Maternity 125
A client at 39 weeks gestation overhears her health care provider say to the nurse, "Her Bishop score is 10." The client asks the nurse, "What does that mean?" What is the nurse's best response? A."Your baby is in a good position to deliver." B."Your cervix is ready for labor." C."Labor will start in the next 24 hours." D."Your amniotic sac will rupture soon."
B."Your cervix is ready for labor."
The nurse is preparing a teaching session for a group of newly pregnant women and their significant other. When discussing fatigue early in pregnancy, which statements will the nurse include in the teaching plan? (Select all that apply.) A."Fatigue is a result from the hormonal changes early in pregnancy." B."You need to take 4 to 5, 60 minute naps per day." C."Make sure you keep your fluid intake to 1500 mL/day." D."Highly caffeinated drinks need to be avoided in pregnancy." E."Keep up your regular 45 minutes of stationary cycling per day."
A."Fatigue is a result from the hormonal changes early in pregnancy." D."Highly caffeinated drinks need to be avoided in pregnancy." E."Keep up your regular 45 minutes of stationary cycling per day."
The nurse is providing care to an infant at 24 hours old. Upon assessment, the nurse observes milia on the newborn's nose. What is the nurse's next action? A.Document the findings in the newborn's chart. B.Ask another nurse to confirm the findings. C.Assess the mother for the presence of milia. D.Contact the pediatric health care provider.
A.Document the findings in the newborn's chart.
Twenty-four hours after admission to the newborn nursery, the nurse assesses a full-term infant who has developed localized swelling on the right side of the head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line? A.Cephalohematoma, which is caused by forceps trauma B.Subarachnoid hematoma, which requires immediate drainage C.Molding, which is caused by pressure during labor D.Subdural hematoma, which can result in lifelong damage
A. Cephalohematoma, which is caused by forceps trauma
A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A.Come to the clinic today for an ultrasound. B.Go immediately to the emergency department. C.Lie on your left side for about 1 hour and see if the bleeding stops. D.Take a urine specimen to the laboratory to see if you have a urinary tract infection (UTI). A.Come to the clinic today for an ultrasound. B.Go immediately to the emergency department. C.Lie on your left side for about 1 hour and see if the bleeding stops. D.Take a urine specimen to the laboratory to see if you have a urinary tract infection (UTI).
A. Come to the clinic today for an ultrasound.
The nurse is teaching a nursing student about the abbreviation GTPAL to note pregnancy outcomes. The nurse determines the teaching was successful when the students relates the abbreviation GTPAL to which terms? (Select all that apply. A.Gravidity B.Total C.Parity D.Born Alive E.Living
A. Gravidity E.Living Gravidity and Living are correct. T - term pregnancies, born after 37 weeks gestation. P - preterm pregnancies, born between 20 and 37 weeks. A - abortions, delivery before 20 weeks.
The health care provider states to the nurse, the baby is in a left occiput anterior (LOA) position. The laboring client asks, "What does that mean?" What descriptions will the nurse use when teaching the client about the LOA fetal position? (Select all that apply.) A."The baby's head is in your pelvis." B."The baby's feet can be felt on your left side." C."The baby's back is on your right side." D."That is the ideal fetal birthing position." E."The baby is looking down towards the floor"
A. The baby's head is in your pelvis." D."That is the ideal fetal birthing position." E."The baby is looking down towards the floor"
What specific instructions will the nurse include in the pregnancy client's teaching plan who is also human immunodeficiency virus (HIV) positive? (Select all that apply.) A. Use condoms when having sex. B. Zidovudine prescription helps decrease risk of fetal exposure. C. Increase your intake of fruits and vegetables in pregnancy. D. Weekly prenatal appointments 36 weeks through delivery. E. Breastfeeding is not recommended.
A.Use condoms when having sex. B.Zidovudine prescription helps decrease risk of fetal exposure. E.Breastfeeding is not recommended.
What specific instructions will the nurse include in the pregnancy client's teaching plan who is also human immunodeficiency virus (HIV) positive? (Select all that apply.) A.Use condoms when having sex. B.Zidovudine prescription helps decrease risk of fetal exposure. C.Increase your intake of fruits and vegetables in pregnancy. D.Weekly prenatal appointments 36 weeks through delivery. E.Breastfeeding is not recommended.
