Maternal A

A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching?

The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy.

A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take?

The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism.

A nurse is demonstrating to a client how to bathe her newborn. In which order should the nurse perform the following actions? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus outward using plain water. The nurse should then wash the newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump followed by washing the newborn's legs and feet. The last step of the bath should be to clean the newborn's diaper area.

A client who is at 34 weeks of gestation asks the nurse how she will know when she is in labor and should go to the hospital. Which of the following responses should the nurse make?

The nurse should inform the client that a sign of true labor is the bloody show, which is a blood-tinged discharge from the vagina that occurs when the cervix begins to efface and dilate. This is an indication that the client should go to the hospital.

A nurse is teaching a client who is pregnant about managing nausea and vomiting. Which of the following instructions should the nurse include in the teaching?

The nurse should instruct the client to eat high-carbohydrate foods (for example, toast, potatoes, and rice) to decrease nausea and vomiting. The nurse should also instruct the client to avoid spicy, fatty, or fried foods.

A nurse is teaching a new mother about steps the nurses will take to promote the security and safety of the newborn. Which of the following statements should the nurse make?

The nurse should teach the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of her newborn's safety.

A nurse is teaching a client who is at 35 weeks of gestation about clinical manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?

A headache that is unrelieved by analgesia may indicate preeclampsia and should be reported to the provider. Braxton Hicks contractions are an indication that the uterus is preparing for labor and is an expected clinical manifestation at 35 weeks of gestation. Shortness of breath is related to the enlarging uterus interfering with the expansion of the diaphragm and is an expected clinical manifestation at 35 weeks of gestation. Swelling of feet and ankles is due to the enlarging uterus interfering with blood return to the heart and is an expected clinical manifestation at 35 weeks of gestation.

A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take?

The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.

A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching?

The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr prior to testing.

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following?

The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many women experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?

The nurse should report an elevated BUN to the provider since it can indicate dehydration.

A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?

The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops.

A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care?

Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period. Offering the client a glass of cold milk with her first meal should not be included in the plan of care because traditional Hispanic practices include drinking warm beverages following birth. Bathing the client within 12 hr following delivery should not be included in the plan of care because traditional Hispanic practices include delaying bathing for 14 days following delivery. Ambulating the client within 24 hr following delivery should not be included in the plan of care because traditional Hispanic practices include bed rest for 3 days following delivery.

A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?

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

A staff nurse on an obstetric unit is caring for a client who is scheduled for an induced abortion. The staff nurse informs the nurse manager that she has a moral issue with the client's decision. Which of the following actions should the nurse manager take?

The nurse manager should take into account the staff nurse's moral beliefs and recognize that she also has rights and responsibilities concerning the care of a client who is undergoing an induced abortion. Therefore, the nurse manager should reassign the care of the client to another staff nurse.

A nurse is calculating a client's expected date of birth using Naegele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth?

When using Naegele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.

A nurse in an antepartal clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Progress Notes Fundal height 30 cm Good fetal movement Not experiencing headache, dizziness, blurred vision, or vaginal bleeding Fetal heart rate 110/min A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider.

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider. An Hct of 39% is within the expected reference range and is not indicative of a postpartum complication. A serum albumin level of 4.5 g/dL is within the expected reference range. This finding is consistent with mild preeclampsia and does not indicate a worsening of the condition. A WBC of 9,000/mm3 is within the expected reference range.

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse request the provider see first?

A client who is at 11 weeks of gestation and reports abdominal cramping When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first. Wrong Answers A client who is at 15 weeks of gestation and reports tingling and numbness in her right hand A client who is at 20 weeks of gestation and reports constipation for the past 4 days A client who is at 8 weeks of gestation and reports having three bloody noses in the past week

A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

A client who is pregnant should increase her folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects. A client who is pregnant should increase her caloric intake by 340 cal during the second trimester and by 452 cal during the third trimester. A client who is pregnant should consume 3 L of water each day. A client who is pregnant should increase her protein intake to 71 g each day during the second and third trimesters.

A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?

Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions.

A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)?

At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHTs just above the symphysis pubis.

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?

Behavioral responses to a newborn's pain include facial expressions (for example, chin quivering, grimacing, and furrowing of the brow).

A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect?

Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress.

A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?

Epigastric pain is a clinical manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority.

A nurse is assessing a client who is in labor and notes early decelerations on the fetal monitor. Which of the following findings should the nurse identify as a possible cause of the early decelerations?

The nurse should identify fetal head compression as a likely cause of the early decelerations on the fetal monitor. Early decelerations are an expected fetal pattern caused by fetal head compression due to uterine contractions, fundal pressure, and vaginal examinations.

A nurse on the postpartum unit is caring for a client following a cesarean birth. Which of the following assessments is the nurse's priority?

When using the airway, breathing, circulation approach to client care, the nurse should place the priority in the immediate postpartum period on assessing the amount of postpartum lochia. The greatest risk to the client is bleeding and postpartum hemorrhage.

