Maternity HESI

potential complications of oxytocin

-tachysytole -late decelerations -uterine rupture -edema

Which purposes of placental functioning should the nurse include in a prenatal class? Select all that apply. 1. It cushions and protects the baby. 2. It maintains the temperature of the baby. 3. It is the way the baby gets food and oxygen. 4. It prevents all antibodies and viruses from passing to the baby. 5. It provides an exchange of nutrients and waste products between the mother and developing fetus.

3, 5 The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the placenta.

A multigravida client arrives at the labor and delivery unit and tell the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 bpm. What action should the nurse implement next?

Complete a sterile vaginal exam. A vaginal exam should be preformed after the rupture of membranes to determine the presence of a prolapsed cord.

A pregnant client with Mitral stenosis class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client?

Complete bedrest decreases oxygen needs and demands on the heart muscle tissue

HESI HINT:101 High-Risk Disorders

Coumadin may not be taken during pregnancy due to its ability to cross the placenta and affect the fetus. Heparin is the drug of choice, it does not cross the placental membrane

Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which indicates to the nurse that the medication is having the desired effect? A. Weight gain B. Reduction of fever C. Improved caloric intake D. Reduction of edema

D

At 39 weeks gestation, a multigravida is having a non stress test (NST). The fetal heart rate has remained non reactive during 30 minted of evaluation. Based on this fining, what action should the nurse implement? A. Initiate an IV infusion B. Observe the FHR pattern for 30 more minutes C. Schedule a biophysical profile D. Place an acoustic stimulator on the abdomen

D

The nurse is caring for a female client, a primigravida with preeclampsia. Findings include +2 proteinuria, BP 172/112, facial and hand swelling, complaints of blurry vision and a severe frontal headache. Which medication should the nurse anticipate for this client? A. Clonidine hydrochloride B. Carbamazepine C. Furosemide D. Magnesium Sulfate

D

The nurse is reviewing the serum laboratory finding for a 5-day-old infant with congenital adrenal hyperplasia. Which laboratory results should be reported to the HCP immediately? A. Bilirubin of 1.5 B. Glucose of 80 C. Potassium of 4.5 D. Sodium of 119

D

The parents of a newborn tell the nurse that their baby is already trying to walk. How should the nurse respond? A. Encourage the parents to report this to the HCP B. Acknowledge the parents' observation C. Schedule the newborn for further neurological testing D. Explain the newborn's normal stepping reflex

D

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply A. Avoid stimulation. B. Decrease fluid intake. C. Expose all of the newborn's skin. D. Monitor skin temperature closely. E. Reposition the newborn every 2 hours. F. Cover the newborn's eyes with eye shields or patches.

D. Monitor skin temperature closely. E. Reposition the newborn every 2 hours. F. Cover the newborn's eyes with eye shields or patches.

HESI HINT: 13 Anatomy and Physiology of Reproduction and Antepartum

Teach clients to report immediately any of the following danger signs. Early intervention can optimize maternal and fetal outcome. Possible indications of preeclampsia and eclampsia are: -Visual disturbances -Swelling of face, fingers, or sacrum -Severe, continuous headache -Persistent vomiting -Epigastric pain -Infecetion. Signs include: chills, temp >100.4, dysuria, abdominal pain -fluid discharge or bleeding from vagina (anything orhter than normal leukorrhea) -Change in fetal movement or increased FHR

. Patient concerned about yellow nipple discharge.

Tell the patient it is normal.

A nurse is performing an assessment of a female client with suspected mittelschmerz. Which question does the nurse ask the client to elicit data specific to this disorder?

"Do you have sharp pain on the right or left side of your pelvis?" -Mittelschmerz ("middle pain") refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain, which is fairly sharp, is felt on the right or left side of the pelvis.

A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat her urinary tract infection but expresses concern that her baby will be born with an infection. Which response should the nurse make to help ease these fears?

"Now that you have taken the medication as prescribed, we'll keep monitoring you closely and repeat the urine culture before you leave today."

. Primigravida, 36 week, admitted, water broke, 2cm dilated, 50% effaced, -2 station, vertex presentation, greenish colored amniotic fluid, contractions Q3-5 min with deceased in FHR after the last 4 contraction peaks. What to do FIRST?

02 via facemask.

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2.Inadequate urinary output 3.Client perception of body changes 4.Potential for imbalanced body fluid volume

1 The priority nursing consideration for a client who delivered 2 hours ago and who has an episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1. "I should stay on the diabetic diet." 2."I should perform glucose monitoring at home." 3."I should avoid exercise because of the negative effects on insulin production." 4."I should be aware of any infections and report signs of infection immediately to my health care provider (HCP)."

3 Exercise is safe for a client with gestational diabetes mellitus and is helpful in lowering the blood glucose level. Dietary modifications are the mainstay of treatment, and the client is placed on a standard diabetic diet. Many clients are taught to perform blood glucose monitoring. If the client is not performing the blood glucose monitoring at home, it is performed at the clinic or HCP's office. Signs of infection need to be reported to the HCP.

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2.A multiparous client who delivered 6 hours ago 3.A multiparous client who delivered a large baby after oxytocin induction 4.A primiparous client who delivered 6 hours ago and had epidural anesthesia

3 The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than the other clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 4 that present the risk for hemorrhage.

A postpartum client who is Rh-negative refuses to receive Rho(D) immune globulin (RhoGAM) after delivery of an infant who is Rh-positive. Which information should the nurse provide this client? A. RhoGam prevents maternal antibody formation for future Rh-positive babies B. RhoGAM is not necessary unless all her pregnancies are Rh-positive C. The R-positive factor from the fetus threatens her blood cells D. The mother should receive RhoGAM when the baby is Rh-negative

A

A primipara has delivered a stillborn fetus at 30 weeks gestation. To assist the parents with the grieving process, which intervention is most important to implement? A. Provide an opportunity for the parents to hold their infant in privacy B. Assist the couple in completing a request for autopsy C. Encourage the couple to seek family counseling within the next few weeks D. Explain the possible causes of the fetal demise

A

One day after vaginal delivery of a full term baby, a postpartum client's WBC is 15,000. What action should the nurse take first? A. Check the differential, since the WBC is normal for this client B. Assess the client's temperature, pulse, and respirations q4h C. Notify the HCP, since this finding is indicative of infection D. Assess the client's perineal area for signs of a perineal hematoma

A

The nurse is planning care for a client at 30 weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory stress syndrome? A. Betamethasone (Celestone) 12mg deep IM B. Butorphanol 1mg IV push q2h PRN pain C. Ampicillin 1 gram IV push q8hr D. Terbutaline (Brethine) 0.25 mg subq q15 min x3

A

While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that falls and rises abruptly with a "V" shaped appearance. What action should the nurse take first? A. Change the maternal position B. Administer O2 at 10/L by mask C. Prepare for a potential cesarean D. Allow the client to begin pushing

A

A 1-hour oral glucose tolerance test is performed on a pregnant client, with a result of 155 mg/dL. The nurse tells the client that:

A 3-hour glucose tolerance test will likely be performed to confirm gestational diabetes

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The health care provider has documented the presence of Goodell's sign. This finding is most closely associated with which characteristic? A. A softening of the cervix B. The presence of fetal movement C. The presence of human chorionic gonadotropin in the urine D. A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus

A. A softening of the cervix

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? A. Delivery of the fetus B. Strict monitoring of intake and output C. Complete bed rest for the remainder of the pregnancy D. The need for weekly monitoring of coagulation studies until the time of delivery

A. Delivery of the fetus

A pregnant client asks the nurse about the types of exercises that are allowable during pregnancy. The nurse should tell that client that which exercise is safest? A. Swimming B. Scuba diving C. Low-impact gymnastics D. Bicycling with the legs in the air

A. Swimming

HESI HINT:97 High-Risk Disorders

Although delivery is often described as the "cure" for preeclampsia the client can convulse up to 48 hrs after delivery

A client at 35 weeks gestation complains of a "pain whenever the baby moves." On assessment, the nurse notes the client's temperature to be 101.2 (38.4), with severe abdominal or uterine tenderness on palpation. The nurse knows that these findings are indicative of what condition? A. Round ligament strain B. Chorioamnionitis C. Abruptio placenta D. Vital infection

B

The nurse is conducting postpartum teaching with a mother who is breastfeeding her infant. When discussing birth control, which method should the nurse recommend to this client as for her to use in preventing an unwanted pregnancy? A. Breastfeed exclusively at least every 3-4hours B. Condoms and contraceptive foam or gel C. Rhythm method (natural family planning) D. Combined estrogen progesterone oral contraceptive

B

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? A. "come to the clinic immediately." B. "the vaginal discharge may be bothersome, but is a normal occurrence." C. "report to the emergency department at the maternity center immediately." D. "use tampons if the discharge is bothersome, but to be sure to change the tampons every 2 hours."

B. "the vaginal discharge may be bothersome, but is a normal occurrence."

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? A. A temperature of 100.4 ° F B. An increase in the pulse rate from 88 to 102 beats/minute C. A blood pressure change from 130/88 to 124/80 mm Hg D. An increase in the respiratory rate from 18 to 22 breaths/minute

B. An increase in the pulse rate from 88 to 102 beats/minute

Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority nursing assessment? A. Uterine tone B. Blood pressure C. Amount of lochia D. Deep tendon reflexes

B. Blood pressure

The nurse is assisting a client undergoing induction of labor at 41 weeks' gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? A. Notify the health care provider. B. Discontinue the infusion of oxytocin (Pitocin). C. Place oxygen on at 8 to 10 L/minute via face mask. D. Contact the client's primary support person(s) if not currently present.

B. Discontinue the infusion of oxytocin (Pitocin).

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider? A. Hemoglobin of 11 g/dL B. Fetal heart rate of 180 beats/minute C. Maternal pulse rate of 85 beats/minute D. White blood cell count of 12,000 cells/mm3

B. Fetal heart rate of 180 beats/minute

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? A. G=3, T=2, P=O, A=O, L=1 B. G=2, T=1, P=O, A=O, L=1 C. G=1, T=1, P=1, A=0, L=1 D. G=2, T=0, P=O, A=O, L=1

B. G=2, T=1, P=O, A=O, L=1

A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first?

Bathe the infant with an antimicrobial soap

HESI HINT: 27 Intrapartum Nursing Care

Be able to differentiate true labor from false labor TRUE LABOR -Pain in lower back that radiates to abdomen -Pain accompanied by regular rhythmic contractions -Contractions that intensify with ambulation -Progressive cervical dilation and effacement FALSE LABOR -Discomfort localized in abdomen -No lower back pain -Contractions decrease in intensity or frequency with ambulation

HESI HINT: 4 Anatomy and Physiology of Reproduction and Antepartum

Because some women experience implantation bleeding or spotting, they do not know they are pregnant.

HESI HINT: 2 Anatomy and Physiology of Reproduction and Antepartum

Between ovulation and the beginning of the next menstrual cycle, there are usually exactly 14 days. In other words, ovulation occurs 14 days before the next menstrual period.

The nurse is assessing a 2-hour-old infant by cesarean delivery at 39 weeks gestation. Which assessment finding should receive the highest priority when planning this infant's care? A. Blood pressure 76/42 B. Faint heart murmur C. Respiratory rate 76 D. Blood glucose 45

C

What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula? A. Body temperature B. Level of pain C. Time of first void D. Number of vessels in the cord

C

The nurse in a maternity unit is reviewing the clients' records. Which client would the nurse identify as being at the most risk for developing disseminated intravascular coagulation? A. A primigravida with mild preeclampsia B. A primigravida who delivered a 10-lb infant 3 hours ago C. A gravida II who has just been diagnosed with dead fetus syndrome D. A gravida IV who delivered 8 hours ago and has lost 500 ml of blood

C. A gravida II who has just been diagnosed with dead fetus syndrome

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? A. Record the findings. B. Massage the fundus. C. Notify the health care provider (HCP). D. Place the client in Trendelenburg's position.

C. Notify the health care provider (HCP).

A community health nurse visits a family in which a 16 yo unmarried daughter is pregnant with her child and is at 32 weeks gestation. The client tells the nurse that she has been having intermittent back pain since the night before. What is the priority nursing intervention? A. Ask the client's mother to call an ambulance for transport to the hospital immediately D. Determine what physical activities the client has performed for the past 24 hours C. Teach the client how to perform pelvic rock exercises and observe for correct feedback D. Ask the client if she has experienced any recent changes in vaginal discharge

D

A clinic nurse is developing a plan of care for a pregnant client with AIDS. Which problem does the nurse identify as the priority to be addressed in the plan of care?

History of IV drug use

HESI HINT:90 High-Risk Disorders

Hold next dose of mag sulfate and notify HCP if any toxic symptoms occur (<12 respirations/min, urine output <100 mL/4, absent DTR, mag sulfate serum levels >8 mg/dL)

A pregnant client tells the nurse that the first day of her last menstrual period was Aug. 2, 2006. Based on Ngele's rule, what is the estimated date of delivery?

May 9, 2007

A nurse is preparing to care for a client experiencing dystocia. To which of the following interventions does the nurse give priority?

Monitoring fetal status -Dystocia is failure of labor to progress

When explaining "postpartum blues" to a client who is 1 day postpartum, which symtoms should the nurse include in the teaching plan?(Select all that apply)

Mood swings Tearfulness

HESI HINT: 14 Anatomy and Physiology of Reproduction and Antepartum

Most providers prescribe prenatal vitamins to ensure that the client receives an adequate intake of vitamins. However, only the health care provider can prescribe prenatal vitamins. It is the nurse's responsibility to teach about the proper diet and about taking prescribed vitamins as they have been prescribed by the HCP

A nurse is assessing a newborn infant with a diagnosis of gastroschisis. The nurse expects to note that the bowel is located:

Outside the abdominal cavity and not covered with a sac

The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor? (Select all that apply.)

Pain in the lower back that radiates to abdomen Progressive cervical dilation and effacement Regular and rhythmic painful contractions

Gravida 1, para 0, cervix dilated 8 cm, contractions Q2 min, bloody show, and nausea. Nurse Dx?

Pain r/t transitional phase of labor.

After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac Soy Isomil Formula, a soy protein isolate based infant formula. What information should the nurse provide to the mother about newly prescribed formula?

Similac Soy Isomil Formula is a soy based formula that contains sucrose.

HESI HINT:126

The lower the score on the Silverman-Anderson Index of Respiratory Distress, the better the respiratory status of the neonate. A score of 10 indicates that a nebown is in severe respiratory distress. This is the exact opposite of the method used for Apgar scoring.

HESI HINT:95 High-Risk Disorders

The major goal of nursing care is for a client with preeclampsia is to maintain uteroplacental perfusion and prevent seizures. This requires the administration of mag sulfate. Withhold administration of mag sulfate if signs of toxicity exist: respirations <12, absence of DTR, or urine output <30 mL/hr

What foods to avoid during pregnancy?

-raw sprouts -unpasteurized cheese (feta) -raw fish/ shellfish -teas w/ chamomile, peppermint, licorice

Signs of magnesium toxicity

-shallow respirations -oliguria -hyperactive DTR -lost of consciousness -edema

side effects of magnesium sulfate (not toxicity)

-flushed -diaphoresis -headache - nausea

Category 3 Tracing

-late decelerations -variable decelerations -bradycardia

A client in the third trimester of pregnancy is complaining of urinary frequency, and the nurse instructs the client in measures to alleviate the discomfort. Which statement by the client indicates an understanding of these self-care measures?

"I need to drink at least 2000 mL of fluid a day."

A client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which statement by the client indicates the need for FURTHER instruction?

"I need to stay in bed for the rest of my pregnancy."

A postpartum nurse instructs a new mother in how to bathe her newborn. Which statement by the mother indicates a need for FURTHER instruction?

"I should bathe him after a feeding." (may cause regurgitation)

During a prenatal visit, the nurse notes that an adolescent pregnant client with diabetes mellitus has lost 10 lb during the first 15 weeks of gestation. The nurse discusses the weight loss with the client, and the client states, "I don't eat regular meals." The appropriate response is:

"Let's make a list of what you're eating."

