maternity hesi practice

Which finding indicates the development of a complication from bilateral cephalohematomas? 1 Urine output 2 Skin color 3 Glucose level 4 Rooting/sucking reflex

skin color Cephalohematomas are gradually absorbed. As the hematoma resolves, hemolysis of red blood cells occurs, and jaundice or yellowing of the skin may result. Urine output, glucose level, and the rooting/sucking reflex are not affected by a cephalohematoma.

Which information would the nurse provide to the 35-year-old client who is scheduled for vaginal hysterectomy? "You will stop ovulating." 2 "Surgical menopause will happen immediately." 3 "Sexual intercourse will be uncomfortable when you resume it." 4 "A hysterectomy doesn't affect the chronological age when hormonal menopausal symptoms usually occurs."

"A hysterectomy doesn't affect the chronological age when hormonal menopausal symptoms usually occurs.

While being admitted for a lumpectomy the client begins to cry and says, "I found the lump a few months ago, but I didn't go to the health care provider because of what it could be." How would the nurse reply?

This must of been frightening for you

Which would the nurse teach the client about a dinoprostone suppository before having a vacuum curettage abortion for a fetal demise? 1 "You'll be under general anesthesia for insertion of the suppository." 2 "You'll experience copious bleeding for several hours after the abortion." 3 "A temperature of more than 100°F is common for the first 24 to 48 hours." 4 "After the suppository has been inserted, you should lie flat in bed for 15 minutes."

Correct4 "After the suppository has been inserted, you should lie flat in bed for 15 minutes." Remaining supine for 10 to 15 minutes permits the suppository to remain in place while it melts to body temperature. General anesthesia is unnecessary for the insertion of a dinoprostone suppository. The bleeding that occurs after this type of abortion is usually equivalent to that of a heavy menstrual period. Excessive bleeding or cramping should be reported to the primary health care provider. A temperature higher than 100°F (37.8°C) is a danger sign, and the primary health care provider should be notified.

A new mother asks the nurse why her baby seems to have a bowel movement after every feeding. While preparing a response to explain why this is an expected occurrence, the nurse remembers that this regularity indicates that which function is adequate? 1 Fluid intake 2 Cardiac sphincter 3 Pancreatic amylase level 4 Gastrocolic reflex response

Gastrocolic reflex response The gastrocolic reflex is stimulated when the newborn's stomach begins to fill with fluid; this causes an increase in peristalsis, resulting in the passage of stool during or after a feeding. Six to 10 voidings a day of pale straw-colored urine, not the frequency of bowel movements, are indicative of adequate fluid intake. The cardiac sphincter is unrelated to bowel movements; the cardiac sphincter, located between the esophagus and the stomach, is immature in the newborn and is the reason for the newborn's tendency to regurgitate some of the feedings. Although pancreatic amylase is a digestive enzyme, it does not stimulate bowel movements after feedings.

Which clinical manifestations of signs of withdrawal would the nurse expect to identify in a newborn of a known opioid user? Select all that apply. One, some, or all responses may be correct. Correct1 Sneezing Correct2 Hyperactivity Correct3 High-pitched cry Correct4 Exaggerated Moro reflex Incorrect5 Reduced deep tendon reflexes

Sneezing Hyperactivity High-pitched cry exaggerated moro reflex

A few hours after being admitted in early labor, a primigravida perspires profusely and becomes restless, flushed, and irritable and says she is going to vomit. Which phase of the first stage of labor does the nurse suspect the client has entered? 1 Latent 2 Transition 3 Late active 4 Early active

Transition

Whole milk cannot be substituted for formula because it does not meet an infant's requirements for which nutrients? 1 Fat and calcium 2 Vitamin C and iron 3 Thiamine and sodium 4 Protein and carbohydrates

Vit C and iron

Which information would the nurse provide to the client who has just delivered and plans to begin breast-feeding? 1 An increase in contractions may be noted. 2 Weight loss will occur rapidly. 3 Involution of the uterus will be delayed. 4 Application of heat to the breasts is contraindicated.

increase in contractions may be noted Breast-feeding stimulates oxytocin release and uterine contractions. Weight loss may occur slowly for the breast-feeding mother because of her increased nutritional and caloric needs. The increased levels of oxytocin and subsequent uterine contractions will enhance involution. Heat is not contraindicated, and the client may take warm showers. Warm compresses can be used if the mother experiences problems such as engorgement.

When caring for a client in the third trimester of pregnancy with a history of myocardial infarction, which statement made by the client would concern the nurse the most? 1 "I have been tired throughout this pregnancy." 2 "When I stand for a while, my legs get swollen." 3 "I experienced quite a bit of nausea in the first trimester." 4 "I have been using cough drops to try and get rid of my cough."

I have been using cough drops to try and get rid of my cough." Rationale obstetrical clients with a history of myocardial infarction are at risk for cardiac decompensation. A frequent moist cough is a finding associated with cardiac decompensation and should be investigated. The feeling of fatigue throughout the pregnancy has been ongoing and is not a new symptom for the client. Swelling in the lower extremities after standing for long periods and nausea in the first trimester are not uncommon symptoms associated with pregnancy.

A client in labor is admitted to the birthing unit 20 hours after her membranes have ruptured. Which complication would the nurse anticipate when assessing the character of the client's amniotic fluid? 1 Cord prolapse 2 Placenta previa 3 Maternal sepsis 4 Abruptio placentae

Maternal sepsis Prolonged rupture of membranes of more than 18 hours increases the risk of maternal and newborn sepsis. The amniotic fluid must be assessed for color, viscosity, and odor; thick, yellow-stained, cloudy fluid with a foul odor indicates infection. Cord prolapse usually occurs shortly after the membranes rupture; it is unlikely that it will occur 20 hours after the membranes have ruptured. Placenta previa is an abnormally implanted placenta; it is unrelated to ruptured membranes. Abruptio placentae is premature separation of a normally implanted placenta; it, too, is unrelated to ruptured membranes.