HESI: Maternity

A new mother who has been insulin dependent for eight years just delivered spontaneously an 8 pound, 4 ounce infant/3740 grams infant. The nurse obtains a blood glucose reading of 112 mg/dL when the infant is 8 hours old. What is the best nursing action for this client? A. Consult the sliding scale for insulin administration. B. Document the finding in the client's chart. C. Have the charge nurse double check the finding. D. Notify the health care provider (HCP) of this unexpected finding.

B An insulin-dependent diabetic mother may have no insulin requirements during the first 24 hours after the baby is born. This is a normal finding for the client. There is no need for a sliding scale, or to have another nurse check the finding. This finding is expected, so no need to notify the HCP.

A client in early labor is requesting pain medication. The health care provider prescribes butorphanol 0.5 mg IV × 1 now. The only butorphanol available is in a concentration of 2 mg/mL. How many mL will the nurse deliver to the client?

0.25 X m = 1 mL × 0.5 mg = 0.5 = 0.252 mg

A multigravida states to the nurse, "I have to push." The client had a cervical exam less than 10 minutes prior and she was 5/+1/100%. What is the nurse's next action? A. Perform a cervical assessment. B. Encourage the client to pant with contractions. C. Tell the client it is too soon to push. D. Contact the health care provider.

A A multigravida can progress through labor quickly. The head is well applied to the cervix at +1 station. Perform the assessment to determine if she can push. Panting with contraction is good, but it does not evaluate cervical progress. Because the head is down so low, telling the client it is too soon to push may be incorrect information. The HCP will need to be contacted if delivery is imminent.

The nurse is performing teaching for a pregnant client who has been an insulin dependent diabetic since she was 13 year old. Which statement indicates to the nurse that the teaching was effective? A. "My insulin requirements will likely increase around 24 weeks gestation." B. "I will have to take my insulin 4 to 6 times a day between now and 20 weeks." C. "My baby will be born with diabetes and will depend on insulin for life." D. "I will require a cesarean section to safely deliver this baby."

A After the first trimester, placental hormones cause insulin resistance and insulin requirements generally increase at that time through birth. Insulin needs decrease the first trimester. Maternal diabetes does not guarantee the development of diabetes in the newborn. While many moms with diabetes have a cesarean section, it is more likely related to the size of the fetus, as they are often macrosomic. That determination is made closer to term.

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the mother's teaching plan? A. Avoid alcohol within two hours before the next feeding. B. Eat a high-roughage diet to help prevent constipation. C. Increase caloric intake by approximately 500 cal/day. D. Increase fluid intake to at least 3 quarts each day.

A Alcohol should be avoided while breastfeeding because it is excreted in breast milk and may cause a variety of problems, including slower growth and cognitive impairment for the infant. However, if alcohol is consumed, it should be consumed no later than two hours before the next feeding. Options B, C, and D should also be included in diet teaching for a breastfeeding mother; however, because these do not involve safety of the infant, they do not have the same degree of importance as option A.

Twenty-four hours after admission to the newborn nursery, the nurse assesses a full-term infant who has developed localized swelling on the right side of the head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line? A. Cephalohematoma, which is caused by forceps trauma B. Subarachnoid hematoma, which requires immediate drainage C. Molding, which is caused by pressure during labor D. Subdural hematoma, which can result in lifelong damage

A Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on the cranium during vaginal delivery, and is a common variation of the newborn. Options B and D both involve intracranial bleeding and could not be detected by physical assessment alone.

A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for discharge. Which nursing action should be included in this infant's discharge teaching plan? A. Observe the parents applying a Pavlik harness. B. Provide a referral for an orthopedic surgeon. C. Schedule a physical therapy follow-up home visit. D. Teach the parents to check for hip joint mobility.

A It is important that the hips of infants with hip dysplasia are maintained in an abducted position, which can be accomplished by using the Pavlik harness; this keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum. Early treatment often negates the need for surgery, and option B is not indicated until approximately 6 months of age. Option C is not indicated for hip dysplasia. It is best for the pediatrician to monitor hip joint mobility, and teaching the parents to perform this technique is likely to increase their anxiety.

A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? A. Breastfeed the infant, ensuring that both breasts are completely emptied. B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast. C. Breastfeed on the unaffected breast only until the mastitis subsides. D. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.

A Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue. Option B is less painful but does not facilitate complete emptying of the breast tissue. Option C will not relieve the engorgement on the affected side. Option D will not decrease antibiotic effects on the infant.

The nurse is providing care to an infant at 24 hours old. Upon assessment, the nurse observes milia on the newborn's nose. What is the nurse's next action? A. Document the findings in the newborn's chart. B. Ask another nurse to confirm the findings. C. Assess the mother for the presence of milia. D. Contact the pediatric health care provider.

A Milia are common tiny white raised areas, generally located on an infant's nose or face. They are self-resolving, requiring no immediate medical attention. Teach the mother that the milia will generally resolve in a month. Only documentation is required for this client.

On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on February 15 and that previously her periods were regular (28-day cycle). Her pregnancy test is positive. What is this client's expected date of birth? A. November 22 B. November 8 C. December 22 D. October 22

A Option A correctly applies the Nägele's rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15 + 7 = 22). Options B, C, and D are not calculated correctly.

The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? A. Two weeks before menstruation B. Immediately after menstruation C. Immediately before menstruation D. Three weeks before menstruation

A Ovulation occurs 14 days before the first day of the menstrual period. Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of the menstrual cycle varies. Options B, C, and D are incorrect.

A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A. Come to the clinic today for an ultrasound. B. Go immediately to the emergency department. C. Lie on your left side for about 1 hour and see if the bleeding stops. D. Take a urine specimen to the laboratory to see if you have a urinary tract infection (UTI).

A Third-trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound. Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which is life threatening to the mother and fetus. If those symptoms were described, option B would be appropriate. Option C does not address the cause of the symptoms. The client is not describing symptoms of a UTI.

A prenatal client at 35 weeks gestation reports to the clinic for routine prenatal care. The nurse assesses the client and notices: constricted pupils, erratic behavior, and multiple injection marks along the veins of both of the client's arms. What is the nurse's next action? A. Notify the health care provider. B. Ask the client who is her supplier. C. Ask the client if she uses condoms when having sex. D. Report this client to the Department of Human Services.

A This client demonstrates signs of IV recreational drug use. This client needs help and can only be prescribed by the care provider. Knowing the supplier of the drugs and condom use are irrelevant to the client's immediate needs. A social worker will likely contact DHS, if needed.

The nurse is providing care for a woman who just delivered. The umbilical cord extends from the vagina accompanied by a gush of blood. What is the next nursing action? A. Massage the fundus. B. Take the mother's blood pressure. C. Place a straight catheter. D. Assign the second Apgar score.

A These are signs that the placenta has separated from the uterus. Implement interventions that would promote the uterus to contract, such as massaging the fundus or placing the infant to breast. If oxytocin is in use, the health care provider may prescribe a rapid infusion of oxytocin. This is a normal finding with the delivery of the placenta. The increase in blood volume with pregnancy accommodates this gush of blood and therefore the blood pressure will not be impacted. There is no indication in the normal scenario that a catheter is indicated. It can take up to 30 minutes for the uterus to release the placenta. The second Apgar needs to be assessed at 5 minutes after birth.

The nurse is preparing to administer an IV pain medication to a client in labor. What will the nurse include in this client's plan of care related to the administration of the medication? (Select all that apply.) A. Administer the medication only when the client is having a contraction. B. Assess the fetal heart rate (FHR) for 10 minutes prior to administering the pain medication. C. Stop the mainline IV fluid during the administration of the medication. D. Have the mother do slow, deep-chest breathing during the administration. E. Use a 16-gauge needle to administer the medication through the existing IV. F. Inject the medication into the existing mainline bag of D5LR.

