Custom: Simulation Day

A nurse is preparing an in-servie about St. john's wort. Which of the following information should the nurse include in the teaching?

"St. John's wort can cause photophobia." The nurse should teach the client that St. John's wort may cause photophobia; therefore, the client should wear protective clothing, sun screen, and sun-glasses when outside.

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

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

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

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

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

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

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in". Which of the following repsonses should the nurse make?

In 3 to 5 days By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milk.

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider?

Urinary output 40 mL in 2 hr Urinary output is critical for the excretion of magnesium from the body. The nurse should report an hourly output below 30 mL/hr to the provider immediately and discontinue the medication.

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?

"Baby powder will help prevent a diaper rash." Lotions, creams, oils, or powders can alter a newborn's skin and provide a medium for bacterial growth or cause an allergic response. Powders can be inhaled, leading to respiratory distress. This statement requires the nurse to clarify instruction on newborn care.

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

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

A nurse in a prenatal clinic is caring for a cleint who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will cintinue until delivery. Which of the following responses should the nurse make?

"It occurs during the first trimester and near the end of the pregnancy." Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the end of the pregnancy as the enlarging uterus places pressure on the bladder.

A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include?

"Position the newborn at a 45-degree angle in the car seat." The nurse should instruct the parent to place the newborn at a 45° angle to prevent the newborn's head from falling forward and obstructing the airway.

A nurse is teaching a client about black cohosh. Which of the following information should the nurse include in the teaching?

-"Black cohosh should not be taken during pregnancy." Black cohosh has estrogenic properties and should not be taken during pregnancy.

A nurse is caring for a newborn who is 72 hr old. The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.

-Administer oral morphine -Swaddle the newborn -Continue NAS scoring as prescribed

A nuurse is instructing a women who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching?

-Consume foods fortified with folic acid. Increased consumption of folic acid in the 3 months prior to conception, as well as throughout the pregnancy, reduces the incidence of neural tube defects in the developing fetus.

A nurse is caring for a newborn who is 8 hr old. Diagnostic Results 0900: ABO/Rh: A positive Coombs test, indirect: positive (negative) Total bilirubin 6.2 mg/dL (1.0 to 12.0 mg/dL) Urine toxicology screen: positive for cocaine and marijuana (negative) Medical History Spontaneous vaginal birth Pregnancy complicated by maternal history of illicit drug use Apgar scores: 7 at 1 min; 8 at 5 min Birth weight 2,948 gm (6 lb 8 oz) Gestational age: 38 weeks Maternal prenatal laboratory results: ABO/Rh: O positive Urine toxicology screen: positive for cocaine and marijuana (negative) Nurses Notes 0800: Newborn is alert and active with a strong cry. Skin color is consistent with the newborn's genetic background. Respirations are easy and unlabored. Anterior fontanel even and soft. Molding of skull noted. Generalized edematous area noted on occiput. Newborn is breastfeeding vigorously every 2 to 4 hr. No void or stool noted since birth. Vital Signs 0800 : Axillary temperature 37.1° C (98.8° F) Heart rate 132/min Respiratory rate 52/min Based on the information in the newborn's medical record, the nurse determines that the newborn is at risk for developing which of the following complications? Complete the following sentence by using the list of options. The nurse should recognize the newborn is at risk for developing _________________ (Selet one) [Jaundice, subgaleal hemorrhage, hypoglycemia] and _____________ (Select one) [anemia, von willebrand disease, neonatal abstinence syndrome].

-Jaundice -Anemia Dropdown 1 Hypoglycemia is incorrect. The newborn has no risk factors for developing hypoglycemia. Risk factors for hypoglycemia include hypothermia, preterm gestation, maternal diabetes, low birth weight, small for gestational age, large for gestational age, and the presence of respiratory distress. Additionally, the newborn is breastfeeding every 2 to 4 hr, which is within the expected range. Jaundice is correct. A positive Coombs test indicates the presence of anti-A and anti-B maternal antibodies within the newborn's blood. These antibodies will result in an accelerated destruction of the newborn's type A blood cells. The by-product of red blood cell hemolysis is bilirubin. The accelerated breakdown of the red blood cells can lead to excess bilirubin accumulating within the newborn's skin, mucus membranes, and sclera, resulting in a yellow discoloration known as jaundice. The nurse should continue to monitor the newborn's bilirubin levels. Subgaleal hemorrhage is incorrect. The newborn has no risk factors or manifestations of a subgaleal hemorrhage. A subgaleal hemorrhage can occur due to the shearing forces associated with a vacuum extraction or forceps-assisted delivery. The trauma to the scalp can result in bleeding within the subgaleal space. Manifestations include a boggy scalp, increasing head circumference, and signs of blood loss, such as tachycardia and pallor. Dropdown 2 Anemia is correct. A positive Coombs test indicates the presence of anti-A and anti-B maternal antibodies within the newborn's blood. These antibodies will cause an accelerated destruction of the newborn's type A blood cells. The accelerated hemolysis can result in anemia. Neonatal abstinence syndrome is incorrect. While the newborn's toxicology screen did demonstrate the presence of cocaine and marijuana, neither of those substances cause neonatal abstinence syndrome. Newborns who have been exposed to opioids while in utero are at risk for demonstrating manifestations of opioid withdrawal after birth. Opioids include heroin, morphine, methadone, meperidine, and oxycodone. Von Willebrand disease is incorrect. This condition is a form of hemophilia, which results in prolonged bleeding related to a deficiency of one of the clotting factors. The most common manifestation of this disorder is increased bleeding from the mucus membranes. There is no information in the newborn's medical record or assessment that indicates the newborn is at risk for developing this condition.

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take?

-Observe for crowning. In the descent phase of the second stage of labor, crowning occurs when the fetal head is at +2 to +4 station. Because this is the client's third childbirth experience, it is reasonable to assume that delivery is imminent.

A nurse is assessing a newborn who has Trisomy 21 (Down Syndrome). Which of the following are common characteristics? (SATA)

-Transverse -Protruding tongue *A common characteristic of newborns who have Trisomy 21 is transverse palmar creases. *A common characteristic of newborns who have Trisomy 21 is protruding tongue.

