Maternal & Newborn Health - Archer Review (1/2)

Choice A is correct. Placenta previa typically manifests as painless vaginal bleeding after 20 weeks gestation.

A 38-week pregnant woman comes into the emergency department complaining of vaginal bleeding. The client is not in obvious distress or pain. Which statement by the client would lead the nurse to suspect placenta previa? A. "I don't feel any pain at all. It's just the bleeding that concerns me." B. "I feel like I'm about to go into labor. My tummy is starting to contract." C. "I started bleeding when I picked up my 3-year-old son, who weighs 32 pounds." D. "I feel like I'm about to vomit."

Choice A is correct. Rho(D) immune globulin is administered to Rh-negative mothers to prevent them from producing antibodies against any Rh-positive fetus. "This shot is meant to prevent my baby from developing antibodies against my blood, right?" indicates that the client needs further teaching, as the client is incorrectly summarizing what occurs during Rh incompatibility. During a pregnancy, Rh antibodies produced in the woman's body can cross the placenta and attack fetal blood cells. This can lead to serious health problems, even death, for a fetus or a newborn.

A G1P0 client currently in the 28th week of gestation whose blood type is A negative was advised to receive a Rho(D) immune globulin intramuscular injection today. Which statement by the client indicates the need for further teaching about this therapy by the nurse? A. "This shot is meant to prevent my baby from developing antibodies against my blood, right?" B. "I understand that if we find out my baby is Rh-positive, I'll need another one of these injections after delivery." C. "This shot should help to protect me in future pregnancies if this baby comes out Rh positive, although each future pregnancy will require a repeat dose." D. "This shot will prevent me from making Rh antibodies."

Choice A is correct. Placenta previa may occur as early as 20 gestational weeks. The manifestations of painless, bright red vaginal bleeding coincide with this condition. Commonly, the presentation of placenta previa is a finding on routine ultrasound examination at approximately 16 to 20 weeks.

A client at 32 gestational weeks reports the sudden onset of painless, bright red vaginal bleeding. The assessment showed a normal fetal heart rate and a non-tender uterus. The nurse understands that this client is at the highest risk of developing A. placenta previa. B. threatened abortion. C. placental abruption. D. uterine souffle.

Choice A is correct. Female clients of Middle Eastern descent who continue to follow Middle Eastern traditions will often dress in traditional Middle Eastern attire. Although this attire varies based on the specific region from which the client's descents originated, as well as any specific religious beliefs held, traditions generally dictate that women are covered from head to toe. Dressing in this manner results in reduced sun exposure on the client's skin. Unless the client's diet is rich in good sources of vitamin D, the client will need vitamin D supplementation. Vitamin D deficiency in a pregnant woman causes deficiency in the fetus.

A client of Middle Eastern descent is currently 24 weeks gestation. Based on the client's culture, the client usually wears a long robe covering the client's arms and body, with a shawl covering the head and neck. Based on this information, which supplement will the nurse most likely anticipate providing to the client? A. Vitamin D B. Vitamin C C. Calcium D. Zinc

Choice D is correct. Lochia is vaginal discharge following childbirth. At one day postpartum, the client's discharge is expected to be dark red or red-brown, similar to a heavy menstrual discharge, and should have a fleshy, earthy odor. A client with foul-smelling lochia should prompt further evaluation by the nurse, as lochia which smells foul or fishy could indicate infection. Additionally, the nurse may need to elaborate further on the discharge color rather than simply using the term "red," as the anticipated discharge color at this point in the postoperative period should likely be darker in color.

A nurse is assigned to care for four clients who are each one day postpartum. Following the nurse performing an initial assessment on each client, which finding would prompt further evaluation by the nurse? A. A client complaining of mild pain B. A client with a pulse rate of 65 bpm C. A client with colostrum discharge from both breasts D. A client with red, foul-smelling lochia

Choice A is correct. Rh-negative women should have an indirect Coombs' test to determine whether they are sensitized (have developed antibodies) as a result of previous exposure to Rh-positive blood. This testing is done at the first prenatal visit.

A pregnant client who is Rh-negative is ordered an indirect Coomb's test. The nurse understands that the purpose of this test is to determine if A. antibodies are present from previous exposure to Rh-positive blood. B. the amount of time that it takes for fetal blood to clot. C. the blood type, Rh factor, and antibody titer of the newborn D. the fetus has a risk of developing pernicious anemia later in life.

Choice B is correct. This is a reassuring finding. Ten kicks noticed during a 1 - 2 hour period are considered normal.

A prenatal client is worried about her fetus' activity, so she performs a "kick count". She informs the nurse that while laying down, she felt ten kicks in one hour. The nurse should tell this client that: A. She'll need to come into the clinic and have a non-stress test performed. B. Ten kicks in an hour is a reassuring finding. C. She is dehydrated and should drink more water before re-trying the kick count. D. She should get up and walk for ten minutes and then re-try the test.

hypotension; 0.9% saline bolus

Immediately following the placement of the epidural, the client is at the highest risk for _____ and the nurse anticipates a prescription for _____

Choice A is correct. Oligohydramnios results from a severe reduction in the amount of amniotic fluid. It results in less than expected fetal growth. Also, because of the low amount of amniotic fluid, the fetus will be more easily outlined and palpated.

At 25 weeks gestation, a pregnant client presents with a uterine growth size that is less than expected, decreased fetal movement, and an easily palpable fetus. Which of the following is this likely related to? A. Oligohydramnios B. Macrosomia C. Hydramnios D. Amniotic fluid embolism

late decelerations; reduced blood flow to the placenta

Based on the fetal heart rate tracing, the client is experiencing ______ that is caused by ______

Choice C is correct. The left lateral position improves placental blood flow and oxygen supply to the fetus. This should be the nurse's first intervention.

The client is undergoing labor in the delivery room. The fetal monitor shows that there are late decelerations. What is the initial action of the nurse? A. Call the doctor immediately. B. Let the client deep-breathe slowly and relax. C. Let the client lie on her left side. D. Prepare for Cesarian delivery.

hypoglycemia; cyanotic extremities; axillary temperature

The neonate is at greatest risk for _____ due to the neonates ____ and _____

This client is pregnant and has had two other pregnancies before the current one. This would make her a gravida three (G3). She delivered one child at 40 weeks of gestation, which is one-term birth (T1). She delivered one child at 33 weeks (P1). She has had two live births (L2).

The nurse is assessing a client who is five months pregnant and has a son born at 40 weeks of gestation and a daughter born at 33 weeks of gestation. It would be correct for the nurse to document this client's GTPAL as A. G4-T1-P1-A0-L2 B. G3-T1-P1-A0-L2 C. G3-T1-P1-A0-L3 D. G3-T2-P0-A0-L2

Choice B is correct. A prolapsed umbilical cord is a serious finding that may lead to fetal hypoxia. The nurse must act quickly if this is suspected. Common fetal heart rate patterns observed during a prolapsed umbilical cord include variable decelerations, sustained bradycardia, or prolonged decelerations. All of these patterns are non-reassuring.

The nurse is caring for a client in labor experiencing a prolapsed umbilical cord. The nurse anticipates that the fetal heart rate pattern will likely show A. early decelerations. B. variable decelerations. C. late decelerations. D. normal variability.

Choice A is correct. Alpha-fetoprotein (AFP) is a substance produced by the developing baby, which can enter both the amniotic fluid and the mother's bloodstream. Normally, a small amount of AFP is present in both the amniotic fluid and the maternal blood. However, in cases where a woman is carrying a baby with Down syndrome, AFP blood levels may be lower. Conversely, if AFP levels are elevated, it serves as a signal for the physician to conduct further investigations, as it may indicate the possibility of a neural tube defect or be related to a multifetal pregnancy. Regardless of the underlying cause of these variations in AFP levels, it is essential for the nurse to promptly inform the primary healthcare provider (PHCP) of the test results.

The nurse is caring for a pregnant client with a decreased alpha-fetoprotein level. The nurse plans to A. notify the primary healthcare provider (PHCP) of the results. B. instruct the client to increase their intake of folic acid. C. document the result as normal. D. obtain a urine specimen.

Choice A is correct. A reactive NST is an expected finding and indicates fetal well-being. A reactive finding indicates fetal well-being; specifically, the fetal heart rate increased by 15 beats per minute, lasting for 15 seconds.

The nurse is caring for a primigravida client with the following clinical data. The nurse should take which of the following actions based on the result? See the image below. A. Inform the client of the normal finding B. Prepare the client for a contraction stress test C. Arrange for a repeat test D. Inquire if the client ate prior to the test

Choice A is correct. A displaced fundus is an indication of a distended bladder. The nurse should assess the client for bladder distention and encourage the client to empty her bladder.

