300 1600 1400
1500 For the laboring woman with diabetes, intravenous (IV) saline or lactated Ringer's is given, and blood glucose levels are monitored every 1 to 2 hours. Glucose levels are maintained below 110 mg/dL (6.11 mmol/L) throughout labor to reduce the likelihood of neonatal hypoglycemia. If necessary, an infusion of regular insulin may be given to maintain this level. The insulin infusion would be given at 1500, based on the blood glucose level being higher than 110 mg/dL (6.11 mmol/L).
The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement? "The muscle opening that leads into the stomach is not mature." "He needs to get food orally to make vitamin K." "The newborn's gut is sterile at birth." "His stomach can hold approximately 10 ounces."
"His stomach can hold approximately 10 ounces." A newborn's stomach capacity is approximately 30 to 90 mL or 1 to 3 ounces. The gut is sterile at birth but changes rapidly depending on what feeding is received. Colonization of the gut is dependent on oral intake; oral intake is required for the production of vitamin K. The cardiac sphincter that leads into the stomach and nervous control of the stomach are immature.
A client at 11 weeks' gestation experiences pregnancy loss. The client asks the nurse if the bleeding and cramping that occurred during the miscarriage were caused by working long hours in a stressful environment. What is the most appropriate response from the nurse? "It is hard to know why a woman bleeds during early pregnancy." "I can understand your need to find an answer to what caused this. Let's talk about this further." "Your spontaneous bleeding is not work-related." "Something was wrong with the fetus."
"I can understand your need to find an answer to what caused this. Let's talk about this further." Talking with the client may assist her to explore her feelings. She and her family may search for a cause for a spontaneous early bleeding so they can plan for future pregnancies. Even with modern technology and medical advances, however, a direct cause cannot usually be determined.
When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed? " I will change my baby's diapers frequently." "It is not necessary to give my baby a bath daily." "I will give sponge baths until the umbilical cord falls off." "I can use talc powders to prevent diaper rash."
"I can use talc powders to prevent diaper rash." Talc powders can be a respiratory hazard and should not be used with a newborn. All other statements are correct
The parents of a newborn male ask the nurse about circumcision. They are undecided as to what to do. Which response by the nurse is best? "I recommend you discuss the pros and cons of circumcision with the newborn's health care provider." "Circumcision is best because it will prevent the baby from obtaining a sexually transmitted infection." "If you do not circumcise your baby, he will have difficulty maintaining adequate hygiene." "It is best not to circumcise your baby because the procedure is very painful for newborns."
"I recommend you discuss the pros and cons of circumcision with the newborn's health care provider." If the parents decide to have their male newborn circumcised, informed consent is necessary. It is the health care provider's responsibility to obtain informed consent, although the nurse may be responsible for witnessing the parents' signatures to written documentation of that consent. If the parents have unanswered questions, the nurse will notify the health care provider before the procedure is done. Circumcision will decrease the chance of obtaining an STI but will not prevent them in the future. Hygiene can be maintained with proper retraction of the foreskin. The procedure is painful, but all pros and cons should be discussed before making a decision
A pregnant client with a history of asthma since childhood presents for a prenatal visit. What statement by the client alerts the nurse to perform further assessment? "I sometimes get a bit wheezy." "Certain substances make me sneeze." "I sometimes get a feeling of euphoria." "I have trouble getting comfortable in bed."
"I sometimes get a bit wheezy." Wheezing is a classic symptom of asthma. This statement should alert the nurse to the possibility that the client's asthma is not being well-controlled and needs further evaluation and possible intervention. The other statements do not relate to the typical presentation of this disease in pregnancy nor are they cause for concern.
A pregnant women calls the clinic to report a small amount of painless vaginal bleeding. What response by the nurse is best? "Please come in now for an evaluation by your health care provider." "If the bleeding lasts more than 24 hours, call us for an appointment." "Bleeding during pregnancy happens for many reasons, some serious and some harmless." "Lie on your left side and drink lots of water and monitor the bleeding."
"Please come in now for an evaluation by your health care provider." Bleeding during pregnancy is always a deviation from normal and should be evaluated carefully. It may be life-threatening or it may be something that is not a threat to the mother and/or fetus. Regardless, it needs to be evaluated quickly and carefully. Telling the client it may be harmless is a reassuring statement, but does not suggest the need for urgent evaluation. Having the mother lay on her left side and drink water is indicated for cramping.
The student nurse is attending her first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response? "There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." "A newborn delivered by cesarean has less sensory stimulation to breathe." "Surfactant may be missing from the lungs depending on the newborn's gestational age." "The respiratory centers in the brain have not been stimulated when a newborn is delivered by a cesarean delivery."
"There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery." The process of labor stimulates surfactant production, and much of the fetal lung fluid is squeezed out as the fetus moves down the birth canal. This so-called vaginal squeeze is an important way nature helps to clear the airway in preparation for the first breath. The vaginal squeeze also plays a role in stimulating lung expansion. The pressure of the birth canal on the fetal chest releases immediately when the infant is born. The lowered pressure from chest expansion draws air into the lungs.
A client in her first trimester arrives at the emergency room with reports of severe cramping and vaginal spotting. On examination, the health care provider informs her that no fetal heart sounds are evident and orders a dilatation and curettage (D&C). The client looks frightened and confused and states that she does not believe in induced abortion (medical abortion). Which statement by the nurse is best? "Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications." "I know that it is sad but the pregnancy must be terminated to save your life." "You have experienced an incomplete abortion (miscarriage) and must have the placenta and any other tissues cleaned out." "The choice is up to you but the health care provider is recommending an induced abortion (medical abortion).
"Unfortunately, the pregnancy is already lost. The procedure is to clear the uterus to prevent further complications." The nurse should not inform the client what she must do but supply information about what has happened and teach the client about the treatments that are used to correct the situation. A threatened spontaneous abortion (miscarriage) becomes an imminent (inevitable) miscarriage if uterine contractions and cervical dilation (dilatation) occur. A woman who reports cramping or uterine contractions is asked to seek medical attention. If no fetal heart sounds are detected and an ultrasound reveals an empty uterus or nonviable fetus, her health care provider may perform a dilatation and curettage (D&C) or a dilation and evacuation (D&E) to ensure all products of conception are removed. Be certain the woman has been told the pregnancy was already lost and all procedures, such as suction curettage, are to clear the uterus and prevent further complications such as infection, not to end the pregnancy. This scenario does not involve an abortion (elective termination of pregnancy) or an incomplete miscarriage.
A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective? "We will apply a moisture barrier cream with every diaper change to prevent diaper rash." "It is best practice to change the diaper every 2 to 4 hours, even during the night." "We will fold down the front of her diaper under the umbilical cord until it falls off." "We should clean the skin with soap and water after each bowel movement."
"We will fold down the front of her diaper under the umbilical cord until it falls off." In order to prevent the cord from becoming irritated and help dry it out, the diaper is rolled down in the front. A newborn's diaper needs to be changed frequently; however, the baby does not need to be awoken during the night. Warm water or wipes are sufficient to clean the perineal area at diaper changes. Barrier creams may be used as needed, but should not be applied after every diaper change.