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

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

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the providers orders. Which of the following orders requires clarification?

Ambulate twice daily. A provider's order to allow the client to ambulate requires clarification. The client who has severe preeclampsia should be placed on bedrest in a quiet, nonstimulating environment to prevent seizures and promote optimal placental blood flow.

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

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

A nurse midwife is examining a client who is primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirms to the nurse that the client is in labor?

Cervical dilation Cervical dilation and effacement are indications of true labor.

A nurse is caring for a client who is breastfeeding and states that her nipples are sore. Which of the following intervention should the nurse suggest?

Change the newborn's position on the nipples with each feeding. When the client's nipple is sore due to breastfeeding, the client should break the suction with her finger, remove the newborn from the breast, and try a different position. The newborn's mouth should be open wide before connecting with the nipple.

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

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

A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate?

Daily jogging for up to 30 minutes is fine throughout the pregnancy." While weight-bearing exercises might become uncomfortable in the last trimester, they are generally not contraindicated, providing the client stays hydrated and avoids becoming overheated for extended periods.

A nurse is planning care for a newborn who is small for festational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

Monitor blood glucose levels. Decreased stores of glycogen and a lower rate of gluconeogenesis place newborns who are SGA at higher risk for hypoglycemia. Monitoring of blood glucose levels is a priority intervention.

A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn's chest circumference?

Nipple line The nurse should measure the newborn's chest circumference at the nipple line.

A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's unltrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following intervetnions should be included in the newborn's plan of care?

Observe for meconuium in repsiratory secretions. When a fetus is SGA, there is an increased risk for intrauterine hypoxia due to the presence of meconium in the amniotic fluid. The nurse should observe for meconium in respiratory secretions when suctioning the newborn at delivery. Newborns who are SGA are at risk for perinatal asphyxia due to the stress of labor and are often depressed. They require careful resuscitation and suctioning at delivery.

A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervenation at this time?

Palpate the client's uterine fundus. Although the expectation is moderate bleeding in the first 2 hr after delivery, saturating a perineal pad in 15 min or less indicates excessive blood loss. The priority nursing intervention is to palpate the client's fundus to determine the presence of uterine atony, followed by fundal massage to stimulate uterine muscle tone.

A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?

Perform a sharp hand clap near the infant. To elicit the Moro reflex, the nurse performs a sharp hand clap near the newborn and observes symmetric abduction and extension of the arms, fanning of the fingers with the thumb and forefinger to form a C, and then a return to a relaxed flexion position.

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Slightly above the umbilicus At 22 weeks of gestation, the fundal height should be just above the level of the umbilicus. The distance in centimeters from the symphysis pubis to the top of the fundus is a gross estimate of the weeks of gestation.

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

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

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean bith. Which of the following client statements should indicate to the nurse the teaching is effective? (SATA)

"I will resume taking my prenatal vitamins," "I will call my provider if I have discharge from my incision," "I should not have unrelieved pain in my abdomen," Prenatal vitamins are often continued after birth for 6 weeks to ensure adequate vitamin intake and to promote healing. The client should report incisional discharge, redness, ecchymosis and/or edema, because it can be an indication of infection. A client will have abdominal pain and tenderness from the surgical procedure. Unrelieved pain can be an indication of infection.

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

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

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

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

A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching?

"These exercises help pelvic muscles to stretch during birth." Kegel exercises improve the strength of perineal muscles, facilitating stretching and contracting during childbirth.

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

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

A nurse in a prenatal clinic is caring for a client who believes that she might be preganat because she feels the baby moving. Which of the following statments should the nurse make?

"This is a presumptive sign of pregnancy." Presumptive signs of pregnancy include physical changes that are apparent to the client, such as quickening.

A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone gel. Which of the following statements should the nurse include in the teaching?

"This medication promotes softening of the cervix." Dinoprostone is used to prepare (or ripen) the cervix for the induction of labor in clients who are at term.

A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer?

"You must be feeling scared and powerless". This response illustrates the therapeutic communication technique of restatement. The nurse shows empathy for the client by recognizing that the client is concerned about the safety of the fetus and is powerless to do anything about the situation. This open-ended statement encourages further communication by the client.

A nurse at a prenatal clinic is caring who is in her first trimester of prenancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in her life. Which of the following is an appropriate response by the nurse?

-"Ambivalent feelings are quite common for women early in pregnancy." This response uses the therapeutic communication technique of providing information while addressing the client's concerns and feelings. This statement is true and gives the client the information she needs; many antepartum women experience similar feelings in early pregnancy.

A nurse is teaching the parent of a newborn about the bottle feeding. Which of the following statements by the parent indicates a need for further instruction?

-"I will tip the nipple so air is present as baby sucks." The nipple should be held so it fills only with formula. The infant should not be permitted to suck air.

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

-Ceftriaxone as prescribed -Assess for signs of sepsis -Pyelonephritis -Urine output -Uterine contractions The nurse should administer ceftriaxone as prescribed and assess for signs of sepsis because the client is most likely experiencing pyelonephritis as evidenced by bilateral flank pain, dysuria, and chills. Because pyelonephritis is an extension of a UTI or might have spread from some other area, the client is at risk for sepsis. The nurse should monitor the client's urine output and for uterine contractions because pyelonephritis can increase the risk of preterm labor.

A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment finding should the nurse report to the provider first?

-Continuous contraction lasting 2 min A uterus contracting for more than 90 seconds is a sign of tetany and could lead to uterine rupture, which is the greatest risk to the client at this time. The nurse should report this finding immediately.

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the clients perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

-Document the findings and continue to monitor the client. These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. Small clots are common. The nurse should document the findings and continue to monitor the client.

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

-Dry, cracked skin A newborn who is postmature has dry, cracked skin.

A nurse is teaching a client who is at 23 weeks of gestatiion and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client?

-Empty her bladder immediately prior to the procedure. Emptying the bladder before amniocentesis prevents possible puncture of the bladder and displacement of the uterus and fetus.

