maternity hesi questions

A client whose weight was average for her height before becoming pregnant expresses concern about her 15-lb (6.8-kg) weight gain after only 23 weeks of pregnancy. Which is an appropriate response?

"Your weight is as expected for someone at 23 weeks' gestation, so continue with your current diet." The recommended average weight gain is 2.2 to 5.5 lb (1-2.5 kg) during the first 12 weeks, then approximately 1 lb (0.45 kg) per week until birth; 14 to 16 lb (6.4-7.3 kg) is an appropriate weight gain at 23 weeks' gestation.

Which musculoskeletal changes directly place pregnant clients at increased risk for falls? Select all that apply. One, some, or all responses may be correct.

- joint laxity - impaired balance - shifting center of gravity

things that can cause small for gestational age (SGA)

- meconium aspiration - hypothermia - hyperviscosity

Which breathing technique would the nurse instruct the client to use as the head of the fetus is crowning?

Blowing

A client at 35 weeks' gestation calls the prenatal clinic, concerned that she has "not felt the baby move as much as usual." The nurse would direct the client to call back after taking which action?

Drink a glass of orange juice and time 10 fetal movements Drinking orange juice can increase fetal movement.

A client is undergoing diagnostic testing for myasthenia gravis. Which test would the nurse identify as the most specific for this diagnosis?

Edrophonium chloride test

Which clinical finding is an indicator of placental separation?

Lengthening of the umbilical cord As the placenta separates and descends down the uterus, the cord descends down the vaginal canal and appears to lengthen.

omphalocele

Omphalocele, also known as exomphalos, is a birth defect of the abdominal (belly) wall. The infant's intestines, liver, or other organs stick outside of the belly through the belly button. The organs are covered in a thin, nearly transparent sac that hardly ever is open or broken.

Simple interventions that can decrease the discomfort associated with an episiotomy or perineal lacerations

Simple interventions that can decrease the discomfort associated with an episiotomy or perineal lacerations include encouraging the woman to lie on her side whenever possible and use a pillow when sitting. Other interventions include application of an ice pack; topical medication (if ordered); dry heat; cleansing with a squeeze bottle; and a cleansing shower, tub bath, or sitz bath. Many of these interventions, especially ice packs, sitz baths, and topical applications (e.g., witch hazel pads), are also effective for hemorrhoids

Which clinical manifestations accompany methamphetamine use? Select all that apply. One, some, or all responses may be correct.

Tachycardia Hyperthermia Methamphetamine is a stimulant that causes a surge of dopamine and blocks its reuptake. The sympathetic nervous system is activated, resulting in an increase in the heart rate. Because methamphetamine affects the central nervous system, the body temperature will increase, sometimes to dangerous levels.

The nurse is preparing to administer dinoprostone (Cervidil) under the direction of the health care provider. Which assessment finding should the nurse relay to the health care provider?

Temperature of 101??? F (38.3??? C). Cervidil is used to induce labor. The nurse should observe for and report maternal fever to the health care provider, as this may indicate an adverse effect of the medication.

A 42-year-old client at 39 weeks' gestation has a reactive nonstress test (NST). Which interpretation pertains to this result?

This is the desired response at this stage of gestation An NST indicates that the fetus is healthy because there is an active pattern of fetal heart rate acceleration with movement. The result is positive and desired;

thyrotoxicosis (thyroid storm)

a complication of hyperthyroidism that occurs when excessive amounts of thyroid hormone are released into the circulation requires monitoring (telemetry) and supportive care for symptoms ( fever, tachycardia, hypertension, gastrointestinal distress). clients with thyroid storm may be diaphoretic the UAP can promote client comfort by providing showers or bed baths and frequent linen changes. UAP can also help maintain comfort by ensuring that the client has ice water lowering the room temperature and providing cool cloths

The nurse is caring for a client who is four days postpartum. What color should the nurse expect the lochial discharge to be?

brown Lochia refers to the uterine discharge passed after a client gives birth. After three to four days, lochial discharge changes to a pink or brown color.

which medication is used as first line treatment for urinary tract infections in pregnant women?

cephalexin

the nurse is aware that a postpartum client is at increased risk for endometritis. what risk factor did the nurse identify?

client was in labor for 30 hours prolonged labor and premature rupture of membranes is a risk factor for the development of endometritis as micro-organisms have increased access to the opened uterus.