A nurse has been assigned to assess a pregnant client for placental abruption (abruptio placentae). For which classic manifestation of this condition should the nurse assess? painless bright red vaginal bleeding increased fetal movement generalized vasospasm "knife-like" abdominal pain with vaginal bleeding
"knife-like" abdominal pain with vaginal bleeding The classic manifestations of abruption placenta are painful dark red vaginal bleeding, "knife-like" abdominal pain, uterine tenderness, contractions, and decreased fetal movement. Painless bright red vaginal bleeding is the clinical manifestation of placenta previa. Generalized vasospasm is the clinical manifestation of preeclampsia and not of abruptio placentae.
What is the expected range for respirations in a newborn? 40 to 80 breaths per minute 10 to 30 breaths per minute 30 to 60 breaths per minute 20 to 40 breaths per minute
30 to 60 breaths per minute Although episodic breathing is normal and short periods of apnea can occur, the normal respiratory rate for a newborn is 30 to 60 breaths per minute. For adults, it is typically 8 to 20 breaths per minute.
A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life? 10% to 15% of their birth weight 20% of their birth weight 5% to 10% of their birth weight 15% to 18% of their birth weight
5% to 10% of their birth weight Adequate digestion and absorption are essential for newborn growth and development. Normally, term newborns lose 5% to 10% of their birth weight as a result of insufficient caloric intake within the first week after birth.
When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voidings per day is a good indicator of adequate fluids? 6 to 8 4 to 6 2 to 4 8 to 10
6 to 8 From birth to about 3 months of age, the newborn's kidneys are unable to concentrate urine and they will urinate frequently. Approximately 6 to 8 voidings per day is average and indicates adequate fluid intake.
When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voidings per day is a good indicator of adequate fluids? 8 to 10 4 to 6 2 to 4 6 to 8
6 to 8 From birth to about 3 months of age, the newborn's kidneys are unable to concentrate urine and they will urinate frequently. Approximately 6 to 8 voidings per day is average and indicates adequate fluid intake.
The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: 5 to 9. 1 to 2. 12 to 15. 7 to 10.
7 to 10. An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring
A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of: 7. 8. 5. 6.
7. The newborn would receive an Apgar score of 7: 1 point for heart rate (<100 beats/minute), 2 points for respiratory rate (regular respirations at a rate between 30 and 60 breaths/minute), 2 points for muscle tone (tight flexion), 1 point for reflex irritability (grimace), and 1 point for skin color (acrocyanosis).
A nurse is assessing a newborn five minutes after birth and notes: HR 110 bpm; a good, strong cry; well flexed extremities; grimacing when slapped on the sole of the foot; and normal pigment in most of the body, with blue hands and feet. What Apgar score will the nurse document for this infant? 9 6 8 7
8 The heart rate of 110 bpm, the strong cry, and the muscles of the extremities being well flexed each indicate a score of 2 in the heart rate, respiratory effort, and muscle tone areas, respectively. The grimace in response to a slap to the sole of the foot and the blue at the extremities each indicate a score of 1 for the reflex irritability and color areas, respectively. Thus, the total Apgar score for this infant is 8 (2 + 2 + 2 + 1 + 1 = 8).
A client is 33 weeks' pregnant and has had diabetes since age 21. When checking her fasting blood glucose level, which value would indicate the client's disease is controlled? 85 mg/dl 120 mg/dl 45 mg/dl 136 mg/dl
85 mg/dl Recommended fasting blood glucose levels in pregnant clients with diabetes are 60 to 95 mg/dl. A fasting blood glucose level of 45 g/dl is low and may result in symptoms of hypoglycemia. A blood glucose level below 120 mg/dl is recommended for 2-hour postprandial values. A blood glucose level above 136 mg/dl in a pregnant client indicates hyperglycemia.
A client is 33 weeks' pregnant and has had diabetes since age 21. When checking her fasting blood glucose level, which value would indicate the client's disease is controlled? 45 mg/dl 120 mg/dl 136 mg/dl 85 mg/dl
85 mg/dl Recommended fasting blood glucose levels in pregnant clients with diabetes are 60 to 95 mg/dl. A fasting blood glucose level of 45 g/dl is low and may result in symptoms of hypoglycemia. A blood glucose level below 120 mg/dl is recommended for 2-hour postprandial values. A blood glucose level above 136 mg/dl in a pregnant client indicates hyperglycemia.
A pregnant client is screened for tuberculosis during her first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. Which sign would indicate a positive test result? An indurated wheal under 10 mm in diameter appears in 6 to 12 hours. A flat, circumscribed area under 10 mm in diameter appears in 6 to 12 hours. An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. A flat circumscribed area over 10 mm in diameter appears in 48 to 72 hours.
An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. A positive PPD result would be an indurated wheal over 10 mm in diameter that appears in 48 to 72 hours. The area must be a raised wheal, not a flat, circumscribed area.
The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? Reduced risk of penile cancer Lower rate of urinary tract infections Anesthetic may not be effective during the procedure Fewer complications than if done later in life
Anesthetic may not be effective during the procedure The anesthetic block is not always effective when used and not all providers will even use anesthetics prior to the procedure, thus the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications than if circumcised later in life are advantages to the procedure.
A nurse is caring for a pregnant client with sickle cell anemia. What should the nursing care for the client include? Select all that apply. Teach the client meticulous handwashing. Assess serum electrolyte levels of the client at each visit. Instruct the client to consume protein-rich food. Urge the client to drink 8 to 10 glasses of fluid daily. Assess hydration status of the client at each visit.
Assess hydration status of the client at each visit. Urge the client to drink 8 to 10 glasses of fluid daily. Teach the client meticulous handwashing. The nurse caring for a pregnant client with sickle cell anemia should teach the client meticulous handwashing to prevent the risk of infection, assess the hydration status of the client at each visit, and urge the client to drink 8 to 10 glasses of fluid daily. The nurse need not assess serum electrolyte levels of the client at each visit or instruct the client to consume protein-rich food.
A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first? Assess the client's vital signs. Obtain a surgical consent from the client. Administer oxygen to the client. Provide emotional support to the client and significant other.
Assess the client's vital signs. A suspected ectopic pregnancy can put the client at risk for hypovolemic shock. The assessment of vital signs should be performed first, followed by any procedures to maintain the ABCs. Providing emotional support would also occur, as would obtaining a surgical consent, if needed, but these are not first steps.
The nurse is caring for a newborn who has a large surface area to body mass ratio. What action will the nurse take to help this newborn regulate temperature? Monitor the newborn's skin for changes related to fluid loss, such as turgor. Assure the newborn has a cap on the head and is kept covered. Maintain accurate intake and output and monitor for dehydration. Educate the parents to rinse the newborn skin well after using soap.
Assure the newborn has a cap on the head and is kept covered. Newborns have a large surface area to body mass ratio and are particularly susceptible to heat loss. The nurse will assure the newborn wears a cap on the head and is kept covered to avoid heat loss. The nurse would monitor intake and output but not related to temperature regulation. The skin of the newborn should be dried well after any liquid is noted (urine, cleansing wipes, etc.) to prevent temperature loss but not specifically because of the large surface area. The newborn's skin needs to be monitored but not specifically for temperature regulation.