The nurse working in the maternity ward is caring for a 24-hour post-partum client. When assessing the client, the nurse notes that her fundus is firm at the level of the umbilicus and is veering a little bit to the right. The initial action for the nurse is to: A. Check for bladder distention B. Check the client's blood pressure C. Check if the client has been given oxytocin D. Check the pad count

Choice B is correct. The nurse with this patient should expect an infant born with low birth weight. Preeclampsia often results in blood being shunted away from the fetus; growth restriction is commonly found in infants born to these women.

The obstetric nurse is reading the prenatal client's chart. The nurse notes that the patient is suffering from preeclampsia and knows to observe for which complications in the newborn? A. Shaking and agitation B. Low birth-weight C. Abnormal kidney function D. Blurred vision

Choice A is correct. The Moro reflex occurs in response to a slight drop, sudden movement of the crib, or a loud noise; the newborn quickly makes a symmetrical abduction of the extremities and places the index fingers and thumbs into a "C" shape.

Which of the following best describes a newborn reflex that includes a hand opening with abducted and extended extremities following a jarring motion? A. Moro reflex B. Grasp reflex C. Babinski reflex D. Rooting reflex

Choice A is correct. Amenorrhea (absence of menstrual period) is a presumptive sign of pregnancy. Presumptive signs of pregnancy are symptoms and signs that the patient experiences. Presumptive signs may resemble pregnancy signs and symptoms but may also be caused by other etiologies. While amenorrhea is a presumptive sign of pregnancy, missing a period can also result from other conditions such as stress, hypothyroidism, and anorexia.

A 28-year-old female presents to the obstetrics office, suspecting she may be pregnant. Which of the following would the nurse recognize as a presumptive sign of pregnancy? A. Amenorrhea B. Positive fetal cardiac activity on ultrasound C. Enlarged uterus D. Auscultation of fetal heart tones

Choice A is correct. Here, the nurse should immediately suspect abruptio placentae, as this client presents with the classic signs of severe pain and vaginal bleeding. Abruptio placentae (called abruptio placentae, placental abruption, or premature separation of the placenta) is the premature separation of a normally implanted placenta from the uterus. Placental abruption presents a significant risk for both the woman and the fetus. Once the premature placental separation begins, the woman becomes at risk for hemorrhage and consequent hypovolemic shock and clotting abnormalities. Similarly, risks to the fetus include asphyxia, excessive blood loss, prematurity, and fetal demise.

A 35-week pregnant client arrives at an emergency department complaining of heavy, painful vaginal bleeding. The nurse should immediately suspect which condition? A. Abruptio placentae B. Placenta previa C. Prelabor rupture of the membranes D. Passage of the mucus plug

Choice D is correct. A nonstress test (NST) is a non-invasive test performed in pregnancies over 28 weeks gestation. During the procedure, fetal heart rate and uterine contractions are recorded using external electronic monitors and correlated with fetal movements as reported by the mother. This test determines the fetus's condition during the third trimester of pregnancy.

A 38-week pregnant client is scheduled to undergo a nonstress test (NST). While speaking with the nurse, the client inquires regarding the purpose of this type of testing. The most appropriate response by the nurse would be which of the following? A. "This test determines whether you are ready for labor induction." B. "A nonstress test assesses your blood sugar control." C. "This testing provides an accurate determination of fetal age." D. "A nonstress test assesses the fetal condition in the third trimester."

Choices A, C, D, and E are correct. Apnea, gasping, or heart rate less than 100 bpm indicates that the team should begin positive pressure ventilation (PPV) within one minute after birth. The unit can also consider a trial of PPV if it cannot maintain oxygen saturation despite using oxygen or continuous positive airway pressure (CPAP). If a newborn has aspirated meconium (Choice E), which can cause respiratory distress and airway obstruction, PPV may be required to maintain adequate oxygenation.

As the nurse in the delivery room caring for a newly born infant, you observe the infant's initial assessment. Which of the following signs would indicate that positive-pressure ventilation is needed? Select all that apply. The infant is apneic. The bottom of the term-29infant's feet are blue. The infant's heart rate is < 100 beats per minute. The infant is gasping. Meconium aspiration syndrome

Choice C is correct. Yogurt is a dairy product and therefore contains lactose. Breastfeeding mothers with infants who are lactose intolerant should avoid dairy products such as cheese, milk, and yogurt.

A breastfeeding mother is struggling to care for her infant with lactose intolerance. Which of the following foods should the mother avoid? A. Leafy greens B. Red meats C. Yogurt D. Wheat rolls

Choice D is correct. A pregnancy test (urine or serum) is a probable sign of pregnancy. Elevated HCG levels may be caused by other reasons such as ectopic pregnancy, user error, or recent abortion/miscarriage.

A client presented to the clinic stating that her home pregnancy test was positive. The nurse understands that this is a A. positive sign of pregnancy. B. presumptive sign of pregnancy. C. possible sign of pregnancy. D. probable sign of pregnancy.

Choice C is correct. An ectopic pregnancy (EP) is a medical emergency. The imaging of choice is a transvaginal ultrasound, as this type of ultrasound may visualize an extrauterine gestational sac with a yolk sac or embryo (with or without a heartbeat).

A client presents to the emergency department (ED) with a suspected ectopic pregnancy. The nurse anticipates which diagnostic test will confirm this finding? A. Nonstress testing B. Abdominal radiograph (x-ray) C. Transvaginal ultrasound D. Doppler transducer

Choice C is correct. Vitamin C increases the absorption of iron. Due to the vitamin C concentration in orange juice, consuming the iron supplement with orange juice would aid in the absorption of the iron supplement.

A client visits an antepartum clinic for a check-up and is prescribed iron supplements. Which instruction should the nurse provide to the client regarding her iron supplement therapy? A. You must take the iron supplements with milk. B. Consume the iron supplements with meals. C. Take the iron supplement with orange juice. D. Avoid consuming large amounts of water when taking the iron supplement, as this can cause nausea.

Choice D is correct. The initial action the nurse should take is to assess the fetal status following the spontaneous rupture of the client's membranes. Although numerous methods may be utilized to evaluate fetal status, assessing fetal heart tones provides reliable information in a relatively prompt manner. Following the assessment of fetal heart tones, the nurse should then assess the color and quality of the amniotic fluid.

A client who is pregnant at 39 weeks gestation spontaneously ruptured her membranes while ambulating to the bathroom. After the client returns to bed, which of the following should be the nurse's initial action? A. Assess the color of the amniotic fluid B. Perform a vaginal examination to assess the cervix for dilation C. Inform the client she is now on strict bed rest until further notice D. Assess the fetal heart tones

Choice A is correct. Salt should be restricted in the client with mildly high blood pressure. A blood pressure that is considered moderately high is about 140/90 mmHg. These patients should begin treatment by reducing salt intake and assessing behavioral areas that may need adjustment, such as smoking cigarettes or failing to exercise.

At her first visit, a prenatal client is found to be suffering from mildly high blood pressure. The nurse should have her client reduce which dietary component? A. Salt B. Magnesium C. Potassium D. Calcium

Choice D is correct. Testosterone is not typically measured in prenatal clients. If a testosterone level needs to be measured, it will be estimated via a blood draw rather than a urinalysis.

At the initial prenatal visit, and often the subsequent visits, the health care provider will obtain a clean catch urine specimen to look for all of the following, except: A. Ketones B. Sexually transmitted infections C. Glucose D. Testosterone levels

Choice B is correct. The spinal change that is common in pregnancy is lordosis. This is the result of the increasing weight of the enlarging uterus and the effect of gravity. As a fetus grows, a variety of changes appear in a pregnant woman's body. The thoracic and lumbar spine curvature change, pain in the low back, and pelvic region can increase, and the balance and gait pattern also changes. Some studies report that the center of gravity of pregnant women moves towards the abdomen, resulting in an increase in lumbar lordosis, posterior tilt of the sacrum, and movement of the head to the back to compensate for the increased weight as the fetus grows.

A pregnancy-related spinal change that can alter mobility is known as: A. Ankylosing spondylosis B. Lordosis C. Scoliosis D. Kyphosis

Choice C is correct. Severe preeclampsia is characterized by high blood pressure, proteinuria (presence of protein in urine), and organ dysfunction. It is a serious condition that requires immediate medical intervention to prevent complications for both the mother and the baby. Severe preeclampsia is diagnosed If one or more of the following criteria are present: Blood pressure of ≥160 mm Hg systolic or ≥110 mm Hg diastolic or higher on two occasions at least 6 hr apart while the client is on bed rest Oliguria of <500 mL in 24 hr Cerebral or visual disturbances Pulmonary edema or cyanosis Epigastric or right upper quadrant pain Impaired liver function as indicated by abnormally elevated blood concentrations of liver enzymes (to twice normal concentration), severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses or both Thrombocytopenia 8. Renal insufficiency

A pregnant client at 37 weeks gestation arrives at the hospital with the following signs and symptoms: severe headache, blurred vision, and epigastric pain not relieved by pain medication. The nurse suspects the client is experiencing which condition? A. Preterm labor B. Ectopic pregnancy C. Severe preeclampsia D. Pre-eclampsia

Choice A is correct. Mineral oil is contraindicated in pregnancy as it decreases nutrient absorption in the mother.