A client diagnose with scabies has been prescribed lindane lotion. What is the recommended method of administration of this medicated lotion? (Select of that apply.)

- Leave the lotion on the skin for 8 to 12 hours and then wash off. - Apply a thin layer of lotion on the skin from the neck to soles of the feet.

Which nursing interventions are applicable to a client receiving an infusion of magnesium sulfate for severe preeclampsia? Select all that apply. One, some, or all responses may be correct.

- Restricting visitors - Maintaining a quiet environment

Which education would the nurse provide the parents of an exclusively breast-fed infant about vitamin D supplementation? Select all that apply. One, some, or all responses may be correct.

-"Do not administer more than 400 IU per day." - "Read the syringe before administering the vitamin D."

pharmacologic interventions for postpartum discomfort

Pharmacologic interventions are commonly used to relieve or reduce postpartum discomfort. Most health care providers routinely order a variety of analgesics to be administered as needed, including both opioid and non-opioid (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs]) medications. In some hospitals NSAIDs are administered on a scheduled basis, especially if the woman had perineal repair. Topical application of antiseptic or anesthetic ointment or spray can be used for perineal pain. Patient-controlled analgesia (PCA) pumps and epidural analgesia are commonly used to provide pain relief after cesarean birth.

The nurse in the postpartum unit is teaching self-care to a group of new mothers. Which color would the nurse teach them that the lochial discharge will be on the fourth postpartum day?

Pinkish brown Lochia serosa is the expected vaginal discharge between the third and tenth postpartum days; it is pinkish to brownish

The nurse should be aware that which condition is a contraindication to inducing labor?

Placenta previa. Placenta previa is a condition in which the placenta is implanted in the lower portion of the uterus, covering all or partially the cervix. Induction of labor is contraindicated in clients with this condition. The placenta previa can cause hemorrhaging if the fetus is delivered vaginally, so clients with this complication will be scheduled for a cesarean section around the 37-38th week of gestation to avoid the complication of hemorrhaging.

The nurse is caring for a 30-year-old client who is pregnant with twins. The client, who is in her second trimester, had a low prepregnancy weight and is currently being treated for a urinary tract infection. For which condition should the nurse monitor?

Spontaneous preterm labor. Spontaneous preterm labor occurs when a client has regular contractions and cervical changes prior to 36 weeks gestation. Risk factors for spontaneous preterm labor include infection, bleeding in the second trimester, and low prepregnancy weight and being pregnant with multi-gestation fetuses.

The nurse is assessing a client for risk of falls. Which client behavior would be the most informative to the nurse?

The client is able to rise from a chair without using arms for support and walk 10 feet and turn around.

bilateral salpingo-oophorectomy

A bilateral salpingo-oophorectomy is a surgery to remove both your fallopian tubes and ovaries. You may be having a bilateral salpingo-oophorectomy for different reasons, such as you have an ovarian cyst or have a high chance of having ovarian cancer in the future. Your doctor will explain why you're having the surgery.

Which characteristics are observed in clients who have cocaine addiction? Select all that apply. One, some, or all responses may be correct.

Anxiety Palpitations Weight loss

Along with appropriate hand hygiene and respiratory etiquette, what nursing actions should be done next to prevent spread of a communicable disease from an infected client?

Assist with rapidly identifying the disease and immediately isolating.

Using the 5-digit system, determine the obstetric history in this situation: The client is 38 weeks into her fourth pregnancy. Her third pregnancy, a twin gestation, ended at 32 weeks with a live birth, her second pregnancy ended at 38 weeks with a live birth, and her first pregnancy ended at 18 weeks.