A, B Administering the IV pain med during a contraction decreases the initial amount of analgesic to the fetus. Assessing the FHR prior to the administration establishes a baseline. Analgesics can often decrease FHR variability. Stopping the mainline fluid would produce a bolus of analgesic when restarting the mainline fluid. Deep chest breathing is often used in early labor. There is no indication of the phase of labor in the stem. A 16-gauge needle is a large bore needle use for rapid infusion. This medication does not need to be delivered rapidly. IV analgesics are administered through the post closest to the patient and not through the mainline fluid.

The clinic nurse takes a phone call from a client who reports she is at 12 weeks gestation. Which statements indicate to the nurse the client may be having a spontaneous abortion? (Select all that apply.) A. "I am having severe abdominal cramping." B. "I am passing blood clots from my vagina." C. "I have a low-grade fever of 99°F/37.2°C." D. "My partner and I had sex last night." E. "My blood type is O negative."

A, B Vaginal bleeding and passing clots or tissue before 20 weeks gestation with cramping are signs indicative of a spontaneous abortion. A low-grade fever and sexual intercourse do not support the signs of a spontaneous abortion. If a client is O negative and has a spontaneous abortion, she will need to be treated with RhoGAM.

The nurse is providing care for a laboring client with a GTPAL of 65005 at term. Which assessments will the nurse include in this client's plan of care for after delivery? (Select all that apply.) A. Fundal assessment should be made every 5 minutes for 30 minutes after delivery of the placenta. B. Assess for lochia every 5 minutes for 30 minutes after delivery of the placenta. C. Place the infant to breast immediately after delivery. D. Encourage the mother to talk to her newborn. E. Wrap the infant in a warm, sterile blanket immediately after delivery.

A, B , C This client is at risk for a postpartum hemorrhage. The fundus needs to remain firm and frequent assessment is needed to evaluate the fundus and flow of the lochia. Placing the infant to breast will stimulate the release of oxytocin to help the uterus to contract. Talking to the infant encourages bonding. Ideally, the infant will be placed on the maternal chest or abdomen to facilitate heat transfer. There is no need for a sterile blanket.

The labor and delivery nurse is admitting a client at 34 weeks gestation who reports contractions every 3 to 4 minutes for the past hour. What will the nurse include in the client's plan of care? (Select all that apply.) A. Place an electronic fetal monitor. B. Collect a urine sample. C. Left lateral position. D. Administer fluids. E. Dim the lights.

A, B, C, D Monitoring the frequency and duration of the contractions, and the fetal response to the contractions is essential. A urine sample may indicate a urinary tract infection which could stimulate contraction. Left lateral position will take the weight of the fetus off of the major blood vessels. Preterm labor may be caused by dehydration, so fluids are necessary. Dim the light is for the mom with gestation hypertension when the nurse is concerned about seizure activity, and an action that is not necessary for this client.

The nurse is providing care to a client at term undergoing an oxytocin induction. At last check she was 6/+1/100%. For the most recent five contractions, the fetal heart rate has fallen below the baseline after the onset of the contraction, and returns to baseline 20 to 30 seconds after the end of the contraction. What actions must the nurse take? (Select all that apply.) A. Contact the health care provider. B. Stop the infusion of oxytocin. C. Increase the infusion of the mainline IV fluid. D. Apply oxygen by facemask. E. Reposition the client.

A, B, C, D, E The fetal heart rate patterns are displaying a pattern of late decelerations, which is a sign of utero-placental insufficiency. Actions must be taken to increase placental perfusion. This is an obstetrical emergency and the health care provider must be notified.

During stage two of labor, what assessments must the labor nurse perform? (Select all that apply.) A. Fetal heart rate before the contraction B. Fetal heart rate during the contraction C. Fetal heart rate after the contraction D. Frequency of contractions E. Duration of contractions F. Uterine tone between contractions

A, B, C, D, E, F The nurse must assess the fetal heart rate before, during and after the contractions to determine the fetal response to the contractions. Frequency may slow during the second stage. Duration will help facilitate decent of the presenting part. The uterine tone between contractions should be soft to facilitate placental filling after the contraction.

As the placenta is delivered during a cesarean section the health care provider states, "It looks like at least a 25% abruption." Which concerning signs will the postpartum nurse include in the client's assessment? (Select all that apply.) A. Bleeding gums B. Petechia C. Hypertension D. Oozing blood from IV site(s) E. Bradycardia

A, B, D The client is at risk for disseminated intravascular coagulation (DIC) from the blood loss with an abruption. This disease impairs the ability of the blood to clot. Signs of DIC include bleeding/bruised gums, petechial on pressure points such as under a blood pressure cuff or on the back, oozing of blood from previous puncture sights, such as an IV or injection sight. The client may have tachycardia and hypertension to compensate for the blood loss.

The nurse is reviewing the prenatal record for a client scheduled for a glucose challenge test. Which maternal findings place this client at an increased risk for developing gestational diabetes? (Select all that apply.) A. The client is 37 years old. B. The client is pregnant for the second time. C. The client is having twins. D. The client's pre-pregnant weight was 190 pounds/86 kilograms. E. The client's blood pressure is 132/88 mm Hg.

A, C, D Risk factors for gestational diabetes include maternal age over 35, multiple gestation, obesity, family history of diabetes and large gestational fetus. Multiparity and a slightly elevated blood pressure are not risk factors for gestational diabetes.

The nurse is teaching the pregnant client about fetal growth and development. Which client statements indicate understanding of the teaching? (Select all that apply.) A. My baby gets oxygen through the placenta. B. I can eat all I want the last 4 weeks of pregnancy. C. The amniotic fluid helps with muscle development. D. I need to stay under a blanket, to keep my baby warm. E. My baby will gain about a half a pound per week after 36 weeks.

A, C, E Caloric intake increase should be about 500 additional calories per day at 36 to 40 weeks gestation. The amniotic fluid keeps the fetus in a thermal environment. No need to stay under a blanket. The remaining statements are true.

A client is admitted to the hospital at 28 weeks of gestation in preterm labor. The nurse administers three doses of terbutaline sulfate, 0.25 mg subcutaneously. Which side effects will the nurse anticipate for this client? (Select all that apply.) A. Feeling of nervousness B. Depressed reflexes C. Tachycardia D. A flushed warm feeling E. Restlessness

A, C, E Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of nervousness. Options B and D are side effects of magnesium sulfate.

The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor? (Select all that apply.) A. Pain in the lower back that radiates to abdomen B. Contractions decreased in frequency with ambulation C. Progressive cervical dilation and effacement D. Discomfort localized in the abdomen E. Regular and rhythmic painful contractions

A, C, E These are all signs of true labor. Options B and D are signs of false labor.

A pregnant teen says to the nurse, "I hope nothing happens to my breasts while I am pregnant!" What will the nurse include in the client's plan of care regarding breast changes in pregnancy? (Select all that apply.) A. Areola darkening B. Retraction of the nipple C. Breasts become shiny D. Veins easier to see under the skin E. Pinkish nipple discharge

A, D Areola becomes darker and the veins in the breast are more pronounced. Nipples become pronounced, not retract. Shiny skin indicates accumulation of fluid under the skin with stretching. Discharge from the nipple may be colostrum, which is creamy and light yellow.