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the clients blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

-Evaluate the firmness of the uterus. The first action the nurse should take using the nursing process is to assess the client. A blood pressure of 60/50 mm Hg can indicate postpartum hemorrhage; therefore, the first action the nurse should take is to evaluate the firmness of the uterus to determine if there is uterine atony.

A nurse in a prenatal clinic is cating for a client who is suspected of having a hydratidiform mole. Which of the following findings should the nurse expect to observe in this client?

-Excessive uterine enlargement A hydatidiform mole is a rare tumor that forms inside the uterus at the beginning of a pregnancy and results in the over-production of tissue that would normally develop into the placenta. This tissue consists of fluid-filled vesicles. A rapidly enlarging uterus is a classic finding in clients who have a molar pregnancy. It is often accompanied by severe nausea and vomiting, elevated human chorionic gonadotropin levels, signs of hyperthyroidism, and early onset of preeclampsia.

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse located the featal heart tones above the clients umbilicus at midline. The nurse shuold suspect that the fetus is in which of the following positions?

-Frank breech With a frank breech presentation, the fetal heart is generally above the level of the client's umbilicus.

A nurse is caring a client who is 3 days postpartum and is attemping to breastfeed. Which of the following findings indicate mastits?

Red and painful area in one breast. Mastitis often appears as a red, hard, and painful area on the breast, commonly in the upper outer quadrant. Although mastitis can occur in both breasts, it is usually unilateral. A client who has mastitis can also influenza-like manifestations, such as fever, chills, headache, and myalgia. After delivery, the nurse should instruct the client to observe the breasts for indications of mastitis and to notify her provider if they occur.

A nurse is completeing the asmissin assessment of a cleitn who is at 38 weeks gestation and has servere preesclampsia. Which of the following is an expected finding?

Report of headache Manifestations of severe preeclampsia include severe (usually frontal) headache, blurred vision, photophobia, scotomas, right upper quadrant pain, irritability, presence of clonus and brisk deep tendon reflexes, nausea, vomiting, hypertension, oliguria, and proteinuria.

A nurse is preparing to administer mafnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client?

Respiratory rate Magnesium sulfate is typically administered to a client in preterm labor to achieve the tocolytic (uterine relaxation) effect. Magnesium sulfate depresses the function of the central nervous system, causing respiratory depression. Baseline assessment of respiratory status, checking the respiratory rate frequently, and reassessment of respiratory status with each change in dosage of magnesium sulfate is the primary focus when assessing the client. There is a narrow margin between what is considered a therapeutic dose and a toxic dose of magnesium sulfate.

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

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

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

Take Action: -IV fluids -Encourage the client to eat small frequent meals Potential Condition: -Hyperemesis gravidarum Parameters to monitor: -Hematocrit -Intake and output The nurse should administer IV fluids and encourage the client to eat small frequent meals because the client is most likely experiencing hyperemesis gravidarum. The client is exhibiting symptoms of dehydration such as hypotension, tachycardia, dry mucous membranes, delayed skin turgor, and has experienced significant weight loss within the last 2 weeks. The client's urinalysis shows a moderate number of ketones which could indicate dehydration as well. Therefore, the nurse should monitor the client's vital signs, laboratory studies such as hematocrit and intake and output which would provide information about the client's hydration status.

A nurse is caring for a client who is at 34 weeks of gestation and has preeclampsia. A nurse is reviewing the client's electronic medical record. For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

The nurse should recognize that a prescription to encourage the client to lay in a supine position is contraindicated. The nurse should encourage the client to lay in a side-lying position. The nurse should anticipate the provider to prescribe dim lighting to decrease environmental stimuli. The nurse should anticipate the provider to prescribe a loading dose of magnesium sulfate 4 g IV bolus, following by 2 g/hr maintenance dose. The nurse should anticipate the provide to prescribe monitoring the client's blood pressure every 15 to 30 min. The nurse should determine that collecting a urine specimen for culture and sensitivity is non-essential for a client who has preeclampsia. The nurse should collect a urine specimen for culture and sensitivity if the client presents with manifestations of a UTI. The nurse should anticipate the provider restricting hourly fluid intake to 125 mL/hr.

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make?

The presenting part is 1 cm above the ischial spines. Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is minus (-) 1, then the presenting part is 1 cm above the ischial spines.

A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

Unilateral, cramp-like abdominal pain An ectopic pregnancy is one in which the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop in this area. The most common site is within a fallopian tube; however, ectopic pregnancies can occur in the ovary, the abdomen, and in the cervix.

A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching?

Vaginal intercourse can be resumed after 2 weeks. The client should avoid vaginal intercourse and the use of tampons for 2 weeks following discharge.

A nurse is preparing to asminister vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?

Vastus lateralis The nurse should administer vitamin K, or phytonadione, into the vastus lateralis muscle in the thigh. This medication prevents and treats hemorrhagic disease of the newborn, as newborns are born with vitamin K deficiency.

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of cirumcision care?

-"I'll expect the plastic ring to fall off by itself within a week." -"I'll call the doctor if I see any bleeding." -"I'll make sure his diaper is loose in the front." "I'll expect the plastic ring to fall off by itself within a week" is a correct statement. With the Plastibell procedure, the plastic ring detaches in about 5 to 8 days."I'll apply petroleum jelly to his penis with diaper changes" is an incorrect statement. With the Plastibell technique, no petroleum jelly is necessary."I'll wash his penis with warm water and mild soap each day" is an incorrect statement. The client should not use soap or commercial cleansing wipes until the circumcision has healed, which takes at least 5 to 6 days."I'll call the doctor if I see any bleeding" is a correct statement. The client should report any bleeding immediately."I'll make sure his diaper is loose in the front" is a correct statement. Applying a loose diaper prevents pressure over the circumcision area.

A nurse in a prenatal clinic overhears a newly licensed nurse discussing conception with a client. Which of the following statements by the newly licensed nurse requires intervention by the nurse?

-"Implantation occurs between 2 and 3 weeks after conception." This statement requires clarification because implantation occurs between 6 to 10 days following conception.