The nurse is caring for a pregnant client who indicates that she is fond of meat, works with children, and has a pet cat. Which instructions should the nurse give this client to prevent toxoplasmosis? Select all that apply. Avoid contact with children when they have a cold. Keep the cat outdoors at all times. Avoid cleaning the cat's litter box. Avoid outdoor activities such as gardening. Eat meat cooked to 160° F (71° C).
Avoid outdoor activities such as gardening. Eat meat cooked to 160° F (71° C). Avoid cleaning the cat's litter box. To minimize risk of toxoplasmosis, the nurse should instruct the client to eat meat that has been cooked to an internal temperature of 160° F (71° C) throughout and to avoid cleaning the cat's litter box or performing activities such as gardening. Avoiding children with colds is unreasonable when working with children, and contact with children with colds is not a cause of toxoplasmosis. The cat should be kept indoors to prevent it from hunting and eating birds or rodents.
Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing? Limit the bathing time to 5 minutes. Postpone breastfeeding until after the initial bath. Bathe the baby in water between 90 and 93 degrees. Bathe the baby under a radiant warmer.
Bathe the baby under a radiant warmer. Bathing a newborn under a radiant warmer helps to prevent heat loss. To minimize the effects of cold stress during the bath, the nurse should also prewarm blankets, dry the child completely to prevent heat loss from evaporation, encourage skin-to-skin contact with the mother, promote early breastfeeding, used heated and humidified oxygen, and defer bathing until the newborn is medically stable. Limiting the length of time spent bathing the baby is secondary to maintaining the baby's body temperature. Having warm water is also important but is irrelevant if the baby is not kept warm under a warmer.
A nurse is preparing a nursing care plan for a client who is admitted at 22 weeks' gestation with advanced cervical dilation (dilatation) to 5 cm, cervical insufficiency, and a visible amniotic sac at the cervical opening. Which primary goal should the nurse prioritize at this point? Give birth vaginally Education on causes of cervical insufficiency for the future Bed rest to maintain pregnancy as long as possible Notification of social support for loss of pregnancy
Bed rest to maintain pregnancy as long as possible At 22 weeks' gestation, the fetus is not viable. The woman would be placed on total bed rest with every attempt made to halt any further progression of dilation (dilatation) of the cervix. The nurse would not want this fetus to be born vaginally at this stage of gestation. It is not the nurse's responsibility to notify the client's social support of a possible loss of the pregnancy. It is not appropriate at this time to educate the mother on causes of cervical insufficiency for future pregnancies.
A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition? Caput succedaneum Molding Harlequin sign Increased intracranial pressure
Caput succedaneum Caput succedaneum is swelling of the soft tissue of the scalp caused by pressure of the presenting part on a partially dilated cervix or trauma from a vacuum-assisted delivery. This finding is often of concern for the families. Reassure them that the caput will decrease in a few days without treatment. Increased intracranial pressure would involve the entire scalp and not just a small portion. There would also be other neurologic signs accompanying it. Molding is an elongated head shape caused by overlapping of the cranial bones as the fetus moves through the birth canal. This will also resolve in a few days without treatment. The Harlequin sign is characterized by a clown-suit-like appearance of the newborn where the skin is dark red on one side of the body and the other side is pale. This is a harmless condition which occurs most frequently with vigorous crying or with the infant lying on his or her side.
A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed? Check blood glucose. Place child in a radiant warmer. Assess the baby's temperature. Assess for pain source.
Check blood glucose. One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteriness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level. Cold stress and pain are potential considerations to rule out if hypoglycemia is not the cause; however, jitteriness is not a recognized sign of these.
The nurse is assessing a 35-year-old woman at 22 weeks' gestation who has had recent laboratory work. The nurse notes fasting blood glucose 146 mg/dl (8.10 mmol/L), hemoglobin 13 g/dl (130 g/L), and hematocrit 37% (0.37). Based on these results, which instruction should the nurse prioritize? Check blood sugar levels daily. Include iron-enriched foods in the diet. the signs and symptoms of urinary tract infection Take daily iron supplements.
Check blood sugar levels daily. An elevated blood glucose is concerning for diabetes. A fasting blood glucose level of greater than 140 mg/dl (7.77 mmol/L) or random level of greater than 200 mg/dl (11.10 mmol/L) is concerning; this must be followed up to ensure the client is not developing gestational diabetes. The hemoglobin and hematocrit are within normal limits for this client. The values should be hemoglobin greater than 11 g/dl (110 g/L) and hematocrit greater than 33% (0.33). Values lower than that are possible indications of anemia and would necessitate further evaluation. An individual with higher than normal blood glucose levels is at risk for developing urinary tract infection. This will usually happen after the glucose levels are elevated. Anemia can be treated by increasing the consumption of iron-enriched foods and taking a daily iron supplement.
The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant? Check the name on the baby's identification bracelet. Send a family member to accompany the infant when leaving the room. Provide a list of approved visitors who came spend time with the infant. Check the identification badge of any health care worker before releasing baby from room.
Check the identification badge of any health care worker before releasing baby from room. Infant abduction is a concern, and all personnel should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant. There may not always be a family member around to accompany the infant and they may not be allowed admittance to treatment rooms or other such areas. Checking the name on the baby's identification bracelet will not stop abduction. Providing a list of approved visitors may help prevent abduction from individuals outside the medical facility but will not stop someone posing as an employee from abducting the infant.
The nurse is comforting and listening to a young couple who just suffered a spontaneous abortion (miscarriage). When asked why this happened, which reason should the nurse share as a common cause? Lack of prenatal care The age of the mother Chromosomal abnormality Maternal smoking
Chromosomal abnormality The most common cause for the loss of a fetus in the first trimester is associated with a genetic defect or chromosomal abnormality. There is nothing that can be done and the mother should feel no fault. The nurse needs to encourage the parents to speak with a health care provider for further information and questions related to genetic testing. Early pregnancy loss is not associated with maternal smoking, lack of prenatal care, or the age of the mother
A woman in her 20s has experienced a spontaneous abortion (miscarriage) at 10 weeks' gestation and asks the nurse at the hospital what went wrong. She is concerned that she did something that caused her to lose her baby. The nurse can reassure the woman by explaining that the most common cause of miscarriage in the first trimester is related to which factor? Exposure to chemicals or radiation Advanced maternal age Chromosomal defects in the fetus Faulty implantation
Chromosomal defects in the fetus Fetal factors are the most common cause of early miscarriages, with chromosomal abnormalities in the fetus being the most common reason. This client fits the criteria for early spontaneous abortion (miscarriage) since she was only 10 weeks' pregnant and early miscarriage occurs before 12 weeks.
The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client? Monitor the client's beta-hCG level. Monitor the client's vital signs and bleeding. Monitor the fetal heart rate (FHR). Monitor the mass with transvaginal ultrasound.
Chromosomal defects in the fetus Fetal factors are the most common cause of early miscarriages, with chromosomal abnormalities in the fetus being the most common reason. This client fits the criteria for early spontaneous abortion (miscarriage) since she was only 10 weeks' pregnant and early miscarriage occurs before 12 weeks.