The health care provider states to the nurse, the baby is in a left occiput anterior (LOA) position. The laboring client asks, "What does that mean?" What descriptions will the nurse use when teaching the client about the LOA fetal position? (Select all that apply.) A. "The baby's head is in your pelvis." B. "The baby's feet can be felt on your left side." C. "The baby's back is on your right side." D. "That is the ideal fetal birthing position." E. "The baby is looking down towards the floor"

A, D, E In an LOA position the baby is head down, the occipital bone in in the anterior portion of the maternal pelvis, the fetal back is on the maternal left side, the breech is in the fundus of the uterus and the feet are on the opposite side of the back.

The nurse is teaching a nursing student about the abbreviation GTPAL to note pregnancy outcomes. The nurse determines the teaching was successful when the students relates the abbreviation GTPAL to which terms? (Select all that apply.) A. Gravidity B. Total C. Parity D. Born Alive E. Living

A, E Gravidity and Living are correct. T - term pregnancies, born after 37 weeks gestation. P - preterm pregnancies, born between 20 and 37 weeks. A - abortions, delivery before 20 weeks.

The nurse is providing care to an infant born 2 minutes ago with an Apgar of 8 at one minute. What nursing actions must the nurse include in the newborn's plan of care over the next 30 minutes? (Select all that apply.) A. Temperature B. Heart rate C. Apgar score D. Blood pressure E. Blood glucose

A,B,C Temperature indicates if the newborn is thermodynamically stable. Heart rate supports circulation status of the newborn. The first Apgar score is performed at 1 minute and the second at 5 minutes of age. Blood pressure and blood glucose are not indicated unless the newborn appears somehow compromised.

A primigravida at term presents to the labor and delivery unit smiling and states to the nurse, "I am in labor." The nurse assesses the client's cervical dilation and finds it is 2/50%/-1. The fetal heart rate is stable at 135 to 145 beats/min, and membranes are intact. Maternal vital signs are stable. What are the nursing actions for this phase/stage of labor? (Select all that apply.) A. Encourage the mother to ambulate. B. Have the mother use slow, deep breathing with contractions. C. Encourage the mother to urinate every 1 to 2 hours. D. Assess the fetal heart tones every 15 minutes. E. Assess for cervical dilation every hour.

A,B,C The client is in the latent phase of the first stage of labor. Ambulation will encourage fetal descent. The contractions are mild in this phase and deep chest breathing will help facilitate relaxation. Urination will help keep the pelvic area evacuated, to promote fetal descent. Fetal heart tones are assessed every 30 to 60 minutes, depending on the protocol of the birthing facility. Frequent assessment of cervical dilation can introduce infection. Cervical dilation should only be performed as needed.

A client at term presents to labor and delivery in spontaneous labor; contractions are occurring every 3 to 4 minutes and they are 60 seconds in duration. The client states to the nurse, "I think I have a break out of my genital herpes." What actions will the nurse take next? (Select all that apply.) A. Observe the client's perineum. B. Contact the health care provider. C. Assess ongoing acyclovir treatment. D. Open a vaginal delivery pack. E. Assess her partner's penis for lesions.

A,B,C The nurse needs to verify the client's statement. The health care provider will determine the route of delivery. If active lesions are present, the recommendation is for a cesarean section. Clients with known genital herpes can be treated throughout pregnancy. At 36 weeks, prophylactic antiviral treatment may be initiated. Do not open a pack of instruments until the route of delivery is determined. Assessing her partner's penis is not relevant to client care at this time.

The nurse is teaching a prenatal class about the structure of the pelvis and is using a model of a pelvis in the presentation. Which statements will the nurse include in the teaching plan? (Select all that apply.) A. "The baby has to pass through the true pelvis." B. "The pelvis consists of three distinct features." C. "The true pelvis is below the pelvic brim." D. "The ischial spines determine how low the baby is located." E. "The shape of the pelvis does not impact the labor process."

A,B,C,D A gynecoid shape pelvis is the most favorable for birthing. The remaining statements are true.

The nurse is teaching a group of teen girls about their reproductive system and pregnancy. What risk factors for an unplanned pregnancy will the nurse include in the teaching plan for these girls? (Select all that apply.) A. Poverty B. Family problems C. Early onset of menarche D. Sexual exploration E. Group think

A,B,C,D,E These are all high risk factors for an adolescent pregnancy. These risk factors can lead to adverse prenatal outcomes.

An 18-year-old client states to the nurse that she wants to understand all of her options for birth control. What assessments will the nurse include in the client's intake interview? (Select all that apply.) A. Sexual frequency B. History of blood clots C. Comfort in touching her genitalia D. Preferences for different methods E. Religious beliefs F. Allergies

A,B,C,D,E,F If a client has sex frequently, a hormonal method may be best. If sex is infrequent, then a barrier method may be best. If a client has a history of blood clots, then a hormonal method may not be safe for her. If a client is not comfortable touching her own genitalia, then a diaphragm is not for her. Ask the client what she knows about the methods, and her preferences. Preferences will likely increase compliance. If a method causes a spontaneous abortion of a fertilized egg, then that method may not be preferable for some religions. If a client is allergic to latex, that must be known if she is planning on having her partner use a condom.

The nurse is providing care to a 1-hour-old neonate born to mother who took insulin throughout her pregnancy. Which conditions will the nurse include in the infant's assessment throughout its hospitalization? (Select all that apply.) A. Hypoglycemia B. Respiratory distress syndrome C. Hypernatremia D. Congenital anomalies E. Absent Moro reflex

A,B,D Newborn of diabetic mothers are at risk for hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, and congenital anomalies. Hypernatremia and absent neonatal reflexes are not associated with these infants.

An insulin-dependent client with gestational diabetes mellitus is in the second stage of labor. What supplies will the delivery nurse gather for care of the newborn? (Select all that apply.) A. Erythromycin ointment B. Scale C. Vacuum extractor D. Measuring tape E. Blood glucose testing kit

A,B,D,E Erythromycin ointment, a scale, and measuring tape are needed for all deliveries. The neonate is at risk for hypoglycemia after delivery and blood glucose monitoring is necessary. The vacuum extractor may be necessary if the mom is having trouble delivering the infant. However, this piece of equipment is for the mom and not the neonate.

The labor and delivery nurse is providing care to a mother who has experienced a fetal demise in utero at 36 weeks gestation. What will the nurse include in this client's plan of care? (Select all that apply.) A. Contact the hospital chaplain. B. Ask about the last fetal movements. C. Apply the electronic fetal cardiac monitor. D. Ask about plans for labor pain management. E. Ask the parents if they want to hold the baby after birth.

A,B,D,E The chaplain can provide the additional emotional support needed during this difficult time. The chaplain may be present at the birth to baptize the baby, depending on the beliefs of the parents. Asking about last fetal movements can give an approximate indication of when the demise may have occurred. If the baby has been dead for 3 or more weeks, the mom is at risk for developing DIC. Pain management plans are necessary to facilitate the birth of choice for this couple. Ask the parents how involved they want to be with the baby after birth. Age, faith, and culture have implications on these after birth events. The electronic monitor may be useful for timing contractions, but there is no cardiac activity to measure for this fetus.

A client at 34 weeks gestation arrives to the clinic and says to the nurse that she thinks she is having contractions. What actions will the nurse include in this client's plan of care? (Select all that apply.) A. State to her, "Let me know if you have a contraction during your visit today." B. Ask the client, "Are the contractions painful?" C. Tell the client, "You have nothing to worry about." D. Ask her, "Do they come a frequently as every 5 minutes?" E. Tell the client, "It is time for you to go directly to labor and delivery." F. Inform her, "Those could be Braxton-Hicks contractions."