A nurse is providing teaching about newborn care to a client who is 2 hr postpartum. Which of the following statements by the client indicates a need for further teaching?

-"My baby's temperature will be checked rectally every hour." The newborn's axillary temperature should be checked every hour until the newborn's temperature stabilizes. Frequent rectal temperature checks are not recommended and can lead to rectal mucosal injury.

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

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

A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breating. The cleint says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?

-Assist the client to breathe into a paper bag. This client is experiencing respiratory alkalosis due to hyperventilation. The client should be assisted to breathe into a paper bag or to cup her hands over her mouth to increase the carbon dioxide level, which replaces the bicarbonate ion.

A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the clients blood pressure reading as 82/52 mm Hg. Which of the following nursing interventation should the nurse perform?

-Assist the client to turn onto her side. Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena cava. Turning the client to her right side relieves this pressure and restores blood pressure to the expected reference range.

A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?

-Asymmetric thigh folds Gluteal and thigh skin folds that are not equal and symmetric is a sign of DDH.

A nurse is caring for a newborn. Which of the following assessment findings require follow-up by the nurse? Click to highlight the statements in the assessment findings that require follow-up by the nurse.

-Axillary temperature 36.1° C (97° F) -Respiratory rate 78/min -Yellow discoloration noted of sclera and oral mucosa -Nasal flaring present -Breastfed x 1 in the past 6 hr for 10 min In response to a low body temperature, the newborn will attempt to warm themselves by increasing their basal metabolic rate. This can result in depletion of glucose stores and hypoglycemia. Temperature instability, either below or above the expected reference range, can be a manifestation of sepsis or infection. The nurse should follow-up on this finding. This heart rate is above the expected reference range. Tachypnea is associated with respiratory distress, sepsis, cold stress, and hypoglycemia. The nurse should follow-up on this finding. Yellow sclera and oral mucosa are associated with hyperbilirubinemia and sepsis. The liver of the newborn has a reduced ability to metabolize and excrete bilirubin, which is a by-product of the breakdown of red blood cells. The excess circulating bilirubin can accumulate in the skin, sclera, and mucus membranes, leading to yellow discoloration. A change in the color of the newborn can also be a manifestation of sepsis. This includes jaundice, cyanosis, or pallor. The nurse should follow-up on this finding. Nasal flaring is an indication of respiratory distress. Additional manifestations of respiratory distress can include tachypnea, retractions, and grunting with respirations. The nurse should follow-up on this finding. This feeding pattern is below the expected frequency for feeding. A newborn is expected to breastfeed every 2 to 4 hr for at least 15 to 20 min each time. Regular frequent feeding can prevent the development of hypoglycemia. During the first few days of life, newborns may need to be awakened to feed. The nurse should follow-up on this finding.

A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (SATA)

-Blot the perineal area dry -Clean the perineal area from front to back -Perform hand hygiene before and after voiding -Wash the perineal area using a squeeze bottle of warm water after each voiding Good perineal care is important to clean the skin folds, which often contain secretions that act as a medium for micro-organism growth. Therefore, the area should be thoroughly dried by blotting. Good perianal care is important to clean the skin folds, which often contain secretions that harbor micro-organisms. Wiping from front to back decreases the chances of transmitting fecal organisms to other areas, such as the urinary meatus, episiotomy incision, or lacerations resulting from childbirth. Hand hygiene is the primary method of reducing micro-organisms on the hands and thereby reducing the risk of transmission that can lead to infection. Apply ice packs to the perineal area several times daily is incorrect. Ice packs may be applied to the perineal area for the first 24 to 48 hr to decrease edema and to provide an anesthetic effect. This would not be indicated after that time, nor does it provide any preventative benefits from infection. Rinsing with a solution of water is more effective at removing micro-organisms than wiping.

A nurse is caring for a client who is 42 weeks of gestation. Based on the assessment findings, which of the following actions should the nurse plan to take? Click to specify whether the nurse's planned actions are anticipated, nonessential, or contraindicated. -Increase the oxytocin infusion to 13 mu/min. -Place client in a side-lying position. -Initiate bolus of primary IV fluids. -Apply oxygen at 10 L/min via venturi mask. -Perform sterile vaginal examination (SVE). -Assign a Bishop score. -Perform an amniotomy.

-Increase the oxytocin infusion to 13 mu/min is contraindicated. This client has a category 3 fetal heart rate tracing indicating absent baseline variability and either late, or recurrent variable decelerations. Increasing the oxytocin infusion would likely cause a further decline in fetal well-being. Therefore, the nurse should stop the infusion of oxytocin, not increase the rate of infusion. -Place client in a side-lying position is anticipated. This client has a category 3 fetal heart rate tracing indicating absent baseline variability and either late, or recurrent variable decelerations. These findings are consistent with manifestations associated with fetal hypoxia. Placing the client is a side-lying position increases client oxygenation and cardiac output, thereby increasing blood flow and oxygenation to the fetus. -Initiate bolus of primary IV fluids is anticipated. This client has a category 3 fetal heart rate tracing indicating absent baseline variability and either late, or recurrent variable decelerations. These findings are consistent with manifestations associated with fetal hypoxia. Initiating a bolus of the primary IV fluids increases the client's blood volume which increases their oxygenation and cardiac output, thereby increasing blood flow and oxygenation to the fetus. -Apply oxygen at 10 L/min via venturi mask is contraindicated. The nurse should apply oxygen at 10 L/min via a nonrebreather mask, not a venturi mask. A nonrebreather mask will provide the client with a greater concentration of oxygen than the venturi mask, thereby increasing the amount of oxygen received by the fetus. -Perform sterile vaginal examination (SVE) is anticipated. This client has a category 3 fetal heart rate tracing indicating absent baseline variability and either late, or recurrent variable decelerations. These findings are consistent with findings associated with fetal hypoxia and could be caused by a prolapsed umbilical cord; therefore, the nurse should perform a SVE to assess for the presence of a hidden prolapsed umbilical cord. -Assign a Bishop score is nonessential. A Bishop score is used to assess the cervix prior to induction of labor to determine the likelihood of a vaginal delivery. The Bishop score should have been assigned before the induction of labor. -Perform an amniotomy is contraindicated. The nurse should not plan to perform an amniotomy as this action is not within the nurse's scope of practice. If an amniotomy is needed, the procedure should be performed by the provider with the assistance of the nurse.