A female client with insulin-dependent diabetes arrives at the clinic seeking a plan to get pregnant in approximately 6 months. She tells the nurse that she want to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client?

"Maintain blood sugar levels in a constant rage within normal limits during pregnancy."

A nurse assists the primary healthcare provider in performing an amniotomy on a client in labor. In which order should the nurse perform the following actions after the amniotomy?

1. Determining the fetal heart rate 2. Noting the quantity, color, and odor of the amniotic fluid 3. Taking the client's temperature, pulse, and blood pressure 4. Replacing soiled underpads from beneath the client's buttocks 5. Planning evaluation of the client for signs and symptoms of infection

A nurse is monitoring a client after vaginal delivery notes a constant trickle of bright-red blood from the client's vagina. In which order would the nurse perform the following actions?

1. Assessing the client's fundus 2. Checking the client's vital signs 3. Contacting the physician 4. Changing the client's peripads 5. Documenting the findings

What happens if your 1 hour glucose test is elevated?

Do a 3 hour glucose test

IV LR 1000 mL with oxytocin (Pitocin) 40 units to deliver 15mL/hr. How many milli-units/minute is the client receiving?

10 mu/min.

When do you screen for trisomy 21 and neural tube defects?

10-12 weeks

A multigravida asks a nurse when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted as early as:

14 to 16 weeks of gestation

HESI HINT:121 Postpartum High Risk Disorders

During medical emergencies such as bleeding episodes, clients need calm, direct explanations and assurance that all is being done that can be done. If possible, allow support person at bedside

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? 1. Encourage the mother to breast-feed soon after birth. 2.Support the mother in her reaction to the newborn infant. 3.Tell the mother that it is important to hold the newborn infant. 4.Document a complete account of the mother's reaction on the birth record.

2 Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the client's feelings.

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. 1. Bed rest as a necessary preventive measure may be prescribed. 2.Routine administration of subcutaneous heparin may be prescribed. 3.An overbed lift may be necessary if the client requires a cesarean section. 4.Less frequent cleansing of a cesarean incision, if present, may be prescribed. 5.Thromboembolism stockings or sequential compression devices may be prescribed.

2, 3, 5 The obese pregnant client is at risk for complications such as venous thromboembolism and increased need for cesarean section. Additionally, the obese client requires special considerations pertaining to nursing care. To prevent venous thromboembolism, particularly in the client who required cesarean section, frequent and early ambulation (not bed rest), prior to and after surgery, is recommended. Routine administration of prophylactic pharmacological venous thromboembolism medications such as heparin is also commonly prescribed. An overbed lift may be needed to transfer a client from a bed to an operating table if cesarean section is necessary. Increased monitoring and cleansing of a cesarean incision, if present, will likely be prescribed due to the increased risk for infection secondary to increased abdominal fat. Thromboembolism stockings or sequential compression devices will likely be prescribed because of the client's increased risk of blood clots.

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Encourage ambulation hourly. 2.Assess vital signs every 4 hours. 3.Measure fundal height every 4 hours. 4.Prepare an ice pack for application to the area

4 A hematoma is a localized collection of blood in the tissues of the reproductive sac after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 3 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma. Ambulation hourly increases the risk for bleeding. Client assessment every 4 hours is too infrequent.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? A. Provide pain relief measures. B. Prepare the client for an amniotomy. C. Promote ambulation every 30 minutes. D. Monitor the oxytocin (Pitocin) infusion closely.

A. Provide pain relief measures.

A nurse provides instruction regarding prenatal care to a client with a history of heart disease. The nurse tells the client that:

Physical activity should be limited so that demand does not exceed the functional capacity of the heart.

A nurse is performing an assessment of a client who is at 20 weeks of gestation. The nurse asks the client to void, then measures the fundal height in centimeters. Which approximate measurement does the nurse expect to see?

20 cm

A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of impending convulsion?

3+ deep tendon reflexes and hyperclonus.

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? A. Tachypnea and retractions B. Acrocyanosis and grunting C. Hypotension and bradycardia D. Presence of a barrel chest and acrocyanosis

A. Tachypnea and retractions

Receiving report on laboring pt from ER. Water broke and didn't know it. First thing the nurse does?

Take temperature. RATIONALE: Length of time membranes ruptured is important to monitor for infection.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? A. The diet should include additional fluids. B. Prenatal vitamins should be discontinued. C. Soap should be used to cleanse the breasts. D. Birth control measures are unnecessary while breast-feeding.

A. The diet should include additional fluids.

Normal respiratory rate for a newborn infant

30 to 60 breaths/min

HESI HINT: 34 Intrapartum Nursing Care

Give the oxytocin after the placenta is delivered because the drug will cause the uterus to contract. if the oxytocic drug is administered before the placenta is delivered, it may result in a retained placenta, which predisposes the client to hemorrhage and infection

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? 1. "I should increase my sodium intake during pregnancy." 2."I should lower my blood volume by limiting my fluids." 3."I should maintain a low-calorie diet to prevent any weight gain." 4."I should drink adequate fluids and increase my intake of high-fiber foods."

4 Constipation can cause the client to use the Valsalva maneuver. The Valsalva maneuver should be avoided in clients with cardiac disease because it can cause blood to rush to the heart and overload the cardiac system. Constipation can be prevented by the addition of fluids and a high-fiber diet. A low-calorie diet is not recommended during pregnancy and could be harmful to the fetus. Sodium should be restricted as prescribed by the health care provider because excess sodium would cause an overload to the circulating blood volume and contribute to cardiac complications. Diets low in fluid can cause a decrease in blood volume, which could deprive the fetus of nutrients.

When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?

At 30 weeks of gestation Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy, when they are beginning to anticipate the onset of labor and the birth of their child.

A 30-year-old female client with insulin dependent diabetes tells the PN that she wants to become pregnant. Which subject is most important for the PN to discuss with the client?

Glycemic control during pregnancy

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is appropriate?

A home pregnancy test can be used right after your first missed period

A nurse working in a prenatal clinic is reviewing the records of several clients scheduled for prenatal visits today. Which client does the nurse identify as being at risk for abruptio placentae?

A hypertensive client A pack-a-day smoker

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period will be

January 30-31

The PN is completing the daily assessment of a 2-day-old newborn. Which finding should the PN report to the nurse that indicates impaired hearing

Absence of the startle or blink reflex to loud sound

38 weeks, laboring, which finding (condition) warrants a cesarean?

Active herpes lesions on perineum.

. Neonate under radiant warmer, naso-oral suctioned. Which indicates infant is "vigorous"?

Active movement and lusty cry.

HESI HINT:84 High-Risk Disorders

Acyclovir (used to treat herpes simplex) is not recommended during pregnancy

A nurse is caring for a client in labor who has sickle cell anemia. Which intervention does the nurse implement to help prevent a sickling crisis?

Administering oxygen as prescribed

A woman in labor suddenly experiences chest pain and dyspnea, and the nurse suspects the presence of amniotic fluid embolism (AFE). The nurse immediately:

Administers oxygen to the woman

A nurse is assisting a physician in performing a physical examination of a client who has just been told that she is pregnant. The physician tells the nurse that the Goodell sign is present. The nurse understands that this sign is indicative of:

An increase in vascularity and hyptertrophy of the cervix

The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention.

An over-distended bladder could be traumatized during labor, as well as prolong the progress of labor.

HESI HINT:129

Antibiotic dosage is based on the neonate's weight in kilograms. Peak and trough drug levels are drawn to evaluate whether therapeutic drug levels have been achieved. Closely monitor the neonate for adverse effects of all drugs.

A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as most likely the result of:

Anxiety and the need for support

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client? A. Providing sitz baths B. Encouraging fluid intake C. Placing ice on the perineum D. Monitoring hemoglobin and hematocrit levels

B. Encouraging fluid intake

A nurse is assessing a newborn with a diagnosis of congenital diaphragmatic hernia (CDH). Which assessment finding would the nurse specifically expect to note in the newborn?

Bowel sounds heard over the chest

Which method of removing the breast from the baby's mouth should the practical nurse reinforce with the mother to prevent trauma to her breast?

Break the suction by inserting a finger into the corner of the baby's mouth

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? A. "I should stay on the diabetic diet." B. "I should perform glucose monitoring at home." C. "I should avoid exercise because of the negative effects on insulin production." D. "I should be aware of any infections and report signs of infection immediately to my health care provider."

C. "I should avoid exercise because of the negative effects on insulin production."

Which assessment finding following an amniotomy should be conducted first? A. Cervical dilation B. Bladder distention C. Fetal heart rate pattern D. Maternal blood pressure

C. Fetal heart rate pattern

difference between CVS and amniocentesis

CVS does not test for neural tube defects

A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of:

Calcium gluconate

One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM X 1. What action should the nurse take immediately?

Call the heathcare provider to question the prescription

Cesarean - hemorrhage risk assessment?

Check for fundal firmness Q15 min. RATIONALE: Risk for postpartum hemorrhage is decreased when uterus is firm after delivery. Q15 min checks stimulate fundus to contract and prevents bleeding.

A nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be taking insulin. The nurse tells the client that if signs and symptoms of hypoglycemia occur, she must immediately:

Check her blood glucose level

1st trimester, Hgb 8.6, Hct 25.1, what food should the nurse encourage?

Chicken.

HESI HINT:74 High-Risk Disorders

Clients with prior traumatic deliver, hx of D&C, and multiple abortions (spontaneous or induced) and daughters of diethylstilbestrol (DES) mothers may experience miscarriage or preterm labor related to incompetent cervix. The cervix may be surgically repaired prior to pregnancy, or during gestation. A cerclage (a McDonald suture) is placed around the cervix to constrict the internal os. The cerclage may be removed prior to labor if labor is planned or left in place if certain birth is planned.

A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instructions should the nurse provide?

Come into the clinic today for an ultrasound

DM I, HbgA1c level 7.8 at 10 weeks pregnant. What should the nurse do?

Contact MD for BPP (BioPhysical Profile).

The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take?

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

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? A. "I should breast-feed every 2 to 3 hours." B. "I should change the breast pads frequently." C. "I should wash my hands well before breast-feeding." D. "I should wash my nipples daily with soap and water."

D. "I should wash my nipples daily with soap and water."

The nurse has instructed a pregnant client in measures to prevent varicose veins during pregnancy. Which statement by the client indicates a need for further instructions? A. "I should wear panty hose." B. "I should wear support hose." C. "I should wear flat nonslip shoes that have good support" D. "I should wear knee-high hose, but I should not leave them on longer than 8 hours."

D. "I should wear knee-high hose, but I should not leave them on longer than 8 hours."

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider? A. Urinary output has increased. B. Dependent edema has resolved. C. Blood pressure reading is at the prenatal baseline. D. The client complains of a headache and blurred vision.

D. The client complains of a headache and blurred vision.

HESI HINT: 41 Intrapartum Nursing Care

Do not wait until a 1 minute Apgar is assigned to begin resuscitation of the compromised neonate

A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion>

Epigastric pain

HESI HINT:110 High-Risk Disorders

Estrogen-containing birth control pills affect glucose metabolism by increasing resistance to insulin. Use of an intrauterine device may be associated with increased risk for infection in these already vulnerable women

The nurse attempts to help and unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate?

Grief related to her perceptions about loss of this child.

During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take?

Have her cup both hands over her nose and mouth while breathing. Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes transient respiratory alkalosis, so the client should cup both her hands over her mouth and nose so that she can rebreathe carbon dioxide.

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client?

Have the client empty her bladder.

A nurse is caring for a postpartum client who had a low-lying placenta. The nurse assesses the client most closely for:

Hemorrhage

A primigracida at 40-weeks gestation is receiving oxytocin to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin?

Hyperstimulation

The PN is caring for a full-term newborn whose mother has DM. The PN should monitor the neonate for what possible condition?

Hypoglycemia

A postpartum client asks a nurse when she may safely resume sexual activity. The nurse tells the client that she may resume sexual activity:

In 2 to 4 weeks

A nurse performing an assessment of a pregnant client is preparing to take the client's blood pressure. The nurse positions the client:

In a sitting position with the arm in a horizontal position at heart level

HESI HINT:119 Postpartum High Risk Disorders

In most cases, a mother who is on antibiotic therapy can continue to breastfeed unless the HCP thinks the neonate is at risk for sepsis by maternal contact. Sulfa drugs are used cautiously in lactating mothers because they can be transferred to the infant in breast milk

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response based on what knowledge?

It is difficult to consume 18mg of additional iron by diet alone

What is bethamethasone used for?

It is used during PPROM for baby's premature lungs

A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Ngele's rule, what is the estimated date of delivery?

May 9, 2006

HESI HINT:69 The Normal Newborn

Physiologic jaundice occurs at 2 to 3 days of life. If it occurs before 24 hours or persists beyond 7 days, it becomes pathologic. Typically, questions ask about the normal problem of physiologic jaundice, which occurs 2-3 days after birth due to the immature liver's normal inability to keep up with RBC destruction and to bind bilirubin. Remember unconjugated bilirubin is the culprit.

40 weeks pregnant, laboring, patient states supine is position of comfort, the nurse should?

Place pillow wedge under right hip. RATIONALE: Hypotension from pressure on vena cava is risk, the wedge relieves the pressure on the vena cava.

A nurse assists a pregnant client who is in the second trimester into lithotomy position on the examining table in the obstetrician's office. The client suddenly becomes dizzy, lightheaded, nauseated, and pale. The nurse immediately:

Positions the client on her side

Postpartum temporary bed-rest should be placed if?

Positive Homan's sign.

HESI HINT:65 The Normal Newborn

Postnatally, the fetal structures of foramen ovale, ductus arteriosus, and ductus venosus should close. If they do not, cardiac and pulmonary compromise will develop.

A nurse is told that a newborn with myelomeningocele will be admitted to the newborn nursery. In which position does the nurse plan to place the infant?

Prone (to prevent pressure on the sac until surgical repair can be performed)

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." Which intervention should the nurse implement first?

Provide assistance to the mother to begin breastfeeding as soon as possible after delivery Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery.

The PN should ensure that the healthcare provider writes a prescription for Rho(D) immune globulin for which client?

Rh-negative mother with an Rh-positive baby

Rh negative refuses Rhogam after delivery.

Rhogam prevents maternal antibody formation for future Rh positive babies.

HESI HINT:122 Postpartum High Risk Disorders

Risk factors for hemorrhage including dystocia, prolonged labor, overdistended uterus, abruptio placentae, and infection

HESI HINT:83 High-Risk Disorders

Rubella is teratogenic to the fetus during the first trimester, causing congenital heart disease, congenital cataracts, or both. All women should have their titers checked during pregnancy. If a woman's titers are low, she should receive the vaccine after delivery and be instructed not to get pregnant within 3 months. Breastfeeding mothers may take the vaccine

The nurse should explain to a 30-year old gravid client that alpha fetoprotein testing is recommended for which purpose?

Screen for neural tube defects

HESI HINT:130

Sepsis can be indicated by both a temperature increase and a temperature's decrease.

HESI HINT:99 High-Risk Disorders

Should these clients experience preterm labor, the used of beta-adrenergic agents such as terbutaline (Brethine) and ritodrine HCl (Yutopar) is contraindicated because of the risk for myocardial ischemia

Which intervention should the PN use to facilitate mother-infant attachment in a 15 year old primigravida who seems to ignore her newborn?

Show the mother how the baby initiates interaction and responds to her

HESI HINT: 3 Anatomy and Physiology of Reproduction and Antepartum

Sperm live approximately 3 days (48 to 72 hours), and eggs live about 24 hours. A couple must avoid unprotected intercourse for several days before the anticipated ovulation and for 3 days after ovulation to prevent pregnancy.

A client admitted with preeclampsia is having a seizure. What action should the PN take?

Stay with the client and call for help

HESI HINT: 48 Intrapartum Nursing Care

Stop continuous infusion at end of stage I or during transition to increase effectiveness of pushing

HESI HINT: 73 The Normal Newborn

Teach parents to take infants temperature, both axillary and rectal. Axillary is recommended, but some pediatricians request a rectal (core) temperature. Axillary: place thermometer under infants arm and hold thermometer in place for 5 minutes Rectal: Use thermometer with blunt end. Insert thermometer ¼ to ½ inch and hold in place for 5 min. Hold feet and legs firmly.