G4, T1, P1, A1, L3 Four pregnancies = G (gravida) 4. One pregnancy that ended at 38 weeks = T (term) 1. One pregnancy that ended at 32 weeks = P (preterm) 1. One pregnancy that ended at 18 weeks = A (abortion) 1. One set of twins and a singleton = L (living) 3.

Gastroschisis

Gastroschisis is a birth defect that develops in a baby while a woman is pregnant. is when a baby is born with the intestines sticking out through a hole in the belly

when examining multipara the nurse notes that the fetus is in breech position. the nurse is aware that which complication may occur as a result of this position?

prolapsed umbilical cord the breech position is at risk factor for development of a prolapsed umbilical cord

physical exam of a primigravida admitted for delivery shows cervical dilation of 6cm and fetal position at the -1 station. the client tells the nurse that contractions started 12 hours ago and have gradually increased in frequency, length, and discomfort. the nurse notes contractions every 3 to 5 minutes that last 45 to 60 seconds. based on the findings the nurse knows that the client has reached which phase of labor?

stage I active phase in the active phase of labor contractions of moderate strength are seen lasting 45-60 seconds and occurring every 3-5 minutes. during this phase the cervix dilates from 4 to 7 cm. this phase is considered the onset of true labor

ways to prevent varicose veins (varicosities) in pregnant women

varicose veins are enlarged abnormally thick dilated veins that typically develop in the lower legs. pregnant women are more prone to the development of varicose veins due to increased blood volume and increased pressure in the lower extremities. the nurse should instruct the client to maintain healthy weight gain during pregnancy as excess weight creates excess pressure on the veins leading to an increased risk for varicose veins healthy weight gain during pregnancy is 25-35 pounds

a multipara at 27 weeks gestation is admitted with preterm premature rupture of membranes (PPROM). after a thorough assessment the nurse concludes there are no signs of infection, no malpresentation, no contractions, and no cervical dilation. which statement made by the nurse is correct?

you'll have to stay in the hospital until your baby is ready to be born PPROM is the rupture of membranes before 37 weeks gestation. since PPROM is associated with several serious complications (infection, umbilical cord prolapse, placental abruption, prematurity and respiratory distress syndrome) management with bed rest is undertaken in the hospital. in more than 50% of the cases spontaneous start of labor will occur within 6 days

A variety of nonpharmacologic measures are used to reduce postpartum discomfort

These include distraction, imagery, therapeutic touch, relaxation, acupressure, aromatherapy, hydrotherapy, massage therapy, music therapy, and transcutaneous electrical nerve stimulation (TENS).

Where would the nurse expect the fundus to be located 3 days after a cesarean birth?

Three fingerbreadths below the umbilicus The fundus descends 1 fingerbreadth per day from the first postpartum day. So 3 days after birth, the fundus would be 3 fingerbreadths below the umbilicus.

intravenous furosemide has been prescribed for a client with severe edema and hypertension. Which subjective clinical manifestations lead the nurse to suspect that the furosemide is infusing too rapidly?

Tinnitus Weakness Leg cramps

Which characteristic uniquely associated with psychophysiological disorders would differentiate them from somatic symptom disorders?

Underlying pathophysiology Psychophysiological disorders have an underlying pathophysiology or actual physical cause, whereas somatic symptom disorders usually do not.

Neonatal Abstinence Syndrome (NAS)

a condition in which a child, at birth, goes through withdrawal as a consequence of maternal drug use

Which direction regarding daily caloric intake would be included when discussing diet during pregnancy with a 24-year-old primigravida who is 5 feet 6 inches tall (168 cm) and weighs 130 lb (59 kg)?

340 more calories during the second trimester Data provided indicate this client is of average weight and height. An extra 340 calories per day during the second trimester is the recommended caloric increase for adult women who are of average weight; this increase will meet the nutritional needs of both fetus and mother during the second trimester.