A.Use condoms when having sex. B.Zidovudine prescription helps decrease risk of fetal exposure. E.Breastfeeding is not recommended.
Which client statement indicates to the nurse that the she understands her pre-pregnancy instructions? A."I will take 2000 mg of vitamin C daily." B."I will take 400 mcg of folic acid daily." C."I will take an extra 2000 IU of vitamin D." D."I will increase my intake of calcium to 250 mg/day."
B. "I will take 400 mcg of folic acid daily."
The labor and delivery nurse is providing care to a client at term with known cardiac disease. Which focused assessments will the nurse include in the client's plan of care? (Select all that apply.) A.Elevated temperature B.Cough C.Fetal tachycardia D.Uterine tenderness E.Dyspnea F.Chest pain
B. Cough E. Dyspnea F.Chest pain
The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn at home. The woman tells the nurse, "I don't know what is wrong. I love my baby, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should the nurse determine the client is experiencing?
B. Postpartum blues
The nurse is discussing many of the changes a pregnancy brings to a couple. Which of the father's statements concerns the nurse the most? (Select all that apply.) A."I am not sure I know how to be a father." B."I do not want to be a father!" C."I did not think pregnancy would happen so soon." D."I am not sure I want to share my wife with a newborn." E."I am sure I am not the father of this baby."
B."I do not want to be a father! "E."I am sure I am not the father of this baby."
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information? A.Maternal blood pressure B.Maternal temperature C.Fetal heart rate (FHR) D.White blood cell count (WBC)
C.Fetal heart rate (FHR)
The nurse is providing care to a newborn just delivered from a mom who is positive for Hepatitis B. What additional care will the nurse plan for this neonate? (Select all that apply.) A.Place the baby next to the mother's face, eye-to-eye, immediately after delivery. B.Delay the application of eye prophylaxis until 2 to 3 hours after birth. C.Remove any maternal blood from the infant immediately after birth. D.Bathe the neonate prior to administering the vitamin K injection. E.Perform a gastric lavage prior to initiating breastfeeding.
C.Remove any maternal blood from the infant immediately after birth. D.Bathe the neonate prior to administering the vitamin K injection.
The nurse is providing care to a postpartum client with O negative blood who is antibody positive. The newborn is O negative. What is the best nursing action for this client? A.Obtain a consent for a blood transfusion for the infant. B.Explain how RhoGAM works in the maternal blood. C.Prepare the father for the test to determine his blood type. D.Ask the mother if she desires any more children
D.Ask the mother if she desires any more children
Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." What is the next nursing action? A.Assess the husband's feelings about his wife's decision to breastfeed their baby. B.Ask the woman to describe why she was unsuccessful with breastfeeding her last child. C.Encourage the woman to develop a positive attitude about breastfeeding to help ensure success. D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? A. Two weeks before menstruation B. Immediately after menstruation C.Immediately before menstruation D.Three weeks before menstruation
A. Two weeks before menstruation
The clinic nurse is reviewing signs of pre-term labor with a client at 28 weeks gestation. Which client statements indicate to the nurse further teaching is necessary? (Select all that apply.) A."I expect the discharge from my vagina will change from thick to brown over the next two weeks." B. "I will call my health care provider if I experience regular contractions that get stronger over time." C. "I will call my health care provider if I think I broke my bag of waters." D. "The baby's movements will decrease and be almost still from here on out." E. "I should expect low back pain and diarrhea as the baby grows."
A."I expect the discharge from my vagina will change from thick to brown over the next two weeks. "D."The baby's movements will decrease and be almost still from here on out." E."I should expect low back pain and diarrhea as the baby grows."
The clinic nurse is reviewing signs of pre-term labor with a client at 28 weeks gestation. Which client statements indicate to the nurse further teaching is necessary? (Select all that apply.) A."I expect the discharge from my vagina will change from thick to brown over the next two weeks." B."I will call my health care provider if I experience regular contractions that get stronger over time." C."I will call my health care provider if I think I broke my bag of waters." D."The baby's movements will decrease and be almost still from here on out." E."I should expect low back pain and diarrhea as the baby grows."