An 11-week pregnant client is complaining to the nurse about her hemorrhoids. The nurse understands that hemorrhoids occur because of pressure on the rectal veins from the bulk of the growing fetus. All of the following are measures to alleviate hemorrhoid pain, except: A. Instruct the client to use mineral oil to soften her stools. B. Rest in a side-lying position daily. C. Increase the client's fiber and water intake. D. Apply a cold compress to the area.

Choice C is correct. Breastfeeding causes the release of oxytocin which stimulates uterine contractions. The client may describe a cramping type of sensation which is expected. The cramping sensation is generally strongest two to three days postpartum.

The nurse is assessing a client who is two days postpartum and is breastfeeding her infant and reports uterine contractions while breastfeeding. The nurse should take which action? A. Perform a vaginal examination B. Prepare the client for a pelvic ultrasound C. Reassure the client that this is a normal finding D. Instruct the client to bottle feed the infant until the sensation subsides

Choice B is correct. Mastitis commonly occurs 2-4 weeks postpartum. The client often experiences flu-like symptoms (fever, malaise, and axillary lymphadenopathy). The affected breast usually is tender, has erythema, and is swollen. The client's manifestation classically coincides with this infection.

The nurse is caring for a client two weeks postpartum with reports of flu-like symptoms, headache, and tenderness to the left breast. On examination, the nurse assesses enlarged axillary lymph nodes. The client is demonstrating manifestations of A. Endometritis B. Mastitis C. Pelvic inflammatory disease D. Cystitis

Choice B is correct. Infants with erythroblastosis fetalis are anemic from the destruction of RBCs. Severely affected infants may develop hydrops fetalis, a severe anemia resulting in heart failure and generalized edema. This hemolysis stems from maternal-fetal blood incompatibility.

The nurse is caring for a newborn with erythroblastosis fetalis. The nurse understands that this disease is characterized by A. excessive red blood cell production that requires therapeutic blood donation. B. incompatibility between maternal and fetal blood. C. an excessive amount of circulating white blood cells (WBC). D. erythrocytes become shaped like a sickle and sensitive to hypoxia.

Choice D is correct. Bed rest should be maintained to conserve energy and decrease cardiac stress.

The nurse is caring for a pregnant client with heart disease undergoing labor. All of the following are appropriate nursing interventions, except: A. Attach the client to a cardiac monitor and place an external fetal monitor. B. Manage pain early in labor. C. Use controlled pushing efforts. D. Encourage ambulation.

Choice B is correct. The initial action of the nurse when she finds that the fundus is soft and boggy is to massage it until it is firm. Massaging the fundus stimulates it to contract and expels blood clots. The goal is to make the fundus firm, which is essential for preventing postpartum hemorrhage.

The nurse is in the postpartum unit assessing a client who gave birth 2 hours ago. The nurse notes that the client's fundus is soft and boggy. Her perineal pads have been changed twice over the past 2 hours. What is the initial action of the nurse? A. Apply pressure on the fundus. B. Massage the fundus until it is firm. C. Notify the physician. D. Elevate the client's legs.

Choices C and D are correct. C is correct. The client should be advised to monitor for edema in one leg as a sign of postpartum thrombophlebitis. If swelling is noted, the nurse should measure both lower extremities and compare the circumference of the affected with the unaffected. D is correct. The client should be advised to monitor for tenderness in one leg as a sign of postpartum thrombophlebitis. Edema, pain, and redness would be expected findings in whichever leg the clot is occluding.

The RN is discussing the signs and symptoms of postpartum thrombophlebitis with an expectant mother. The client should be instructed to monitor for which of the following symptoms? Select all that apply. +2 pulses Bilateral redness. Edema in one leg. Tenderness. Unilateral cyanosis. Hypotension.

Choice B is correct. Early ultrasound examination, typically performed between weeks 6 and 9 of pregnancy, is one of the most accurate methods for determining gestational age during the first trimester. The ultrasound can measure the length of the fetus (crown-rump length) and provide a highly accurate estimate of gestational age. This method is particularly reliable during the first trimester when fetal development is relatively consistent among pregnancies.

The nurse is interviewing a client who is pregnant in her first trimester, and the client inquires about their gestational age. The nurse understands which assessment will provide the most accurate gestational age? A. Nägele's rule B. Ultrasonography C. Fundal height D. Human chorionic gonadotropin (HCG) levels

Choice B is correct. The most appropriate client to transfer from the maternity unit to the medical-surgical unit to make a bed available is the client who is postpartum after delivering her baby via cesarean section and needs close observation for surgical wound healing and pain management.

The charge nurse must transfer a client from the maternity unit to the medical-surgical unit to make a bed available. It would be most appropriate for the nurse to transfer the client who is A. experiencing preterm contractions and requires continuous monitoring for potential preterm labor. B. postpartum following a cesarean section and needs close observation for surgical wound healing and pain management. C. admitted for pre-eclampsia and is experiencing a frontal headache. D. in her second trimester, undergoing evaluation for suspected gestational diabetes and requires a nonstress test.

Choice A is correct. A normal fetal heart rate typically ranges between 120-160 bpm. A fetal heart rate of 90-100 bpm may indicate fetal distress or compromise and requires immediate assessment and intervention by a healthcare provider.

The labor and delivery unit charge nurse has received a change-of-shift report on the following clients in labor. Which client should the charge nurse ask a staff member to see first? A. A 28-year-old primigravida at 39 weeks gestation, currently in active labor, with a fetal heart rate of 90-100 bpm. B. A 35-year-old multipara at 41 weeks gestation, currently in early labor, with a history of rapid labor in her previous delivery. C. A 20-year-old multipara at 37 weeks gestation, currently in active labor, with a history of two previous cesarean deliveries. D. A 25-year-old multipara at 38 weeks gestation, currently in early labor, with cervical dilation of 3 cm.

Choice A is correct. Glucose in the urine may indicate gestational diabetes, as up to half of female clients have glucose in their urine at some time during pregnancy. Glucose in the urine may mean that a pregnant client has gestational diabetes. The nurse should promptly alert the health care provider (HCP) to allow further assessment into the cause of the glucose present in the client's urine.

The nurse at a gynecology clinic speaks with a 25-year-old, 32-week pregnant client. The nurse assesses the client and the client's laboratory results. Which of the following findings should most concern the nurse? A. Glucose present in the urine B. The client reports +1 pedal edema at the end of the day C. The client reports increased vaginal discharge D. A hemoglobin level of 14 g/dL

Choice B is correct. February 12th. Remember, the equation for Nagele's Rule is to subtract three months from the first day of the woman's last menstrual period plus seven days.

The nurse calculates that, using Nagele's rule, the estimated due date for a 29-year-old woman who is pregnant for the first time, and whose last period started on May 5th, will be on which date? A. February 5th B. February 12th C. January 28th D. April 12th

Choice A is correct. Chronic hypotension is not a risk factor for preeclampsia; therefore, this is the correct answer to the question. Instead, a history of high blood pressure is a risk factor. This hypertension is defined as a blood pressure reading above 140/90 mmHg.

The nurse caring for a pregnant client should recognize that all of the following are risk factors for preeclampsia except: A. Chronic hypotension B. Age C. Race D. Family history of preeclampsia

Choice C is correct. The nurse should always confirm first whether another staff member returned the baby to the nursery. The nurse should not cause a false alarm in the institution. A Code Pink notifies all hospital staff of a possible infant abduction.

The nurse comes into the client's room to check on her and her newborn child. The client tells the nurse that another nurse just came and took the baby back to the nursery. What would be the initial action of the nurse? A. Alert security personnel about an infant abduction and call a code. B. Ask the mother what the nurse who took her baby looked like. C. Call the nursery to ask if the baby was returned to the nursery. D. Ask the mother if she asked the nurse for a code word.

Choice D is correct. Expulsion of the placenta does not trigger the production of oxytocin. The oxytocin continues to increase before placental expulsion. Increasing oxytocin following the baby's birth helps in uterine contractions, aiding placental separation and expulsion. Following the baby's birth, oxytocin is induced by the skin contact between mother and child. Additionally, stimulating the mother's nipples through breastfeeding (suckling) stimulates the posterior pituitary gland to produce oxytocin, causing the release of milk from the alveoli into the ducts.