A,B,D,F Braxton Hicks contractions are painless, irregular contractions that often occur in pregnancy. Asking the client to inform the nurse would allow the nurse to palpate the contraction for intensity and determine the duration. Do not dismiss the client's concerns. Contraction that is regular, e.g. every 5 minutes for more than an hour, may be a sign of preterm labor and requires further assessment. There is no need to go to labor and delivery until further assessments determine she is in preterm labor.

A client at 36 weeks gestation presents to labor and delivery and states to the nurse, "I have been leaking fluid for about 2 days now. At first I thought it was urine. Now, I am not so sure." Which nursing actions are most appropriate for this client? (Select all that apply.) A. Assess maternal vital signs. B. Place an electronic fetal monitor. C. Place a peri pad. D. Assess the fluid for a foul odor. E. Obtain a maternal blood glucose. F. Obtain a complete blood count.

A,B,D,F Until rupture of membranes has been ruled out, the nurse must provide care as if they are ruptured. Since it has been 2 days with leaking fluid, the client may have developed chorioamnionitis. With that, the client may be febrile, and the fetus may display tachycardia. A foul odor may indicate an intrauterine infection. A CBC will give an indication of the maternal white count. Additionally, monitor for uterine tenderness. Blood cultures will likely be ordered. A peri pad should not be placed as that may produce a medium for bacterial growth. Maternal blood glucose will not be impacted by chorioamnionitis.

What specific instructions will the nurse include in the pregnancy client's teaching plan who is also human immunodeficiency virus (HIV) positive? (Select all that apply.) A. Use condoms when having sex. B. Zidovudine prescription helps decrease risk of fetal exposure. C. Increase your intake of fruits and vegetables in pregnancy. D. Weekly prenatal appointments 36 weeks through delivery. E. Breastfeeding is not recommended.

A,B,E Condoms are always recommended for clients who are HIV positive. These are true statements about zidovudine and breastfeeding. Fruits and vegetables are good sources of roughage for all pregnant women, not just women with HIV. Weekly prenatal appointments are recommended for all women at 36 weeks to delivery.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instructions are most effective in preventing nipple soreness? (Select all that apply.) A. Massage a small amount of medical-grade lanolin into the nipple. B. Increase nursing time gradually over several days. C. Ensure that the baby is positioned correctly for latching on. D. Manually express a small amount of milk before nursing. E. Wear a cotton bra with nonbinding support.

A,C Medical-grade lanolin is a natural product that restores moisture to the nipple. The most common cause of nipple soreness is incorrect positioning of the infant on the breast for latching on. The baby's body is in alignment with the ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast. Option B is important but is not necessary for all women. Option D helps soften an engorged breast and encourages correct infant latching on but is not the best answer. Option E helps prevent chafing, and nonbinding support aids in prevention of discomfort from the stretching of the Cooper ligament.

The nurse is preparing a memory box of items from the care of an infant who died in utero. What items will the nurse plan on including in the box? (Select all that apply.) A. Measuring tape B. Erythromycin ointment tube C. Infant hat D. Infant blanket E. Bottle of formula

A,C,D The measuring tape, hat, and blanket are mementos from the birth and were used in the care of the infant. There is no need to open supplies, such as the ointment and the bottle of formula, when they will not be used in the care of the infant.

Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.) A. Cramping with bright red spotting B. Increased urination C. Lack of tenderness of the breast D. Increased amounts of discharge E. Increased right-side flank pain

A,C,E Options A and C are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client's menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. Option E could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture. Options B and D are normal signs during the first trimester of a pregnancy.

Which client statement indicates that she understands the instructions of breastfeeding her newborn? (Select all that apply.) A. "Breastfeeding my infant consistently every 3 to 4 hours decreases the likelihood of me ovulating." B. "Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk." C. "I should avoid foods that usually give me gas." D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings." E. "When I feed my baby, I should start on the breast the baby stopped on last." F. "I should drink fluids when breastfeeding my baby, especially at night."

A,C,E,F Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method. Option B is incorrect because alcohol can immediately enter the breast milk. Gas forming vegetables, such as broccoli and onion, can cause the baby to have gases. Taking a warm shower will stimulate the production of milk, which will be more painful after breastfeedings. Baby's will breastfeed until satisfied, which may not empty the second breast and increase the risk for mastitis if breasts are not emptied. Drinking fluids help establish supply of breast milk.

The nurse is preparing a teaching session for a group of newly pregnant women and their significant other. When discussing fatigue early in pregnancy, which statements will the nurse include in the teaching plan? (Select all that apply.) A. "Fatigue is a result from the hormonal changes early in pregnancy." B. "You need to take 4 to 5, 60 minute naps per day." C. "Make sure you keep your fluid intake to 1500 mL/day." D. "Highly caffeinated drinks need to be avoided in pregnancy." E. "Keep up your regular 45 minutes of stationary cycling per day."

A,D,E Fatigue in early pregnancy can come from the hormonal changes associated with pregnancy. Maintaining a regular exercise routine can help combat fatigue. Napping is encouraged, but 4 to 5 hours of napping is excessive. Fluid intake should be at least 2000 mL/day. Avoid fluids and foods that have stimulants.

The labor and delivery nurse is admitting a client at 32 weeks gestation. She reports epigastric pain, weight gain of 10 pounds in 1 week, and spots in front of her eyes. What nursing actions will the nurse include in this client's plan of care? (Select all that apply.) A. Dipstick urine for protein B. Assess for a rigid abdomen C. Briskly tap the costovertebral angle bilaterally D. Assess the patellar reflex bilaterally E. Determine the presence of clonus

A,D,E This client is demonstrating signs of gestational hypertension and possibly preeclampsia. Assess for hypertension and the presence of protein in the urine. Reflexes at >+2 and the presence of clonus assess for hyper-stimulation of the central nervous system. A rigid abdomen is associated with an abruption. Assessment of the costovertebral with a painful response may indicate pyelonephritis.

The nurse is providing care to a 1-hour-old infant. An assessment of gestational age is performed and the nurse estimates the age at 39 to 40 weeks. What findings will the nurse document in the infant's chart? (Select all that apply.) A. Vernix in the creases of the neck B. Lanugo covering the entire back C. Creases over the anterior 1/3 of the foot D. Breast tissue less than 0.5 cm in both breasts E. Labia majora covers the labia minora.

A,E Vernix in neck creases and the labia majora covering the labia minora are signs of a term infant. Lanugo covering the back, foot creases anterior third and breast tissue less than 0.75 cm are assessment findings associated with preterm infants.

When a new mother receives her infant for the first time, which behavior is most reassuring to the nurse? A. She holds the infant in her lap, undresses the infant, and examines the infant completely. B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. C. She reassures the infant not to cry and she then cuddles the infant to her own body. D. She eagerly reaches for the infant and then hands the baby off to the father.

B Attachment and bonding theory indicates that most mothers will demonstrate behaviors described in option B during the first visit with the newborn, which may be at delivery or later. After the first visit, the mother may exhibit different touching behaviors such as eagerly reaching for the infant and cuddling the infant close to her.

A newly pregnant client is crying loudly and reports to the clinic nurse over the phone that she took a prescribed narcotic pain medication 4 weeks ago. What is the nurse's next response? A. "You have nothing to worry about." B. "When did your last period begin?" C. "Come to the clinic today for an ultrasound." D. "I'll let your health care provider know."

B Begin with an assessment to determine how pregnant the client is. Determine if she ingested the narcotic during the pre-embryonic period, or the time when the fertilized egg is passing through the fallopian tubes. If the embryo is not attached to maternal circulation, there is no cause for concern. Do not offer false reassurance. Data needs to be collected first. Perform non-invasive, low cost assessments first. The health care provider needs to be notified if there is a cause for concern.