A nurse is admitting a client who has a dianosis of preterm labor. The nurse antipates a presctiption by the provider for which of the following medications? (SATA).

-Indomethacin -Magnesium sulfate Indomethacin is used to relax uterine smooth muscles and suppress uterine activity in clients who have a diagnosis of preterm labor. Magnesium sulfate is a tocolytic and stops contractions in clients experiencing preterm labor.

A nurse is completing a health historu for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications?

-Intrauterine growth restriction Clients who smoke place their newborns and themselves at risk for diverse complications, including fetal intrauterine growth restriction, placental abruption, placenta previa, preterm delivery, and fetal death.

A nurse is caring for a newborn who is 4 hr old. Vital Signs 0800: Axillary temperature 36.5° C (97.7° F) Heart rate 132/min Respiratory rate 52/min Nurses Notes 0800: The newborn is alert and active with an occasional strong cry. Skin color is consistent with the newborn's genetic background. Anterior fontanel even and soft. Molding of skull noted with overlapping of sutures. Generalized soft swelling noted to the occipital area. Respirations easy and unlabored. Newborn is breastfeeding at least every 2 to 3 hr. Diagnostic Results 0800: The newborn is alert and active with an occasional strong cry. Skin color is consistent with the newborn's genetic background. Anterior fontanel even and soft. Molding of skull noted with overlapping of sutures. Generalized soft swelling noted to the occipital area. Respirations easy and unlabored. Newborn is breastfeeding at least every 2 to 3 hr. Medical Hx Spontaneous vaginal delivery 4 hr ago Pregnancy complicated by maternal history of illicit drug use Birth weight 2,948 gm (6 lb 8 oz) Gestational age 38 weeks Maternal prenatal laboratory results: ABO/Rh: O+ Urine toxicology screen: positive for cocaine and marijuana (negative) After reviewing the information in the newborn's medical record, the nurse should recognize that the newborn is at risk for developing which of the following complications? Complete the following sentence by using the list of options. The newborn is at risk for developing (select from dropdown list, [neonatal abstinence sundrome, seizures, hypoglycemia, jaundice]) as evidenced by the (select from dropdown list) [neurological findings, indirect coombs test results, feeding pattern, urine toxicology screen results].

-Jaundice -Indirect Coombs test The newborn has a risk of developing jaundice as evidenced by the indirect Coombs test. A positive indirect Coombs test indicates the presence of anti-A and anti-B maternal antibodies within the newborn's blood. These antibodies will result in an accelerated destruction of the newborn's type A blood cells. The by-product of red blood cell hemolysis is bilirubin. The accelerated breakdown of the red blood cells can lead to excess bilirubin, accumulating within the newborn's skin, mucus membranes, and sclera, and result in jaundice. The newborn's results were positive, which indicates the presence of anti-A and anti-B maternal antibodies within the blood, and increases the risk for jaundice.

A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant?

-Maintain the integrity of the sac. Myelomeningocele is a congenital disorder that causes the spine and spinal canal to not close prior to birth, which results in the spinal cord, meninges, and nerve roots protruding out of the child's back in a fluid-filled sac. Before surgery, the infant must be handled carefully to reduce damage to the exposed spinal cord and to maintain the integrity of the sac.

A nurse is preparing a client who is in active labor for epidural analgesia. Which of the following actions should the nurse take?

-Obtain a 30 min electronic fetal monitoring (EFM) strip prior to induction. The nurse should obtain a 20 to 30 min EFM strip before induction of the spinal anesthesia. The strip should be evaluated as baseline information. After induction, fetal heart rate and pattern is assessed and documented every 5 to 10 min and emergency care is provided for fetal distress, such as bradycardia or late decelerations.

A nurse is caring for a 22-year-old female client who reports lower abdominal and pelvic pain. Vital Signs 0900: Temperature 36.7° C (98.1° F) Heart rate 82/min Respirations 20/min Blood pressure 120/64 mm Hg Oxygen saturation 98% on room air 1 Week After Initial Visit, 1100: Temperature 36.9° C (98.4° F) Heart rate 78/min Respirations 18/min Blood pressure 122/67 mm Hg Oxygen saturation 99% on room air Providers Presciptions 0930: Prepared the client for pelvic examination and cervical cultures for gonorrhea and chlamydia 7 days later: Administer ceftriaxone 250 mg IM now Administer azithromycin 1 g PO now Nurses Notes 0900: Reports low abdominal and pelvic pain for the past 3 weeks that worsened with current menstrual cycle. Denies vaginal discharge or odor. Reports that she has had unprotected sexual intercourse with 3 individuals over the last 2 months. Reports having a history of gonorrhea and chlamydia for which she has been treated 4 times over the past year. Client has history of hepatitis A. 0930: Notified provider of client's report of low abdominal and pelvic pain for a total of 3 weeks so far worsening with current menstrual cycle as well as history of STI's and multiple sexual partners. New prescriptions received. 1000: Provider at bedside. Pelvic examination performed, cervical cultures obtained and sent to the laboratory. Scheduled client to return to clinic in 1 week for results. Instructed not to have any type of sexual contact until result are received. Client verbalized understanding and consent. 1 Week After Initial Visit, 1100: Client returned to clinic for test results and was notified that both gonorrhea and chlamydia cultures are positive. Antibiotics administered. See medication administration record (MAR). Diagnostic Results 0900: Reports low abdominal and pelvic pain for the past 3 weeks that worsened with current menstrual cycle. Denies vaginal discharge or odor. Reports that she has had unprotected sexual intercourse with 3 individuals over the last 2 months. Reports having a history of gonorrhea and chlamydia for which she has been treated 4 times over the past year. Client has history of hepatitis A. 0930: Notified provider of client's report of low abdominal and pelvic pain for a total of 3 weeks so far worsening with current menstrual cycle as well as history of STI's and multiple sexual partners. New prescriptions received. 1000: Provider at bedside. Pelvic examination performed, cervical cultures obtained and sent to the laboratory. Scheduled client to return to clinic in 1 week for results. Instructed not to have any type of sexual contact until result are received. Client verbalized understanding and consent. 1 Week After Initial Visit, 1100: Client returned to clinic for test results and was notified that both gonorrhea and chlamydia cultures are positive. Antibiotics administered. See medication administration record (MAR). Medication Administration Record 0900: Reports low abdominal and pelvic pain for the past 3 weeks that worsened with current menstrual cycle. Denies vaginal discharge or odor. Reports that she has had unprotected sexual intercourse with 3 individuals over the last 2 months. Reports having a history of gonorrhea and chlamydia for which she has been treated 4 times over the past year. Client has history of hepatitis A. 0930: Notified provider of client's report of low abdominal and pelvic pain for a total of 3 weeks so far worsening with current menstrual cycle as well as history of STI's and multiple sexual partners. New prescriptions received. 1000: Provider at bedside. Pelvic examination performed, cervical cultures obtained and sent to the laboratory. Scheduled client to return to clinic in 1 week for results. Instructed not to have any type of sexual contact until result are received. Client verbalized understanding and consent. 1 Week After Initial Visit, 1100: Client returned to clinic for test results and was notified that both gonorrhea and chlamydia cultures are positive. Antibiotics administered. See medication administration record (MAR). Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing (select condition) due to (select finding). Condition -Pelvic Inflammatory Disease (PID) -Liver Failure -Primary Dsymernorrhea -Oral Candidiasis -Endometriosis Finding -Recurring STI's -The use of oral contraceptives -A history of hepatitis A -Administration of ceftriaxone -Pain with the menstrusl cycle