The nurse has just assisted in delivering a newborn and is now attempting to deliver the placenta. Which of the following is not triggered by the expulsion of the placenta? A. Decrease in progesterone B. Decrease in estrogen C. Increase in prolactin D. Production of oxytocin

Choice A is correct. It is widely accepted that a finding of a single transverse palmar crease on the palm - often referred to as a simian line or simian crease - is often observed in a wide range of chromosomal defects, including, but not limited to, Down syndrome, congenital limb deficiency, trisomy 13/18/21, 4p, 18q, etc. Although this finding does not in and of itself render a diagnosis of a chromosomal disorder, this finding by the nurse would necessitate the need to alert the newborn's primary health care provider (HCP), as genetic and chromosomal testing will likely need to be performed.

The nurse in the delivery room has just delivered a newborn from a 41-year-old mother. Which assessment finding would lead the nurse to suspect Down syndrome in the newborn? A. Simian crease B. Jitteriness C. Acrocyanosis D. Uneven skin folds in the newborn's buttocks when the legs are extended

Choice A is correct. Leg cramping is common in pregnancy and may occur more in the overnight hours. For a pregnant client endorsing these leg cramps, the client should be instructed to increase their dietary intake of foods rich in vitamin D and magnesium. Foods rich in vitamin D and magnesium include avocados, blackberries, spinach, and collard greens.

The nurse in the obstetrics clinic is interviewing a client who is pregnant and reporting nocturnal leg cramps. The nurse should encourage the client to consume foods rich in A. magnesium. B. iron. C. vitamin c. D. phosphorus.

Choices A and C are correct. A fetal heart rate of 170 beats per minute is fetal tachycardia and should be reported to the healthcare provider. Any increase in fetal heart rate above 160 is considered tachycardia. It is problematic and requires intervention when it persists for longer than 10 minutes. Variable decelerations need to be reported to the healthcare provider immediately. They are sharp and profound drops in the fetal heart rate unrelated to the time of contractions and are a non-reassuring sign on a fetal heart rate strip. Variable decelerations are caused by cord compression, such as a prolapsed cord, and are an emergency requiring quick nursing intervention.

The nurse is assessing a client in the second stage of labor. Which findings should be reported to the primary healthcare provider (PHCP)? Select all that apply. Sustained fetal heart rate of 170 beats per minute Early decelerations Variable decelerations The client feels the urge to push Uterine contractions every 2-3 minutes

Choices A, B and E are correct. Infants born before 37 weeks gestation have low stores of glucose and therefore hypoglycemia is a common complication of prematurity. Blood glucose should be monitored closely (Choice A). Preterm infants are at risk for poor thermoregulation and hypothermia due to decreased stores of muscle and fat. Their body temperatures should be regulated via incubator, radiant warming, bundling, or other methods of temperature control, as indicated (Choice B). Neonates born at 31 weeks gestational age are considered premature and are at risk for a number of complications due to their underdeveloped organ systems. Respiratory distress syndrome (Choice E) is a common complication of prematurity, caused by a lack of surfactant in the lungs. Babies with RDS may have difficulty breathing and require oxygen therapy or mechanical ventilation.

The nurse is assigned to take care of a baby who is 31 weeks gestation in the neonatal intensive care unit. Which of the following potential complications must be monitored for in a neonate of this gestational age? Select all that apply. Hypoglycemia Hypothermia Birth injuries Fat wasting Respiratory distress syndrome (RDS)

Choice C is correct. By 20 weeks gestation, the fetus is approximately 20 cm long or 7 ½ inches. This statement reflects a proper understanding of the mother regarding fetal development and does not require further teaching.

The nurse is attending to a client who is 20 weeks pregnant and has completed patient education. Which of the following statements by the client indicates that she has a good understanding of her baby's development? A. "My baby is able to breathe now." B. "My baby can open his eyes." C. "My baby is about 7 ½ inches long." D. "My baby has fully grown fingernails."

Choices A, B, D, and E are correct. A is correct. Newborns often have jaundice due to an immature liver that cannot efficiently process bilirubin, a byproduct of the breakdown of red blood cells. This leads to the accumulation of bilirubin in the blood, causing the yellowish discoloration of the skin and whites of the eyes that is characteristic of jaundice (Maternal / Newborn Foundations of Maternal-Newborn & Women's Health Nursing, 7th Edition). B is correct. Phototherapy, or light therapy, is a standard treatment for newborn jaundice. The baby's skin absorbs the light, which changes the structure of the bilirubin molecules in a way that allows them to be excreted in the urine and stool (Maternal / Newborn Foundations of Maternal-Newborn & Women's Health Nursing, 7th Edition). D is correct. This is a characteristic presentation of newborn jaundice. The yellowish discoloration typically starts on the face. Then it spreads downwards to the chest, abdomen, arms, and legs as the bilirubin level increases (Maternal / Newborn Foundations of Maternal-Newborn & Women's Health Nursing, 7th Edition). E is correct. This is a critical point. If severe jaundice in a newborn is not treated, the high

The nurse is caring for a 1-day old newborn client diagnosed with jaundice. Which of the following statements is true regarding jaundice in newborns? Select all that apply. -Newborn jaundice is often caused by the baby's liver being immature. -Phototherapy is a common treatment for newborn jaundice. -Breastfeeding should be stopped if a newborn has jaundice. -A jaundiced newborn's skin will appear yellow, starting with the face and progressing downwards. -Severe, untreated newborn jaundice can lead to kernicterus, a type of brain damage.

Choice B is correct. Indomethacin is a cyclooxygenase inhibitor indicated as a tocolytic in preterm labor. This medication relaxes the uterus and therefore decreases uterine contractions.

The nurse is caring for a client at 29 weeks gestation who is at risk for delivering preterm. Which of the following medications would the nurse anticipate the primary healthcare provider (PHCP) to prescribe? A. Methotrexate B. Indomethacin C. Oxytocin D. Folic acid

Choice B is correct. The linea alba is the line that marks the longitudinal division of the midline of the abdomen—darkens to become the linea nigra due to hormone changes during pregnancy. This dark pigmentation may extend from the symphysis pubis to the top of the fundus and becomes darker as pregnancy progresses. This hyperpigmentation is temporary and typically disappears after childbirth due to hormonal changes during pregnancy.

The nurse is caring for a client in her second trimester who presents to the maternity clinic expressing concern that the dark, vertical line present on the midline of her abdomen may pose a danger to her baby. Which of the following would be the most appropriate action for the nurse to take in response to the client's concern? A. Refer the client to a dermatologist for assessment. B. Educate the client that this is a common occurrence in pregnancy called linea nigra, which usually disappears after childbirth. C. Ask the client what types of foods she has been ingesting. D. Educate the client that this is a common occurrence in pregnancy called linea nigra, which typically remains following childbirth.

Choice C is correct. A prolapsed umbilical cord is a serious finding that may lead to fetal hypoxia. The nurse must act quickly if this is suspected. Nursing and medical care will overlap, but one of the earliest interventions is to reposition the client either knee to chest, Trendelenburg, or hips elevated with pillows with a side-lying position maintained. The goal of repositioning is to position the woman's hips higher than her head to shift the fetal presenting part toward her diaphragm.

The nurse is caring for a client in labor and discovers the client has a completely prolapsed umbilical cord. The nurse should take which action? A. Encourage the client to push at the next contraction B. Administer nasal cannula oxygen at 2 liters/minute C. Position the client knee to chest D. Obtain a prescription for oxytocin

Choice B is correct. Early decelerations are a reassuring finding caused by infant head compression, which is a normal part of labor.

The nurse is caring for a client in labor experiencing early decelerations. Which of the following actions should the nurse take? A. Reposition the patient on her side B. Document the findings C. Discontinue oxytocin infusion D. Prepare for an amnioinfusion

Choice A is correct. ➢ The client's total number of pregnancies (including the current one) is three. This is documented under gravida (G). She is currently pregnant, had one ectopic pregnancy, and was pregnant with twins. ➢ The client has had one-term birth: the twins were born at 39 gestational weeks. This is documented under the term (T). Term is any birth after 37 gestational weeks. ➢ The client has not had any preterm (P) births (any birth between 20 and 37 gestational weeks). ➢ The client has had one ectopic pregnancy, which is documented as an abortion (A). ➢ The client has two living (L) children, the twins, who were born at 39 gestational weeks.