What is priority for the nurse to do when transporting a newborn back to the mother after completing the hearing test? Inform the mother of the results of the hearing test completed on the newborn. Determine if it is time for the mother to breastfeed the newborn and assist as needed. Compare the identification bracelets prior to leaving the newborn with the mother. Explain the procedure completed on the newborn to the mother.
Compare the identification bracelets prior to leaving the newborn with the mother. Accurate infant identification is imperative in hospital protocols. The nurse should always compare the newborn's identification bracelet with that of the mother to ensure that the correct newborn is being given to the correct mother. The nurse will provide the results of the test and assist with breastfeeding; however, these are not priority as the nurse could come back if needed. The nurse should explain a procedure before it is completed
The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide? Birth trauma noted on left upper outer thigh. Mottling noted on left upper outer thigh. Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh. Harlequin sign noted on left upper outer thigh.
Congenital dermal melanocytosis (slate gray nevi) noted on left upper outer thigh. A congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spot) is bluish-black areas of discoloration on the back and buttocks or extremities of dark-skinned newborns. The Harlequin sign refers to the dilation of blood vessels on only one side of the body, giving the newborn the appearance of wearing a clown suit. Mottling occurs when the lips, hands, and feet appear blue from immature peripheral circulation. Birth trauma is a possibility; however, there would be notations of an incident and possibly other injuries would be noted.
The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? Convection Conduction Evaporation Radiation
Convection There are four main ways that a newborn loses heat; convection is one of the four and occurs when cold air blows over the body of the infant resulting in a cooling to the infant. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn. Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. The cold air blowing on the infant's skin will cause heat loss.
The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success? Use of cameras at all doors Cooperation by the parents with the hospital policies Use of monitor attached to babies Use of pass codes onto the unit
Cooperation by the parents with the hospital policies The most essential piece to an effective infant abduction prevention plan is the cooperation of the parents. If the parents are not willing to participate in the unit policy, the unit is at risk. Using pass codes, placing cameras at each door, and using monitors on the infants will all help, but only if the parents are cooperative.
The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth? Heel but no anterior creases Creases covering one fourth of the foot Creases on two-thirds of the foot Longitudinal but no horizontal creases
Creases on two-thirds of the foot As an infant matures in utero, sole creases become prominent to a greater amount. The term infant should have at least two-thirds of the foot covered by creases. These creases should be horizontal and not longitudinal, They should be in the ball of the foot before moving to the heel.
The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client? Injecting 1cc of medication Using a 21-gauge needle Injecting at a 45-degree angle Injecting the medication into the vastus lateralis
Injecting the medication into the vastus lateralis Use of the vastus lateralis is the preferred site for administration of the medication. The nurse would use a 22- to 25-gauge needle and inject 0.5 cc of medication at a 90-degree angle.
A nurse is caring for a young woman who is in her 10th week of gestation. She comes into the clinic reporting vaginal bleeding. Which assessment finding best correlates with a diagnosis of hydatidiform mole? Dark red, "clumpy" vaginal discharge Painful uterine contractions and nausea Bright red, painless vaginal bleeding Brisk deep tendon reflexes and shoulder pain
Dark red, "clumpy" vaginal discharge Women with hydatidiform mole ("molar pregnancy") often pass blood clots or watery brown/dark red discharge from the vagina in the first trimester. If a complete molar pregnancy continues into the second trimester undetected, other signs and symptoms appear. The woman often presents with complaints of dark to bright red vaginal bleeding and pelvic pain. Infrequently, she will report passage of grapelike vesicles.
A woman with cardiac disease at 32 weeks' gestation reports she has been having spells of light-headedness and dizziness every few days. Which instruction should the nurse prioritize? Increase fluids and take more vitamins. Discuss induction of labor with the health care provider. Decrease activity and rest more often. Bed rest and bathroom privileges only until birth.
Decrease activity and rest more often. If the client is developing symptoms associated with her heart condition, the first intervention is to monitor activity levels, decrease activity, and treat the symptoms. At 32 weeks' gestation, the suggestion to induce labor is not appropriate, and without knowledge of the type of heart condition one would not recommend an increase of fluids or vitamins. Total bed rest may be required if the symptoms do not resolve with decreased activity.
The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize? Report tachypnea. Put warming blanket over infant. Document normal findings. Recheck blood pressure in 15 minutes.
Document normal findings. These vital signs are within normal limits and should be documented. The heart rate should be 110 to 160 bpm; RR should be 30 to 60 breaths per minute. The axillary temperature can range from 97.7°F to 99.6°F (36.5°C to 37.5°C). Blood pressure should be 60-80/40-45 mm Hg. There is no need to contact the health care provider, recheck the blood pressure in 15 minutes, or place a blanket on the infant.
A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take? Stimulate the neonate. Inform the charge nurse. Call the primary care provider. Document the data.
Document the data. The nurse should document the findings as this neonate's assessment is within the normal range. The normal respiratory rate is 30 to 60 breaths/min and should be counted for a full minute when the neonate is quiet. A neonate starts with a low blood pressure (60/40 mm Hg) and a high pulse (120 to 160 beats/min). Normal temperature range is between 97.7°F (36.5°C) and 99.5°F (37.5°C).
The nurse is assessing reflexes in a newborn infant. What can the nurse do to elicit the rooting reflex? Turn the head to one side without moving the rest of the body. Place a gloved finger in the newborn's mouth. Gently stroke the newborn's cheek. Startle the newborn by letting the head drop back slightly.
Gently stroke the newborn's cheek. Stroking the newborn's cheek and observing for the newborn to turn toward the touch with the mouth open elicit the rooting reflex. Placing a gloved finger in the newborn's mouth elicits the suck reflex. Startling the newborn elicits the Moro reflex. Turning the newborn's head to one side elicits the tonic neck reflex.
The nurse is appraising the laboratory results of a pregnant client who is in her second trimester and notes the following: thyroid stimulating hormone (TSH) slightly elevated, glucose in the urine, complete blood count (CBC) low normal, and normal electrolytes. The nurse prioritizes further testing to rule out which condition? Anemia Preeclampsia Gestational diabetes Hyperthyroidism
Gestational diabetes Glycosuria, glucose in the urine, may occur normally during pregnancy; however, if it appears in the urine, the client should be sent for testing to rule out gestational diabetes. Preeclampsia, anemia, and hyperthyroidism are not related to glucose nor to renal function. A slightly elevated TSH would indicate possible hypothyroidism instead of hyperthyroidism. Anemia would be indicated by below normal hematocrit. If the client's CBC is low normal than the nurse should monitor future results to ensure the client's counts are not dropping. It would also be appropriate for the nurse to investigate possible dietary issues. Preeclampsia would be best monitored by the blood pressure readings.