The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn at home. The woman tells the nurse, "I don't know what is wrong. I love my baby, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should the nurse determine the client is experiencing? A. Taking-in phase B. Postpartum blues C. Attachment difficulty D. Letting-go phase

B During the postpartum period, when serum hormone levels fall, women are emotionally labile, often crying easily for no apparent reason. This phase is commonly called postpartum blues, which peaks around the fifth postpartum day. The taking-in phase is the period following birth when the mother focuses on her own psychological needs; typically, this period lasts for 24 hours. Crying is not a maladaptive attachment response. It indicates a normal physical and emotional response. The letting-go phase is when the mother sees the child as a separate individual.

The nurse determines that a 22-year-old, pregnant client's normal intake of calcium is approximately 500 mg. The client states she prefers non-fat milk over 2% fat milk. How many additional 8-ounce (30 mL) glasses of non-fat milk will the nurse recommend to meet the minimum daily calcium requirements? A. 1 B. 2 C. 3 D. 4

B Each 30 mL of non-fat milk contains approximately 300 mg of calcium. Adding 2 glasses of milk will increase the calcium intake by 600 mg to a total of 1100 mg daily. This meets the daily intake of 1000 daily.

When returning for the results of her maternal serum alpha-fetoprotein (MSAFP), a primigravida asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to best describe how the test is interpreted? A. If MSAFP estriol levels are high and the human chorionic gonadotropin (hCG) level is low, results are positive for a possible chromosomal defect. B. If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect. C. If MSAFP and estriol levels are within normal limits, there is a guarantee that the baby is free of all structural anomalies. D. If MSAFP, estriol, and hCG are absent in the blood, the results are interpreted as normal findings.

B Low levels of MSAFP and estriol and elevated levels of hCG found in the maternal blood sample are indications of possible chromosomal defects. High levels of MSAFP and estriol in the blood sample after 15 weeks of gestation can indicate a neural tube defect, such as spina bifida and anencephaly, not chromosomal defects. One of the limitations of the multiple marker screening is that any defects covered by skin will not be evident in the blood sampling. After 15 weeks of gestation, there will be traces of MSAFP, estriol, and hCG in the blood sample.

During a prenatal visit, the nurse discusses with a pregnant client the effects of smoking on the fetus. Which statement is most characteristic of an infant whose mother smoked during pregnancy? A. Lower Apgar score recorded at delivery B. Lower initial weight documented at birth C. Higher oxygen use to stimulate breathing D. Higher prevalence of congenital anomalies

B Smoking is associated with low-birth-weight infants. Therefore, mothers are encouraged not to smoke during pregnancy. Options A, C, and D have not been clearly associated with smoking during pregnancy, but there is a strong correlation between smoking and lower birth weights.

The postpartum client has a rubella vaccine ordered prior to discharge. The nurse reviews with the student nurse the proper technique to use when administering this immunization. Which student statement indicates to the nurse the correct technique is planned? A. At a 90 degrees angle B. At a 45 degrees angle C. Into the client's vein D. Under the client's tongue

B The preferred route for administration of the rubella vaccine is subcutaneous. A subcutaneous administration of a medication is delivered at a 45 to 60 degrees angle. A 90 degrees angle is for an IM injection. Delivering the immunization into a vein is for the IV route. Sublingual route is for under the tongue.

A new mother asks the nurse, "How do I know that my baby is getting enough breast milk?" Which explanation is most appropriate? A. "Make sure you weigh the baby at the same time every day to assure weight gain." B. "Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." C. "Offer the baby extra no less than 3 ounces of bottled milk after each feeding." D. "If you're concerned, you might consider bottle feeding so that you can monitor intake."

B The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative of adequate nutrition, most home scales do not measure this accurately, and the suggestion will likely make the mother anxious. Option C causes nipple confusion and diminishes the mother's milk production. Option D does not address the client's question.

The clinic nurse is performing an assessment on a client who is 20 weeks gestation, which was confirmed by ultrasound. When performing the fundal height assessment, where will the nurse start palpating the abdomen? A. Midway between the symphysis pubis and the umbilicus B. At the umbilicus C. Between the umbilicus and the xiphoid process. D. Two cm below the xiphoid process.

B The uterus enlarges 1 cm per week after about 18 weeks of pregnancy, ± 2 cm. At 20 weeks the uterus should be around the umbilicus. By 38 weeks the uterus is at the xiphoid process.

The laboring client at term states to the nurse, "I think my water just broke." The nurse observes a shiny, gelatinous, rope-like structure protruding from the client's vaginal area. What is the next nursing action? A. Call for help. B. Place the client in knee-chest position. C. Increase the mainline IV fluids. D. Reassure the client.

B This client is showing signs of an obstetric emergency of a prolapsed umbilical cord. Compression of the cord can lead to fetal anoxia. Placing the client in knee-chest position reduces the weight of the presenting part off of the cord. The nurse will need to complete the remaining options, but oxygenation of the fetus takes priority.

The laboring client requests an epidural placement for labor pain. The standing order is for 1000 mL of LR to infuse over 15 minutes prior to the placement of the epidural. The client asks, "How come I have to have so much fluid so fast?" What is the nurse's best response? A. "It is to prevent supine hypotension." B. "It is to help prevent low blood pressure." C. "It is to ensure adequate oxygenation to just your brain." D. "It will help you keep cool during epidural placement."

B With epidural placement, vascular relaxation can occur with subsequent hypotension. Increasing the fluid volume can help place increased tension on the vascular space, and combat the possible hypotension with the placement of an epidural. Supine hypotension occurs when the weight of the fetus is on the vena cava, resulting in hypotension. Hypotension can cause a decrease in oxygen to all of the major organs, and to the fetus. An increase in fluid volume is not related to if a client feels warm or cool.

A client at 34 weeks gestation reports to the clinic nurse that she has frequent indigestion. What should the nurse include in the client's teaching plan? (Select all that apply.) A. "I'll ask your health care provider to prescribe ondansetron for you." B. "Have you tried taking Tums for your indigestion?" C. "The baby is getting big, which reduces the size of the stomach." D. "Try eating small meals, 6 times per day." E. "You have no cause to be worried."

B, C, D Calcium carbonate (Tums) is safe to take during pregnancy and is effective over-the-counter treatment for indigestion. At 34 weeks the fetus is about 4 cm below the xiphoid and crowding the abdominal contents. Since the stomach is smaller, eating small and frequent meals may help the indigestion. Ondansetron, or Zofran, can be used in pregnancy, but is not an initial treatment. Reassure the client, not dismiss her concern with "You have no cause to be worried."

The clinic nurse is reviewing phone messages left from postpartum clients during the lunch break. Which calls will the nurse return before the others? (Select all that apply.) A. The mother who reports her baby who is having trouble latching on to her breast while feeding. B. The mother who reports her vaginal discharge went from brown to bright red. C. The mother who reports her vaginal flow smells "like a chicken farm." D. The mother who reports she had sex before her six-week check-up. E. The breast-feeding mother who reports redness and a painful right breast.