The nurse is caring for a client in the third trimester of pregnancy. Which of the following assessment findings would be expected? Select All That Apply. Persistent abdominal pain Increased fetal movement Swollen ankles and feet Weight loss Decreased frequency of urination

Choice D is correct. Regardless of the mode of delivery, this is the normal postpartum fundus at one to two hours. Immediately after delivery and expulsion of the placenta, the uterus is about the size of a grapefruit and is located midline in the abdomen, halfway between the umbilicus and the symphysis pubis. Over the next several hours, the fundus will rise on the midline of the stomach to the level of or slightly above the umbilicus. Subsequently, the height of the fundus decreases by at least 1 cm or one fingerbreadth daily as the uterus goes through the process of involution. By the 10th day, the fundus is usually not palpable. Uterine "involution" refers to the return of the uterus to its pre-pregnancy size and condition. Involution begins soon after the expulsion of the placenta and occurs due to the contraction of the uterine smooth muscle. Assessing the fundus (top of the uterus) is a crucial component of post-delivery assessment—a lack of proper uterine involution results in complications such as postpartum hemorrhage.

The nurse is caring for a client who delivered a set of twins one hour ago via Cesarean section. What are the expected findings during the fundal assessment? A. The fundus is hard, midline, and 1-2 fingerbreadths above the umbilicus. B. The fundus need not be assessed because of the C-section. C. The fundus is to the right of the umbilicus and soft. D. The fundus is hard, midline, and at the level of the umbilicus.

Choice D is correct. During a pulmonary embolism, circulation in the pulmonary bed is altered, thus affecting the client's oxygenation. Oxygen should be started immediately at 8-10 liters per minute to decrease hypoxia.

The nurse is caring for a client who has just given birth and is resting in the postpartum unit when suddenly she feels a sharp pain in the chest and is having difficulty breathing. Upon assessment by the nurse, she has a heart rate of 120 and a respiratory rate of 24. She is suspected of having a pulmonary embolism. What should be the initial action of the nurse? A. Start a peripheral vascular access device B. Monitor the client's blood pressure C. Draw up morphine sulfate D. Give oxygen via face mask at 8-10 liters per minute

Choice C is correct. Depression and anxiety can still be effectively treated while a client is pregnant. SSRIs (citalopram, sertraline, fluoxetine) can be effectively continued while a client is pregnant to cause mood stabilization and prevent depressive episodes. The only SSRI likely to be switched is paroxetine because of its slight risk for teratogenicity. Thus, the client may have to be switched to a safer agent like sertraline if they take paroxetine. Even electroconvulsive therapy (ECT) is safe for a pregnant client.

The nurse is caring for a client who is six weeks pregnant and inquires about her prescribed antidepressant. Which statement, if made by the client, would indicate effective understanding? A. "I will need to stop my antidepressant until after I have delivered." B. "I will not need an antidepressant while pregnant because pregnancy causes depression remission." C. "I may have to switch to a new antidepressant while I am pregnant." D. "If I continue my antidepressant medication, I must undergo a cesarean section at delivery."

Choice A is correct. Manual cervical exams should be questioned if a client has placenta previa. The reasoning is that palpation of the placenta previa through a partially dilated cervix may cause severe hemorrhage.

The nurse is caring for a client with placenta previa. Which of the following orders by the primary healthcare provider (PHCP) should the nurse question? A. Manual cervical exam B. Transabdominal ultrasound C. Nonstress test D. Transvaginal ultrasound

Choice B is correct. A transvaginal ultrasound is a gold standard in diagnosing placenta previa. A transvaginal ultrasound is more accurate than transabdominal ultrasound in determining the location of the placenta. Please recognize that the vagal ultrasound probe can safely be inserted a few inches from the cervix to capture the placenta alteration. Any advancement of the probe into the cervix could cause bleeding. However, if done according to the recommendations, the appropriate angle between the cervix and the vaginal ultrasound probe prevents the probe from accidentally moving into the cervical canal.

The nurse is caring for a client with suspected placenta previa. The nurse anticipates a prescription for which diagnostic test to confirm this finding? A. Manual cervical exam B. Transvaginal ultrasound C. Contraction stress test D. Nonstress test

Choice C is correct. When a neonate develops hypoglycemia, norepinephrine is released, causing tachycardia which causes an increase in glucose metabolism. This increase in glucose metabolism depletes the neonate's reserve of glucose. If a neonate is experiencing cold stress, the nurse should warm the neonate by applying warm clothes, removing the neonate from any drafts, and ensuring the neonate is dry. The nurse should assess the neonate for hypoglycemia via heel stick once the neonate's temperature stabilizes.

The nurse is caring for a neonate experiencing cold stress. The nurse should also assess the neonate for A. hyperglycemia. B. increased muscle tone. C. hypoglycemia. D. metabolic alkalosis.

Choice D is correct. Radiation is one of the mechanisms of heat loss. Radiant heat loss occurs when heat is transferred between two objects, not in direct contact. Radiant heat loss may occur if the infant is placed near windows, air conditioner vents, or drafts. Heat is transferred from a warmer to a cooler object -the infant's warmth is lost to the cooler object (e.g., windows/ cooler window glass). Radiant heat loss can occur despite the surrounding (ambient) air. Ambient will not fix this problem. The nurse must remove the source of the radiant heat loss, not adjust the air temperature.

The nurse is caring for a newborn immediately following birth. Which of the following actions by the nurse will prevent radiant heat loss in the newborn? A. Drying the newborns skin with a towel B. Placing the newborn on a padded, covered surface C. Using warmed, humidified oxygen D. Positioning the bassinet away from windows

Choice A is correct. The drug-dependent newborn is irritable and very sensitive to environmental stimuli. He/she should have limited sensory input to allow extensive rest periods.

The nurse is caring for a newborn of a heroin-addicted mother. Which nursing intervention should the nurse implement in caring for this newborn? A. Decrease the newborn's sensory stimulation. B. Perform activities in one setting. C. Loosely wrap the neonate in a blanket. D. Place the newborn in a stimulating environment.

Choice B is correct. This response is inadequate, as the client has the right to an accurate and complete explanation about any procedures planned or, in this case, currently being performed. This response by the nurse fails to provide the client with accurate, real-time information.

The nurse is caring for a pregnant client with placenta previa. While administering oxygen and starting an intravenous infusion, the client becomes anxious and asks the nurse what is happening. The nurse says not to worry and that everything is under control. What is the best description of the nurse's response? A. This is an incorrect response, as the health care provider (HCP) should be the one to offer information and assurances. B. This response is inadequate, as the client has the right to understand the type of treatment being received and the reason for the treatment. C. This response is effective, as the reply serves to lower the client's anxiety. D. This response is adequate, as the nurse's actions are routine, follow the orders of the health care provider (HCP), and therefore require no explanation.

Choices B, C, and E are correct. B is correct. A respiratory rate of 88 is tachypneic, which would be expected for an infant experiencing neonatal abstinence syndrome (NAS). Tachypnea is a common sign of NAS, as is respiratory distress. It is not uncommon to appreciate an increased work of breathing, including things such as nasal flaring, head bobbing, and retractions in these infants. C is correct. Diaphoresis or excessive sweating is a common symptom of infants with neonatal abstinence syndrome. Most of these infants are incredibly irritable, hot, and sweaty. It is similar to the withdrawal you would expect in an adult that goes cold turkey on a drug . E is correct. Newborns experiencing Neonatal Abstinence Syndrome (NAS) often display hyperactive reflexes. This heightened neurological excitability is a hallmark of NAS and may manifest as jitteriness, a high-pitched cry, or an exaggerated startle response. The hyperactive reflexes result from the newborn's withdrawal from the substances they were exposed to in utero.

The nurse is caring for an infant whose mother used heroin during pregnancy. Which signs and symptoms would the nurse expect to see in this infant experiencing withdrawal? Select all that apply. Temperature 36.5 degrees Celsius. Respiratory rate 88. Diaphoretic. Constipation. Hyperactive reflexes.

Choice A is correct. Uterine atony is the most common cause of PPH. This is when the uterus fails to contract after delivery. Additionally, delivery with instruments such as forceps raises the risk of PPH because of the trauma the devices may cause.

The nurse is caring for assigned clients. The nurse should recognize that the patient at most significant risk for postpartum hemorrhage (PPH) is the client who has which of the following? A. Uterine atony and delivered with the assistance of forceps B. Postpartum urinary incontinence and diuresis C. An active outbreak of genital herpes and had a cesarean section D. Gestational diabetes and has postpartum hyperglycemia

Choice A is correct. A newborn that has not yet passed meconium within 24 to 48 hours after birth should be evaluated for Hirschsprung's disease.

The nurse is caring for four newborns during her shift in the unit. After performing an assessment, which newborn should the nurse give her attention to? A. A 48-hour old newborn that has not yet passed meconium. B. A 3-day old infant with mild jaundice and a bilirubin of 3 mg/dL. C. A 3-hour old infant that has just passed meconium. D. A 5-day old infant with a positive Babinski reflex.

Choice A is correct. Environmental factors such as soft mattresses/bedding, blankets, bumper pads affixed to the crib, and accessories in the crib increase the risk for SIDS dramatically. The recommended sleeping position for an infant is supine, with no stuffed animals, blankets, or accessories.