A."I expect the discharge from my vagina will change from thick to brown over the next two weeks." D."The baby's movements will decrease and be almost still from here on out." E."I should expect low back pain and diarrhea as the baby grows."
The nurse is interviewing a newly pregnancy client who is 16-years old. Which client statement indicates teaching is necessary for a safe pregnancy? (Select all that apply.) A.I hate "milk." B."I only want to gain 10 pounds." C."I will never have sex again." D."My sister is pregnant too." E."I refuse to wear maternity clothes."
A."I hate milk." B."I only want to gain 10 pounds. " E. I refuse to wear maternity clothes."
The clinic nurse is providing care to a client at 20 weeks gestation. They are reviewing literature about gestational diabetes mellitus (GDM). Which statement indicates to the nurse the client understands the information? A."I will have to drink the sweet syrup at my next appointment." B."I am at risk for GDM because I am 30 years old." C."If I develop GDM, I have no increased risk for diabetes later in life." D."GDM can only be controlled with insulin injections."
A."I will have to drink the sweet syrup at my next appointment."
A new mother asks the nurse, "How do I know that my baby is getting enough breast milk?" Which explanation is most appropriate?
A."Make sure you weigh the baby at the same time every day to assure weight gain."
The nurse is performing teaching for a pregnant client who has been an insulin dependent diabetic since she was 13 year old. Which statement indicates to the nurse that the teaching was effective? A."My insulin requirements will likely increase around 24 weeks gestation." B."I will have to take my insulin 4 to 6 times a day between now and 20 weeks." C."My baby will be born with diabetes and will depend on insulin for life." D."I will require a cesarean section to safely deliver this
A."My insulin requirements will likely increase around 24 weeks gestation."
The nurse is teaching a prenatal class about the structure of the pelvis and is using a model of a pelvis in the presentation. Which statements will the nurse include in the teaching plan? (Select all that apply.) A."The baby has to pass through the true pelvis." B."The pelvis consists of three distinct features." C."The true pelvis is below the pelvic brim." D."The ischial spines determine how low the baby is located." E."The shape of the pelvis does not impact the labor process."
A."The baby has to pass through the true pelvis." B."The pelvis consists of three distinct features." C."The true pelvis is below the pelvic brim." D."The ischial spines determine how low the baby is located."
An induction of labor is planned for the client with diabetes mellitus and dependent on insulin since the age of 10. The nurse is gathering supplies to care for the client during the induction. What supplies will the nurse gather? (Select all that apply.) A.An fusion pump for 3 lines B.NPH insulin for IV infusion C.Normal saline D.10% dextrose solution E.Glucose monitoring kit
A.An fusion pump for 3 lines C.Normal saline D.10% dextrose solution E.Glucose monitoring kit
The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the mother's teaching plan? A.Avoid alcohol within two hours before the next feeding. B.Eat a high-roughage diet to help prevent constipation. C.Increase caloric intake by approximately 500 cal/day. D.Increase fluid intake to at least 3 quarts each day.
A.Avoid alcohol within two hours before the next feeding.
As the placenta is delivered during a cesarean section the health care provider states, "It looks like at least a 25% abruption." Which concerning signs will the postpartum nurse include in the client's assessment? (Select all that apply.) A.Bleeding gums B.Petechia C.Hypertension D.Oozing blood from IV site(s) E.Bradycardia
A.Bleeding gums B.Petechia D.Oozing blood from IV site(s)
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? A.Breastfeed the infant, ensuring that both breasts are completely emptied. B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast. C.Breastfeed on the unaffected breast only until the mastitis subsides. D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
The nurse is providing care to a client at term undergoing an oxytocin induction. At last check she was 6/+1/100%. For the most recent five contractions, the fetal heart rate has fallen below the baseline after the onset of the contraction, and returns to baseline 20 to 30 seconds after the end of the contraction. What actions must the nurse take? (Select all that apply.) A.Contact the health care provider. B.Stop the infusion of oxytocin. C.Increase the infusion of the mainline IV fluid. D.Apply oxygen by facemask. E.Reposition the client.