The nurse is appraising the laboratory results of a pregnant client who is in her second trimester and notes the following: thyroid stimulating hormone (TSH) slightly elevated, glucose in the urine, complete blood count (CBC) low normal, and normal electrolytes. The nurse prioritizes further testing to rule out which condition? Anemia Hyperthyroidism Gestational diabetes Preeclampsia
Gestational diabetes Glycosuria, glucose in the urine, may occur normally during pregnancy; however, if it appears in the urine, the client should be sent for testing to rule out gestational diabetes. Preeclampsia, anemia, and hyperthyroidism are not related to glucose nor to renal function. A slightly elevated TSH would indicate possible hypothyroidism instead of hyperthyroidism. Anemia would be indicated by below normal hematocrit. If the client's CBC is low normal than the nurse should monitor future results to ensure the client's counts are not dropping. It would also be appropriate for the nurse to investigate possible dietary issues. Preeclampsia would be best monitored by the blood pressure readings.
A client tells that nurse in the doctor's office that her friend developed high blood pressure on her last pregnancy. She is concerned that she will have the same problem. What is the standard of care for preeclampsia? Take a low-dose antihypertensive prophylactically. Take one aspirin every day. Monitor the client for headaches or swelling on the body. Have her blood pressure checked at every prenatal visit.
Have her blood pressure checked at every prenatal visit. Preeclampsia and eclampsia are common problems for pregnant clients and require regular blood pressure monitoring at all prenatal visits. Antihypertensives are not prescribed unless the client is already hypertensive. Monitoring for headaches and swelling is a good predictor of a problem but doesn't address prevention—nor does it predict who will have hypertension. Taking aspirin has shown to reduce the risk in women who have moderate to high risk factors, but has shown no effect on those women with low risk factors.
The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2oF (36.2oC) an hour after birth. Which intervention should the nurse prioritize for this family? Place a second stockinette on the baby's head. Help the mother provide skin-to-skin (kangaroo) care. Administer a warm bath with temperature slightly higher than usual. Place the infant under a radiant warmer.
Help the mother provide skin-to-skin (kangaroo) care. The nurse should encourage bonding to continue. One way to help the infant get warm is to help the parents provide kangaroo care, which involves skin-to-skin contact and parent/baby coverage with blankets. Once the infant is taken for the initial assessment, placement under the radiant heater would then be appropriate. Placing a second stockinette is a potential option; however, it would not be as effective as the skin-to-skin contact. The bath would not be undertaken until the infant's temperature is stabilized within the normal range.
The nurse is explaining to new parents the various vaccinations their newborn will receive before being discharged home. Which immunization should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life? HiB Vitamin K HBV immunoglobin Hep B
Hep B Hep B is the vaccination against hepatitis B and recommended by the CDC. It has been found to help prevent cirrhosis and liver cancer later in life. The HBV immunoglobin may be given in conjunction with the hep B if the mother is found to be HBV positive. The HiB is given later, usually at the 2-month visit. Vitamin K is given soon after birth to reduce the risk of bleeding
A pregnant client with sickle cell anemia is admitted in crisis. Which nursing intervention should the nurse prioritize? antibiotics antihypertensive drugs diuretic drugs IV fluids
IV fluids A sickle cell crisis during pregnancy is usually managed by exchange transfusion, oxygen, and IV fluids. Antihypertensive drugs usually aren't necessary. Diuretics would not be used unless fluid overload resulted. The client would be given antibiotics only if there were evidence of an infection.
A nurse is preparing to administer phytonadione to a newborn. After confirming the order, what will the nurse do next? Determine the newborn's weight. Administer the medication. Identify the newborn. Assess the newborn for bleeding.
Identify the newborn. The nurse will identify the correct newborn before administering phytonadione (vitamin K). The newborn's weight is not needed to calculate the dosage as all newborns receive 0.5 mg IM within one hour of birth. Phytonadione is given to decrease the risk of hemorrhage.
A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem? Notify the doctor to come suture the site of the bleeding. Clean the cord with soap and water, as oozing of blood is a common finding. Remove the clamp and replace with another one just above the old one. Inspect the clamp to insure that it is tightly closed and applied correctly.
Inspect the clamp to insure that it is tightly closed and applied correctly. Cord clamps can become loosened in such cases as a newborn with a large amount of Wharton jelly in the cord when the jelly begins to disintegrate. Also, cord clamps can be defective. The nurse must inspect the cord to determine what the problem is and why the cord is bleeding. Washing the cord does not address the problem and the nurse should not remove the clamp because the bleeding will get worse. However, the doctor does not need to be contacted at this point. The nurse should inspect the clamp, ensuring that it is tight and apply a new clamp closer to the skin level if needed.
The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize? Instill 0.5% ophthalmic tetracycline. Instill 0.5% ophthalmic erythromycin. Watch for signs of eye irritation. Instill 0.5% ophthalmic silver nitrate.
Instill 0.5% ophthalmic erythromycin. The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin ointment or 1% tetracycline eye drops. Although 1% silver nitrate drops were once used, it has been discontinued due to its ineffectiveness. The nurse would not wait to see if the eyes show signs of irritation before administering the medication. Delaying could lead to preventable blindness.
The nurse is assessing a mother who just delivered a 7 lb (3136 g) baby via cesarean delivery. Which assessment finding should the nurse prioritize if the mother has a history of controlled atrial fibrillation? Jugular distention Nausea and vomiting Abdominal cramps Urinary retention
Jugular distention A woman who has a cardiac condition is at increased risk in the postpartum period. The most important nursing action is to monitor for signs of cardiac decompensation. The nurse should monitor for and report jugular distention, clubbing, and slow capillary refill time. If an irregular pulse is noted, compare it to the apical pulse. The abdominal cramps may be related to the uterus involution. The nausea and vomiting and urinary retention may be related to the surgical procedure and not necessarily the cardiac issue.
The ability of the nurse to identify irregular findings during a physical assessment aids in rapid diagnosis and treatment of possible complications. The nurse assesses a newborn and notes tachycardia. The nurse notifies the health care provider based on the understanding that further assessment is necessary for which condition? drug withdrawal hypothermia anemia infection
drug withdrawal Tachycardia may be found with volume depletion, cardiorespiratory disease, drug withdrawal, and hyperthyroidism.
A nurse is teaching a new mother about her neonate and the changes that are occurring as the neonate adapts to life outside the client's uterus. The nurse would incorporate understanding of which change when describing the neonate's current status? Select all that apply. The respiratory system is now fluid filled and under high pressure. The neonate's body temperature is maintained by the extrauterine environment. Right atrial pressure is greater than the left leading to closure of the foramen ovale. Lungs are now responsible for the exchange of oxygen and carbon dioxide. The liver begins functioning as the ductus venosus closes.
Lungs are now responsible for the exchange of oxygen and carbon dioxide. The liver begins functioning as the ductus venosus closes. With the neonate, the lungs are now responsible for gas exchange, and the respiratory system is an air-filled, low-pressure system. Hepatic portal circulation begins with closure of the ductus venosus. The neonate's body temperature is maintained through a flexed posture and brown fat
The nurse is caring for a pregnant client with fallopian tube rupture. Which intervention is the priority for this client? Monitor the mass with transvaginal ultrasound. Monitor the fetal heart rate (FHR). Monitor the client's beta-hCG level. Monitor the client's vital signs and bleeding.