HESI HINT:80 High-Risk Disorders

Tetracycline is contraindicated in pregnancy because it darkens the teeth of the newborn

What does a positive indirect cooms test mean?

That mother has RH + antibodies in stream

A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. The nurse tells the client:

That this is a normal postpartum occurrence

While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedneum. Which additional information should the nurse provide this new mother?

The scalp edema will subside in a few days after birth

A couple has been trying to conceive for 9 months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child?

They use lubricants with each sexual encounter to decrease friction

HESI HINT:125

To avoid metabolic problems brought on by cold stress, the first step and number 1 priority in managing the newborn is to prevent loss of body heat; that is followed by the ABC's. Neonates produce heat by nonshivering thermogenesis, which involves the burning of brown fat. The neonate is easily stressed by hypothermia and develops acidosis as a result of hypoxia. If infant is cold, the first signs exhibited are prolonged acrocyanosis, skin mottling, tachycardia, and tachypnea. If an infant is cold-stressed, warm slowly over 2-4 hours because rapid warming may produce apnea. A neonate needs glucose; he or she has little glycogen storage and needs to be fed

A nurse caring for a hospitalized client with a diagnosis of abruptio placentae and develops a nursing care plan incorporating interventions to be implemented in the event of shock. If signs of shock develop, to promote tissue oxygenation, the nurse would immediately:

Turn the client on her side

The PN is assessing a client who is 12 hours post delivery. Which finding regarding the level of the fundus should the PN report to the charge nurse?

Two fingerbreadths above the umbilicus

Most accurate way to determine fetal position at 29 weeks gestation.

Ultrasound. RATIONALE: Provides direct view of the fetus.

normal wbc pregnancy

Up to 30,000

A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data would indicate to the nurse that the client is experiencing magnesium sulfate toxicity?

Urine output 90mL / 4 hours

Patient asks if she can use the same diaphragm for birth control after her pregnancy, the nurse answers ...

Use alternative form of birth control until new diaphragm can be obtained.

. Post partum teaching to prevent pregnancy.

Use condom and spermicidal gel.

In PACU, the most important assessment for first 8 hours after cesarean:

Uterine atony. RATIONALE: Uterine atony can lead to hemorrhage.

A nurse is monitoring a fetal heart rate (FHR). The nurse documents a reassuring FHR pattern in the record on noting:

Variability of 6 to 25 beats/min

HESI HINT:91 High-Risk Disorders

When administering mag sulfate, always have antidote available (calcium gluconate)

bethamethasone (celestone) effects maternal __

blood glucose

How do you get amniotic fluid volume?

by ultrasound

blurry vision and clonus are signs of

preeclampsia

When does immunoglobulin m elevate?

presence of infection

What technique should you use if baby is unable to latch due to severe engorgment?

reverse pressure

HESI HINT: 60 Normal Postpartum

"Postpartum blues"are usually normal, especially 5 to 7 days after delivery (unexplained tearfulness, feeling down, and having decreased appetite) Encourage use of support persons to help with housework for first 2 postpartum weeks. Refer to community resources.

The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process? 1. "We want to attend a support group." 2."We never want to try to have a baby again." 3."We are going to try to adopt a child immediately." 4."We are okay, and we are going to try to have another baby immediately."

1 A support group can help the parents to work through their pain by nonjudgmental sharing of feelings. The correct option identifies a statement that indicates positive, normal grieving. Although the other options may indicate reactions of the client and significant other, they are not specifically a part of the normal grieving process.

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? 1. "Your type of pelvis has a narrow pubic arch." 2. "Your type of pelvis is the most favorable for labor and birth." 3. "Your type of pelvis is a wide pelvis, but it has a short diameter." 4. "You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."

2 A gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. An android pelvis (resembling a male pelvis) would be unfavorable for labor because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with a normal or moderately narrow pubic arch. A platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate.

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan? 1. Therapeutic abortion is required. 2.Isoniazid plus rifampin will be required for 9 months. 3.She will have to stay at home until treatment is completed. 4.Medication will not be started until after delivery of the fetus.

2 More than 1 medication may be used to prevent the growth of resistant organisms in a pregnant client with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for the pregnant client is isoniazid plus rifampin daily for 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. The client does not need to stay at home during treatment, and therapeutic abortion is not required.

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? 1. "It connects the pulmonary artery to the aorta." 2. "It is an opening between the right and left atria." 3. "It connects the umbilical vein to the inferior vena cava." 4. "It connects the umbilical artery to the inferior vena cava."

3 The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? 1. "It promotes the fertilized ovum's chances of survival." 2. "It promotes the fertilized ovum's exposure to estrogen and progesterone." 3. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." 4. "It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone."

3 The tubal isthmus remains contracted until 3 days after conception to allow the fertilized ovum to develop within the tube. This initial growth of the fertilized ovum promotes its normal implantation in the fundal portion of the uterine corpus. Estrogen is a hormone produced by the ovarian follicles, corpus luteum, adrenal cortex, and placenta during pregnancy. Progesterone is a hormone secreted by the corpus luteum of the ovary, adrenal glands, and placenta during pregnancy. Luteinizing hormone and follicle-stimulating hormone are excreted by the anterior pituitary gland. The survival of the fertilized ovum does not depend on it staying in the fallopian tube for 3 days.

The PN is collecting the obstetrical history for a client at 12-weeks gestation who is at the clinic for the first prenatal visit. The client reports one live birth at 38-weeks gestation and a spontaneous abortion at 13-weeks. Using the TPAL system, which designation is the most accurate summary of the client's obstetrical history?

3-1-0-1-1

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. 1. Uterine rigidity 2.Uterine tenderness 3.Severe abdominal pain 4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age

4, 5, 6 Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability.

The nurse is preparing to give an enema to a laboring client. Which client would require most caution when carrying out this procedure?

A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.

HESI HINT:72 The Normal Newborn

A 7 lb 8 oz baby would need 50 calories x7 lbs = 350 calories plus 25 calories (1/2 lb or 8 oz) =375 calories per day. Most infant formulas contain 20 calories per oz. Dividing 375 by 20 =18.75 oz of formula needed per day.

HESI HINT:77 High-Risk Disorders

A client who is at 32 weeks' gestation calls the HCP because she is experiencing dark-red vaginal bleeding. She is admitted to the emergency department, where the nurse determines the FHR to be 100 bpm. The client's abdomen is rigid and boardlike, and she is complaining of severe pain. What action should the nurse take first? First, the nurse must use her or his knowledge base to differentiate between abruptio placentae (this client) and placenta previa (painless bright-red bleeding occurring in the third trimester) The nurse should immediately notify the HCP, and no abdominal or vaginal manipulation or examinations should be done. Administer O2 by face mask. Monitor for bleeding at IV sites and gums because of the increased risk for DIC. Emergency cesarean section is required because uteroplacental perfusion to the fetus is being compromised by early separation of the placenta from the uterus.

A nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which of the following clients does the nurse recognize as being at risk for the development of disseminated intravascular coagulation (DIC)?

A client with septicemia A client who had a cesarean section because of abruptio placentae -In the obstetric population, DIC occurs as a result of abruptio placentae, amniotic fluid embolism, dead fetus syndrome (in which the fetus has died but is retained in utero for at least 6 weeks), severe preeclampsia, septicemia, cardiopulmonary arrest, or hemorrhage.

A nurse is conducting a home visit with a mother and her 1-week-old infant, who is at risk for acquired neonatal congenital syphilis. Which finding specific to this disease does the nurse look for while assessing the infant?

A copper-colored rash

HESI HINT:116 Postpartum High Risk Disorders

A nurse must be especially supportive of a postpartum client with infection because it usually implies isolation from newborn until organism is identified and treatment begun. Arrange phone calls to nursery and window viewing. Involve family, spouse, and significant others in teaching and encourage other family members to continue neonatal attachment activities

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. A. Wear a supportive bra. B. Rest during the acute phase. C. Maintain a fluid intake of at least 3000 mL. D. Continue to breast-feed if the breasts are not too sore. E. Take the prescribed antibiotics until the soreness subsides. F. Avoid decompression of the breasts by breast-feeding or breast pump.

A. Wear a supportive bra. B. Rest during the acute phase. C. Maintain a fluid intake of at least 3000 mL. D. Continue to breast-feed if the breasts are not too sore.

What is Naegele's rule?

Add 7 days to the first day of the LMP and subtract 3 months to estimate a woman's EDC

Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home?

Allow the cord to air-dry as much as possible Recent studies have indicated that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process.

HESI HINT:85 High-Risk Disorders

Although metronidazole (Flagyl) is the treatment of choice for some vaginal infections its use is contraindicated in the first trimester of the pregnancy and is use during the second trimester is controversial

HESI HINT: 35 Intrapartum Nursing Care

Application of perineal pads after delivery: -Place two on perineum -Do not touch inside of pad -Do apply from front to back, being careful not to drag pads across the anus

A woman who gave birth 48 hours ago is bottle feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take?

Apply cold compress to both breast for comfort

A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement?

Apply firm pressure to sacral area

The nurse is assessing a client who is having a non-stress test at 41 weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take?

Ask the client if she has felt any fetal movement

The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. the nurse determines that the client is not having contractions, the fetal heart rate baseline is 144bpm, and no FHR accelerations are occurring. What action should the nurse take?

Ask the client if she has felt any movement.

HESI HINT: 9 Anatomy and Physiology of Reproduction and Antepartum

At approximately 28 to 32 weeks' gestation, a plasma volume increase of 25%-40% occurs, resulting in normal hemodilution of pregnancy and Hct values of 32%-42%. High Hct values may look good, but in reality, they represent a gestational hypertension disorder and a depleted vascular space

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan?

Avoid alcohol because it is excreted in breast milk. Alcohol should be avoided while breastfeeding because it is excreted in breast milk and may cause a variety of problems, including slower growth and cognitive impairment for the infant.

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects which finding? A. 22 cm B. 30cm C. 36 cm D. 40cm

B. 30cm

The nurse is assessing a client who is 6 hours post-partum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate? A. Raise the head of the client's bed. B. Obtain hemoglobin and hematocrit levels. C. Instruct the client to request help when getting out of bed. D. Inform the nursery room nurse to avoid bringing the newborn to the client until the mother's symptoms have subsided.

C. Instruct the client to request help when getting out of bed.

Which explanation should the nurse provide to the prenatal client about the purpose of the placenta? A. It cushions and protects the baby. B. It maintains the temperature of the baby. C. It is the way the baby gets food and oxygen. D. It prevents all antibodies and viruses from passing to the baby.

C. It is the way the baby gets food and oxygen.

The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor? A. The contractions are regular. B. The membranes have ruptured. C. The cervix is dilated completely. D. The client begins to expel clear vaginal fluid.

C. The cervix is dilated completely.

The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions? A. "I should avoid between-meal snacks." B. "I should lie down for an hour after eating." C. "I should use spices for cooking rather than using salt." D. "I should avoid eating foods that produce gas and fatty foods."

D. "I should avoid eating foods that produce gas and fatty foods."

The nurse is providing instructions to a maternity client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse? A. "I should increase my sodium intake during pregnancy." B. "1 should lower my blood volume by limiting my Fluids." C. "I should maintain a low-calorie diet to prevent any weight gain." D. "I should drink adequate fluids and increase my intake of high-fiber foods."

D. "I should drink adequate fluids and increase my intake of high-fiber foods."

The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? A. "Your newborn needs vitamin K to develop immunity." B. "The vitamin K will protect your newborn from being jaundiced." C. "Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel. " D. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

D. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? A. A primiparous client who delivered 4 hours ago B. A multiparous client who delivered 6 hours ago C. A primiparous client who delivered 6 hours ago and had epidural anesthesia D. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

D. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? A. Initiate an intravenous line. B. Assess the client's blood pressure. C. Prepare to administer morphine sulfate. D. Administer oxygen, 8 to 10 L/minute, by face mask.

D. Administer oxygen, 8 to 10 L/minute, by face mask.

HESI HINT: 19 Fetal and Maternal Assessment Techniques

Early decelerations, caused by head compression and fetal descent, usually occur between 4 and 7 cm and in the second stage of labor. Check for labor progress if early decelerations are noted

A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. The nurse tells the client to:

Eat carbohydrates such as cereals, rice, and pasta

A woman being seen in the prenatal clinic and complains of morning sickness that continues throughout the day. What does the nurse tell the client to do to overcome this discomfort?

Eat dry crackers every 2 hours to prevent an empty stomach

A nurse teaches a new mother how to perform umbilical cord care and how to recognize the signs of a cord infection. Which of the following findings does the nurse tell the mother is an indicator of infection?

Edema at the base of the cord

The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern?

Edema, basilar rales, and irregular pulse

Which piece of equipment does the nurse use to assess the fetal heartbeat?

Electronic Doppler

At 28-weeks gestation, a client's blood pressure is elevated. What action should the practical nurse take to help this client manage her pregnancy-induced hypertension?

Emphasize the importance of resting on left side in a quiet environment

A nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the mother to:

Gently massage the breasts during breastfeeding to help empty the breasts

Immediately after the delivery of a newborn infant, the nurse prepares to deliver the placenta. The nurse initially:

Instructs the mother to push when signs of separation have occurred

A 39-week primigravida expresses anxiety about how she will handle the labor process. How should the practical nurse respond?

It's normal to be anxious about labor; let's talk about your concerns

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?

January 29 to 30 This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period. The client can expect ovulation to occur January 29 to 30.

HESI HINT:124 Newborn High Risk Disorders

Jitteriness is a clinical manifestation of hypoglycemia and hypocalcemia. Laboratory analysis is indicated to differentiate between the two causes

. Second stage of labor, what does nurse do first?

Let pt know that birth is imminent. RATIONALE: Second stage pt is fully dilated and fetus is crowning.

A nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid

Lima beans

A female client with insulin-dependent diabetes arrives at the clinic seeking a plan to get pregnant in approximately 6 months. She tells the nurse that she wants to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client?

Maintain blood sugar levels in a constant range within normal limits during pregnancy

HESI HINT:135

Maintenance of hydration is crucial for all infants. A preterm infant is already at risk for fluid and electrolyte imbalances cuased by increased body surface area resulting from extended body positioning and larger body area in relation to body weight. Phototherapy treatment for hyperbilirubinemia increases the risk for dehydration.

HESI HINT:120 Postpartum High Risk Disorders

Many times mastitis can be confused with a blocked milk sinus, which is treated by nursing closer to the lump and by rotating the baby on the breast. Breastfeeding is not contraindicated for women with mastitis unless pus is in the breast milk or the ABX of choice is harmful to the infant. If either of these occurs, milk production can still be fostered by manual expression

HESI HINT:86 High-Risk Disorders

Medications usually recommended for a nonpregnant client with an STD may be contraindicated for the pregnant client because of effects on the fetus

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

November 22 correctly applies the Nägele rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15 + 7 = 22).

HESI HINT:98 High-Risk Disorders

Nursing care during labor and delivery for the client with cardiac disease is focused on prevention of cardiac embarrassment, maintenance of uterine perfusion, and alleviation of anxiety

A pregnant woman at 38 weeks' gestation arrives at the emergency department, reporting bright-red vaginal bleeding but denying pain. On the basis of this information, the nurse determines that the client may be experiencing:

Placenta previa

The nurse observes a new mother is rooming in and caring for her newborn infant. Which observation indicated the need for further teaching?

Places the infant prone in the bassinet

A client receiving an epidural anesthesia begins to experience nausea and becomes pate and clammy. What intervention should the nurse implement first?

Raise the foot of the bed

HESI HINT:96 High-Risk Disorders

Rarely are antihypertensive drugs used in the preeclamptic client. The are given only in the event of diastolic BP above 110 mm Hg (danger of stroke) The drug of choice is hydralazine HCl (Apresoline)

An expectant father tells the nurse he fears that his wife "is losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father?

Reassure him that normal maternal-fetal bonding is occurring These behaviors are positive signs of maternal-fetal bonding and do not reflect ambivalence. No intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal bonding during the second trimester.