B, C, E Vaginal discharge should go from red to brown to white. Recurrence of bright red blood is an indication to be seen by her health care provider. Postpartum vaginal flow should have the same odor of menstrual flow. A foul smell indicates a uterine infection. Painful, unilateral and red breast is an indication of mastitis. As these reports present a concern for maternal health, these are the priority calls to return. Trouble latching on may need a consult by the lactation nurse. Having sex before the six week check-up may pose a risk for infection. There were no reported signs of infection from the caller, which decreases the urgency of the return call

The clinic nurse is performing a fundal height assessment on a client in her third trimester. The client states to the nurse, "I am feeling very dizzy when you are pressing on my belly." What are the nurse's best actions to this comment? (Select all that apply.) A. Encourage deep breathing. B. Turn the client to her left side. C. State, "I knew that would happen!" D. Say, "This will only take a few more seconds." E. State, "That is from your baby pressing down on your blood vessels."

B, E The client is exhibiting signs of supine hypotension. Turn the client to her side and inform her of why she was feeling dizzy. Use this as a teaching moment for positioning while at home. Deep breathing promotes relaxation and is not the root cause for this symptom. "I knew that would happen" is non-therapeutic and offers no client reassurance. Prolonging the assessment will only exacerbate the symptoms.

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of bloating. Which nursing action takes the highest priority? (Select all that apply.) A. Call the health care provider to obtain an order to increase her diet. B. Administer the ordered magnesium hydroxide. C. Encourage her to change position every 30 minutes. D. Turn out the lights and discourage visitors. E. Encourage her to breast feed every two hours.

B,C Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. Options A and B are both caused by impaired bowel motility. Option D is not as important as impaired motility.

The pregnant client at 28 weeks gestation complains to the nurse about hemorrhoid pain. What suggestions should the nurse offer the client? (Select all that apply.) A. "Place an ice pack to the hemorrhoids for 60 minutes, three times a day." B. "Find a soft pillow when you are sitting at your desk at work." C. "Walk for 30 minutes at least twice a day." D. "Eat one cup of raspberries or a medium pear every day." E. "Increase your daily protein to 100 g/day."

B,C,D Sitting in a warm sitz bath can bring comfort to hemorrhoid pain. Sitting on a soft pillow can decrease the discomfort associated with hemorrhoid pain. Regular exercise, an increase in fluid and fiber intake can decrease the chances of constipation, and consequently the pain from hemorrhoids. The duration of the ice pack is too long and can damage the tissue. The nutritional guidelines indicate an increase in fiber and fluids, not in protein.

The clinic nurse is providing care to a client at 28 weeks gestation. The client asks, "What does my baby look like now?" How will the nurse respond? (Select all that apply.) A. "Your baby is about 14 inches long." B. "Your baby weighs about 2.5 pounds." C. "The baby's arms are bent at the elbows." D. "Your baby can open and close its eyes now." E. "The baby has fat under its skin."

B,C,D The baby's length is about 10.75 inches long at 28 weeks. Subcutaneous fat forms at about 32 weeks. The remaining characteristics are true.

The nurse is providing care to a laboring client with a GTPAL of 75015. The client reports contractions every 2 to 8 minutes, of moderate intensity, for the past 6 hours. Her cervical exam upon admission is 4/0/75%, and membranes are intact. In the next 20 minutes, what supplies will the nurse gather for this client? (Select all that apply.) A. Erythromycin ophthalmic ointment B. Amnihook C. 1000 mL of D5LR D. Oxytocin E. Blankets

B,C,D This client is having irregular contractions and is at risk for a dysfunctional labor. Since the head is a 0 station, an amniotomy may help facilitate the progress of labor. Also, to help with the progress of labor, the client may need hydration and augmentation with oxytocin. This client's labor may progress quickly once a regular contraction pattern is established; however, birth is not imminent which would require the ointment and the blankets.

The nurse is preparing an infusion of oxytocin to induce labor for a newly admitted client. The order reads, place 30 units of oxytocin in 500 mL of normal saline and start at 1 mL/hour. Increase by 1 mL every 30 minutes until contractions are every 3 to 4 minutes. Oxytoxin is packaged in a glass vial that reads, 1 mL contains 10 units. What supplies will the nurse need to gather to start the infusion? (Select all that apply.) A. 1000 mL bag of normal saline B. Three vials of oxytocin C. 22 gauge IV catheter D. Alcohol wipe E. IV start kit F. One or three mL syringe

B,D,E,F Normal saline is for the oxytocin infusion and the order reads 500 mL not 1000 mL. The main line IV fluid will be a fluid such as D5LR, or LR, for hydration. Three vials of oxytocin equals 30 units, the alcohol wipe will be to open the glass vial to avoid a cut by the glass vial. A 22 gauge IV catheter is too small for an induction. Pregnant women have a nearly 50% increase in their blood volume. In a healthy pregnant woman there is generally no problem inserting an 18 gauge IV catheter. The 1 or 3 mL syringe is used to draw up the oxytocin for the infusion.

The nurse is discussing many of the changes a pregnancy brings to a couple. Which of the father's statements concerns the nurse the most? (Select all that apply.) A. "I am not sure I know how to be a father." B. "I do not want to be a father!" C. "I did not think pregnancy would happen so soon." D. "I am not sure I want to share my wife with a newborn." E. "I am sure I am not the father of this baby."

B,E It is normal for the father to express feelings of ambivalence towards fatherhood, and sharing his wife's attention. Concerning statements include denial of fatherhood.

The labor and delivery nurse is providing care to a client at term with known cardiac disease. Which focused assessments will the nurse include in the client's plan of care? (Select all that apply.) A. Elevated temperature B. Cough C. Fetal tachycardia D. Uterine tenderness E. Dyspnea F. Chest pain

B,E,F Signs of cardiac stress include cough, fatigue, dyspnea, chest pain, and tachycardia. An elevated temperature, fetal tachycardia, and uterine tenderness are signs of an intrauterine infection.

Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home? A. Wash the cord frequently with mild soap and water. B. Cover the cord with a sterile dressing. C. Allow the cord to air-dry as much as possible. D. Apply. baby lotion after the baby's daily bath.

C Recent studies have indicated that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process. Options A, B, and D are incorrect because they promote moisture and increase the potential for infection.

(table) The nurse is providing care to a first time mom in labor. Which assessment finding is most concerning to the nurse? Use the chart above for the finding. A. Slow breathing with mild contractions. B. Epidural placed at 5 cm dilated. C. Head at −2 station. D. Oxytocin augmentation begun.

C Cephalopelvic disproportion indicates the head is not fitting through the pelvis. As labor progresses the head should descend from −2 to +2. The remainder are expected findings.

A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide? A. Lie on your left side and call 911 for emergency assistance. B. Take an antacid and call back if the pain has not subsided. C. Take your blood pressure now, and if it is seriously elevated, go to the hospital. D. See your health care provider to obtain a prescription for a histamine blocking agent.

C Checking the blood pressure for an elevation is the best instruction to give at this time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension. Additional data are needed to confirm an emergency situation as described in option A. Options B and D ignore the threat to client safety posed by a significant increase in blood pressure.

The nurse is reviewing the findings from a pregnant client's glucose challenge test. The results were 156 mg/dL. What is the best nursing action related to this finding? A. Review the term macrosomia with the client. B. Inform the client of signs of hyperglycemia. C. Schedule the client for a return appointment in 1 week. D. Provide the client with information on recording fetal kick counts.

C Clients undergo a glucose tolerance test (GTT) if the initial blood glucose level for the screening is between 140 to 179 mg/dL. The GTT is performed 1 week after the glucose screening test. Macrosomia, or a large baby, is a complication of GDM in pregnancy, but that diagnosis has not been confirmed. Signs of hyperglycemia, hypoglycemia, glucosuria, and ketonuria need to be reviewed when the client is diagnosed with GDM. Since this client is between 24 and 28 weeks gestation, kick counts are not indicated at this gestation.