Monitor the client's vital signs and bleeding. A nurse should closely monitor the client's vital signs and bleeding (peritoneal or vaginal) to identify hypovolemic shock that may occur with tubal rupture. Beta-hCG level is monitored to diagnose an ectopic pregnancy or impending spontaneous abortion (miscarriage). Monitoring the mass with transvaginal ultrasound and determining the size of the mass are done for diagnosing an ectopic pregnancy. Monitoring the FHR does not help to identify hypovolemic shock
The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. The outside temperature is 55°F (12.8°C). Which action should the nurse prioritize? Check the infant's vital signs. Place another blanket on the infant. Move the infant away from the window. Observe infant's status.
Move the infant away from the window. The nurse should move the infant away from the window to prevent heat loss via radiation. When the nurse moves the newborn away from a cold window, it prevents heat loss from a cold object near the newborn, which is an example of radiation. The other options of placing another blanket, checking vital signs, and observing the infant's status would be accomplish if indicated; however, the priority is to relocate the infant first to a warmer area of the room.
A client is worried that her newborn's stools are greenish, with an unpleasant odor. The newborn is being formula-fed. What instruction should the nurse give this client? Switch to feeding breast milk. No action is need; this is normal. Change to a soy-based formula. Increase the newborn's fluid intake.
No action is need; this is normal. The nurse should tell the client not to worry because it is perfectly normal for the stools of a formula-fed newborn to be greenish, loose, pasty, or formed in consistency, with an unpleasant odor. There is no need to change the formula, increase the newborn's fluid intake, or switch from formula to breast milk.
A new young mother has tested positive for HIV. When discussing the situation with the client, the nurse should advise the mother that she should avoid which activity? breastfeeding handling the infant with open sores future pregnancies cesarean birth
breastfeeding Breastfeeding is a major contributing factor for mother-to-child transmission of HIV. Cesarean birth before the onset of labor and/or rupture of membranes can greatly reduce the chance of transmitting the infection to the infant. Future pregnancies should be discussed and decided on an individual basis. Proper treatment of any open wounds and education should be provided to the mother to ensure she reduces the chance of transmitting HIV to her infant.
A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next? Measure fundal height. Palpate the fundus and check fetal heart rate. Obtain a voided urine specimen and determine blood type. Check deep tendon reflexes.
Palpate the fundus and check fetal heart rate. The classic signs of placental abruption (abruptio placentae) are pain, dark red vaginal bleeding, a rigid, board-like abdomen, hypertonic labor, and fetal distress.
What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia? Start an IV to provide intravenous glucose. Perform a heel stick to obtain a blood sample for testing for glucose level. Feed the newborn some formula immediately. Check the client's blood sugar by a venous blood draw.
Perform a heel stick to obtain a blood sample for testing for glucose level. If a newborn is noted to be jittery or exhibiting symptoms of hypoglycemia, the nurse should first do a heel stick to check the client's glucose level. After the glucose level is determined, then the nurse will determine what interventions to implement. A venous blood draw is not needed to check the newborn's glucose level.
Within three days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest, is lethargic, and has to be awoken to feed. Which condition does the nurse suspect this infant is manifesting? Breastfeeding jaundice. Pathologic jaundice. Bile duct blockage. Physiologic jaundice.
Physiologic jaundice. Physiologic jaundice occurs 48 hours or more after birth. Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Breastfeeding jaundice occurs later within the first week of life. Evidence of bile duct blockage would be more severe and noted at an earlier age.
After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between placental abruption (abruptio placentae) and placenta previa. Which statement will the nurse include in the teaching? Placenta previa causes painful, dark red vaginal bleeding during pregnancy. Placenta previa is an abnormally implanted placenta that is too close to the cervix. Placental abruption results in painless, bright red vaginal bleeding during labor. Placental abruption requires "watchful waiting" during labor and birth.
Placenta previa is an abnormally implanted placenta that is too close to the cervix. Placenta previa is a condition of pregnancy in which the placenta is implanted abnormally in the lower part of the uterus and is the most common cause of painless, bright red bleeding in the third trimester. Placental abruption is the premature separation of a normally implanted placenta that pulls away from the wall of the uterus either during pregnancy or before the end of labor. Placental abruption can result in concealed or apparent dark red bleeding and is painful. Immediate intervention is required for placental abruption.
A pregnant client with type I diabetes asks the nurse about how to best control her blood sugar while she is pregnant. The best reply would be for the woman to: check her blood sugars frequently and adjust insulin accordingly. limit weight gain to 15 pounds during the pregnancy. begin oral hyperglycemic medications along with the insulin she is currently taking. exercise for 1 to 2 hours each day to keep the blood glucose down.
check her blood sugars frequently and adjust insulin accordingly. The goal for a mother who has type I diabetes mellitus is to keep tight control over her blood sugars throughout the pregnancy. Therefore, she needs to test her blood sugar frequently during the day and make adjustments in the insulin doses she is receiving.
The maternal health nurse is caring for a group of high-risk pregnant clients. Which client condition will the nurse identify as being the highest risk for pregnancy? Loud systolic murmur Secondary hypertension Pulmonary hypertension Repaired atrial septal defect
Pulmonary hypertension Pulmonary hypertension is considered the greatest risk to a pregnancy because of the hypoxia that is associated with the condition. The remaining conditions represent potential cardiac complications that may increase the client's risk in pregnancy; however, these do not present the greatest risk in pregnancy.
The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take? Report the finding to the pediatrician. Since it looks like a milk curd, no action is needed. Rinse the tongue off with sterile water and a cotton swab. Wipe the tongue off vigorously to remove the white patches.
Report the finding to the pediatrician. Although the finding looks like a milk curd, if the white patch remains after feeding, the pediatrician needs to be notified. The likely cause of the white patch on the tongue is a fungal infection called Candida albicans, which the newborn probably contracted while passing through the birth canal. The nurse should not try to remove the patche
The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. Identification bands Glucose water Suction equipment Ophthalmoscope Warmer bed
Suction equipment Identification bands Warmer bed In preparing the delivery room, the nurse should preheat a warmer bed, have suction equipment at bedside, and have the identification bands ready for both the mother and newborn. Glucose water and an ophthalmoscope are not needed immediately after delivery to stabilize the newborn.
A 29-year-old client has gestational diabetes. The nurse is teaching her about managing her glucose levels. Which therapy would be most appropriate for this client? glucagon diet long-acting insulin oral hypoglycemic drugs
diet Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Long-acting insulin usually is not needed for blood glucose control in the client with gestational diabetes. Oral hypoglycemic drugs are usually not given during pregnancy and would not be the first option. Glucagon raises blood glucose and is used to treat hypoglycemic reactions.
Which statement is true regarding fetal and newborn senses? The rooting reflex is an example that the newborn has a sense of touch. A newborn cannot see until several hours after birth. A newborn cannot experience pain. A fetus is unable to hear in utero. A newborn does not have the ability to discriminate between tastes.
The rooting reflex is an example that the newborn has a sense of touch. The rooting reflex is an example of a newborn's sense of touch. Newborns experience pain, have vision, and can discriminate between tastes. The fetus can hear in utero.
The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski sign. Which response would the nurse interpret as normal for the newborn? Toes fan out when sole of foot is stroked. Newborn's toes curl over the nurse's finger. Newborn throws arms outward and flexes knees. Newborn makes stepping motion.