During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement theses actions? (Place the first action on top and the last on the bottom) Provide oxygen via mask reposition client call HCP Increase IV Fluids

Reposition the client Increase IV Fluids provide oxygen via face mask Call HCP To stabilize the fetus, intrauterine reconstitution is first priority, and to enhance fetal blood supply, the laboring client should be repositioned to replace the gravid uterus and to improve fetal perfusion. Secondly, the IV fluids should be increased to expand the maternal circulating blood volume. Next, to optimize oxygenation of the circulatory blood volume, oxygen via face mask should be administered to mother. The HCP should provide other measures to relieve fetal stress.

HESI HINT:102 High-Risk Disorders

Research has found that infection by H pylori is another possible causative factor in hyperemesis. Other pregnancy and nonpregnancy risk factors for hyperemesis is gravidarum include first pregnancy, multiple fetuses, age <24, hx of this condition in other pregnanceis, obesity, and high fat diets

A nurse is performing assessments every 30 minutes on a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings would prompt the nurse to contact the physician?

Respirations of 10 breaths/min

A nurse notes that the laboratory report of a pregnant client with suspected HIV infection indicates leukopenia, thrombocytopenia, anemia, and an increased erythrocyte sedimentation rate. Which laboratory test that would further confirm the presence of HIV does the nurse anticipate that the physician will prescribe?

T-lymphocyte determination

A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate?

Tachycardia and a feeling of nervousness Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of nervousness.

HESI HINT:92 High-Risk Disorders

Tachycardia is the major side effect of tocolytic drugs, which are beta-adrenergic agents, such as terbutaline (Brethine); they are used to stop preterm labor. Teach the client to take her pulse prior to administration and to withold medications if pulse is not within the prescribed parameters (usually withheld if pulse is >120-140) If administration is via a continuous pump, teach client to monitor pulse periodically

A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client?

Take prescribed multivitamin and mineral supplements

A mother with diabetes expresses her plans to breast feed after delivery. When the newborn develops hypoglycemia 2 hours after admission to the newborn nursery, what action should the practical nurse implement?

Take the newborn to the mother to breast feed

A 23- year old client who is receiving Medicid benefits is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client?

Teach the client why keeping prenatal care appointments is important

Baby weighs 7.5 lbs today, tomorrow 7 lbs (5 lb weight loss). What does the nurse do?

Tell mother it is normal. RATIONALE: Newborns can lose 10% of their wt and regain it later.

One hand above pubic symphysis while massaging fundus of a patient who has a boggy uterine tone 15 min after delivery (7 lb baby). What does the nurse tell the patient?

Tell the patient that clots can form in a boggy uterus.

Assessing a 39 week pregnant patient admitted to L&D, which do you call MD for?

Temperature of 101.2

HESI HINT:82 High-Risk Disorders

Toxoplasmosis is usually related to exposure to cats, gardening (where cat feces may be found), or eating raw meat

HESI HINT: 22 Fetal and Maternal Assessment Techniques

When deceleration patterns (late or variable) are associated with decreased or absent variability and tachycardia, the situation is ominous and requires immediate intervention and fetal assessment

Multigravida at term with back labor, cervix is 3 cm dilated, 50% effaced, -1 station.

Apply counter pressure to sacral area. RATIONALE: Caused by malposition of the fetus.

The nurse is planning preconception care for a female client. Which information should the nurse provide the client?

Encourage healthy lifestyles for families desiring pregnancy

Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn?

"Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method.

A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client?

"Do you have a history of rheumatic fever?" Clients with a history of rheumatic fever may develop mitral valve prolapse, which increases the risk of cardiac decompensation due to the increased blood volume that occurs during pregnancy.

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? A. Infection B. Hemorrhage C. Chronic hypertension D. Disseminated intravascular coagulation

B. Hemorrhage

HESI HINT: 33 Intrapartum Nursing Care

Determine cervical dilation before allowing client to push. Cervix should be completely dilated 10 cm before the client begins pushing. If pushing starts too early, the cervix can become edematous and never fully dilate

A pregnant client is seen in the clinic for the first time. This is the client's first pregnancy, and the client tells the nurse that she has diabetes mellitus. The nurse provides instruction to the client regarding health care during pregnancy. Which statements by the client indicate the need for further instruction?

"I need to limit my exercise while I'm pregnant." (Exercise is necessary for the pregnant diabetic client to help maintain control of her diabetes) "I'll come back for a prenatal visit every month during my first trimester."

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? A. Developmental delays because of excessive size B. Maintaining safety because of low blood glucose levels C. Choking because of impaired suck and swallow reflexes D. Elevated body temperature because of excess fat and glycogen

B. Maintaining safety because of low blood glucose levels

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?

Between the time the temperature falls and rises

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny-looking head." Which response by the nurse is best?

"That is normal. The head will return to a round shape within 7 to 10 days."

Terbutaline (Brethine) injections for preterm labor. When do you hold and call the MD?

Bilateral crackles in lungs on auscultation (critical complication). RATIONALE: Could indicate pulmonary edema.

A pregnant client is positive for HIV. The client asks the nurse whether her newborn will contract the virus. The appropriate response is:

"The newborn does have a risk of contracting the infection."

A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate?

"This must be hard for you."

A 24-hour old newborn has a pink popular rash with vesicles superimposed on the thorax, back and abdomen. What action should the nurse implement

Document the finding in the infants record.

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation is appropriate?

"Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative of adequate nutrition, most home scales do not measure this accurately, and the suggestion will likely make the mother anxious.

A multigravida client at 41-weeks gestation presents in the labor and delivery unit afer a non-stress test indicatied that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status?

Biophysical profile (BPP)

Category 1 Tracing

-baseline rate 110-160 -moderate variability -no late/variable decelerations

What are predisposed for toxoplasmosis?

-eating uncooked beef -having many cats

hypothyroidism findings

-fatigue -constipation -cold intolerance -dry skin -weight gain -hair loss -high TSH

risk for preterm labor

-maternal smoking -history of preterm -age of 18-25 -multple gestation

Possible complications of amniocentesis

-maternal/fetal hemorrhage -leakage of amniotic fluid -preterm labor -maternal/fetal infection

what makes up BPP

-muscle tone -fetal movement -FHR/ breathing -amniotic fluid

hyperthyroidism findings

-tachycardia -weight loss -nervousness -frequent stools -hypertension -decreased TSH -palpitations

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. 1. Proteinuria 2. Hypertension 3. Low-grade fever 4. Generalized edema 5. Increased pulse rate 6. Increased respiratory rate

1, 2 The two classic signs of preeclampsia are hypertension and proteinuria. A low-grade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia. Generalized edema may occur, but is no longer included as a classic sign of preeclampsia because it can occur in many conditions.

Patient with preeclampsia is receiving IV Mag 6 grams administered over 20 min. The nurse attaches a volume control device between the infusion pump and the bag of solution labeled "Magnesium Sulfate 20 grams/500 mL of D5W". How many mL should nurse place in volume controlled device?

150 mL

how many wet diapers in the first 48 hours?

2

A nurse performing an assessment of a pregnant client prepares to auscultate the fetal heart sounds, using a Doppler ultrasound stethoscope. By which week of gestation are fetal heart sounds audible with the use of this device?

12 weeks

A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client?

Breastfeed the infant, ensuring that both breasts are completely emptied. Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue.

A primigravdia who is at 34 weeks gestation complains she is experiencing heartburn. What recommendation should the PN make?

Eat five small meals daily

When do you screen for gestational diabetes?

24-28 weeks

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1. Strict bed rest is required after the procedure. 2.Hospitalization is necessary for 24 hours after the procedure. 3.An informed consent needs to be signed before the procedure. 4.A fever is expected after the procedure because of the trauma to the abdomen.

3 Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed to rest, but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in the health care provider's office or in a special prenatal testing unit. Hospitalization is not necessary after the procedure.

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate? 1. Contact the health care provider. 2.Instruct the client to maintain bed rest for the remainder of the pregnancy. 3.Inform the client that these contractions are common and may occur throughout the pregnancy. 4.Call the maternity unit and inform them that the client will be admitted in a preterm labor condition.

3 Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, there is no reason to notify the health care provider. This client is not in preterm labor and, therefore, does not need to be placed on bed rest or be admitted to the hospital to be monitored.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding 2. Check the mother's HR 3. Notify the HCP 4. Tell the client that the FHR is normal

3 The FHR depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester, but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the HCP. Options 2 and 4 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the HCP needs to be notified.

HESI HINT: 31 Intrapartum Nursing Care

Breathing techniques such as deep chest, accelerated, and cued are not prescribed by stage and phase of labor, but by the discomfort level of the laboring woman. If coping is decreasing, switch to a new technique

Which stage of pregnancy do you administer GBS

35 to 37 weeks

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider (HCP)? 1. Urinary output has increased 2. Dependent edema has resolved 3. BP reading is at the prenatal baseline 4. The client complains of a headache and blurred vision

4 If the client complains of a headache and blurred vision, the HCP should be notified, because these are signs of worsening preeclampsia. Options 1, 2, and 3 are normal findings.

The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? 1. The client with mild afterpain. 2.The client with a pulse rate of 60 beats/minute 3.The client with colostrum discharge from both breasts 4.The client with lochia that is red and has a foul-smelling odor

4 Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client.

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? 1. Enlargement of the breasts 2.Complaints of feeling hot when the room is cool 3.Periods of fetal movement followed by quiet periods 4.Evidence of bleeding, such as in the gums, petechiae, and purpura

4 Severe preeclampsia can trigger disseminated intravascular coagulation (DIC) because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the health care provider if noted on assessment. Options 1, 2, and 3 are normal occurrences in the last trimester of pregnancy.

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2°F (37.8°C). What is the priority nursing action? 1. Document the findings 2. Retake the temperature in 15 minutes. 3.Notify the health care provider (HCP). 4.Increase hydration by encouraging oral fluids.

4 The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4°F (38°C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the HCP is not necessary.

The nurse is monitoring a client who is receiving oxytocin (Pitocin) to induce labor. Which assessment finding would cause the nurse to immediately discontinue the oxytocin infusion? A. Fatigue B. Drowsiness C. Uterine hyperstimulation D. Early decelerations of the fetal heart rate

C. Uterine hyperstimulation

A newborn infant iss brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactory but appears dusky. What action should the nurse take first?

Check the infant's oxygen saturation rate

How many chromosomes do humans have?

46

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

5 The Silverman-Anderson index is an assessment scale that scores a newborn's respiratory status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded 0, and a total of 10 indicates maximum respiratory distress. This infant is demonstrating respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory grunting, plus grade 1 for just visible retractions, which is a total score of 5.

How many wet diapers per day?

6-8

A 34 week primigravida woman with preeclampsia is receiving Lactated Ringer's 500mL with mag sulfate 20 grams at rate of 3 grams/hour. How many mL/hr should the nurse program the infusion pump?

75

Proteinuria for preeclampsia

>300 mg

A one-day-old neonate develops a cephalhematoma. The nurse should closely assess the neonate for which common complication? A. Jaundice B. Poor appetite C. Brain damage D. Hypoglycemia

A

What is the most important assessment for the nurse to conduct following the admin of epidural anesthesia to a client who is at 40 weeks gestation? A. Maternal blood pressure B. Level of pain sensation C. Station of presenting part D. Variability of feta heart rate

A

HESI HINT:106 High-Risk Disorders

A higher incidence of fetal anomalies occurs in pregnant women with diabetes. Therefore, fetal surveillance is very important: -Ultrasound examination -Alpha-fetoprotein (to determine neural tube anomalies) -Nonstress and contraction stress tests

A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is

A persistent cold

Immediately after delivery, the uterine fundus should be:

At the level of the umbilicus

A nurse caring for a client in the active stage of labor assesses the fetal status and notes a late deceleration on the monitor strip. In light of this finding, which nursing action is the priority?

Administering oxygen by way of face mask

The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Bassed on this assessment the nurse determines that the neonate has a maturity rating 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (select all that apply)

Admission weight of 4 pounds, 15oz Head to heel length of 17in Frontal occipital circumference of 12.5in

When should you heel stick a baby for PKU?

After a full 24 hours of feeding

When should the baby be burped?

After every 1-2oz NOT THE END

HESI HINT: 52 Normal Postpartum

After the first postpartum day, the most common cause of uterine atony is retained placental fragments. The nurse must check for the presence of fragments of lochial tissue

HESI HINT: 45 Intrapartum Nursing Care

Agonist narcotid drugs (morphine) produce narcosis and have a higher risk for causing maternal and fetal respiratory depression. Antagonist drugs (Stadol, Nubain) have less respiratory depression but must be used with caution in a mother with preexisting narcotic dependency because withdrawal symptoms occur immediately.

A nurse provides instructions regarding postpartum exercises to a client who has delivered a newborn vaginally. The nurse tells the client that:

Alternating contraction and relaxation of the muscles of the perineal area should be practiced

HESI HINT: 42 Intrapartum Nursing Care

Apgar scores of 6 or lower at 5 min require an additional Apgar assessment at 10 minutes

A nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat?

Apple and whole-grain toast

A nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. The nurse tells the mother to:

Apply oil to the affected area on the infant's scalp

A nurse teaching a pregnant client about the expectations and complications of pregnancy is describing Braxton Hicks contractions. The nurse tells the client these contractions:

Are a common occurrence of pregnancy

HESI HINT: 11 Anatomy and Physiology of Reproduction and Antepartum

As pregnancy advances, the uterus presses on abdominal vessels (vena cava and aorta) Teach the woman that a left side-lying position relieves supine hypotension and increases perfusion to uterus, placenta, and fetus

A nurse is preparing to perform the Leopold maneuvers on a pregnant client. The nurse should first:

Ask the client to empty her bladder -In preparation for the Leopold maneuvers, the nurse first asks the woman to empty her bladder, which will contribute to the woman's comfort during the examination. Next the nurse positions the client supine with a wedge placed under the hip to displace the uterus. Often the Leopold maneuvers are performed to aid the examiner in locating the fetal heart tones.

A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. Which of the following should be the focus of the nurse's response?

Asking the client and her partner if they would like the nurse to stay in the room Offering to remain with the client and her partner offers support without providing false reassurance.

HESI HINT: 57 Normal Postpartum

Assess for thromboembolism: examine legs of postpartum client daily for pain, warmth, and tenderness or a swollen vein that is tender to the touch

. Patient had twins born to multigravida, 12 hours ago. Nursing Dx?

Assess fundal tone and lochia flow.

Sore nipples on day 2 of breastfeeding.

Assess infants position while feeding. RATIONALE: To make sure baby is latching properly.

HESI HINT:105 High-Risk Disorders

GLUCOSE SCREEN Client does not have to fast for this test. 50 g of glucose is given and blood is drawn after 1 hour. If the blood glucose is greater than 140, a 3 hour glucose tolerance test (GTT) is done

After a vaginal delivery, a woman suddenly begins to complain of severe pelvic pain and extreme fullness in the vagina, and the nurse suspects uterine inversion. The nurse immediately prepares to:

Assist in repositioning the uterus through the vagina into a normal position

The nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse should include which intervention in the plan of care? A. Monitoring the newborn's vital signs routinely B. Maintaining standard precautions at all times while caring for the newborn C. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems D. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment

B. Maintaining standard precautions at all times while caring for the newborn

HESI HINT:112 High-Risk Disorders

Babies delivered abdominally miss out on the vaginal squeeze and are born with more fluid in their lungs, predisposing them to transient tacypnea (TTN) and respiratory distress

A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide?

Breastfeed the infant every 2 hours. The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. If the infant does not feed adequately and empty the breast, using a breast pump helps extract the milk and relieve some of the discomfort. Dehydration irritates swollen breast tissue. Skipping feedings may cause further engorgement and discomfort.

Baby born breech, in the NICU they assess?

Ortolani's test. RATIONALE: (from Saunders, couldn't find it in HESI). It is a test of hip laxity, used to diagnose hip dysplasia.

A client at 40 weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptures spontaneously at home. She is in active labor, and feels the need to bear down and push. What information is most important for the nurse to obtain first? A. Estimated amount of fluid B. Any odor noted when membranes ruptured C. Color and consistency of fluid D. Time the membranes ruptured

C

A full term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first? A. Suction the oral and nasal passages B. Give oxygen by positive pressure C. Stimulate the infant to cry D. Turn the infant onto the right side

C

caput succedaneum vs cephalohematoma

Caput Succedaneum- soft tissue swelling, that can cross suture lines Cephalohematoma- subperiosteal hemorrhag that does NOT cross suture lines.