-Pelvic Inflammatory Disease (PID) -Recurring STI's Condition Pelvic inflammatory disease (PID) is correct. Several factors increase a client's risk for developing PID. These factors include being female and less than 25 years of age, having multiple sexual partners, having a history of sexually transmitted infections and PID, and never having been pregnant. The nurse should recognize that the client is at risk for developing PID and should counsel the client about the potential adverse effects of PID including infertility and ectopic pregnancy. Endometriosis is incorrect. Endometriosis is the presence of endometrial tissue outside of the uterus, which is thought to occur through retrograde menstruation during the menstrual cycle. Endometriosis is characterized by pelvic pain, pain with sexual intercourse, and dysmenorrhea. Primary dysmenorrhea is incorrect. Primary dysmenorrhea is pain during the menstrual cycle that occurs because of excessive prostaglandin secretion during the luteal phase of the ovulatory cycle. Primary dysmenorrhea is characterized by lower abdominal cramps, back pain, weakness, nausea/vomiting/diarrhea, sweating, and central nervous system manifestations such as headache, dizziness, syncope, and the inability to concentrate. Liver failure is incorrect. While this client has a history of hepatitis A, this does not place the client at risk for liver failure. Hepatitis A is a self-limiting infection characterized by malaise, fatigue, decreased appetite, pain in the right upper quadrant of the abdomen, nausea, and itching. Oral candidiasis is incorrect. Oral candidiasis occurs as an adverse effect to the administration of antibiotics such as azithromycin as well as in clients who are immunocompromised. Oral candidiasis is characterized by difficulty swallowing, pain behind the sternum, and cottage-cheese like plaques in the oral cavity. Finding Recurring STI's is correct. Several factors increase a client's risk for developing PID. These factors include being female and less than 25 years of age, having multiple sexual partners, a history of sexually transmitted infections and PID, and never having been pregnant. The nurse should recognize that the client is a risk for developing PID and should counsel the client about the potential adverse effects consequences of PID including infertility and ectopic pregnancy. The use of oral contraceptives is incorrect. The use of oral contraceptives does not cause a client to be at a greater risk for PID. However, the nurse should be aware that the use of an intrauterine device places clients at a greater risk for developing PID for up to 3 weeks after insertion. Pain with the menstrual cycle is incorrect. The client is not at risk for developing PID due to pain during the menstrual cycle. However, the nurse should be aware that pain, especially pain that is increased during the menstrual cycle, can be a manifestation of endometriosis. History of hepatitis A is incorrect. A history of hepatitis A does not place the client at risk for developing PID. Hepatitis A is a self-limiting infection characterized by malaise, fatigue, decreased appetite, pain in the right upper quadrant of the abdomen, nausea, and itching. Administration of ceftriaxone is incorrect. Ceftriaxone is administered for the treatment of PID and does not place the client at an increased risk for developing PID.

A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care?

Place the newborn in the prone position. Placing the newborn in the prone position prevents trauma to the lesion. The newborn's knees should be assessed for evidence of skin breakdown.

A nurse is caring for a newborn 1 hr following birth. Medical History 1000: 39-week gestation Emergency cesarean birth for abruptio placenta and non-reassuring fetal heart rate Apgar 5 at 1 min, 8 at 5 min Positive pressure ventilation given for 1 min followed by free flow oxygen. Vital Signs 1000: Temperature: 36.6° C (97.9° F) Axillary Heart rate: 180/min Respiratory rate: 80 /min Oxygen saturation 96% 1030: Temperature: 36.6° C (97.9° F) Axillary Heart rate: 188/min Respiratory rate: 84/min Oxygen saturation 97% Diagnostic Results 1030: Hemoglobin: 9 g/dL (14 to 24 g/dL) Hematocrit: 35% (44 to 64%) Platelet count: 210,000/mm3 (150,000 to 300,000 mm3) White blood cells: 9,500/mm3 (9,000 to 30,000/mm3) Serum glucose: 130 mg/dL (40 to 45 mg/dL) Nurses' Notes 1000: Newborn placed on radiate warmer. Color consistent with newborn's genetic background. Acrocyanosis present. Mild grunting, nasal flaring, and intermittent retractions noted. Select the 5 findings the nurse should report to the provider. -Respiratory assessment -Hemoglobin -Hematocrit -Serum glucose -Temperature -Heart rate -White blood cells