A.Contact the health care provider. B.Stop the infusion of oxytocin. C.Increase the infusion of the mainline IV fluid. D.Apply oxygen by facemask. E.Reposition the client.
A primigravida at term presents to the labor and delivery unit smiling and states to the nurse, "I am in labor." The nurse assesses the client's cervical dilation and finds it is 2/50%/-1. The fetal heart rate is stable at 135 to 145 beats/min, and membranes are intact. Maternal vital signs are stable. What are the nursing actions for this phase/stage of labor? (Select all that apply.) A.Encourage the mother to ambulate. B.Have the mother use slow, deep breathing with contractions. C.Encourage the mother to urinate every 1 to 2 hours. D.Assess the fetal heart tones every 15 minutes. E.Assess for cervical dilation every hour.
A.Encourage the mother to ambulate. B.Have the mother use slow, deep breathing with contractions. C.Encourage the mother to urinate every 1 to 2 hours.
An insulin-dependent client with gestational diabetes mellitus is in the second stage of labor. What supplies will the delivery nurse gather for care of the newborn? (Select all that apply. A.Erythromycin ointment B.Scale C.Vacuum extractor D.Measuring tape E.Blood glucose testing kit
A.Erythromycin ointment B.Scale D.Measuring tape E.Blood glucose testing kit
The nurse is providing care for a laboring client with a GTPAL of 65005 at term. Which assessments will the nurse include in this client's plan of care for after delivery? (Select all that apply.) A.Fundal assessment should be made every 5 minutes for 30 minutes after delivery of the placenta. B.Assess for lochia every 5 minutes for 30 minutes after delivery of the placenta. C.Place the infant to breast immediately after delivery. D.Encourage the mother to talk to her newborn. E.Wrap the infant in a warm, sterile blanket immediately after delivery.
A.Fundal assessment should be made every 5 minutes for 30 minutes after delivery of the placenta. B.Assess for lochia every 5 minutes for 30 minutes after delivery of the placenta. C.Place the infant to breast immediately after delivery.
The nurse is providing care to a 1-hour-old neonate born to mother who took insulin throughout her pregnancy. Which conditions will the nurse include in the infant's assessment throughout its hospitalization? (Select all that apply.) A.Hypoglycemia B.Respiratory distress syndrome C.Hypernatremia D.Congenital anomalies E.Absent Moro reflex
A.Hypoglycemia B.Respiratory distress syndrome D.Congenital anomalies
A mother who is breastfeeding her baby receives instructions from the nurse. Which instructions are most effective in preventing nipple soreness? (Select all that apply.) A.Massage a small amount of medical-grade lanolin into the nipple. B.Increase nursing time gradually over several days. C.Ensure that the baby is positioned correctly for latching on. D.Manually express a small amount of milk before nursing. E.Wear a cotton bra with nonbinding support.
A.Massage a small amount of medical-grade lanolin into the nipple. C.Ensure that the baby is positioned correctly for latching on.
The nurse is preparing a memory box of items from the care of an infant who died in utero. What items will the nurse plan on including in the box? (Select all that apply.) A.Measuring tape B.Erythromycin ointment tube C.Infant hat D.Infant blanket E.Bottle of formula
A.Measuring tape C.Infant hat D.Infant blanket
The nurse is teaching the pregnant client about fetal growth and development. Which client statements indicate understanding of the teaching? (Select all that apply.) A.My baby gets oxygen through the placenta. B.I can eat all I want the last 4 weeks of pregnancy. C.The amniotic fluid helps with muscle development. D.I need to stay under a blanket, to keep my baby warm. E.My baby will gain about a half a pound per week after 36 weeks.
A.My baby gets oxygen through the placenta. C.The amniotic fluid helps with muscle development. E.My baby will gain about a half a pound per week after 36 weeks
The nurse is teaching the pregnant client about fetal growth and development. Which client statements indicate understanding of the teaching? (Select all that apply.) A.My baby gets oxygen through the placenta. B.I can eat all I want the last 4 weeks of pregnancy. C.The amniotic fluid helps with muscle development. D.I need to stay under a blanket, to keep my baby warm. E.My baby will gain about a half a pound per week after 36 weeks.