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his 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?

Cephalhematoma, which is caused by forceps trauma Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and skull.

A 4-week old premature infant has been receiving epoetin alfa (Epogen) for the last tree weeks. Which assessment finding indicates to the nurs that the drug is effective?

Change in indirect bilirubin from 12mg/dl to 8mg/dl

A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symtoms are this newborn likely to exhibit?

Chocking, coughing, and cyanosis

HESI HINT:67 The Normal Newborn

Circumcision has become controversial because there is no real medical indication for the procedure, and it does not cause trauma and pain to the newborn. It was once thought to decrease the incidence of penile and cervical cancer, but some researchers say that it is unfounded.

HESI HINT: 51 Normal Postpartum

Client and family teaching is a common subject. Remember that when teaching the first step is to assess the clients (parents) level of knowledge and to identify their readiness to learn. Client teaching regarding lochia changes, peripheral care, breastfeeding, and sore nipples are subjects commonly tested on

HESI HINT: 54 Normal Postpartum

Client should void within 4 hours of delivery. Monitor client closely for urine retention. Suspect retention if voiding is frequent and <100 mL per voiding

A client who is at 23-week gestation calls the clinic and reports that she is concerned because fluid is leaking from her vagina. What should the PN tell the client

Come to the office immediately to have the fluid checked

A multigravida client arrives at the labor and delivery unit and tell the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140-150 beats/minute. What action should the nurse implement next?

Complete a sterile vaginal exam

A nurse caring for a client in labor performs an assessment. The client is having consistent contractions less than 2 minutes apart. The fetal heart rate (FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased variability. In light of these findings, the appropriate nursing action is:

Contacting the physician

APGAR 3. Intervention?

Continue resuscitation efforts.

Newborn respiratory rate of 40 breaths per minute and cyanotic hands and feet:

Continue to monitor (normal).

A client in her third trimester asks the PN to explain how she can tell true labor from false labor. What information about the contractions experienced during true labor should the PN relay to the client?

Continue to occur with walking

A nurse is performing an assessment of a pregnant woman to determine whether labor has begun. For which sign of true labor does the nurse assess the client?

Contractions that begin in the lower abdomen and back and radiate over the entire abdomen

Which assessment finding indicates to the PN that the neonate is post mature?

Cracked, peeling skin

Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.)

Cramping with bright red spotting Lack of tenderness of the breast Increased right-side flank pain

A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). What is the nest explanation for this finding? A. They thyroxine level is low because the TSH level is high B. High thyroxine levels normally occur in breastfeeding infants C. The thyroid gland does not produce normal levels of thyroxine for seven weeks after birth D. The TSH is high because of the low production of T4 by the thyroid

D

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? A. Protects the newborn's eyes from possible infections acquired while hospitalized. B. Prevents cataracts in the newborn born to a woman who is susceptible to rubella. C. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. D. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection.

D. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a woman with an untreated gonococcal infection.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? A. Variability B. Accelerations C. Early decelerations D. Variable decelerations

D. Variable decelerations

A nurse is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe preeclampsia. Which finding would prompt the nurse to contact the physician?

Diaphoresis and tachycardia

A woman with severe preeclampsia delivers a healthy newborn infant and continues to receive magnesium sulfate therapy in the postpartum period. Twenty-four hours after delivery, the client begins passing more than 100 mL of urine every hour. The nurse recognizes this volume of urine output as an indication of:

Diminished edema and vasoconstriction in the brain and kidneys -In this client, diuresis is a positive sign, indicating that edema and vasoconstriction in the brain and kidneys have decreased. Diuresis also reflects increased tissue perfusion in the kidneys.

HESI HINT: 71 The Normal Newborn

Do NOT feed a newborn when the respiratory rate is over 60. Inform the physician and anticipate gavage feedings in order to prevent further energy utilization and possible aspiration

A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue and a moist cough. Which question is most important for the nurse to ask this client?

Do you have a history of rheumatic fever?

A nurse assessing a pregnant client's deep tendon reflexes notes a reflex of 2+. The nurse should:

Document the finding

A nurse is assessing a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which of the following actions should the nurse perform in response to this observation?

Documenting the finding

A nurse is changing the diaper of a 1-day-old full-term female newborn. The nurse notes that the labia are edematous and darker than the surrounding skin and that a white mucous vaginal discharge is present. On the basis of these findings, the nurse determines that the appropriate action is:

Documenting the findings (normal findings)

To maintain optimal thermoregulation for a newborn infant, what intervention should the PN implement daily?

Dress the infant with a diaper shirt, a cap, and blankets

A nurse is reviewing the medical record of a pregnant client with sickle cell anemia. To which of the following information related by the client would the nurse give the highest priority?

Drinking less than 4 glasses of fluid daily

HESI HINT: 131

Drugs used to treat neonatal infections can be ototoxic and nephrotoxic. Close monitoring of therapeutic levels and observation for side effects are required.

HESI HINT:114 High-Risk Disorders

Due to the exploration and cleansing of the uterus just after delivery of the placenta, the amount of lochia may be scant in the recovery room. However, pooling in the vagina and uterus while on bed rest may result in blood running down the clinents leg when she first ambulates. Cesarean birth clients have the same lochial changes, placental site healing, and aseptic needs as do vaginal birth clients

Patient is 5 weeks pregnant, educate on nutrition...

Eat a well balanced diet, adjust PRN for proper weight gain.

A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client's temperature and notes that it is 38° C (100.4° F). The most appropriate nursing action would be to:

Encourage the intake of oral fluids

The total bilirubin level of a 36-hour, breastfeeding newborn is 14mg/dl. Based on this finding, which intervention should the nurse implement?

Encourage the mother to breast feed frequently

The Total bilirubin of a 36-hour, breastfeeding newborn is 14mg/dL. Based on this finding, Which intervention should the nurse implement?

Encourage the mother to breastfeed frequently.

A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement?

Encourage the mother to stop feeding for a few minutes and comfort the infant. The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often more successful.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness?

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

deep variable decelerations are normal after AROM

FALSE

Assessing a 3 day old with cephalohematoma. What intervention is highest priority?

Examine Q8 hrs for jaundice (look for hyperbilirubinemia). RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.

24 hours after birth, cephalohematoma, what intervention?

Examine jaundice Q8 hours. RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.

What information should the practical nurse reinforce before a gravid client begins prescription for an iron supplement to prevent iron-deficiency anemia?

Expect stools to be dark green or black

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?

Explain this is a normal finding. The client is describing lochia serosa, a normal change in the lochial flow

A client is active labor complains of cramps in her leg. What intervention should the nurse implement?

Extend the leg and dorsiflex the foot

What is a reactive non stress test

FHR increased 15bpm from baseline, for 15 seconds... twice in 15 minutes

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?

Fetal heart rate (FHR) The FHR should be assessed before and after the procedure to detect changes that may indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix is favorable. The fluid should be assessed for color, odor, and consistency.

HESI HINT: 12 Anatomy and Physiology of Reproduction and Antepartum

Fetal well-being is determined by assessing fundal height, fetal heart tones and rate, fetal movement, and uterine activity (contractions). Changes in FHR are the first and most important indicators of compromised blood flow to the fetus and these changes require action! Remember: normal FHR is 110-160

. Newborn assessment for respiratory distress.

Flaring of the nares. RATIONALE: Forced inspiration, grunting, tachy (respirations >60), cyanosis, and retractions over chest wall).

. Full term infant, vaginal birth, placed in radiant warmer, is apneic. What to do FIRST?

Flick soles of feet. RATIONALE: Infant needs additional stimulation to initiate breathing.

Rheumatic fever hx as a child, resulted in heart damage, risk for CHF post delivery. Nursing Dx?

Fluid volume excess. RATIONALE: 3rd spacing.

HESI HINT: 6 Anatomy and Physiology of Reproduction and Antepartum

For many women, battering (emotional or physical abuse) begins during pregnancy. Women should be assessed for abuse in private, away from the male partner, by a nurse who is familiar with local resources and knows how to determine the safety of the client

To measure contractions...

From beginning of a contraction, to the beginning of the next contractions.

HESI HINT: 17 Fetal and Maternal Assessment Techniques

Gestational age is best determined by an early sonogram rather than a later one

The healthcare provider prescribes terbutaline (Brethine) for a clint in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition.

Gestational diabetes

Abacavir (ziagen) 450 mg po tid ordered for HIV positive. Stock is 300 mg tabs. Give?

Give 1.5 tabs.

FHR decreases after each contraction. What should the nurse do?

Give 10 lpm 02 via mask.

The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn which infectious organism will this treatment prevent from harming the infant?

Gonorrhea

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?

Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.

HESI HINT: 32 Intrapartum Nursing Care

Hyperventilation results in respiratory alkalosis that is caused by blowing off too much CO2 Sx include: dizziness, tingling of fingers, stiff mouth. Have woman breathe into cupped hands or paper bag in order to re-breathe CO2

38 week (IDM) infant of diabetic mother admitted to NICU @ 8.2 lbs. What is the priority Nursing Dx?

Hypoglycemia.

HESI HINT:68 The Normal Newborn

Hypothermia (heat loss) leads to depletion of glucose and therefore, to the use of brown fat (special fat deposits fetus develop in last trimester; they are important to thermoregulation) for emergency. This results in ketoacidosis and possible shock. Prevent by keeping neonate warm!

HESI HINT: 43 Intrapartum Nursing Care

IV administration of analgesics is preferred to IM administration for a client in labor because the onset and peak occur more quickly and the duration of the drug is shorter. It is important to know the following: IV ADMINISTRATION -Onset: 5 minutes -Peak: 30 minutes -Duration: 1 hour IM ADMINISTRATION -Onset: within 3o minutes -Peak: 1-3 hours after injection -Duration: 4-6 hours

Immediately after birth a newborn infant is suctioned, dried and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse preform next?

Initiate positive pressure ventilation

. 12 hours after birth, mother c/o vaginal pressure, fundus firm @ midline, with moderate

Inspect perineal and rectal area.

What action by the practical nurse is beneficial to the client who is breastfeeding and has engorged breasts?

Instruct and assist the client to massage her breasts

A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client's oxygen saturation on pulse oximetry is 92%. The nurse first:

Instructs the client to take several deep breaths

Nutrition teaching for pregnant teens.

Iron-deficient anemia.

After the delivery of a newborn, a nurse performs an initial assessment and determines that the Apgar score is 8. The nurse interprets this score as indicating that the infant:

Is adjusting well to extrauterine life

HESI HINT:63 The Normal Newborn

It is difficult to differentiate between caput succedaneum (edema under the scalp) and cephalohematoma (blood under the periosteum) The caput crosses suture lines and is usually present at birth, whereas the cephalohematoma does not cross suture lines and manifests a few hours after birth. The danger of cephalohematoma is increased bilirubinemia due to excess RBC breakdown.

A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide?

It is important that you want to take part in your care

HESI HINT: 28 Intrapartum Nursing Care

It is important to know the normal findings for a client in labor -Normal FHR in labor: 110-160 -Normal maternal BP: <140/90 -Normal maternal pulse: <100 -Normal maternal temp: <100.4 -Slight elevation in temp may occur because of dehydration and work of labor. Anything higher indicates infection and must be reported immediately

HESI HINT: 15 Anatomy and Physiology of Reproduction and Antepartum

It is recommended that pregnant women consume the equivalent of 3 cups of milk or yogurt per day. This will ensure that the daily calcium needs are met and help to alleviate the occurrence of leg cramps

A client at 14-weeks gestation tells the PN that she has not had any alcohol during her first trimester but wants to have a glass of wine with dinner now. Which response is best for the PN to provide?

It is recommended that you abstain from drinking any alcohol throughout your pregnancy

HESI HINT:109 High-Risk Disorders

It is useful to discontinue long-acting insulin administration on the day before delivery is planned because insulin requirements are less during labor and drop precipitously after delivery

HESI HINT: 56 Normal Postpartum

Kegel exercises increase the integrity of the introitu and improve urine retention. Teach client to alternate contraction and relaxtation of the pubococcygeal muscles.

Symptoms of hemorrhage/bleeding out:

LR 200 mL/hr using 18 gauge needle.

HESI HINT:134

Lab tests measure total and direct (conjugated, excretable, non-fat soluble) bilirubin levels. The dangerous bilirubin is the unconcjugated, indirect (fat-soluble) type, which is measured by subtracting the direct from the total bilirubin.

HESI HINT: 21 Fetal and Maternal Assessment Techniques

Late decelerations indicate uteroplcental insufficiency (UPI) and are associated with conditions such as postmaturity, preeclampsia, DM, cardiac disease, and abruptio placentae

When monitoring a laboring client, which fetal heart rate finding should the practical nurse report to the charge nurse immediately?

Late declarations

A gravida 1 para 1 client is scheduled to be discharged from the postpartum unit with her infant. Which action by the mother should the practical nurse identify as a need for further information about infant care?

Leaves her baby on the bed while in the shower

HESI HINT: 30 Intrapartum Nursing Care

Meconium-stained fluid is yellow-green or gold-yellow and may indicate fetal stress

HESI HINT: 5 Anatomy and Physiology of Reproduction and Antepartum

Look for signs of maternal-fetal bonding during pregnancy, for example, talking to fetus in utero, massaging abdomen, and nicknaming fetus are all healthy psychosocial activities

During a prenatal visit, the nurse discusses the effects of smoking on the fetus with a client. Which statement is most characteristic of an infant whose mother smoked during pregnancy compared with the infant of a nonsmoking mother?

Lower initial weight documented at birth Smoking is associated with low-birth-weight infants. Therefore, mothers are encouraged not to smoke during pregnancy.

Which nursing intervention would be most helpful in relieving postpartum uterine contractions or "afterpains?"

Lying prone with a pillow on the abdomen

HESI HINT: 36 Intrapartum Nursing Care

Methergine is NOT given to clients with HTN because of its vasoconstrictive action. Pitocin is given with caution to those with HTN

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tese between contractions, BP 110/68 FHR 110 beats/min, cervix 1 cm dialated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?

Monitor bleed from IV sites

A primigravida is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum (HG), Which priority action in the plan of care should the PN address?

Monitor nutritional and fluid intake and output

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities?

Move about every hour Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous return.

A neonate is irritable, cries incessantly, and has a temperature of 99.4° F. The neonate is also tachypneic, diaphoretic, feeding poorly, and hyperactive in response to environmental stimuli. The nurse determines that these signs and symptoms are consistent with:

Neonatal abstinence syndrome (drug withdrawal in the neonate)

Are cephalohematomoas present at birth?

No they form between 24-48 hours

A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for discharge. Which nursing intervention should be included in this infant's discharge teaching plan?

Observe the parents applying a Pavlik harness. It is important that the hips of infants with hip dysplasia are maintained in an abducted position, which can be accomplished by using the Pavlik harness; this keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum.

One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first?

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

HESI HINT: 25 Fetal and Maternal Assessment Techniques

Percutaneous umbilical blood sampling (PUBS) can be done during pregnancy under ultrasound for prenatal diagnosis and therapy. Hemoglobinopathies, clotting disorders, sepsis, and some genetic testing can be done using this method

A nurse teaching a pregnant client about measures to strengthen the pelvic floor instructs the client to:

Perform Kegel exercises in 10 repetitions, three times per day

A nurse is assisting a midwife who is assessing a client for ballottement. Which action does the nurse anticipate that the midwife will employ to test for ballottement?

Performing a sudden tap on the cervix -Near midpregnancy, a sudden tap on the cervix during a vaginal exam may cause the fetus to rise in the amniotic fluid and then rebound to its original position, a phenomenon known as ballottement.

Water broke, umbilical cord is on perineum, what does nurse do?

Place pt in trendelenburg. RATIONALE: Take the pressure off the presenting part of cord by vaginal exam and holding up the presenting part as much as possible.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the nurse take immediately?