A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first?

When using the urgent vs. nonurgent approach to client care, the nurse should determine that the greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take immediately after delivery is to dry the newborn.

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?

An adverse effect of terbutaline is hypokalemia. Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr. An adverse effect of terbutaline is hypotension. An adverse effect of terbutaline is hyperglycemia.

A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound?

An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?

Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider.

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)

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

A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make?

Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, which will identify whether or not the contractions are adequate for progression of labor.

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?

Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider.

A nurse is teaching a new mother about newborn safety. Which of the following instructions should the nurse include in the teaching?

Room-sharing is recommended during the first few weeks. This allows the parents to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parents to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome.

A nurse is reviewing the medical record of a client who is one day postpartum. The client had a vaginal birth with a fourth-degree perineal laceration. The nurse should contact the provider regarding which of the following prescriptions?

The nurse should not administer a rectal suppository or enema to a client who has a fourth-degree perineal laceration. These can cause separation of the suture line, bleeding, or infection.

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?

Swelling of the face, sacral area, and hands can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.

A nurse is teaching a client who is at 8 weeks of gestation about exercise. Which of the following instructions should the nurse include in the teaching?

The nurse should instruct the client to engage in 30 min of moderate exercise every day to improve muscle tone throughout her pregnancy.

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?

The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation.

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

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

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next?

The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions.

A nurse is observing a new mother caring for her crying newborn who is bottle feeding. Which of the following actions by the mother should the nurse recognize as a positive parenting behavior?

Lays the newborn across her lap and gently sways. This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn.

A nurse is preparing to administer hepatitis B immune globulin to a newborn. The prescription states, "Administer 5 mcg IM once today." Available is a 5 mL vial with 10 mcg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 10 mcg/mL and the prescription reads 5 mcg, it makes sense to administer 0.5 mL. The nurse should administer hepatitis B immunoglobulin 0.5 mL IM.

A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?

The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil. A popliteal angle of 90° is an indicator of physical maturity with increasing gestational age after 26 weeks. Creases over the entire sole of a newborn's foot are an indicator of physical maturity with increasing gestational age after 26 weeks. Raised areolas with 3 to 4 mm buds is an indicator of physical maturity with increasing gestational age after 26 weeks.

A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following images indicates the first step of Leopold maneuvers?

Evidence-based practice indicates the nurse should perform this step first when performing Leopold maneuvers. During this step, the nurse palpates the client's abdomen with her palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus.

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?

Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.

A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take?

Having the client change position is an appropriate intervention for a variable deceleration to relieve umbilical cord compression.

A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse include in the plan of care for lactation suppression?

Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement.

A nurse is teaching a client about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?

Rho(D) immune globulin is given following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.

A nurse is caring for a client and her partner who have experienced a fetal death. Which of the following actions should the nurse take?

Take photos of the newborn to give to the parents. The nurse should create a memory box that includes mementos of the newborn (for example, photos, the newborn's ID bands, the newborn's hat, and the newborn's blanket).

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?

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

A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take next?

When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask to ensure adequate oxygenation to the fetus.

A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?

The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse. From gestational weeks 18 to 32, the height of the fundus is approximately equal to the number of weeks of gestation plus or minus 2 cm. Therefore, the nurse should expect the fundal height for this client should be 16 to 20 cm.

A nurse is providing discharge teaching to a client who is postpartum and was taking insulin for gestational diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

The nurse should instruct the client to get a 2-hr oral glucose tolerance test 6 to 12 weeks postpartum and every 3 years to screen for type 2 diabetes mellitus

A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply.)

A heart rate of 154/min is correct. The expected reference range for a newborn's heart rate is from 110/min to 160/min while awake. An axillary temperature of 36° C (96.8° F) is incorrect. The expected reference range for a newborn's axillary temperature is from 36.5° C (97.7° F) to 37.8° C (100.0° F). A respiratory rate of 58/min is correct. The expected reference range for a newborn's respiratory rate is from 30/min to 60/min. A length of 43 cm (16.9 in) is incorrect. The expected reference range for a newborn's length is from 45 to 55 cm (17.7 to 21.7 in). A weight of 2.6 kg (5 lb 12 oz) is correct. The expected reference range for a newborn's weight is from 2.5 to 4 kg (5.5 lb to 8.8 lb).

A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests?

A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with real-time ultrasound.

A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?

The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer

A nurse is reviewing the laboratory report of a client who is 24 hr postpartum following a vaginal delivery. Which of the following laboratory results should the nurse identify as an indication of a postpartum infection?

The nurse should realize that this value exceeds the expected reference range for a postpartum client and indicates an infection.

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?

The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin.

A nurse is providing teaching about comfort measures to a client who is breastfeeding and is experiencing engorgement. Which of the following nonpharmacological measures should the nurse include in the teaching?

The nurse should suggest applying cold compresses or ice packs to alleviate the discomforts of engorgement in the client who is breastfeeding.