A.My baby gets oxygen through the placenta. C.The amniotic fluid helps with muscle development. E.My baby will gain about a half a pound per week after 36 weeks.
The nurse is teaching a group of teen girls about their reproductive system and pregnancy. What risk factors for an unplanned pregnancy will the nurse include in the teaching plan for these girls? (Select all that apply.) A.Poverty B.Family problems C.Early onset of menarche D.Sexual exploration E.Group think
A.Poverty B.Family problems C.Early onset of menarche D.Sexual exploration E.Group think
The nurse is just starting the shift and is proving care to a laboring woman at term. The fetal heart rate by internal monitor has been 120 to 122 for the past 30 minutes. What are the best nursing actions? (Select all that apply.) A.Reposition the client. B.Administer oxygen by facemask. C.Increase the rate of the mainline IV fluids. D.Assess the client's blood pressure. E.Assess for recent administered medications. F.Ask the support person to leave the room.
A.Reposition the client. B.Administer oxygen by facemask. C.Increase the rate of the mainline IV fluids D.Assess the client's blood pressure. E.Assess for recent administered medications. F.Ask the support person to leave the room.
A client at 34 weeks gestation arrives to the clinic and says to the nurse that she thinks she is having contractions. What actions will the nurse include in this client's plan of care? (Select all that apply.) A.State to her, "Let me know if you have a contraction during your visit today." B.Ask the client, "Are the contractions painful?" C.Tell the client, "You have nothing to worry about." D.Ask her, "Do they come a frequently as every 5 minutes?" E.Tell the client, "It is time for you to go directly to labor and delivery." F.Inform her, "Those could be Braxton-Hicks contractions."
A.State to her, "Let me know if you have a contraction during your visit today." B.Ask the client, "Are the contractions painful?" D.Ask her, "Do they come a frequently as every 5 minutes?" F.Inform her, "Those could be Braxton-Hicks contractions."
The nurse is reviewing the prenatal record for a client scheduled for a glucose challenge test. Which maternal findings place this client at an increased risk for developing gestational diabetes? (Select all that apply.) A.The client is 37 years old. B.The client is pregnant for the second time. C.The client is having twins. D.The client's pre-pregnant weight was 190 pounds/86 kilograms. E.The client's blood pressure is 132/88 mm Hg.
A.The client is 37 years old. C.The client is having twins. D.The client's pre-pregnant weight was 190 pounds/86 kilograms.
A client presents to the emergency department with complaints of severe lower left abdominal pain and vaginal spotting. Her last menstrual period was 5 weeks ago. What are the nurse's next actions? (Select all that apply.) A.Notify the operating room staff. B.Check the results of the HCG test. C.Ask the client to describe the color of the vaginal bleeding. D.Ask the client if she has ever been diagnosed with pelvic inflammatory disease. E.Draw the client's blood for a type and cross match.
B. Check the results of the HCG test. C. Ask the client to describe the color of the vaginal bleeding. D. Ask the client if she has ever been diagnosed with pelvic inflammatory disease. E. Draw the client's blood for a type and cross match.
The nurse is providing care to a laboring client with a GTPAL of 75015. The client reports contractions every 2 to 8 minutes, of moderate intensity, for the past 6 hours. Her cervical exam upon admission is 4/0/75%, and membranes are intact. In the next 20 minutes, what supplies will the nurse gather for this client? (Select all that apply.) A.Erythromycin ophthalmic ointment B. Amnihook C.1000 mL of D5LR D.Oxytocin E.Blankets
B.Amnihook C.1000 mL of D5LR D.Oxytocin
The nurse is providing care to a laboring client with a GTPAL of 75015. The client reports contractions every 2 to 8 minutes, of moderate intensity, for the past 6 hours. Her cervical exam upon admission is 4/0/75%, and membranes are intact. In the next 20 minutes, what supplies will the nurse gather for this client? (Select all that apply.) A.Erythromycin ophthalmic ointment B.Amnihook C.1000 mL of D5LR D.Oxytocin E.Blankets
B.Amnihook C.1000 mL of D5LR D.Oxytoci
The clinic nurse is performing an assessment on a client who is 20 weeks gestation, which was confirmed by ultrasound. When performing the fundal height assessment, where will the nurse start palpating the abdomen? A.Midway between the symphysis pubis and the umbilicus B.At the umbilicus C.Between the umbilicus and the xiphoid process. D.Two cm below the xiphoid process.