Place the client in a lateral position. The nurse should immediately turn the client to a lateral position or place a pillow or wedge under one hip to deflect the uterus. Other immediate interventions include increasing the rate of the main line IV infusion and administering oxygen by facemask. If the blood pressure remains low after these interventions or decreases further, the anesthesiologist or health care provider should be notified immediately. To continue to monitor blood pressure without taking further action could constitute malpractice.

Six hours after an oxytocin (Pitocin) 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?

Place the client in a slight Trendelenburg position. The goal is to relieve pressure on the umbilical cord, and placing the client in a slight Trendelenburg position is most likely to relieve that pressure. The FHR pattern is indicative of a variable fetal heart rate deceleration, which is typically caused by cord compression and can occur with or without contractions.

HESI HINT:81 High-Risk Disorders

Podophyllin, which is usually used to treat HPV, is contraindicated in pregnancy because it is associated with fetal death, preterm labor, and cervical carcinoma. Quadrivalent human papilomavirus (types 6,11,16,18) recombinant vaccine (Gardasil) is available to nonpregnant females 9 years and older to prevent HPV

The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn son at home. The woman tells the nurse, "I don't know what is wrong. I love my son, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should the nurse determine the client is experiencing?

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

HESI HINT: 8 Anatomy and Physiology of Reproduction and Antepartum

Practice calcualting EDB. If the first day of a women's last normal menstrual period was October 17, what is her ED, busing Nagele rule? July 24. Count back 3 months and add 7 days (always give February 28 days)

HESI HINT: 7 Anatomy and Physiology of Reproduction and Antepartum

Practice determining gravidity and parity, A women who is 6 weeks pregnant has the following maternal history: -2-year-old healthy daughter -miscarriage at 10 weeks -abortion at 6 weeks, 5 years earlier -Current pregnancy, she is gravida 4, para 1, (only 1 delivery after 20 weeks gestation) GTPAL = 4-1-0-2-1

A client admitted to the maternity unit 12 hours ago has been experiencing strong contractions every 3 minutes but has remained at station 0. The fetal heart rate on admission was 140 beats/min and regular. The fetal heart rate is slowing, and a persistent nonreassuring fetal heart rate pattern is present. The appropriate nursing action in this situation is:

Preparing the client for a cesarean delivery

A nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which of the following situations would the nurse suspect in light of this observation?

Pressure on the fetal head during a contraction

Eye ointment QS is for?

Prevent eye infection.

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." Which intervention is best for the nurse to implement First?

Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing intervention in the care of this client?

Providing pain relief

HESI HINT: 46 Intrapartum Nursing Care

Pudental block and subarachnoid (saddle) block are used only in the second stage of labor. Peridural and epidural blocks may be used during all stages of labor.

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. Which intervention has the highest priority?

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

HESI HINT: 49 Intrapartum Nursing Care

REGIONAL BLOCK ANESTHESIA AND FETAL PRESENTATION: -Internal rotation is harder to achieve when the pelvic floor is relaxed by anesthesia; this results in a persistent occiput-posterior position of fundus -Monitor fetal position. Remember, the mother cannot tell you she has back pain, which is the cardinal sign of persistent posterior fetal position -Regional blocks, especially epidural and caudal blocks, commonly result in assisted (forceps or vaccum) delivery because of the inability to push effectively during the second stage.

Newborn assessment that indicates a cardiac problem?

RR 78/min. RATIONALE: Normal respiratory rate for a newborn is 40 - 60.

The nurse is providing discharge teaching for a client who is 24 hours post partum. The nurse explains to the client that her vaginal discharge will change from red to pink then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do?

Reduce activity level and notify the healthcare provider.

A 30-year-old multiparous woman who has a 3-year old boy and a newborn girl tells the nurse, "my son is so jealous of my daughter, I don't know how ill ever manage both children when I get home." How should the nurse respond?

Regression in behaviors in the older child is a typical reaction so he needs attention at this time

HESI HINT: 58 Normal Postpartum

Remember RhoGAM is given to an Rh-negative mother who delivers an Rh-positive fetus and has a negative direct Coombs test. If the mother has positive Coombs test, there is no need to give RhoGAM because the mother is already sensitized

HESI HINT:118 Postpartum High Risk Disorders

Remember the risk for postpartum infections is higher in clients who experienced problems during pregnancy (e.g. anemia and diabetes) and who experienced trauma during labor and delivery

HESI HINT:132

Renal immaturity in a preterm infant makes the monitoring of the administration of IV fluids and drug therapy crucial. Closely monitor BUN and creatinine levels when administering the -mycin antibiotics to treat infections in a neonate.

A client is admitted to the hospital for an emergency cesarean delivery. Contractions are occurring every 15 minutes, the client has a temperature of 100° F, and the client reports that she last ate 2 hours ago. The client also states that "everything happened so fast" and that she has had no preparation for the cesarean delivery. Which of the following actions should the nurse take first?

Reporting the time of last food intake to the physician

Heelstick blood specimen on neonate for T4 and TSH prior to D/C home on 2 day old. Parents ask why, the nurse states?

Required by law to screen for metabolic def.

The PN is assigned a newborn male infant with an Apgar score of 9. Which finding should the PN report to the charge nurse?

Resting heart rate 100 beats/minute with a swish

A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse:

Simultaneously provides pressure over the lower uterine segment

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?

Skin color that is slightly jaundiced Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of the hands and feet) is a common finding in newborns; it occurs because the capillary system is immature. Milia are small white papules present on the nose and chin that are caused by sebaceous gland blockage and disappear in a few weeks. Small red patches on the cheeks and trunk are called erythema toxicum neonatorum, a common finding in newborns

A nurse is monitoring a client in labor for signs of intrauterine infection. Which sign, indicative of infection, would prompt the nurse to contact the healthcare provider?

Strong-smelling amniotic fluid

HESI HINT: 62 The Normal Newborn

Suction the mouth first and then the nose. Stimulating the nares can initiate inspiration, which could cause aspiration of mucus in the oral pharynx

A delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table, and the nurse positions the client:

Supine with a wedge under the right hip

HESI HINT:76 High-Risk Disorders

Suspect ectopic pregnancy in any woman of childbearing age who presents at an emergency room, clinic, or office with unilateral of bilateral abdominal pain. Most are misdiagnosed as appendicitis

what is a contraction stress test?

Testing FHR response to uterine contractions

HESI HINT:128

The PO2 should be maintained between 50 and 90 mm Hg. PO2 <50 signifies hypoxia, Po2 >90 signifies oxygen toxicity problems

In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan?

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

A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective?

The client experiences diuresis within 24 to 48 hours.

After an unplanned cesarean section, the nurse finds the client in emotional distress, tearfully expressing bewilderment, sadness, and feelings of failure and regret because she could not deliver vaginally. Which of the following conclusions should the nurse make?

The client is experiencing low self-esteem.

Which event should the practical nurse identify that indicates childbirth education for a pregnant client was successful?

The client rehearsed labor and practiced skills to master pain

Client teaching is an important part of the perinatal nurse's role. Which factor has the greatest influence on successful teaching of the pregnant client?

The client's investment in what is being taught When teaching any client, readiness to learn is related to how much the client has invested in what is being taught or how important the materials are to the client's particular life. For example, the client with severe morning sickness in the first trimester may not be ready to learn about labor and delivery but is probably very ready to learn about ways to relieve morning sickness.

HESI HINT: 47 Intrapartum Nursing Care

The first sign of a block's effectiveness is usually warmth and tingling in the ball of the foot or the big toe

A nurse is reviewing the criteria for early discharge of a newborn infant. Which of the following, if noted in the infant, would indicate that the criteria for early discharge have been met?

The infant has urinated. The infant has passed 1 stool. Vital signs are documented as normal. The infant has completed one successful feeding.

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. The nurse tells the client that:

The infant should receive both the vaccine and hepatitis immune globulin soon after birth

A full-term infant is transferred to the nursery from labor and delicery. Which information is most important for the nurse to receive when planning immediate care for the newborn?

The infants condition at birth and treatment received.

HESI HINT: 1 Anatomy and Physiology of Reproduction and Antepartum

The menstrual phase varies in length in most women

. Fundus hand placement: 1 massages the fundus the other is for...

The other hand anchors the lower uterine section.

HESI HINT:87 High-Risk Disorders

The outcome of adolescent pregnancy depends on prenatal care. Nutrition is a key factor because the adolescent's physiologic needs for growth are already higher, and the additional stress of pregnancy only increases those needs

HESI HINT:113 High-Risk Disorders

The preferable low-transverse uterine incision usually results in less postoperative pain, less bleeding, and fewer incidents of ruptured uterus. The classical vertical incision of the uterus may involve part of the fundus, resulting in more posoperative pain, more bleeding, and increased chance for uterine rupture

When does "normal jaundice" occur?

after 24 hours of age

HESI HINT:94 High-Risk Disorders

The uterus is most sensitive to becoming tetanic at the beginning of the infusion. The client must always be attended and contractions monitored. Contractions should last no longer than 90 seconds to prevent fetal hypoxia

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client?

There is a strong enough, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair

HESI HINT:66 The Normal Newborn

These neurologic reflexes are transient and, as such, disappear usually within the first year of life. In the pediatric client, prolonged presence of these reflexes can indicate CNS defects. Anticipate questions regarding newborn reflexes. Phyiscal assessment questions focus on normal characteristics of the newborn and the differentiation of conditions such as caput succedaneum and cephalohematoma

A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couples ability to conceive a child?"

They use lubricants with each sexual encounter to decrease friction.

Placental abruption is suspected in a client who is experiencing vaginal bleeding. On assessment, which of the following findings would the nurse expect to note?

Uterine tender to palpation

When do you administer RHogam?

at 28 weeks

What happens if you see yellow discharge after a circumcision?

This is normal for the healing process

The nurse is assessing the umbilical cord of a newborn. Which finding constutes a normal finding?

Three vessels: two arteries and one vein

MVA, 36 weeks, BP 80/50, HR 130, what does the nurse do?

Tilt the backboard to displace uterus.

How should the practical nurse determine the frequency of a laboring client's contractions?

Time between the beginning of one contraction and the beginning of the next

HESI HINT:133

To assess for skin jaundice, apply pressure with thumb over bony prominences to blanch skin. After thumb is removed, the area will look yellow before normal skin color reappears. The best areas for assessment are the nose, forehead, and sternum. In dark-skinned infants, observe conjunctival sac and oral mucosa.

HESI HINT:70 The Normal Newborn

To evaluate exact urine output, weigh dry diaper before applying. Weigh the wet diaper after the infant has voided. Calculate and record each gram of added weight as 1 ml urine

Primipara 20 week, schedule u/s, what's the reason for the u/s?

To evaluate fetal growth and to determine gestational age.

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?

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

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?

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

HESI HINT:127

Watch a newborn's Hct. It is difficult to oxygenate either an anemic newborn (lack of oxygen-carrying capacity) or a newborn with polycythemia (Hct >80%, thick, sluggish circulation)

HESI HINT:123 Postpartum High Risk Disorders

What immediate nursing actions should be taken when a postpartum hemorrhage is detected? -Perform fundal massage -Notify the HCP if the fundus does not become firm with massage -Count pads to estimate blood loss -Assess and record vital signs -Increase IV fluids (additional IV line may be indicated) -Administer oxytocin infusion as prescribed

HESI HINT:108 High-Risk Disorders

When a pregnant woman is admitted with a dx of DM: -she is more prone to preeclampsia, hemorrhage, and infection -Most diabetic pregnancies are allowed to progress to term (38 to 40 weeks) as long as metabolic control is maintained and fetal growth is within standards

HESI HINT: 53 Normal Postpartum

Women can tolerate blood less, even slightly excessive blood loss, in the postpartal period because of the 40% increase in plasma volume during pregnancy. In the postpartal period, a woman can void up to 3000 mL/day to reduce the volume increase that occurred during pregnancy

HESI HINT: 55 Normal Postpartum

Women often have a syncopal (fainting) spell on the first amblation after delivery (usually related to vasomotor changes, orthostatic hypotension) The astute nurse will check client's H/H for anemia and BP, sitting and lying downt o ascertain orthostatic hypotension

HESI HINT:104 High-Risk Disorders

Women who suffer from hyperemesis gravidarum are often deficit in thiamin, riboflavin, vitamin B6, vitamin A and retionol-binding proteins

What is the antidote of magnesium sulfate?

calcium carbonate

The patient is 38 weeks gestation and the nurse notes a decrease in the fetal heart rate (FHR) from 145 to 115 for a period of 15 minutes. How will the nurse document this finding?

change in baseline

what test is used for chromosomal testing?

chronic villus sampling

mother just lost her baby and has engorged breasts, how to stop?

cold compression

goals of tocolysis

delay preterm delivery within 48 hours of steroids to prevent neonatal respiratory distress

difference between postpartum hemorrhage and delivery of placenta

delivery of placenta has an urge to push, uterus contracts

What is the follicular phase?

first day of menstration

phases of ovarian cycle

follicular phase, ovulation, luteal phase

What should you do if you get a nonreactive stress test?

follow up with ultrasound or BPP

What hormone is insulin resistant?

hCS

sulfonamides cause what in newborns?

jaundice

open glottis pushing

method of expelling the fetus that is characterized by pushing with contractions using an open glottis so that air is released during the pushing effort

high levels of alpha-fetoprotein

neural tube defect

negative CST

no significant variable decelerations or no late decelerations

If FHR is 90 bpm what type of pushing would the nurse encourage?

open glottis pushing

non-stress test

screen FHR and accelerations

interventions at home for epiosiomity

sitz bath 3 times a day

funis souffle

sounds from umbilical cord, in sync with fetal heart rate

Why give fluid bolus before administering epidural

to maintain fluid volume... epidural main side effect is hypotension

Low levels of alpha-fetoprotein

trisomy 21

Breech position is a risk factor for what?

umbilical cord prolapse

Which umbilical vessel sends oxygenated blood from placenta to fetus?

umbilical vein

when do you use ice packs

up until 24 hours after birth and for only 10 minutes at a time

The nurse performs Leopold's maneuvers on a patient prior to auscultating the FHR with a handheld doppler. The nurse palpates the fetal head at the fundus and the presenting part is not engaged. Where would the nurse position the doppler to evaluate the FHR?

upper fundal area

signs of preterm labor

uterine contractions, cramps, constant or irregular low backache, pelvic pressure, leaking amniotic fluid

A primigravida client who is 5cm dilated, 90% effaced and 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider?

A platelet count of 67.000/mm3

A nurse answers a call light in the room of a woman who was just admitted in early latent labor. The woman is lying flat on her back on the bed. The husband reports excitedly, "I think my wife is going into shock or something! She was just lying there, and then she turned so pale, and her hands are so clammy. She said she was dizzy and sick to her stomach." The nurse notes on the noninvasive blood pressure monitor that the woman's pulse is 58 beats/min and her blood pressure is 90/50 mm Hg. The nurse interprets these findings as indications that the woman is experiencing:

Altered tissue perfusion related to hypotensive syndrome (vena cava syndrome)

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? A. Identify the types of accelerations. B. Assess the baseline fetal heart rate. C. Determine the intensity of the contractions. D. Determine the frequency of the contractions.

B. Assess the baseline fetal heart rate.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? A. Ambulation B. Rest between contractions C. Change positions frequently D. Consume oral food and fluids

B. Rest between contractions

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? A. Strict bed rest is required after the procedure. B. Hospitalization is necessary for 24 hours after the procedure. C. An informed consent needs to be signed before the procedure. D. A fever is expected after the procedure because of the trauma to the abdomen.

C. An informed consent needs to be signed before the procedure.

The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? A. Warming the crib pad B. Closing the doors to the room C. Drying the infant with a warm blanket D. Turning on the overhead radiant warmer

C. Drying the infant with a warm blanket

HESI HINT:79 High-Risk Disorders

Clients with abruptio placentae or placenta previa should undergo NO abdominal or vaginal manipulation -No Leopold maneuvers -No vaginal exam -No rectal exam, enemas, or suppositories -No internal monitoring

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?

Come to the clinic today for an ultrasound. Third-trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound. Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which is life threatening to the mother and fetus.