The nurse is discussing sudden infant death syndrome (SIDS) with the parents of a newborn. Which of the following statements, if made by the parents, would require follow-up? A. "I have been keeping my baby warm with extra blankets while he sleeps." B. "I give my baby a pacifier at night while he sleeps." C. "I am keeping my baby up to date on his scheduled vaccinations." D. "I replaced my baby's sheepskin bedding with a firm mattress."

Choices C, D, and E are correct. C is correct. A priority nursing intervention with PROM is to monitor for infection. One of the most critical observations you must make is of the color, odor, consistency, and amount of the amniotic fluid when the rupture of membranes occurs. Any discolored or malodorous fluid may indicate an infection. After the breakdown of membranes occurs, the nurse should monitor the mother's temperature, WBC count, CRP, and other disease markers. D is correct. It is essential to assess the color, odor, consistency, and amount of fluid when the rupture of membranes occurs. If the liquid is green or yellow and rancid, it indicates infection. If the fluid is brown or black, it means meconium passing in utero. The expected finding of amniotic fluid is a clear fluid with no odor. E is correct. PROM may lead to preterm birth if it occurs before 37 weeks of gestation. If the membranes rupture prematurely and labor does not spontaneously begin, healthcare providers may need to induce labor to prevent infections and other complications. If the membranes rupture before 37 weeks gestation, the correct terminology is PPROM.

The nurse is educating a group of nursing students about complications during pregnancy. Which of the following statements is true regarding the premature rupture of membranes (PROM)? Select all that apply. -"PROM is when the membranes rupture before 37 weeks gestation." -"In a normal delivery, membranes are expected to rupture before labor begins." -"A priority nursing intervention with PROM is to monitor for infection." -"When observing the fluid after the rupture of membranes, it should be clear and without odor." -"PROM may lead to preterm birth if before 37 weeks

Choices C, D, and E are correct. LMWH is the anticoagulant of choice during pregnancy because it does not cross the placenta, but one may switch to warfarin in the post-partum period. While warfarin is contraindicated during active pregnancy due to its potential to cause congenital fetal disabilities, maternal/fetal bleeding, and miscarriages, it is considered safe in the post-partum period. Warfarin is also safe for lactating or breastfeeding women. The client will need a minimum of 3 to 6 months of anticoagulation and, therefore, will be requiring anticoagulation for a few weeks, even after delivery. Additionally, the risk of recurrent venous thromboses is high up to 6 weeks postpartum. Since the client does not like injections, oral anticoagulation with warfarin is an option for her after delivery (choice C). Long-term treatment with LMWH may decrease bone mineral density (osteopenia, osteoporosis) and increase the risk of fractures (choice D). For those with pre-existing osteoporosis and fracture risk, close monitoring is needed when on long-term LMWH therapy. It is common to have some bruising and swelling at the injection site. However, the presence of blisters and necrotic areas (

The nurse is educating a pregnant client who is admitted with deep vein thrombosis in her left lower extremity. The client is at 24 weeks of gestation. The client is placed on Low Molecular Weight Heparin (LMWH). Which of the following statements by the client indicates that she understands the education regarding LMWH? Select all that apply. - "My blood thinner will be stopped soon after delivery." - "Since I am on LMWH, I must have a planned cesarean section." - "I hate injections. I will likely switch to warfarin after delivery." - "There is an increased risk of fractures with long term LMWH therapy." - "If I notice blisters or black-red areas at the injection site, then I will hold LMWH and immediately contact the doctor." - "If I decide to switch to warfarin after delivery, then I should not breastfeed."

• The client reports giving bottles of formula at night and breastfeeding during the day. • After three minutes of feeding, the client removed the infant from the breast.

The nurse is performing a follow-up assessment on a client breastfeeding a three-day-old infant Click to highlight the findings that require follow-up by the nurse Note: Tap to highlight and select the answer. • The client reports giving bottles of formula at night and breastfeeding during the day. • The client was wearing a supportive bra before the feeding. • The client's nipples showed no evidence of cracking and appeared moist. • The client supported the infant's head and neck in her hand, with the infant's body resting on pillows alongside her hip. • The infant latched onto the nipple with much areola on the underside covered by the baby's mouth. • The infant suckling pattern is smooth and continuous, with occasional pauses to rest. • Audible sucking and swallowing were heard. • After three minutes of feeding, the client removed the infant from the breast. • The client burped the newborn following the feeding.

Choice B is correct. Engrossment is used to describe the initial paternal bonding. This is characterized by the father having a face-to-face fascination with the newborn and the ability for the father to start the bonding process.

The nurse is performing a home visit to the parents of a newborn. The nurse witnesses the father's direct eye contact with the infant and shows affection. The nurse should document this finding as A. binding-in. B. engrossment. C. entrainment. D. detachment.

Choice B is correct. The APGAR score is 2. This critical finding requires aggressive care, including immediate transfer to the neonatal intensive care unit (NICU). Cyanotic trunk and extremities - 0 Pulse 70/minute - +1 (any pulse less than 100/min) No grimace - 0 Limp muscle tone - 0 Irregular respiratory rate of 10/min - +1

The nurse is performing an assessment on a newborn delivered five minutes ago. The nurse observes that the infant has a cyanotic trunk and extremities, pulse of 70/minute, limp muscle tone, no grimace, and a respiratory rate of 10/minute and irregular. The nurse is correct in assigning the APGAR score of A. 1 B. 2 C. 3 D. 7

Choice A is correct. Young pregnant women should be taught that most women (carrying one fetus) with a healthy pre-pregnancy weight require an additional 350 extra calories per day beginning in the second trimester of pregnancy (i.e., weeks 13 to 26). Similarly, an increase of approximately 450 calories per day is indicated during the third trimester (i.e., after 26 weeks) and continuing throughout the pregnancy (following birth, nutritional requirements vary based on whether the client is breastfeeding).

The nurse is planning a series of classes for young pregnant women. Which of the following discussion topics should the nurse include in a class related to nutrition during pregnancy? A. The need to increase caloric intake by about 350 calories during the second trimester of gestation B. The need to increase caloric intake by about 450 calories during the second trimester of gestation C. The need to increase caloric intake by about 350 calories during the third trimester of gestation D. The need to increase caloric intake by about 400 calories during the third trimester of gestation

Choice A is correct. Leopold maneuvers is a non-invasive technique that uses palpation through the abdominal wall to determine the presentation and location of the fetus. These maneuvers are typically done after 24 weeks but should be done in about 36 weeks for a more accurate assessment.

The nurse is preparing to perform Leopold maneuvers on a client who is pregnant. The nurse understands that the purpose of this procedure is to A. determine the location and presentation of the fetus. B. prevent compression to the inferior vena cava. C. measure the involution progress of the uterus. D. assess whether the amniotic sac has ruptured.

Choice A is correct. A Nonstress test does not require a client to abstain from eating or drinking before the test. This statement is false and would require follow-up.

The nurse is providing education to a client who is pregnant about a nonstress test (NST). Which of the following statements by the client would require a follow-up? A. "I cannot have anything to eat eight hours prior to this test." B. "I will have an external monitor across my abdomen." C. "A reactive result means my baby is doing well." D. "If this test is abnormal, I will need further testing."

Choices A, B, C, and D are correct. A is correct. Mothers are at an increased risk for clots for about 6 to 8 weeks after delivery. This is due to a natural increase in clotting factors in the body at this time. When there are increased clotting factors, clots form more readily. B is correct. Mothers should avoid going on car rides longer than 4 hours for a few weeks after they give birth, as the increase in clotting factors after birth puts them at higher risks for clots. Sitting still in for longer than 4 hours could be dangerous due to the likelihood of developing a clot. C is correct. This is excellent advice to share with expecting mothers. One of the essential ways to prevent postpartum thrombophlebitis is early ambulation. By encouraging them to get up and walk as soon as they are able, the likelihood of them developing clots will decrease. D is correct. When legs are crossed for a prolonged period, increased pressure and immobility can lead to clot development. These mothers should be encouraged to avoid crossing legs and ambulate as soon and often as they are able.

The nurse is providing education to a group of pregnant women regarding the prevention of postpartum thrombophlebitis. Which statement by one of the expecting mothers would indicate a correct understanding of the teaching? Select all that apply. "After giving birth, we are at an increased risk of clots for 6 to 8 weeks." "We shouldn't go on car rides longer than 4 hours for a few weeks after giving birth." "After delivery, we should get up and walk as soon as we are able." "Avoiding crossing our legs will help prevent clots from forming." "Having a vaginal delivery will increase the risk for postpartum clots"

Choice C is correct. Preeclampsia occurs when a woman develops high blood pressure after 20 weeks of gestation.