B.At the umbilicus
A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide? A.Avoid using the breast pump. B.Breastfeed the infant every 2 hours. C.Reduce fluid intake for 24 hours. D.Skip feedings to let the sore breasts rest.
B.Breastfeed the infant every 2 hours
When a new mother receives her infant for the first time, which behavior is most reassuring to the nurse? A.She holds the infant in her lap, undresses the infant, and examines the infant completely. B.Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. C.She reassures the infant not to cry and she then cuddles the infant to her own body. D.She eagerly reaches for the infant and then hands the baby off to the father.
B.Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.
During a prenatal visit, the nurse discusses with a pregnant client the effects of smoking on the fetus. Which statement is most characteristic of an infant whose mother smoked during pregnancy?A.Lower Apgar score recorded at delivery B.Lower initial weight documented at birth C.Higher oxygen use to stimulate breathing D.Higher prevalence of congenital anomalies
B.Lower initial weight documented at birth
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding? A. Cyanosis of the hands and feet B.Skin color that is slightly jaundiced C.Hair located on the back of the shoulders D.Red patches on the cheeks and trunk
B.Skin color that is slightly jaundiced
The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur? A.January 14 to 15 B.January 22 to 23 C.January 29 to 30 D.February 6 to 7
C. January 29 to 30 Rationale:This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period.
Six hours after an oxytocin induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement? A.Increase the IV fluids. B.Begin oxygen by nasal cannula at 2 L/min. C.Place the client in a slight Trendelenburg position. D.Assess for cervical dilation.
C. Place the client in a slight Trendelenburg position.
The nurse is reviewing the findings from a pregnant client's glucose challenge test. The results were 156 mg/dL. What is the best nursing action related to this finding? A.Review the term macrosomia with the client. B.Inform the client of signs of hyperglycemia. C.Schedule the client for a return appointment in 1 week. D.Provide the client with information on recording fetal kick counts.
C. Schedule the client for a return appointment in 1 week.
When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation? A. Milia are red marks made by forceps and will disappear within 7 to 10 days. B. Meconium is the first stool and is usually yellow gold in color. C. Vernix is a white cheesy substance, predominantly located in the skin folds. D. Pseudostrabismus found in newborns is treated by minor surgery.
C. Vernix is a white cheesy substance, predominantly located in the skin folds.
A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color. Which action should the nurse take next? A.Instruct the client to go to the emergency room. B.Recommend vaginal douching. C.Explain this is a normal finding. D.Determine if ovulation has occurred.
C.Explain this is a normal finding.
The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take next? A.Administer oxygen by facemask. B.Notify the health care provider of the client's symptoms. C.Have the client breathe into her cupped hands. D.Check the client's blood pressure and fetal heart rate.
C.Have the client breathe into her cupped hands.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. What is the next nursing action? A.Use thread to tie off the umbilical cord. B.Provide privacy for the woman. C.Reassure the husband and keep him calm. D.Put the newborn to the breast immediately.
D.Put the newborn to the breast immediately.
An expectant father tells the nurse he is concerned about some of his wife's behaviors. He states that she is constantly rubbing her abdomen and talking to the baby. Which recommendation should the nurse make to this expectant father? A.Suggest that his wife seek professional counseling to deal with her symptoms. B.Explain that his wife is exhibiting ambivalence about the pregnancy. C.Ask him to report similar abnormal behaviors at the next prenatal visit. D.Reassure him that normal maternal-fetal bonding is occurring.
D.Reassure him that normal maternal-fetal bonding is occurring.