A nurse is caring for a client experiencing hypotonic labor contractions. The client is discouraged by the lack of progress with labor but refuses an amniotomy or oxytocin (Pitocin) stimulation. The nurse determines that the client's behavior may be a result of:

Concern about her own and the baby's well-being

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? A. Slow the intravenous flow rate. B. Place the client in a high Fowler's position. C. Continue the oxytocin (Pitocin) drip if infusing. D. Administer oxygen, 8 to 10 L/minute, via face mask.

D. Administer oxygen, 8 to 10 L/minute, via face mask

The nurse is performing an assessment on a pregnant client with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis? A. Enlargement of the breasts B. Complaints of feeling hot when the room is cool C. Periods of fetal movement followed by quiet periods D. Evidence of bleeding, such as in the gums, petechiae, and purpura

D. Evidence of bleeding, such as in the gums, petechiae, and purpura

The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action? A. The client with mild afterpains B. The client with a pulse rate of 60 beats/minute C. The client with colostrum discharge from both breasts D. The client with lochia that is red and has a foul-smelling odor.

D. The client with lochia that is red and has a foul-smelling odor.

HESI HINT:78 High-Risk Disorders

DIC is a syndrome of abnormal clotting that is systematic and pathologic. Large amounts of clotting factors, especially fibrinogen, are depleted, causing widespread external and internal bleeding. DIC is related to fetal demise, infection and sepsis, pregnancy-induced HTN (preeclampsia) and abruptio placentae.

A HCP informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruption placentae. What findings should the nurse expect the client to demonstrate?

Dark, red vaginal bleeding. increased uterine irritability. A rigid abdomen

A nurse is assessing the lochia of a client who delivered a viable newborn 1 hour ago. Which type of lochia would the nurse expect to note at this time?

Dark-red lochia rubra

A client with no prenatal care arrives at the labor unit scraming, "The baby is coming!" The nurse preforms a vaginal examination that reveals the cervix is 3 centimeters dialated and 75% effaced. What additional information is most important for the nurse to obtain?

Date of last menstrual period.

The PN observes a woman who gave birth one hour ago touch her newborn son with her fingertips while talking to him in high-pitched tones. What action should the PN take?

Document normal early maternal-infant attachment

HESI HINT: 20 Fetal and Maternal Assessment Techniques

If cord prolapse is detected, the examiner should position the mother to relieve pressure on the cord (i.e. knee chest position) or push the presenting part off the cord until immediate cesarean delivery can be accomplished

HESI HINT: 75 High-Risk Disorders

If hCG levels do not diminish, choriocarcinoma may develop. Pregnancy may mask the signs and symptoms of chroriocarcinoma.

HESI HINT: 29 Intrapartum Nursing Care

If infant's head is floating, watch the cord for prolapse

A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is started on an IV solution of tervutaline (Berthine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug?

Maternal and fetal heart rates.

HESI HINT: 37 Intrapartum Nursing Care

Never give methergine or Hemabate to a client while she is in labor or before delivery of the placenta

A nurse is caring for a client receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. Which of the following findings would prompt the nurse to stop the infusion?

Nonreassuring fetal heart rate pattern

A nurse is monitoring a pregnant client with placental abruption. Which pattern on the fetal monitor indicates to the nurse that fetal tissue perfusion is adequate?

Normal FHR

HESI HINT:100 High-Risk Disorders

Normal diuresis, which occurs in the postpartum period, can pose serious problems to the new mother with cardiac disease because of the increased CO

HESI HINT: 50 Normal Postpartum

Normal leukocytes of pregnancy averages 12,000-15,000. During the first 10 to 12 days postdelivery, values of 25,000 are common. Elevated WBC and the normal elevated ESR may confuse interpretation of acute postpartal infections. For example, if the nurse assess a clients temp to be 101 on the clients second postpartum day, what assessments should be made before notifying the physician? Assess the fundal height and firmness; assess perineal integrity; check for s/sx of thromboembolism assess pulse, respirations, and BP, assess clients subjective description of sx (burning on urination, pain in leg, excessive tenderness of uterus)

The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse?

Notify the health care provider The health care provider should be notified when a client practices pica (craving for and consumption of nonfood substances). The practice of pica may displace more nutritious foods from the diet, and the client should be evaluated for anemia.

The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally which further assessment should the nurse perform?

Observe for an asymmetrical Moro reflex

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately?

Onset of uterine contractions

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the HCP?

Onset of uterine contractions. The onset of uterine contractions places the client at risk for dilation and placental separation, which causes painless hemorrhaging

HESI HINT:107 High-Risk Disorders

Oral hypoglycemics are not taken during pregnancy because of the potential teratogenic effects on the fetus. Insulin is used for therapeutic management

HESI HINT: 24 Fetal and Maternal Assessment Techniques

The danger of nipple stimulation lies in controlling the "dose" of oxytocin delivered by the posterior pituitary. The chance of hyperstimulation or tetany (contractions over 90 seconds or contractions with less than 30 second in between is increased

HESI HINT:117 Postpartum High Risk Disorders

The most common iatrogenic cause of a UTI is urinary catheterization. Encourage clients to void frequently and not ignore the urge. IV antibiotics are usually administered to clients with pyelonephritis

HESI HINT: 26 Fetal and Maternal Assessment Techniques

The most import determinant of fetal maturity for extrauterine survival is the lung maturity: lung surfactant (L/S) ration (2:1 or higher)

A woman whose pregnancy has just been confirmed tells the PN that she jogs 3 miles four times a week and wonders if this much exercise might harm her fetus. What information should the PN provide?

Walking or swimming during the third trimester is a good alternative

HESI HINT: 18 Fetal and Maternal Assessment Techniques

When an amniocentesis is done early in pregnancy, the bladder must be full to help support the uterus and to help push the uterus up in the abdomen for easy access. When an amniocentesis is done in late pregnancy, the bladder must be empty so it will not be punctured.

HESI HINT:93 High-Risk Disorders

Women with previous uterine scars are prone to uterine rupture, especially if oxytocin or forceps are used. If a woman complains of a sharp pain accompanied by the abrupt cessation of contractions, suspect uterine rupture, a medical emergency. Immediate surgical delivery is indicated to save the fetus and mother

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2.Signs of heavy bruising 3.Complaints of intense pain 4.Complaints of a tearing sensation

1 Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor? 1. The appearance of the fetal external genitalia 2. The beginning of differentiation in the fetal groin 3. The fetal testes are descended into the scrotal sac 4. The internal differences in males and females become apparent

1 By the end of the twelfth week, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Differentiation of the external genitalia occurs at the end of the ninth week. Testes descend into the scrotal sac at the end of the thirty-eighth week. Internal differences in the male and female occur at the end of the seventh week.

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The health care provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse document this finding? 1. A normal test result 2. An abnormal test result 3. A high risk for fetal demise 4. The need for a C-section

1 Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by 3 contractions of at least 40 seconds' duration in a 10-minute period. Options 2, 3, and 4 are incorrect interpretations.

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1. "I will need to increase my insulin dosage during the first 3 months of pregnancy." 2."My insulin dose will likely need to be increased during the second and third trimesters." 3."Episodes of hypoglycemia are more likely to occur during the first 3 months of pregnancy." 4."My insulin needs should return to prepregnant levels within 7 to 10 days after birth if I am bottle-feeding."

1 Insulin needs decrease in the first trimester of pregnancy because of increased insulin production by the pancreas and increased peripheral sensitivity to insulin. The statements in options 2, 3, and 4 are accurate and signify that the client understands control of her diabetes during pregnancy.

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. "You will need to bottle-feed your newborn." 2."You will need to feed your newborn by nasogastric tube feeding." 3."You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." 4."You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

1 Perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV are advised not to breast-feed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief? 1. "What can I do for you?" 2."Now you have an angel in heaven." 3."Don't worry, there is nothing you could have done to prevent this from happening." 4."We will see to it that you have an early discharge so that you don't have to be reminded of this experience."

1 When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their health care provider or others on the health care team. It is important for the nurse to be with the parents at this time and to use therapeutic communication techniques. The nurse must also consider cultural and religious practices and beliefs. The correct option provides a supportive, giving, and caring response. Options 2, 3, and 4 are blocks to communication and devalue the parents' feelings.

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra. 2.Rest during the acute phase. 3.Maintain a fluid intake of at least 3000 mL/day. 4.Continue to breast-feed if the breasts are not too sore. 5.Take the prescribed antibiotics until the soreness subsides. 6.Avoid decompression of the breasts by breast-feeding or breast pump.

1, 2, 3, 4 Mastitis is an inflammation of the lactating breast as a result of infection. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply. 1. Allows for fetal movement 2. Surrounds, cushions, and protects the fetus 3. Maintains the body temperature of the fetus 4. Can be used to measure fetal kidney function 5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and the fetus

1, 2, 3, 4 The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely and maintains the body temperature of the fetus. In addition, the amniotic fluid contains urine from the fetus and can be used to assess fetal kidney function. The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the mother and the fetus.

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply. 1. Ballottement 2. Chadwick's Sign 3. Uterine enlargement 4. Positive pregnancy test 5. FHR detected by nonelectronic device 6. Outline of fetus via rdaiography or ultrasonography

1, 2, 3, 4, The probable signs of pregnancy include uterine enlargement, Hegar's sign (compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (softening of the cervix that occurs at the beginning of the second month), Chadwick's sign (violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4), ballottement (rebounding of the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test for the presence of human chorionic gonadotropin. Positive signs of pregnancy include fetal heart rate detected by electronic device (Doppler transducer) at 10 to 12 weeks and by nonelectronic device (fetoscope) at 20 weeks of gestation, active fetal movements palpable by the examiner, and an outline of the fetus by radiography or ultrasonography.

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply. 1. "The ductus arteriosus allows blood to bypass the fetal lungs." 2. "One vein carries oxygenated blood from the placenta to the fetus." 3. "The normal fetal heart tone range is 140 to 160 beats per minute in early pregnancy." 4. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." 5. "Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta."

1, 2, 4 The ductus arteriosus is a unique fetal circulation structure that allows the nonfunctioning lungs to receive only a minimal amount of oxygenated blood for tissue maintenance. Oxygenated blood is transported to the fetus by one umbilical vein. The normal fetal heart tone range is considered to be 110 to 160 beats per minute. Arteries carry deoxygenated blood and waste products from the fetus, and the umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus. Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries.

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment findings indicate to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? Select all that apply. 1. The client has a history of intravenous drug use. 2.The client has a significant other who is heterosexual. 3. The client has a history of sexually transmitted infections. 4. The client has had one sexual partner for the past 10 years. 5. The client has a previous history of gestational diabetes mellitus.

1, 3 HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected woman to her fetus. Clients who fall into the high-risk category for HIV infection include individuals who have used intravenous drugs, individuals who experience persistent and recurrent sexually transmitted infections, and individuals who have a history of multiple sexual partners. Gestational diabetes mellitus does not predispose the client to HIV. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)? 1. Hemoglobin of 11 g/dL (110 mmol/L) 2. Fetal heart rate of 180 beats/minute 3. Maternal pulse rate of 85 beats/minute 4. White blood cell count of 12,000 mm3 (12.0 × 109/L)

2 A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute could indicate fetal distress and would warrant immediate notification of the HCP. By full term, a normal maternal hemoglobin range is 11-13 g/dL (110-130 mmol/L) ) because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000 mm3 (11 to 15 x 10 9/L), up to 18,000 mm3 (18 x 109/L). During the immediate postpartum period, the white blood cell count may be 25,000 to 30,000 mm3 (25 to 30 x 109/L) because of increased leukocytosis that occurs during delivery.

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last normal menstrual period was October 19, 2018. Using Nägele's rule, which expected date of delivery should the nurse document in the client's chart? 1. July 12, 2019 2. July 26, 2019 3. August 12, 2019 4. August 26, 2019

2 Accurate use of Nägele's rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months and add 7 days to the first day of the last menstrual period, and then add 1 year to that date: first day of the last menstrual period, October 19, 2018; subtract 3 months, July 19, 2018; add 7 days, July 26, 2018; add 1 year, July 26, 2019.

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client? 1. "Come to the clinic immediately." 2."The vaginal discharge may be bothersome, but is a normal occurrence." 3."Report to the emergency department at the maternity center immediately." 4."Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours."

2 Leukorrhea begins during the first trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but she should not wear tampons because of the risk of infection. If the client uses panty liners, she should change them frequently.

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? 1. G = 3, T = 2, P = 0, A = 0, L = 1 2.G = 2, T = 1, P = 0, A = 0, L = 1 3.G = 1, T = 1, P = 1, A = 0, L = 1 4.G = 2, T = 0, P = 0, A = 0, L = 1

2 Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies; T is term births, the number born at term (longer than 37 weeks); P is preterm births, the number born before 37 weeks of gestation; A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks of gestation; included in parity if past 20 weeks of gestation); and L is the number of current living children. A woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1, and the number of preterm births is 0. The number of abortions is 0, and the number of living children is 1.

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instruction? 1. "I will record the number of movements or kicks." 2."I need to lie flat on my back to perform the procedure." 3."If I count fewer than 10 kicks in a 2-hour period, I should count the kicks again over the next 2 hours." 4."I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

2 The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify the health care provider (HCP) if she feels fewer than 10 kicks over two consecutive 2-hour intervals or as instructed by the HCP.

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. 1. Breast-feeding needs to be stopped for 3 months. 2.Pregnancy needs to be avoided for 1 to 3 months. 3. The vaccine is administered by the subcutaneous route. 4. Exposure to immunosuppressed individuals needs to be avoided. 5. A hypersensitivity reaction can occur if the client has an allergy to eggs. 6.The area of the injection needs to be covered with a sterile gauze for 1 week.

2, 3, 4, 5 Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. The live attenuated rubella virus is not communicable in breast milk; breast-feeding does not need to be stopped. The client is counseled not to become pregnant for 1 to 3 months after immunization or as specified by the health care provider because of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at the time of the immunization. The client should avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids. The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or necessary reason for covering the area of the injection with a sterile gauze.

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret this finding? 1. The client is measuring large for gestational age. 2.The client is measuring small for gestational age. 3.The client is measuring normal for gestational age. 4.More evidence is needed to determine size for gestational age

3 During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks ± 2 cm. Therefore, if the client is at 28 weeks gestation, a fundal height of 30 cm would indicate that the client is measuring normal for gestational age. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process.

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3 Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is a normal finding.

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply. 1. A primigravida with mild preeclampsia 2.A primigravida who delivered a 10-lb infant 3 hours ago 3.A gravida II who has just been diagnosed with dead fetus syndrome 4.A gravida IV who delivered 8 hours ago and has lost 500 mL of blood 5.A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia

3, 5 In a pregnant client, DIC is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Dead fetus syndrome is considered a risk factor for DIC. Severe preeclampsia is considered a risk factor for DIC; a mild case is not. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage.

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. 1. The contractions are regular. 2.The membranes have ruptured. 3.The cervix is dilated completely. 4.The client begins to expel clear vaginal fluid. 5.The spontaneous urge to push is initiated from perineal pressure.

3, 5 The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 from perineal pressure. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.

A client 32 weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding would indicate the therapeutic drug level has been achieved?

A decrease in respiratory rate from 24 to 16

HESI HINT: 23 Fetal and Maternal Assessment Techniques

A decrease in uteroplacental perfusion results in late decelerations, cord compression results in a pattern of variable decelerations. Nursing interventions should include changing maternal position, discontinuing oxytocin, administering oxygen, and notifying the MD

HESI HINT: 61 The Normal Newborn

A detailed physical assessment is performed by the nurse or physician. Regardless of who performs the physical assessment, the nurse must know normal vs abnormal variations in the newborn. Observations must be recorded and the physician notified regarding abnormalities.

HESI HINT: 40 Intrapartum Nursing Care

A first-degree tear involves not only the epidermis. A second-degree tear involves dermis, muscle, and fascia. A third degree tear extends into the anal sphincter. A fourth degree tear extends up to the rectal mucosa. Tears cause pain and swelling. Avoid rectal manipulations

HESI HINT:115 High-Risk Disorders

A laparotomy of any kind, including cesarena birth, predisposes the client to postoperative paralytic ileus. When the bowel is manipulated during surgery, it ceases peristalsis, and this condition may persist. Symptoms include absent bowel sounds, abdominal distention, tympany on percussion, nausea and vomiting, and of course, obstipation (intractable constipation) Early ambulation is an effective nursing intervention

Rho(D) immune globulin (RhoGam) is prescribed for a client after delivery. Before administering the medication, the nurse reviews the client's history. Which of the following findings is a contraindication to administration of the medication?