Toes fan out when sole of foot is stroked. The Babinski sign is elicited by stroking the lateral sole of the newborn's foot from the heel toward and across the ball of the foot. The toes should fan out. The Moro reflex occurs when the infant is startled and will respond by throwing the arms outward and flexing the knees. The stepping reflex should elicit a stepping motion or walking when held upright. The plantar grasp will occur when a finger is placed just below the newborn's toes and the toes typically curl over the finger
The clinic nurse teaches a client with pregestational type 1 diabetes that maintaining a constant insulin level is very important during pregnancy. The nurse tells the client that the best way to maintain a constant insulin level is to use: regular insulin twice a day. an insulin drip. an insulin pump. an insulin pen.
an insulin pump. Because a pregnant client will have some periods of relative hyperglycemia and hypoglycemia no matter how carefully the client maintains diet and balances exercise levels, an effective method to keep serum glucose levels constant is to administer insulin with a continuous pump during pregnancy.
A nurse is teaching a 30-year-old gravida 1 who has sickle cell anemia. Providing education on which topic is the highest nursing priority? avoidance of infection consumption of a low-fat diet constipation prevention administration of immunoglobulins
avoidance of infection Prevention of crises, if possible, is the focus of treatment for the pregnant woman with sickle cell anemia. Maintaining adequate hydration, avoiding infection, getting adequate rest, and eating a balanced diet are all common-sense strategies that decrease the risk of a crisis. Fat intake does not need to be decreased and immunoglobulins are not normally administered. Constipation is not usually a result of sickle cell anemia.
The nursing instructor is conducting a class explaining the various causes of jaundice in a newborn infant. The instructor determines additional education is warranted after the class chooses which factor as being responsible for newborn jaundice? decreased bilirubin conversion bilirubin hyperexcretion bilirubin overproduction impaired bilirubin excretion
bilirubin hyperexcretion Overexcretion of bilirubin would not cause jaundice. Bilirubin overproduction, decreased bilirubin conjugation or conversion, and impaired bilirubin excretion would cause hyperbilirubinemia, which leads to jaundice.
The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period? heart rate temperature blood sugar Apgar score
blood sugar Most facilities have protocols to guide nursing care in the treatment of hypoglycemia. Many pediatricians have preprinted orders that can be initiated if the glucose level falls below a predetermined level (usually 40-50 mg/dl).
A pregnant woman is diagnosed with placental abruption (abruptio placentae). When reviewing the woman's physical assessment in her medical record, which finding would the nurse expect? gradual onset of symptoms firm, rigid uterus on palpation absence of pain fetal heart rate within normal range
firm, rigid uterus on palpation The uterus is firm-to-rigid to the touch with abruptio placentae. It is soft and relaxed with placenta previa. Bleeding associated with abruptio placentae occurs suddenly and is usually dark in color. Bleeding also may not be visible. A gradual onset of symptoms is associated with placenta previa. Fetal distress or absent fetal heart rate may be noted with abruptio placentae. The woman with abruptio placentae usually experiences constant uterine tenderness on palpation.
While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as: harlequin sign. erythema toxic. congenital dermal melanocytosis (slate gray nevi). stork bites.
harlequin sign. Harlequin sign refers to the dilation of blood vessels on only one side of the body. It gives a distinct midline demarcation, which is pale on one side and red on the opposite. Stork bites are superficial vascular areas found on the nape of the neck, eyelids, between the eyes and upper lip. Congenital dermal melanocytosis (slate gray nevi, previously known as Mongolian spots) are blue or purple splotches that appear on the lower back and buttocks. Erythema toxicum is a benign, idiopathic, generalized, transient rash that resembles flea bites.
A 25-year-old client at 22 weeks' gestation is noted to have proteinuria and dependent edema on her routine prenatal visit. Which additional assessment should the nurse prioritize and convey to the RN or health care provider? initial BP 140/85 mm Hg; current BP 130/80 mm Hg initial BP 100/70 mm Hg; current BP 140/90 mm Hg initial BP 110/60 mm Hg; current BP 112/86 mm Hg initial BP 120/80mm Hg; current BP 130/88 mm Hg
initial BP 100/70 mm Hg; current BP 140/90 mm Hg A proteinuria of trace to 1+ and a rise in blood pressure to above 140/90 mm Hg is a concern the client may be developing preeclampsia. The blood pressures noted in the other options are not indicative of developing preeclampsia. The edema would not necessarily be indicative of preeclampsia; however, edema of the face and hands would be a concerning sign for severe preeclampsia.
The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea of the newborn. The nurse explains that this is due to which occurrence? prolonged unsuccessful vaginal birth loss of blood volume due to hemorrhage lack of thoracic compressions during birth Inadequate suctioning of the mouth and nose of the newborn
lack of thoracic compressions during birth A baby born by cesarean birth does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal birth. This may result in the fluid in the lungs being removed too slowly or incompletely. Research findings support the need for thoracic compression to assist with the removal of the fluid and facilitate adequate breathing in the newborn.
Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy? ondansetron promethazine methotrexate oxytocin
methotrexate Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.
Which medication will the nurse anticipate the health care provider will prescribe as treatment for an unruptured ectopic pregnancy? oxytocin ondansetron promethazine methotrexate
methotrexate Methotrexate, a folic acid antagonist that inhibits cell division in the developing embryo, is most commonly used to treat ectopic pregnancy. Oxytocin is used to stimulate uterine contractions and would be inappropriate for use with an ectopic pregnancy. Promethazine and ondansetron are antiemetics that may be used to treat hyperemesis gravidarum.
A pregnant client diagnosed with hyperemesis gravidarum is prescribed intravenous fluids for rehydration. When preparing to administer this therapy, which solution would the nurse anticipate being prescribed initially? albumin normal saline 0.45% sodium chloride dextrose 5% and water
normal saline For the client with hyperemesis gravidarum, parenteral fluids and drugs are prescribed to rehydrate the client and reduce the symptoms. The first choice for fluid replacement is generally isotonic, such as normal saline, which aids in preventing hyponatremia, with vitamins (pyridoxine, or vitamin B6) and electrolytes added. Dextrose 5% and water and 0.45% sodium chloride are hypotonic solutions that would cause the cells to swell and possibly burst. Albumin could lead to fluid overload.
A woman with an artificial mitral valve develops heart failure at the 20th week of pregnancy. Which measure would the nurse stress with her during the remainder of the pregnancy? beginning a low-impact aerobics program obtaining enough rest maintaining a high fluid intake discontinuing her prepregnancy anticoagulant
obtaining enough rest As the blood volume doubles during pregnancy, heart failure can occur. The pregnant woman needs to obtain adequate rest to prevent overworking the heart. Fluid may need to be restricted.
A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level? after the newborn has received the initial feeding on admission to the nursery 24 hours after admission to the nursery 4 hours after admission to the nursery
on admission to the nursery Typically, a newborn's blood glucose levels are assessed with use of a heel stick sample of blood on admission to the nursery, not 4 or 24 hours after admission to the nursery. It is also not necessary or even reasonable to check the glucose level only after the newborn has been fed.