-Respiratory assessment -Hemoglobin -Hematocrit -Serum glucose -Heart rate Temperature is incorrect. The newborn's temperature is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. Respiratory assessment is correct. The newborn is exhibiting tachypnea, grunting, nasal flaring, and intermittent retractions, which are all findings associated with respiratory distress syndrome. Therefore, the nurse should report these findings to the provider. Serum glucose is correct. The newborn's serum glucose is above the expected reference range. Therefore, the nurse should report this finding to the provider. Hematocrit is correct. The newborn's hematocrit is 35%, which is below the expected reference range. Therefore, the nurse should report this finding to the provider. White blood cell count is incorrect. The newborn's white blood cell count is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. Hemoglobin is correct. The newborn's hemoglobin is 9 g/dL which is below the expected reference range, Therefore, the nurse should report this finding to the provider. Heart rate is correct. The newborn is exhibiting tachycardia, which might require interventions. Therefore, the nurse should report this finding to the provider.

A nurse is caring for a newborn 2 hr following birth. Select the 4 findings the nurse should report to the provider. -Temperature -Respiratory assessment -Serum glucose level -WBC count -Hematocrit -Heart rate

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

A nurse is caring for a client who is in labor. Drag 1 parameter and 1 complication to fill in each blank in the following sentence. Which of the following parameters should the nurse monitor? The nurse should monitor the client's (Select from parameter) due to the risk of (Select from complication). Parameter -Temperature -Clotting factors -Reflexes -Magnesium Levels -Fundal Height Conplication -Seizures -Disseminated intracascular Coagulation (DIC) -Concealed Hemorrage -Respiratory Arrest -Chorioamnionitis

-Temperture -Chorioamnionitis Temperature is correct. A client who has preterm premature rupture of membranes without the presence of contractions is at risk for developing a bacterial infection within the uterus. Chorioamnionitis occurs most often following the rupture of the amniotic membranes, which allows bacteria from the vagina to ascend into the amniotic cavity. Manifestations of chorioamnionitis include an elevated temperature, foul-smelling vaginal discharge, and maternal and/or fetal tachycardia. Chorioamnionitis is correct. A client who has preterm premature rupture of membranes without the presence of contractions is at risk for developing a bacterial infection within the uterus. Chorioamnionitis occurs most often following the rupture of the amniotic membranes, which allows bacteria from the vagina to ascend into the amniotic cavity. Manifestations of chorioamnionitis include an elevated temperature, foul-smelling vaginal discharge, and maternal and/or fetal tachycardia.

A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252g). The nurse should recognize that this client is at risk for which of the following postpartum complications?

-Uterine atony A uterus that is over distended, such as from a macrosomic fetus, has an increased risk of uterine atony.

A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant?

8 Apgar scoring is an assessment of five areas of newborn well-being: respiratory effort, heart rate, muscle tone, reflex irritability, and color. This newborn scores 2 each for heart rate, muscle tone, and reflex irritability. The weak cry and acrocyanosis of the hands and feet score 1 each, for a total of 8.

A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocoltic therapy to which of the following clients?

A client who is experiencing preterm labor at 26 weeks of gestation Tocolytic medications, such as terbutaline, indomethacin, and nifedipine are used to relax the uterus in preterm labor. A client who is in preterm labor at 26 weeks of gestation is a candidate for tocolytic therapy.

A nurse is caring for a client during a nonstress test (NST). At the end of a 30-min period of observation, the nurse notes the following findings: The fetal heart rate baseline is 120/min with minimal variablity and no accelerations. There are two decelerations of 15/min in the fetal heart rate during a period of fetal movement, each last 20 seconds. Which of the following interpretations of these findings should the nurse make?

A nonreactive test An NST that does not produce two or more qualifying accelerations within a 20-min period is interpreted as nonreactive. Qualifying accelerations peak at least 15 /min above the FHR baseline and last at least 15 seconds.

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

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

A nurse is caring for a newborn who was born 6 hr ago. Medical History Maternal: Age: 30 Gravida 2, Para 2 Primary elective cesarean birth at 36 4/7 weeks of gestation α-fetoprotein: Positive Medical History: Unremarkable Surgical history: None Group B Streptococcus ß-hemolytic: Positive Newborn: APGAR scores: 6 and 7 (at 1 min and 5 min) Weight: 2495 grams (5 lb 8 oz) Length: 48 cm (18.9 in) Vital Signs Temperature: 37.2° C (99° F) axillary Heart rate: 120/min Respiratory rate: 50/min Physical Examination Skin warm, dry. Color consistent with genetic background. Mild amount of lanugo noted. Head circumference 34 cm (13.4 inches). Sutures palpable and separated. Anterior and posterior fontanel flat and soft. Eyes evenly spaced with pupils that are equal, round, reactive to light and accommodation. Chest barrel shaped with symmetric respiratory movements. No retractions noted. Abdomen soft, rounded, nondistended. Umbilical cord clamped, no herniations noted. Extremities symmetrical with full range of motion. Spine even. 2 cm X 2 cm sac noted in lumbar area. Moro, plantar, and Babinski reflexes intact. Diaper changed, noted small void and meconium stool.

Actions to Take -Place the newborn in a prone position. - Apply non-adhering sterile saline moist compress. Potential Condition -Meningocele Parameters to Monitor -Head circumference -Cerebrospinal fluid leakage

A nurse is caring for a client who is 31 weeks of gestation. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Actions to Take -Continuous fetal and contraction -Prepare the client for a cesarean birth Potential Condition -Placenta Previa Parameters to Monitor -Uterine contrctions -Postpartum hemorrhage with a firm fundus. The nurse should perform continuous fetal and contraction monitoring and prepare the client for a cesarean birth because the client is most likely experiencing placenta previa. The client is at risk for hypovolemic shock because of significant blood loss, and the well-being of the fetus is at risk. The nurse should monitor the client's uterine activity and for postpartum hemorrhage with a firm fundus because increased uterine activity places the fetus at risk for hypoxia. After surgery, the client's fundus might be firm, but because decreased muscle bundles in the lower uterus are absent, the client might still experience postpartum hemorrhage.