A previous hypersensitivity reaction to immune globulin -Rho(D) immune globulin is indicated when an Rh-negative client is exposed to Rh-positive fetal blood cells in any way

A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not immune to rubella. The nurse tells the client that:

A rubella vaccine must be administered after childbirth

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statement(s)? Select all that apply. A. "I should wear a bra that provides support." B. "Drinking alcohol can affect my milk supply." C. "The use of caffeine can decrease my milk supply." D. "I will start my estrogen birth control pills again as soon as I get home." E. "I know if my breasts get engorged I will limit my breast-feeding and supplement the baby." F. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

A. "I should wear a bra that provides support." B. "Drinking alcohol can affect my milk supply." C. "The use of caffeine can decrease my milk supply." F. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? A. "I will begin abdominal exercises immediately." B. "I will notify the health care provider if I develop a fever." C. "I will turn on my side and push up with my arms to get out of bed." D. "I will lift nothing heavier than my newborn baby for at least 2 weeks."

A. "I will begin abdominal exercises immediately."

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? A. Administer oxygen via face mask. B. Place the mother in a supine position. C. Increase the rate of the oxytocin (Pitocin) intravenous infusion. D. Document the findings and continue to monitor the fetal patterns.

A. Administer oxygen via face mask

The instructor asks a nursing student to list the characteristics of the amniotic fluid. The student responds correctly by listing which as characteristics of amniotic fluid? Select all that apply. A. Allows for fetal movement B. Surrounds, cushions, and protects the fetus C. Maintains the body temperature of the fetus D. Can be used to measure fetal kidney function E. Prevents large particles such as bacteria from passing to the fetus F. Provides an exchange of nutrients and waste products between the mother and the fetus

A. Allows for fetal movement B. Surrounds, cushions, and protects the fetus C. Maintains the body temperature of the fetus D. Can be used to measure fetal kidney function

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. A. Flushing B. Hypertension C. Increased urine output D. Depressed respirations E. Extreme muscle weakness F. Hyperactive deep tendon reflexes

A. Flushing D. Depressed respirations E. Extreme muscle weakness

The nurse is describing cardiovascular system changes that occur during pregnancy to a client and understands that which finding would be normal for a client in the second trimester? A. Increase in pulse rate B. Increase in blood pressure C. Frequent bowel elimination D. Decrease in red blood cell production

A. Increase in pulse rate

The nurse has performed a nonstress test on pregnant client and is reviewing the fetal monitor strip. The nurse interprets the test as reactive. How should the nurse document this finding? A. Normal B. Abnormal C. The need for further evaluation D. That findings were difficult to interpret

A. Normal

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? A. Notify the health care provider (HCP). B. Continue monitoring the fetal heart rate. C. Encourage the client to continue pushing with each contraction. D. Instruct the client's coach to continue to encourage breathing techniques.

A. Notify the health care provider (HCP).

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? Select all that apply. A. Proteinuria B. Hypertension C. Low-grade fever D. Generalized edema E. Increased pulse rate F. Increased respiratory rate

A. Proteinuria B. Hypertension D. Generalized edema

HESI HINT:89 High-Risk Disorders

Although the toxic side effects of mag sulfate are well known and watched for, it is just as important to get serum blood levels of mag sulfate above 4 mg/dL in order to prevent convulsions and to reach therapeutic range

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement made by the client indicates a need for further instruction? A. "I will watch for the evidence of the passage of tissue." B. "I will maintain strict bed rest throughout the remainder of the pregnancy." C. "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." D. "I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding."

B. "I will maintain strict bed rest throughout the remainder of the pregnancy."

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? A. Length of 19 inches B. Abnormal palmar creases C. Birth weight of 6 lb, 14 oz 4. D. Head circumference appropriate for gestational age

B. Abnormal palmar creases

The nurse in a neonatal intensive care nursery (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? A. Turn on the apnea and cardiorespiratory monitors. B. Connect the resuscitation bag to the oxygen outlet. C. Set up the intravenous line with 5% dextrose in water. D. Set the radiant warmer control temperature at 36.50 C (97.6° F).

B. Connect the resuscitation bag to the oxygen outlet.

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother? A. Feed the newborn less frequently. B. Continue to breast-feed every 2 to 4 hours. C. Switch to bottle-feeding the infant for 2 weeks. D. Stop breast-feeding and switch to bottle-feeding permanently.

B. Continue to breast-feed every 2 to 4 hours

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate? A. Elevate the client's legs. B. Massage the fundus until it is firm. C. Ask the client to turn on her left side. D. Push on the uterus to assist in expressing clots.

B. Massage the fundus until it is firm.

The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? A. Providing comfort measures B. Monitoring the fetal heart rate C. Changing the client's position frequently D. Keeping the significant other informed of the progress of the labor

B. Monitoring the fetal heart rate

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? A. Gently push the cord into the vagina. B. Place the client in Trendelenburg's position. C. Find the closest telephone and page the health care provider stat. D. Call the delivery room to notify the staff that the client will be transported immediately.

B. Place the client in Trendelenburg's position.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which finding is noted on assessment? A. Proteinuria of 3+ B. Respirations of 10 breaths/minute C. Presence of deep tendon reflexes D. Serum magnesium level of 6 mEq/L

B. Respirations of 10 breaths/minute

The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? A. The client is a 35-year-old primigravida B. The client has a history of cardiac disease C. The client's hemoglobin level is 13.5 g/dL D. The client is a 20-year-old primigravida of average weight and height

B. The client has a history of cardiac disease

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? A. Soft abdomen B. Uterine tenderness C. Absence of abdominal pain D. Painless, bright red vaginal bleeding

B. Uterine tenderness

HESI HINT: 59 Normal Postpartum

Because Rh immune globulins suppress the immune system, the client who receives both RhoGAM and the rubella vaccine should be tested for rubella immunity at 3 months

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding? A. Scant B. Light C. Heavy D. Excessive

C. Heavy

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is most appropriate? A. Contact the health care provider. B. Instruct the client to maintain bed rest for the remainder of the pregnancy. C. Inform the client that these contractions are common and may occur throughout the pregnancy. D. Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

C. Inform the client that these contractions are common and may occur throughout the pregnancy.

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? A. Document the findings. B. Reassess the client in 2 hours. C. Notify the health care provider. D. Encourage increased oral intake of fluids.

C. Notify the health care provider.

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? A. Monitor fetal heart rate continuously. B. Monitor maternal vital signs frequently. C. Perform a vaginal examination every shift. D. Administer ampicillin 1 g as an intravenous piggyback every 6 hours.

C. Perform a vaginal examination every shift.

The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? A. Assess vital signs every 4 hours. B. Measure fundal height every 4 hours. C. Prepare an ice pack for application to the area. D. Inform the health care provider of assessment findings

C. Prepare an ice pack for application to the area.

What is the nursing action for prolonged decelerations?

Change maternal positioning

The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply. A. Uterine rigidity B. Uterine tenderness C. Severe abdominal pain D. Bright red vaginal bleeding E. Soft, relaxed, nontender uterus F. Fundal height may be greater than expected for gestational age.

D. Bright red vaginal bleeding E. Soft, relaxed, nontender uterus F. Fundal height may be greater than expected for gestational age.

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? A. Notify the health care provider of the findings. B. Reposition the mother and check the monitor for changes in the fetal tracing. C. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. D. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being

D. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2 F. What is the priority nursing action? A. Document the findings. B. Retake the temperature in 15 minutes. C. Notify the health care provider (HCP). D. Increase hydration by encouraging oral fluids.

D. Increase hydration by encouraging oral fluids.

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? A. The mother requests that the window be closed before feeding. B. The mother holds the newborn properly during feeding and burping. C. The mother tests the temperature of the formula before initiating feeding. D. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

D. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

A woman with type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement?

Describe diet changes that can improve the management of her diabetes

HESI HINT:88 High-Risk Disorders

Dystocia frequently requires the use of oxytocin for augmentation or induction of labor. Uterine tetany is a harmful complication, and careful monitoring is required. The desired effect is contractions every 2 to 3 minutes with duration of contractions no longer than 90 sec. Continuously monitor FHR and uterine resting tone. If tetany occurs, turn off oxytocin, turn client to a side-lying position, and administer O2 by face mask. Check output (should be at least 100 mL/4hr) Oxytocins most important side effect is its antidiuretic (ADH) effect, which can cause water intoxication. Using IV fluids containing electrolytes decreases the risk for water intoxication

A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurse's response should be based on what information?

Each pregnancy carries a 50% chance of inheriting the disorder.

The nurse is teaching breastfeeding to prospective parents in a childbirth education calss.. Which instruction should the nurse include as content in the class?

Feed your baby every 2 to 3 hours or on demand, whichever comes first.

A multigravida woman with a history of multiple cesarean births is admitted to the maternity unit in labor. The client is experiencing excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which assessment findings are indicative of complete uterine rupture?

Fetal bradycardia Maternal tachypnea Maternal complaint of sudden sharp abdominal pain

HESI HINT: 38 Intrapartum Nursing Care

Full bladder is one of the most common reasons for uterine atony or hemorrhage in the first 24 hours after delivery. If the nurse finds the fundus soft, boggy and displaced above and to the right of the umbilicus, what actions should be taken first? First, perform fundal massage; then have the client empty her bladder. Recheck fundus every 15 min for 1 hours, then every 30 min for 2 hours

Not Rubella immune (negative titer) and 6 weeks pregnant. When should the vaccine be given?

Give early postpartum within 72 hours. HESI HINT: "Rubella is teratogenic to the fetus during the first trimester, causing congenital heart disease, congenital cataracts, or both. All women should have their titers checked during pregnancy. If a woman's titers are low, she should receive the vaccine after delivery and be instructed not to get pregnant within 3 months. Breast-feeding mothers may take the vaccine" (p. 288).

The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate?

Gonorrhea Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal.

A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. Which is the correct description of this client that should be documented in the medical record?

Gravida 2, para 0 The spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0. Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond.

A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV-infected. Which explanation should the nurse provide?

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

The nurse 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?

Have the client breathe into her cupped hands. Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands.

HESI HINT: 10 Anatomy and Physiology of Reproduction and Antepartum

Hgb and Hct data can be used to evaluate nutritional status. Example: A 22-year old primigravida at 12 weeks gestation has a Hgb of 9.6 and Hct of 31%. She has gained 3 pounds during the first trimester. A weight gain of 2-4 pounds during the 1st trimester is recommended and this client is anemic. Supplemental iron and a diet high in iron are needed. High iron foods: -fish and red meats -cereals and yellow vegetables -green leafy vegetables and citrus fruits -egg yolks and dried fruits

A primigravida, when returning for the results of her multiple marker screening (triple screen), asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to describe best how the test is interpreted?

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

HESI HINT: 111 High-Risk Disorders

If a woman is medicated, the responsible adult accompanying her must sign the necessary consent forms. State laws differ as to the acceptability of a friend signing the consent form rather than a relative

HESI HINT: 39 Intrapartum Nursing Care

If narcotic analgesics are given, raise side rails and place call light within reach. Instruct client not to get out of bed or ambulate without assistance. Caution client about drowsiness as a side effect

24 hour old baby, mom is scared she is not breastfeeding right, the nurse should say...

If your baby's urine is straw colored , then she is feeding well.

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating and states that because she has had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority?

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

HESI HINT:103 High-Risk Disorders

In severe cases of hyperemesis gravidarum, the HCP may prescribe antihistamines, vitamin B6, or phenothiazines to relieve nausea. The provider may also prescribe Reglan to increase the rate at which the stomach moves food into the intestines or antacids to absorb stomach acid and prevent acid reflux

HESI HINT: 16 Fetal and Maternal Assessment Techniques

In some states, screening for neural tube defects by testing either maternal serum alpha-fetoprotein (AFP) levels or amniotic fluid AFP levels is mandated by state law. This screening test is highly associated with both false positives and false negatives

A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement?

Increase the rate of the oxytocin (Pitocin) infusion. The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate the frequency and intensity of contractions.

40 wks, cesarean, receives anticholinergic, atropine 0.4 mg IM as adjunct to inhaled anesthesia. What would be a therapeutic response to the injection?

Increased HR and decrease in oral secretions.

A nurse is monitoring a pregnant client with sepsis for signs of disseminated intravascular coagulopathy (DIC). Which of the following laboratory findings causes the nurse to suspect DIC?

Increased fibrin degradation products -DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Petechiae, oozing from injection sites, and hematuria are indicative of DIC. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and therefore prolonged times); and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area. Fibrinogen and platelets are decreased, prothrombin and activated partial thromboplastin times are prolonged, and fibrin degradation products are increased.

Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.)

Increased heartburn that is not relieved with doses of antacids Chronic headache that has been lingering for a week behind the client's eyes

Cytotec (Misoprostol) for peptic ulcer (Synthetic Prostaglandin E Drug). Nurse response?

Increased risk for spontaneous miscarriage. RATIONALE: Cytotec (Misoprostol) can induce uterine contractions resulting in miscarriage.

A clinic nurse is performing an assessment of an HIV-positive pregnant woman during the 32nd week of gestation. Which finding requires further follow-up?

Increased shortness of breath and bilateral crackles in the lungs

A full term infant is transferred to the nursery from the labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn?

Infant's condition at birth and treatment received

A delivery room nurse performing an initial assessment on a newborn notes that the ears are low set. In light of this finding, which nursing action is appropriate initially?

Notifying the physician

A nurse is monitoring a newborn who has been admitted to the nursery. The nurse notes that the anterior fontanel measures 4 cm across and bulges when the infant is at rest. In light of this observation, what is the appropriate nursing action?

Notifying the physician (may indicate increased intracranial pressure)

On admission to the prenatal clinic, a 23 year old woman tells the nurse that her last menstrual period began on Feb 15, and that her previous periods were regular. Her pregnancy test is positive. The client's expected date of delivery (EDD) would be

November 22

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is close, thick, and high. Based on these data, which intervention should the nurse implement first?

Obtain a specimen for urine

A client in active labor is admitted with preeclamsia. Which assessment finding is most significant in planning this client's care?

Patellar reflex 4+

A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan?

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

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action will the nurse take

Place the woman in lateral position

A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide?

Take your blood pressure now, and if it is seriously elevated, go to the hospital. Checking the blood pressure for an elevation is the best instruction to give at this time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension.

A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother that:

The mother may need to take isoniazid (INH), pyrazinamide, and rifampin (Rifadin) for a total of 9 months

HESI HINT:64 The Normal Newborn

The umbilical cord should always be checked at birth. It should contain 3 vessels: one vein, which carries oxygenated blood to the fetus, and two arteries, which carry unoxygenated blood back to the placenta. There is the opposite of normal circulation in the adult. Cord abnormalities usually indicate cardiovascular or renal anomalies.

A new mother asks the PN to explain the purpose of the cheese-like substance that covered her newborn infant at birth. What information should the PN provide?

To protect fetal skin from amniotic fluid

Oxytocin (Pitocin) 20 units in 1000 LR after delivery is for?

To stimulate uterine contractions to prevent hemorrhage. RATIONALE: Admin after placenta delivery. Prior to placental delivery would cause uterus to contract and retain placenta.

20 weeks gestation, gained 20 lbs, fundal height 20, clear liquid from breasts. What warrants further evaluation?

Too much weight gain, gestational weight gain should only be approx 10.3 lbs.

HESI HINT: 44 Intrapartum Nursing Care

Tranquilizers (ataractics and phenothiazines) such as Phenergan and Vistaril are used in labor as analgesic-potentiating drugs to decrease the amount of narcotic needed to decrease maternal anxiety

A newborn infant boy who is rooming-in with his mother has an axillary temperature of 960 F What action should the practical nurse take first?

Wrap the infant in two warm blankets and a place a cap on his head