The nurse is providing education to a student nurse assigned to care for a pregnant mother with preeclampsia. The nursing student would not need to be corrected if they said which of the following about this condition? A. "If a woman develops high blood pressure at her first prenatal appointment she likely has preeclampsia." B. "The kidneys cause fluid overload leading to preeclampsia." C. "High blood pressure is one of the findings in preeclampsia and occurs after 20 weeks gestation." D. During preeclampsia episodes, the mother experiences frequent nausea and vomiting, sometimes preventing weight gain.

Choice A is correct. This statement is inaccurate and requires follow-up. A CVS is a test used to determine the presence of chromosomal abnormalities and involves the aspiration of small samples from the placenta for prenatal genetic diagnosis. Maternal blood and urine samples are not necessary for this test. While a blood sample may be taken for compatibility testing, a urine sample is typically not required for a chorionic villus sampling (CVS) procedure. The primary procedure involves sampling fetal cells from the placenta using a needle.

The nurse is supervising a nursing student to teach a pregnant client about a scheduled chorionic villus sampling (CVS) test. Which statement, if made by the nursing student, would require follow-up? A. You will need to provide both a urine and blood sample for this test. B. Drink plenty of water prior to this test and do not empty your bladder. C. An ultrasound will be used during this procedure to guide the needle. D. It is okay to eat and drink on the day of the procedure.

Choice B is correct. A CST is indicated for high-risk clients who are in the third trimester. CST requires the client to have contractions either through oxytocin administration or nipple stimulation.

The nurse is teaching a client about a scheduled contraction stress test (CST). Which of the following statements should the nurse include? A. "You will need to consume a liquid with 50 grams of glucose." B. "You may need to stimulate your nipples during this test." C. "A positive result means your baby has had no late decelerations." D. "A negative result means your baby has had variable decelerations."

Choices A, B, C, D, and E are correct. Fiber-dense foods are an excellent choice for individuals who are (and are not) pregnant. They sustain satiety and prevent spikes in blood glucose. Bran, vegetables, whole wheat, beans, and lentils are fiber-rich and would be appropriate to recommend to the client.

The nurse is teaching a client who is pregnant about how to increase the fiber in her diet. It would be appropriate for the nurse to recommend which foods? Select all that apply. Bran muffin Kidney beans Brown rice Whole wheat pasta Corn French fries

Choices B and E are correct. A nonstress test is performed in the third trimester if the client has indications such as a high-risk pregnancy that may result in a stillbirth or complications such as fetal hypoxia. Ultrasounds typically require a full bladder as the fluid moves the uterus upward and assists with visualization.

The nurse is teaching parents about antepartum testing. Which statements should the nurse include? Select all that apply. "Oral glucose tolerance testing will measure fetal activity at certain intervals." "A nonstress test may be used to measure fetal heart rate." "Amniocentesis may be used to assess if you have preeclampsia." "Chorionic villus sampling may be done to assess for neural tube defects." "You may need to fill up your bladder prior to an ultrasound."

Choice D is correct. These symptoms are strongly suggestive of severe pre-eclampsia. Severe pre-eclampsia manifests as epigastric to right-upper quadrant pain suggestive of a liver injury. This, combined with a frontal headache, is highly concerning for severe pre-eclampsia. The client needs to be immediately evaluated as these symptoms may worsen to an eclamptic seizure.

The nurse is triaging phone calls at a local obstetrics clinic. Which client situation requires immediate follow-up? A client reporting A. ten fetal movements in the past hour. B. irregular, painful contractions that are decreased with repositioning. C. abdominal cramping following her amniocentesis six hours ago. D. epigastric pain and a frontal headache not relieved with acetaminophen.

Choice C is correct. If the prenatal client has a current case of placenta previa, the cervix should not be assessed for dilation. Placenta previa arises when the placenta develops in a problematic spot, close to or over the cervical os. To prevent bleeding or premature labor, women with placenta previa shouldn't have their cervix checked manually. Instead, an ultrasound may be performed.

The nurse notes that the 39-week pregnant client is experiencing placenta previa. Knowing the contexts surrounding this condition, the nurse refrains from performing which of the following standard procedures? A. Ultrasonography of the uterus B. Palpating the uterus to determine fetal arrangement C. Checking the cervix for dilation D. Placing the patient on the left side

Choice B is correct. Lanugo is the soft, down hairs present on newborns' shoulders, back, and forehead. It is theorized that this assists in keeping the newborn warm.

The nurse performs a physical assessment on a newborn and observes fine, downy hair on the cheeks and forehead. The nurse analyzes this finding as A. milia. B. lanugo. C. vernix caseosa. D. mongolian spot.

Choice A is correct. ➢ The client's total number of pregnancies (including the current one) is three. This is documented under gravida (G). She is currently pregnant, had one ectopic pregnancy, and was pregnant with twins. ➢ The client has had one-term birth: the twins were born at 39 gestational weeks. This is documented under the term (T). Term is any birth after 37 gestational weeks. ➢ The client has not had any preterm (P) births (any birth between 20 and 37 gestational weeks). ➢ The client has had one ectopic pregnancy, which is documented as an abortion (A). ➢ The client has two living (L) children, the twins, who were born at 39 gestational weeks.

The nurse performs an obstetrics history on a client seeking antenatal care for a confirmed pregnancy. The client reports having six-year-old twins born at 39 gestational weeks. She had an ectopic pregnancy at four gestational weeks that occurred sixteen weeks ago. When completing the client's documentation, the nurse should record the GTPAL as A. G = 3, T = 1, P = 0, A = 1, L = 2 B. G = 3, T = 2, P = 0, A = 1, L = 2 C. G = 4, T = 2, P = 0, A = 1, L = 2 D. G = 3, T = 2, P = 0, A = 1, L = 1

Choice D is correct. A reactive nonstress test is a reassuring finding. In this finding, two or more fetal heart rate accelerations within a 20-minute period were observed. These accelerations should be at least 15 beats per minute (bpm) above baseline for 15 seconds.

The nurse reviews a client's antepartum nonstress test as reactive. The nurse interprets this finding as A. fetal heart rate accelerations less than 15 beats per minute or lasting less than 15 seconds. B. no late decelerations of the fetal heart rate. C. late decelerations are present with a minimum of 50% of the contractions. D. two or more fetal heart rate accelerations within a 20-minute period.

Choices A, B, and E are correct. Potential benefits of delayed cord clamping in the newborn include increased blood volume, decreased risk of brain hemorrhages, increased blood pressure, lower risk of necrotizing enterocolitis, decreased anemia, and improved neurodevelopmental outcomes. Delayed cord clamping allows more blood to flow from the placenta to the baby, which can increase the baby's iron stores (Choice E) and reduce the risk of iron deficiency anemia. Current research indicates that cord clamping can be delayed for 30-60 seconds in vigorous newborns as long as the team manages the newborn's temperature to keep the infant warm.

The nurse understands that which of the following benefits can be attributed to delayed cord clamping in a newborn? Select all that apply. Increased blood volume Decreased brain hemorrhages Decreased risk of polycythemia Decreased jaundice Increased iron stores

Choice B is correct. This response acknowledges the client's dietary change and provides specific advice on enhancing iron absorption. Lemon, rich in vitamin C, can enhance the absorption of non-heme iron from plant-based sources like the iron supplement the client is taking. This response is beneficial and tailored to the client's situation. Tannins are compounds found in coffee and tea that can inhibit the body's iron absorption. Research has shown that adding lemon juice, which is high in vitamin C, can counteract the inhibitory effect of tannins on iron absorption.

The nurse, caring for a G1P0 first-trimester pregnant client with a hemoglobin level of 10 g/dL (Female: 12-16 g/dL), (Pregnant: > 11 g/dL), is informed that the client replaced coffee with hot tea at breakfast and takes iron supplements twice daily. What is the most appropriateresponse by the nurse? A. "You're off to a great start! Tea has much less caffeine than coffee." B. "A little lemon would be a great addition to your cup of tea, as this will help the absorption of your iron pill." C. "Right now, your iron levels are low. Please eliminate all caffeine from your diet, including tea and coffee." D. "That's alright. Drinking coffee or tea will not affect the fetus."

Choice B is correct. Infants need to have their security needs met by being held and cuddled.

The parent of a two-month-old infant informs a nurse that they heard that picking the infant up immediately upon crying will "spoil the baby." What would be the nurse's best response? A. "Let your baby cry a while before picking the infant up." B. "Babies need to be cuddled and comforted, as this does not spoil the infant." C. "You need to feed the infant right away because crying means the infant is hungry." D. "You can just let your infant cry, as the crying will cease once the infant tires."

Choice C is correct. A fetal doppler assessment will not be performed this early in the pregnancy. If this woman is only three days late for her period, she is between 4 and 5 weeks pregnant. Fetal heart tones cannot be heard with the doppler until about 10 - 12 weeks.