The clinic nurse is performing an initial assessment. The client states to the nurse, "I must be pregnant. My breasts are tender; my last period was 5 weeks ago; and, I feel nauseous in the mornings. What is the nurse's best response? A. "Your signs indicate you are pregnant." B. "A pregnancy sounds likely." C. "Have you done a home pregnancy test?" D. "Let's see if I can hear a heartbeat with the Doppler."

C Low cost assessments first to determine if the hormones of pregnancy are causing her symptoms. Other physiologic changes may be responsible for her presenting symptoms. She is displaying presumptive signs of pregnancy. Likely or probable signs are associated with uterine changes, e.g. Chadwick's sign, Goodell's sign, Hegar's sign. Doppler can detect the fetal heart rate around 10 to 12 weeks gestation.

A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. What is the nurse's best action? A. Telling the client and her partner that the labor process is often unpredictable B. Informing the client that this means she will give birth sooner than expected C. Asking the client and her partner if they would like the nurse to stay in the room D. Affirming that the fetal heart rate is remaining within normal limits

C Offering to remain with the client and her partner offers support without providing false reassurance. The length of labor is not always predictable, but options A and B do not offer the client the support that is needed at this time. Option D may be reassuring regarding the fetal heart rate but does not provide the client the emotional support she needs at this time during the labor process.

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. The head is really funny looking." Which response by the nurse is best? A. "This is not an unusually shaped head, especially for a first baby." B. "It may look odd, but newborn babies are often born with heads like that." C. "That is normal. The head will return to a round shape within 7 to 10 days." D. "Your pelvis was too small, so the head had to adjust to the birth canal."

C Option C reassures the mother that this is normal in the newborn and provides correct information regarding the return to a normal shape. Although option A is correct, it implies that the client should not worry. Any implied or spoken "don't worry" is usually the wrong answer. Option B is condescending and dismissing; the mother is seeking reassurance and information. Option D is a negative statement and implies that molding is the mother's fault.

A 38-week primigravida works as an office assistant and sits at a computer 8 hours each day. She tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities? A. Wear support stockings. B. Reduce salt in the diet. C. Move about every hour. D. Avoid constrictive clothing.

C Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous return. Option A would increase venous return from varicose veins in the lower extremities but would be of little help with swelling. Option B might be helpful with generalized edema but is not specific for edematous lower extremities. Option D does not address venous return, and there is no indication in the question that constrictive clothing is a problem.

(table) The nurse is preparing a teaching plan for newly pregnant women. What physiologic skin changes will the nurse include in the plan?Match the term with the common definition. A. (1:A); (2:B); (3:C); (4:D) B. (1:B); (2:C); (3:D); (4:A) C. (1:C); (2:D); (3:A); (4:B) D. (1:D); (2:A); (3:B); (4:C)

C Striae gravidarum are commonly known as stretch marks, they are purplish red marks that can occur in the abdomen, thighs, upper arms, and breasts. Linea nigra is the dark brown streak down the midline of the abdomen. Chloasma is also known as the mask of pregnancy, which are blotches of hyperpigmentation of the forehead, cheeks, and nose. Spider nevi are spider veins that occur on the neck, chest, face, arms, and legs.

The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information? A. Maternal blood pressure B. Maternal temperature C. Fetal heart rate (FHR) D. White blood cell count (WBC)

C The FHR should be assessed before and after the procedure to detect changes that may indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix is favorable. The fluid should be assessed for color, odor, and consistency. Option A should be assessed every 15 to 20 minutes during labor but is not specific for AROM. Option B is monitored hourly after the membranes are ruptured to detect the development of amnionitis. Option D should be determined for all clients in labor.

The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign? A. 3 B. 4 C. 5 D. 8

C The Silverman-Anderson index is an assessment scale that scores a newborn's respiratory status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded 0, and a total of 10 indicates maximum respiratory distress. This infant is demonstrating respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory grunting, plus grade 1 for just visible retractions, which is a total score of 5. Options A, B, and D are not accurate.

A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color. Which action should the nurse take next? A. Instruct the client to go to the emergency room. B. Recommend vaginal douching. C. Explain this is a normal finding. D. Determine if ovulation has occurred.

C The client is describing lochia serosa, a normal change in the lochial flow ©. Options A, B, and D are not recommended for this normal finding.

Six hours after an oxytocin induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement? A. Increase the IV fluids. B. Begin oxygen by nasal cannula at 2 L/min. C. Place the client in a slight Trendelenburg position. D. Assess for cervical dilation.

C The goal is to relieve pressure on the umbilical cord, and placing the client in a slight Trendelenburg position is most likely to relieve that pressure. The FHR pattern is indicative of a variable fetal heart rate deceleration, which is typically caused by cord compression and can occur with or without contractions. Option A may be helpful to increase vascular space but is not as likely to relieve the pressure as the Trendelenburg position. Option B is not helpful with cord compression. Option D is not the priority intervention at this time. After repositioning the client, a vaginal examination is indicated to rule out cord prolapse and assess for cervical change.

The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur? A. January 14 to 15 B. January 22 to 23 C. January 29 to 30 D. February 6 to 7

C This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period. The client can expect ovulation to occur January 29 to 30. Options A, B, and D are incorrect.

A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. What will the nurse document in the client's chart regarding her GTPAL? A. 11001 B. 10010 C. 20010 D. 20100

C This is the client's second pregnancy or second gravid event, so option C is correct. The notation includes number of pregnancies, full term, pre-term (between 20 and 37 weeks), miscarriages before 20 weeks and living children. The spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0. Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond. Option A does not take into account the current pregnancy, nor does option B, which also counts the miscarriage as a "para," an incorrect recording. Although option D is correct concerning gravidity, para 1 is incorrect.

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take next? A. Administer oxygen by facemask. B. Notify the health care provider of the client's symptoms. C. Have the client breathe into her cupped hands. D. Check the client's blood pressure and fetal heart rate.

C Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands. Option A is inappropriate because the carbon dioxide level is low, not the oxygen level. Options B and D are not specific for this situation.

When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation? A. Milia are red marks made by forceps and will disappear within 7 to 10 days. B. Meconium is the first stool and is usually yellow gold in color. C. Vernix is a white cheesy substance, predominantly located in the skin folds. D. Pseudostrabismus found in newborns is treated by minor surgery.

C Vernix, found in the folds of the skin, is a characteristic of term infants. Milia are not red marks made by forceps but are white pinpoint spots usually found over the nose and chin that represent blockage of the sebaceous glands. Meconium is the first stool, but it is tarry black, not yellow. Pseudostrabismus (crossed eyes) is normal at birth through the third or fourth month and does not require surgery.

A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan? A. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. B. Wash off the yellow exudate on the glans once every day to prevent infection. C. Place petroleum ointment around the glans with each diaper change and cleansing. D. Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs.

C With each diaper change, the glans penis should be washed with warm water to remove any urine or feces, and petroleum ointment should be applied to prevent the diaper from sticking to the healing surface. Prepackaged wipes often contain other products that may irritate the site. The yellow exudate, which covers the glans penis as the area heals and epithelializes, is not an infective process and should not be removed. If bleeding occurs at home, the client should be instructed to apply gentle pressure to the site of the bleeding with sterile gauze squares and call the health care provider.

The nurse is providing care to a newborn just delivered from a mom who is positive for Hepatitis B. What additional care will the nurse plan for this neonate? (Select all that apply.) A. Place the baby next to the mother's face, eye-to-eye, immediately after delivery. B. Delay the application of eye prophylaxis until 2 to 3 hours after birth. C. Remove any maternal blood from the infant immediately after birth. D. Bathe the neonate prior to administering the vitamin K injection. E. Perform a gastric lavage prior to initiating breastfeeding.

