chapters 33-35

the nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breastfeeding her newborn. which client statement would indicate a need for further teaching?

I should wash my nipples daily with soap and water

the nurse instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. which student statement indicates that further teaching is needed?

I will flush the eyes after instilling the ointment

the nurse notes hypotonia, irritability, and a poor sucking reflex in a full term newborn on admission to the nursery. the nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome?

abnormal palmar creases

a client in a postpartum unit complains of sudden sharp chest pain and dyspnea. the nurse notes that the client is tachycardic and the respiratory rate is elevated. the nurse suspects a pulmonary embolism. which should be the initial nursing action?

administer oxygen, 8 to 10 L/min by face mask

Rho (D) immune globulin (RhoGAM) is prescribed for a client after delivery and the nurse provides information to he client about the purpose of the medication. the nurse determines that the woman understands the purpose if the woman stats that it will protect her baby from which condition?

being affect by RH incompatibility

a client in preterm labor (31 weeks) who is dilated 4 cm has been started on magnesium sulfate and contractions have stopped. if the client's labor can be inhibited for the next 48 hours the nurse anticipates a prescription for which medication?

betamethasone (celestone)

methylergonovine (methergine) is prescribed for a woman to treat postpartum hemorrhage. before administration of methylergonovine,what is the priority nursing assessment?

blood pressure

the nurse is preparing to care for a newborn receiving phototherapy. which interventions should be included in the plan of care?

monitor skin temperature closely reposition the newborn every 2 hours cover the newborn's eyes with eye shields or patches

the nurse is preparing a plan for a newborn with fetal alcohol syndrome. the nurse should include which priority intervention in the plan of care?

monitor the newborn's response to feedings and weight gain pattern

the nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. the nurse should monitor for which adverse effects of this medication?

flushing depressed respirations extreme muscle weakness

an opioid analgesic I administered to a client in labor. the nurse assigned to care for the client ensures that which mediation is readily available if respiratory depression occurs?

naloxone

which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction?

I will ask the nurse tatted to my infant if I am napping and my husband is not here

a pregnant client is receiving magnesium sulfate for management o preeclampsia. the nurse determines that the client is experiencing toxicity from the medication if which finding is noted on assessment?

respirations of 10 breaths a min

the nurse is assessing a newborn who was born to a mother who is addicted to drugs. which assessment finding would the nurse expect to note during the assessment of this newborn?

Constant crying

the nurse is preparing to care for four assigned clients. which client is at highest risk for hemorrhage?

a multiparous client who delivered a large baby after oxytocin (Pitocin) induction

the nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. which sign if noted would be an early sign of excessive blood loss?

an increase in the pulse rate from 88-102 beats/min

the mother of a newborn calls the clinic and reports that when cleaning the umbilical cord she noticed that the cord was moist and that discharge was present. what is the most appropriate nursing instruction for this mother?

bring the infant to the clinic

the nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of vulvar hematoma. which assessment finding would best indicate the presence of a hematoma?

changes in vital signs

the nurse in a neonatal intensive care nursery receives a telephone call to prepare for the admission of a 43 week gestation newborn with apgar scores of 1 and 4, in planning for admission of this newborn, what is the nurse's highest priority?

connect the resuscitation bag to the oxygen outlet

the postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. the nurse should provide which most appropriate instruction to the mother?

continue to breastfeed every 2 to 4 hours

the nurse is assessing a newborn after circumcision ad notes that the circumcised area is red with a small amount of bloody drainage. which nursing action is most appropriate?

document findings

Chapter 34 the nurse assisted with the delivery of a newborn. which nursing action is most effective in preventing heat loss by evaporation?

drying the infant with a warm blanket

a postpartum client is diagnosed with cystitis, the nurse should plan for which priority nursing action in the care of the client?

encouraging fluid intake

the postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. which sign would the nurse note if superficial venous thrombosis were present?

enlarged, hardened veins

the nurse is preparing to administer beractant (survanta) to a premature infant who has respiratory distress syndrome, the nurse plans to administer the medication by which route?

intratracheal

the nurse is planning care for a newborn of a mother with diabetes mellitus. what is the priority nursing consideration for this newborn?

maintaining safely because of low blood glucose levels

the nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. the nurse should include which intervention in the plan of care?

maintaining standard precautions at all times while caring for the newborn

on assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. the nurse should take which initial action?

massage fundus until it is firm

the nurse prepares to administer vitamin K injection to a newborn and the mother asks the nurse why her infant needs the injection, what best response should the nurse provide?

newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding

the nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. which should be the initial nursing action?

notify the health care provider

methylergonovine (methergine) is prescribed for a client with postpartum hemorrhage, before administering the medication, the nurse contacts the health care provider who prescribed the medication if which condition is documented in the clients medical history?

peripheral vascular disease

the nurse is developing a plan of care for a postpartum client with small vulvar hematoma. the nurse should include which specific action during the first 12 hours after delivery?

prepare an ice pack for application to the area

the nurse administers erythromycin ointment 0.5% to the eyes of a newborn and the mother asks the nurse why this is performed, which explanation is best for the nurse to provide about neonatal eye prophylaxis?

prevents an infection called ophthalmia neonatorum from occurring after delivery in newborn born to a woman with an untreated gonococcal infection

the nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. which assessment findings would alert the nurse to possibility of this syndrome?

tachypnea and retractions

Chapter 35 the nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. which assessment finding would cause the nurse to immediately discontinue the oxytocin infusion?

uterine hyper-stimulation

The nurse is preparing a list of self care instructions for a postpartum client who was diagnosed with mastitis. which instructions would be included in her list?

wear a supportive bra rest during the acute phase maintain fluid intake of at least 3000mL continue to breastfeed if the breast are not too sore