The nurse explains to a pregnant client that she will need to take iron during her pregnancy after being diagnosed with iron-deficiency anemia. The nurse suggests that absorption of the supplemental iron can be increased by taking it with which substance? orange juice legumes meals high in iron milk
orange juice Anemia is a condition in which the blood is deficient in red blood cells, from an underlying cause. The woman needs to take iron to manufacture enough red blood cells. Taking an iron supplement will help improve her iron levels, and taking iron with foods containing ascorbic acid, such as orange juice, improves the absorption of iron.
A nurse is observing the interaction between a new mother and the neonate. The nurse notes that the neonate moves the head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response? habituation self-quieting behavior motor maturity orientation
orientation The neonate is demonstrating orientation, the neonate's ability to respond to auditory and visual stimuli, as demonstrated by the movement of head and eyes to focus on that stimuli. Habituation is the ability to block out external stimuli after the newborn has become accustomed to the activity. Motor maturity depends on gestational age and involves evaluation of posture, tone, coordination, and movements. These activities enable newborns to control and coordinate movement. When stimulated, newborns with good motor organization demonstrate movements that are rhythmic and spontaneous. Self-quieting ability (also called self-soothing) refers to newborns' ability to quiet and comfort themselves.
A 24-year-old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out? prevent maternal D antibody formation. prevent fetal Rh blood formation. stimulate maternal D immune antigens. promote maternal D antibody formation.
prevent maternal D antibody formation. Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus. The administration of Rho(D) immune globulin does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? nonshivering thermogenesis sweating and peripheral vasoconstriction radiation, convection, and conduction lack of brown adipose tissue
radiation, convection, and conduction Heat loss in the newborn occurs primarily through radiation, convection, and conduction because of the newborn's large ratio of body surface to weight and because of the marked difference between core and skin temperatures. Nonshivering thermogenesis is a mechanism of heat production in the newborn. Lack of brown adipose tissue contributes to heat loss, particularly in premature infants, but it is not the predominant form of heat loss. Peripheral vasoconstriction is a method to increase heat production.
A nurse is assessing a newborn with the parents present. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function? orientation to surroundings voluntary movements reflex crying response
reflex The presence and strength of a reflex is an important indication of neurologic development and function. It is built into the nervous system and does not need the intervention of conscious thought to take effect. These reflexes end at different levels of the spine and brain stem, reflecting the function of the cranial nerves and motor system.
A client at 37 weeks' gestation presents to the emergency department with a BP 150/108 mm Hg, 1+ pedal edema, 1+ proteinuria, and normal deep tendon reflexes. Which assessment should the nurse prioritize as the client is administered magnesium sulfate IV? respiratory rate ability to sleep urine protein hemoglobin
respiratory rate A therapeutic level of magnesium is 4 to 8 mg/dl (1.65 to 3.29 mmol/L). If magnesium toxicity occurs, one sign in the client will be a decrease in the respiratory rate and a potential respiratory arrest. Respiratory rate will be monitored when on this medication. The client's hemoglobin and ability to sleep are not factors for ongoing assessments for the client on magnesium sulfate. Urinary output is measured hourly on the preeclamptic client receiving magnesium sulfate, but urine protein is not an ongoing assessment.
A nursing student observing newborns in the nursery is amazed that a crying infant put her fingers in her mouth, instantly stops crying, and then falls asleep. This behavior can best be explained as: social behavior. motor maturity. the sleep state. self-quieting ability.
self-quieting ability. Self-quieting ability refers to newborns' ability to quiet and comfort themselves. Assisting parents to identify consoling behaviors also helps. The sleep state is noted as an infant becoming drowsy and less attentive to the parents and his surroundings. Social behaviors are things such as cuddling and snuggling into the arms of the parents when the newborn is held. Motor maturity refers to posture, tone, coordination, and movements of the newborn.
A 44-year-old client has lost several pregnancies over the last 10 years. For the past 3 months, she has had fatigue, nausea, and vomiting. She visits the clinic and takes a pregnancy test; the results are positive. Physical examination confirms a uterus enlarged to 13 weeks' gestation; fetal heart tones are heard. Ultrasound reveals that the client is experiencing some bleeding. Considering the client's prenatal history and age, what does the nurse recognize as the greatest risk for the client at this time? hypertension premature birth spontaneous abortion (miscarriage) preterm labor
spontaneous abortion (miscarriage) The client's advanced maternal age (pregnancy in a woman 35 years or older) increases her risk for spontaneous abortion (miscarriage). Hypertension, preterm labor, and prematurity are risks as this pregnancy continues. Her greatest risk at 13 weeks' gestation is losing this pregnancy.
A pregnant woman has arrived to the office reporting vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable spontaneous abortion (miscarriage)? no passage of fetal tissue slight vaginal bleeding closed cervical os strong abdominal cramping
strong abdominal cramping Strong abdominal cramping is associated with an inevitable spontaneous abortion (miscarriage). Slight vaginal bleeding early in pregnancy and a closed cervical os are associated with a threatened abortion. With an inevitable abortion, passage of the products of conception may occur. No fetal tissue is passed with a threatened abortion
A nurse is performing an assessment on a new client. The woman estimates that she is approximately 16 weeks pregnant. While assessing her, the nurse asks her about apparent scratch marks on her hands, and she tells the nurse that she has three cats at home. What screening would be prescribed for this woman? herpes simplex virus hepatitis C toxoplasmosis cytomegalovirus
toxoplasmosis Toxoplasmosis is an infection caused by the protozoan Toxoplasma gondii, also referred to as T. gondii. Transmission is via undercooked meat and through cat feces. Toxoplasmosis is a common infection in humans and usually produces no symptoms. However, when the infection passes from the woman through the placenta to the fetus, a condition called congenital toxoplasmosis can occur. Approximately 400 to 4,000 cases of congenital toxoplasmosis occur per year in the United States (Williams, 2007). The classic triad of symptoms for congenital toxoplasmosis is chorioretinitis, intracranial calcification, and hydrocephalus in the newborn.
Which factor would contribute to a high-risk pregnancy? history of allergy to honey bee pollen first pregnancy at age 33 type 1 diabetes blood type O positive
type 1 diabetes A woman with a history of diabetes has an increased risk for perinatal complications, including hypertension, preeclampsia, and neonatal hypoglycemia. The age of 33 without other risk factors does not increase risk, nor does type O-positive blood or environmental allergens.
The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding? greenish black with a tarry consistency tan in color with a firm consistency yellowy mustard color with seedy appearance brownish black with a mucus-like appearance
yellowy mustard color with seedy appearance The evolution of a stool pattern begins with a newborn's first stool, which is meconium. Meconium is composed of amniotic fluid, shed mucosal cells, intestinal secretions, and blood. It is greenish black, has a tarry consistency, and is usually passed within 12 to 24 hours of birth. The first meconium stool passed is semi-sterile, but this changes rapidly with ingestion of bacteria through feedings. After feedings are initiated, a transitional stool develops, which is greenish brown to yellowish brown, thinner in consistency, and seedy in appearance. If breastfed, the stools will resemble light mustard with seed-like particles. If formula-fed, the stools will be tan or yellow in color and firmer. The neonate's stool should not appear brownish-black and mucous-like.