C,D The baby must be cleaned from maternal blood immediately after birth to decrease the risk of newborn Hep B infections. Bathing the baby before the vitamin K will also decrease the risk of infection. Kissing the infant prior to the administration of the hepatitis vaccine is discouraged, to decrease the risk of infection, position the baby to decrease the face-to-face proximity of mother and infant. Perform eye prophylaxis after the face has been cleansed, no need to delay the application of the ointment. No need to perform gastric lavage. Breastfeeding is encouraged.

The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. What is the best nursing action? A. Remove all ice from the client's room. B. Ask the client what foods she might consider eating. C. Remind the client that what she eats affects her baby. D. Notify the health care provider.

D The health care provider should be notified when a client practices pica (craving for and consumption of nonfood substances). The practice of pica may displace more nutritious foods from the diet, and the client should be evaluated for anemia. Option A is overreacting and may be perceived as punishment by the client. Option B allows the dietary department to customize the client's tray but fails to address physiologic problems associated with not consuming nutritious foods in pregnancy. Option C is judgmental and blocks further communication.

A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV infected. Which explanation should the nurse provide? A. Most infants of HIV-positive women will continue to test positive for HIV antibodies. B. Infants who have HIV-positive mothers carry the virus and will eventually develop the disease. C. Medication taken during pregnancy to reduce the mother's viral load ensures that the infant is HIV-negative. D. HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present.

D All newborns of HIV-positive mothers receive passive HIV antibodies from the mother, so the evaluation of an infant for the HIV virus is determined at 18 months of age, when all the maternal antibodies are no longer in the infant's blood. Passive HIV antibodies disappear in the infant within 18 months of age. Option B is inaccurate. Although administration of HIV medication during pregnancy can significantly reduce the risk of vertical transmission, treatment does not ensure that the virus will not become manifest in the infant.

The nurse is discussing the timing of the next prenatal visit for the client at 34 weeks gestation. If the current visit occurred on April 4, which statement indicates the client understands the teaching? A. "See you again on May 2." B. "I will return to the clinic on April 11." C. "My next appointment will be around April 25." D. "I can come in on April 18."

D From 32 to 36 weeks the pregnant client should see her health care provider every 2 weeks. 14 days from April 4 is April 18.

In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan? A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week. B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second week. C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first month. D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.

D In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel closes by the end of the second month. These growth and development milestones are frequently included in questions on the licensure examination. Options A, B, and C are incorrect.

When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. At 16 weeks of gestation B. At 20 weeks of gestation C. At 24 weeks of gestation D. At 30 weeks of gestation

D Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy, when they are beginning to anticipate the onset of labor and the birth of their child. Option D is closest to the time when parents would be ready for such classes. Options A, B, and C are not the best times during a pregnancy for the couple to attend childbirth education classes. At these times they will have other teaching needs. Early pregnancy classes often include topics such as nutrition, physiologic changes, coping with normal discomforts of pregnancy, fetal development, maternal and fetal risk factors, and evolving roles of the mother and her significant others.

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. What is the next nursing action? A. Use thread to tie off the umbilical cord. B. Provide privacy for the woman. C. Reassure the husband and keep him calm. D. Put the newborn to the breast immediately.

D Putting the newborn to the breast will help contract the uterus and prevent a postpartum hemorrhage. This intervention has the highest priority. Option A is not necessary; the infant can be transported attached to the placenta. Option B is an important psychosocial need but does not have the priority of option D. Although the husband is an important part of family-centered care, he is not the most important concern at this time.

The nurse is providing care to a laboring client at term. Which client statement indicates to the nurse that the client is entering stage two of labor? A. "I feel the baby coming out NOW!" B. "I feel like my water just broke." C. "I feel my baby moving around a lot." D. "I feel like I have to push down."

D Stage two is from complete dilation to delivery. Having to push down is often a hallmark sign of this stage. Crowning, or feeling the baby coming out, occurs at the end of stage two. Rupture of membranes and fetal movement are not related to phases and stages of labor.

The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take next? A. Reapply the external transducer. B. Insert the intrauterine pressure catheter. C. Discontinue the oxytocin infusion. D. Continue to monitor labor progress.

D The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should continue to monitor the labor progress and document the findings in the client's record. There is no reason to reapply the external transducer if the FHR tracings are being captured. Options B and C are not indicated at this time.

A 41-week multigravida is receiving oxytocin to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. What is the next nursing action? A. Place a wedge under the client's left side. B. Determine cervical dilation and effacement. C. Administer 10 L of oxygen via facemask. D. Increase the rate of the oxytocin infusion.

D The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate the frequency and intensity of contractions. Options A and C are indicated for fetal stress. A sterile vaginal examination places the client at risk for infection and should be performed when the client exhibits signs of progressing labor, which is not indicated at this time.

An expectant father tells the nurse he is concerned about some of his wife's behaviors. He states that she is constantly rubbing her abdomen and talking to the baby. Which recommendation should the nurse make to this expectant father? A. Suggest that his wife seek professional counseling to deal with her symptoms. B. Explain that his wife is exhibiting ambivalence about the pregnancy. C. Ask him to report similar abnormal behaviors at the next prenatal visit. D. Reassure him that normal maternal-fetal bonding is occurring.

D These behaviors are positive signs of maternal-fetal bonding and do not reflect ambivalence. No intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal bonding during the second trimester. Options A and C are not necessary because the behaviors displayed are normal.

The nurse is providing care to a client who just delivered her sixth term infant. In addition to routine postpartum care, what additional priority nursing action will the nurse include in this client's plan of care? A. Use warm water in the peri bottle to cleanse the peri area after birth. B. Perform fundal assessments every 15 minutes for the first hour after delivery. C. Bring the siblings in to see the newborn at two hours after delivery. D. Weigh the peri pads before and after placement to the peri area.

D This client is at risk for postpartum hemorrhage (PPH). One gram of blood equals one mL of blood loss. Pre and post weighing the peri pad will give a better estimate of blood loss (EBL) after delivery. Warm water to the peri area is a comfort measure, but not as important as the EBL. Fundal massage for this client should be more frequent than every 15 minutes as she is at risk for PPH. Sharing time with siblings is psychosocial; physical needs take priority over psychosocial needs.

One hour following a normal vaginal delivery, a newborn infant's axillary temperature is 96° F/35.6 C, the lower lip is shaking, and when the nurse assesses for a Moro reflex, the baby's hands shake. Which nursing action should the nurse take first? A. Stimulate the infant to cry. B. Wrap the infant in warm blankets. C. Feed the infant formula. D. Obtain a serum glucose level.

D This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level. Option A is an intervention for a lethargic infant. Option B should be done based on the temperature, but first the glucose level should be obtained. Option C helps raise the blood sugar, but first the nurse should determine the glucose level.

The nurse is providing care to a postpartum client with O negative blood who is antibody positive. The newborn is O negative. What is the best nursing action for this client? A. Obtain a consent for a blood transfusion for the infant. B. Explain how RhoGAM works in the maternal blood. C. Prepare the father for the test to determine his blood type. D. Ask the mother if she desires any more children.

D This mother is Rh sensitized by the presence of Rh antibodies in her blood. Once formed, the antibodies will always be present in her blood. If the mother becomes pregnant with an Rh-positive fetus in the future, the baby may become anemic, or suffer an intrauterine death. Since he baby is O-negative, no transfusion is needed. RhoGAM is ineffective if antibodies have formed. No need to test the father since the antibodies have already formed.