A nurse is caring for a client who is at 38 weeks of gestation. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Actions to Take: -Assist the client to a knee chest position -Stop the oxytocin infusion Potential Condition: -Umbilical cord compression Parameters to Monitor: -Fetal heart rate -Oxygen saturation The nurse should assist the client to a knee chest position and stop the oxytocin infusion because the client is most likely experiencing umbilical cord compression indicated by of the late decelerations on the external fetal monitor. The nurse should monitor fetal heart rate and the client's oxygen saturation. If the client is experiencing cord compression, this could be due to a short cord, a knot in the cord, a prolapsed cord, or the cord being wrapped around the fetus's neck. The nurse should discontinue the oxytocin infusion, assist the client to knee chest position to relieve pressure on the cord, administer oxygen to increase perfusion, notify provider, and check for cord prolapse. The nurse should also prepare for delivery.

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

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

A nurse is caring for a newborn who is 30 min old. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? The condition that poses the greatest risk to the newborn is (select from condition) due to (Select from finding). Conditions -Cold Stress -Meconium aspiration syndrome -Hypoglycemia -Jaundice Findings -Gestational Age -Apgar score -Color of amniotic Fluid -Actocyanosis -Birth Weight

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

A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicated to the nurse that the client has blood in the peritoneum?

Cullen's sign Cullen's sign is a blue discoloration similar to ecchymosis around the umbilicus. It indicates hematoperitoneum, a common clinical manifestation of a ruptured ectopic pregnancy.

A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

Drink 48 to 64 ounces of water daily. The client who has preeclampsia is encouraged to drink six to eight 8-ounce glasses of water (48 to 64 ounces) per day. She should avoid alcohol and limit intake of caffeinated beverages.

A nurse is caring for a client following an amnitomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implemet with this client?

Encourage the client to emplty her bladder every 2 hr. A client in labor should be encouraged to empty her bladder every 2 hr. Bladder distention can impede the descent of the fetus and slow the progression of labor. It can also contribute to uterine atony after delivery, increasing the client's risk of postpartum hemorrhage.

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

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

A nurse is caring for a client who is postpartum and received methlergonovine. Which of the following findings indicates that the medication was effective?

Fundus firm to palpation Methylergonovine is an oxytocic medication that is administered to promote uterine contractions. This medication is indicated for treatment of postpartum hemorrhage caused by uterine atony or subinvolution; the desired effect is an increase in uterine tone.

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

Fundus palpable to right of midline Bladder distention results in uterine displacement, pushing the fundus above the umbilicus and away from the midline. The fundus might feel boggy to palpation and does not contract normally.

A nurse is caring for a client who is at 34 weeks of gestation. A nurse reviews the assessment findings and determines that the findings are consistent with which of the following complications? For each assessment finding, click to specify if the assessment finding is consistent with placenta previa or abruptio placenta. Each finding may support more than one disease process. Assessment Finding -Fundal Height -Clients Pain level -Uterine Tone -Hematocrit Level -Desciption of vaginal bleeding

Hematocrit level is consistent with abruptio placentae and placenta previa. Clients who experience abruptio placentae and placenta previa are at an increased risk for hemorrhage due to the blood loss associated with these conditions. This client's hematocrit is 30%, which is below the expected reference range of (> 33%) and an indicator of excessive blood loss. Uterine tone is consistent with placenta previa. The client's abdomen is soft and nontender to palpation and no contractions are observed. The abdomen of a client who has abruptio placentae will be tender and ridged when palpated and might remain hard between contractions, which indicates hypertonicity. Description of vaginal bleeding is consistent with a placenta previa. Clients who have placenta previa have painless, bright red vaginal bleeding, which is what is indicated in the client's medical record. Clients who have abruptio placentae have dark red vaginal bleeding. Client's pain level is consistent with placenta previa. The client denies pain and contractions and reports that their abdomen is not tender when palpated. The client who has abruptio placentae will report moderate to severe pain as well as abdominal tenderness upon palpation. Fundal height is consistent with placenta previa and abruptio placentae. The client who has placenta previa might have an increased fundal height because the placenta rests in the lower uterine segment causing the fetus to position itself higher in the uterus. The client who has abruptio placenta might have an increased fundal height due to covert bleeding. Serial fundal height measurements might be prescribed to assess for continued bleeding.

A nurse is assessing a newborn who has a coarctation of the aorta. Which of the following should the nurse recognize is a clinical manifestation of coarctation of the aorta?

Increased blood pressure in the arms with decreased blood pressure in the legs There is a narrowing next to the ductus arteriosus that results in an increased pressure proximal to the defect, with a decreased pressure distal to the obstruction. Therefore, an increased blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta.

A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make?

Increased progesterone production causes decreased motility of smooth muscle. Increased progesterone production causes a relaxation of the cardiac sphincter of the stomach and delayed gastric emptying, which can result in heartburn.

A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart of 138/min and no uterine contractions. The clients vital sings are BP 98/52, Hr 118, T 36.4. Which of the following is the priority nursing action?

Initiate IV access. Insertion of a large-bore IV catheter is the priority nursing action. The client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops.

A nurse in a pernatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. The bleeding started spintaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following?

Location of the placenta. Painless, spontaneous vaginal bleeding might indicate that the client has placenta previa. Placenta previa is a condition in which the placenta is implanted low in the uterus, sometimes to the point of covering the cervical os. As the cervix effaces, the client begins to bleed. The ultrasound will show the location of the placenta and help to determine what sort of delivery the client requires and how emergent it is.

A nurse is cating for a cleint who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the clients skin color is ashen, and she states she feels weak and light headed. After applying oxygen cia ninrebreather face mask at 10 L/min which of the following actions should the nurse take next?

Massage the client's fundus to promote contractions. A soaked perineal pad in less than 15 min, ashen skin color, and report of weakness and light headedness can indicate that the client is at greatest risk for hypovolemic shock. Therefore, the next action the nurse should take is to massage the client's fundus to expel blood clots and promote uterine contraction to stop the bleeding.