The patient has just arrived for her initial physical examination of her new pregnancy. She received a positive pregnancy test two days ago and is three days late for her period. She asks about the following tests and procedures. She is wondering when they will be performed. The nurse would be correct in explaining which assessment will likely not be completed at this time? A. Calculation of body mass index (BMI) B. Evaluation of areas prone to edema such as the hands, face, and ankles C. Fetal doppler assessment D. Pelvic examination

Choices B, C, and D are correct. B is correct. A massive amount of dark red bleeding is a prominent sign of placental abruption. The bleeding occurs due to the placenta separating from the wall of the uterus. C is correct. Due to the massive amounts of dark red bleeding, hypotension is a sign of placental abruption. When the mother loses large amounts of blood, her blood pressure will drop, potentially resulting in hypovolemic shock. This hypovolemia is treated with IV fluids and blood products such as PRBCs. D is correct. A rigid, board-like abdomen is a sign of placental abruption. This is also due to massive blood loss and internal bleeding. As the placenta separates from the womb's wall, blood accumulates in the abdomen, causing it to become rigid and board-like.

The perinatal nurse is caring for a client experiencing suspected placental abruption. Which of the following signs and symptoms would be expected assessment findings for this client? Select all that apply. Painless bleeding Dark red bleeding Hypotension Rigid abdomen Fetal tachycardia

Choice D is correct. Swimming is the best exercise at this point in the mother's pregnancy. Swimming is low impact and requires no balance, which can be troublesome with the weight a woman carries in her third trimester.

The prenatal client is 7 months pregnant and wants to start an exercise program. The nurse should suggest which of the following exercises to the patient? A. Bike riding B. Circuit training C. Aerial yoga D. Swimming

Choice B is correct. Uterine atony results from the inability of the uterine muscle to contract adequately following birth, leading to vaginal bleeding and/or postpartum hemorrhage. By performing a fundal massage, the nurse will attempt to stimulate the client's uterus to contract.

When assessing a postpartum client, a nurse notes that the client has soaked three perineal pads in the three hours since delivery. The nurse also notes a soft fundus. The initial actionfor the nurse would be which of the following? A. Insert vaginal packing B. Massage the client's fundus C. Apply an ice pack over the client's perineal area D. Administer packed red blood cells

Choice D is correct. A fetal heartbeat can be detected with a doppler as early as 10-12 weeks of pregnancy and is considered a positive or diagnostic sign of fertility. Signs of pregnancy can be possible, probable, or definite. Because likely signs of pregnancy may also occur when other conditions are present, the nurse needs to know what each possible indicator of pregnancy means.

Which of the following clinical manifestations should the nurse document as a positive sign of pregnancy? A. Amenorrhea B. Uterine soufflé C. Positive pregnancy test D. Fetal heartbeat

Choices A, C, and E are correct. Women infected with rubella are at an increased risk of having a miscarriage or a stillbirth. Their infants are more likely to suffer from intrauterine growth restriction and hydrocephaly.

While caring for a newly pregnant mother, the nurse notes that she has a rubella infection. Which of the following conditions would the nurse be concerned about in this case? Select all that apply. Intrauterine growth restriction (IUGR) Hemolytic disease of the newborn Hydrocephaly Large for gestational age infant (LGA) Stillbirth

Choice B is correct. This patient is displaying signs and symptoms of congenital heart disease; specifically coarctation of the aorta. Even if you did not know which congenital heart disease they may have, you would be expected to know that the healthcare provider needs to be notified of these symptoms. Your patient is in normal sinus rhythm and has a normal heart rate for the newborn age group. The systolic murmur, the gradient in peripheral pulses, and 5 second capillary refill are all abnormal. The murmur indicates that there is an opening somewhere in the heart where there should not be. This could be an ASD, VSD, or one of the bypasses in fetal circulation (the ductus arteriosus or foramen ovale) may not have closed on their own. The gradient in pulses indicates that there is more blood flow in the top half of the body than in the lower half - this is what points to coarctation of the aorta. A capillary refill time of 5 seconds is the last abnormal sign for this patient. Capillary refill should be less than 3 seconds in a newborn - delayed capillary refill indicates poor perfusion and must be addressed quickly. It is important to recognize that these are abnormal signs and symptoms

While performing a cardiovascular assessment on an infant at 2 hours of life, you note the following: Normal sinus rhythm HR = 178 Systolic murmur +1 pedal pulses +3 radial pulses 5 second capillary refill No edema What is the priority nursing action after this assessment? A. Continue to monitor B. Notify the health care provider C. Administer PRN acetaminophen D. Re-evaluate the patient in one hour

Choice A is correct: Naegele's rule is limited in calculating the EDD as it assumes that all women ovulate around day 14 of their menstrual cycle. Women all vary biologically and may ovulate on varying days within their cycle. Naegele's rule also incorrectly assumes that all women have cycles that last 28 days.

While the nurse uses Nagele's rule to determine the prenatal clients' estimated due date (EDD), they know that their calculations are limited by the fact that they assume: A. Ovulation occurs on day 14 B. Pregnancy lasts 9 months C. Amenorrhea is the first sign of pregnancy D. Cycles are 30 days in length

Choices A, B, C, D and E are correct. All of these actions are appropriate and expected in this situation. Also, the team should assess both of the mothers for any infectious process. Additionally, the nurse should educate both sets of parents that the risk of transmission of the disease is small. The mother may have concerns about exposure to hepatitis B and C; however, these infections cannot be spread from a woman to an infant through breastmilk. Probably the most critical intervention is to put processes in place to prevent mix-ups of milk from happening again. The healthcare facility should review the incident (Choice E) and take steps to prevent similar errors from occurring in the future, such as staff education, process improvements, or implementing technology to reduce medication errors.

You are a nurse in the local childcare facility. You are feeding an infant from a bottle containing expressed breast milk from the mother, halfway through the feeding, you realize that the breastmilk you are supplying is not for this child. You have mistakenly picked up the breastmilk that was for another woman's child. You should: Select all that apply. - Inform the parent of the child that you are feeding. - Inform the mother of the child whose milk you fed to the child. - Complete an incident report per facility policy. - Inform the providers who are caring for the infants. - Take steps to prevent future errors

Choice B is correct. 25 to 35 pounds. The amount of optimal weight gain during pregnancy is determined based on the woman's body mass index (BMI) before pregnancy. BMI is a measure of body fat calculated from weight and height. Please use the following table to determine the recommended weight gain during pregnancy. A baseline BMI of 22 indicates that this woman's baseline is in the healthy range (Normal BMI = 18.5 to 24.9). The recommended weight gain for this client is 25 to 35 pounds. Weight gain during pregnancy is crucial to the health and well-being of the baby and the mother.

You are caring for a pregnant woman with a baseline BMI of 22. You educate this client on the desirable weight gain during pregnancy with one baby for her is: A. 28 to 40 pounds B. 25 to 35 pounds C. 15 to 25 pounds D. 11 to 20 pounds

Choice D is correct. This is the image showing striae gravidarum. These are reddish-purple stretch marks on the abdomen, breasts, thighs, and upper arms that are due to increasing levels of the melanocyte-stimulating hormone with the increase in estrogen and progesterone levels.

You are seeing patients in an outpatient obstetrical clinic for their regularly scheduled prenatal appointments. Your patient is a G2P1 32-year-old woman who is 32 weeks pregnant. She says to you that she is concerned because she thinks she is developing striae gravidarum. When you assess the patient, what would you expect to see if she does present with this condition? Select the correct image.

Choice B is correct. The nurse should suspect a possible ectopic pregnancy. Abdominal pain, vaginal bleeding, and an adnexal mass are the classic triad for an ectopic pregnancy. The developing chorion produces progesterone. A normal progesterone level is > 15 ng/mL. A lower than normal progesterone level is uncommon in normal pregnancies but is very common in an ectopic pregnancy. Further testing will usually be done to confirm the diagnosis.

Your new client presented with a positive home pregnancy last night. She has abdominal pain, some vaginal bleeding. and you note an adnexal mass on palpation. You order a progesterone level, which returns as 13 ng/mL. Your initial impression is: A. Early normal pregnancy B. Possible ectopic pregnancy C. Abnormal intrauterine pregnancy D. Incorrect home pregnancy test

Choice B is correct. Ondansetron is a 5HT-3 receptor antagonist that treats nausea and vomiting. It may be used in hyperemesis gravidarum when the patient loses weight or cannot cope with pregnancy-related nausea. Prolonged QT interval is a severe side effect of ondansetron.

Your pregnant client has been hospitalized with hyperemesis gravidarum. She is given ondansetron to treat this illness. What serious side effects should the hospital nurses be watching for? A. Continued nausea and vomiting B. Prolonged QT interval C. Respiratory distress D. Constipation