Which statement made by a pregnant client after a prenatal class on fetal growth and development indicates the need for additional teaching?

"The baby gets food from the amniotic fluid." The amniotic fluid serves as a protective environment; the fetus depends on the placenta, along with the umbilical blood vessels, to supply blood containing nutrients and oxygen.

Breast engorgement interventions

Breast engorgement can occur whether the woman is breastfeeding or formula-feeding. The discomfort associated with engorged breasts may be reduced by applying ice packs or cabbage leaves (or both) to the breasts and wearing a well-fitted support bra. Antiinflammatory medications can also help to relieve some of the discomfort. Decisions about specific interventions for engorgement are based on whether the woman chooses breastfeeding or bottle-feeding

The nurse is assisting in the care of a client who is in labor. The nurse notices that when the client pushes, the fetal heart rate slowly declines for 20 seconds before returning to baseline. How should the nurse identify this alteration in fetal heart rate?

Early deceleration. Early decelerations are gradual and temporary decreases in fetal heart rate that correspond with the mother's contractions. Early decelerations are caused by head compression from fundal pressure and considered a normal occurrence during the laboring process.

The nurse is educating a pregnant client about the signs and symptoms of premature labor. Which intervention should the nurse teach the client if premature labor begins?

Empty the bladder. Premature labor can occur at any time. It is important that the nurse educate the client on what signs to look for. The client should also be educated about interventions, such as emptying the bladder, lay down of their left side and drink fluids.

sitz bath

In some facilities, sitz baths may be offered two to four times a day to women with episiotomies, painful hemorrhoids, or perineal edema. Sitz baths provide continuous circulation of water, cleansing and comforting the traumatized perineum. (Cool water reduces pain caused by edema and may be most effective within the first 24 hours). Ice can be added to cool the water to a comfortable level as the woman sits in it. (Warm water increases circulation, promotes healing, and may be most effective after 24 hours). Nurses must be sure that the emergency bell is within easy reach in case the mother feels faint during the sitz bath. Women often take the disposable sitz bath container home. They should be instructed to clean it well between uses.

While conducting prenatal teaching, the nurse explains to clients that there is an increase in vaginal secretions during pregnancy called leukorrhea. Which factor does the nurse identify as the cause of this increase?

Increased production of estrogen

Which rationale accurately explains why insulin is prescribed for clients in acute renal failure?

It promotes transfer of potassium into cells to lower serum potassium levels. Insulin promotes the transfer of potassium into cells, which reduces the circulating blood level of potassium

For which condition are pregnant women at a five- to sixfold increased risk?

Thromboembolic disease Pregnancy is considered a hypercoagulable state, which places pregnant women at a five- to sixfold increased risk of thromboembolic disease

The nurse is counseling a first-time mother who is nervous about caring for her child while alone at home. Which action by the nurse is most helpful in this situation?

Offer the client a list of Internet resources on parenting. Anticipatory guidance helps parents know what to expect. Although plenty of literature is made available to new mothers by the time of discharge, it is also helpful to provide a list of reliable Internet resources that the client may refer to after returning home.

tetralogy or fallot

a cyanotic cardiac defect experience chronic hypoxemia due to decreased pulmonary blood flow and circulation of poor oxygenated blood. to compensate for prolonged tissue hypoxia erythropoietin production increases to produce additional oxygen carrying RBCs. increased RBCs result in increased viscosity of blood or polycythemia ( refers to an increase in the number of red blood cells in the body. The extra cells cause the blood to be thicker, and this, in turn, increases the risk of other health issues, such as blood clots). polycythemia increases the risk for blood clotting which can cause a stroke

Which vitamin is essential for the synthesis of prothrombin by the liver?

K Prothrombin is synthesized in the liver in the presence of vitamin K; vitamin K initiates the vital process of coagulation.

Which is the nurse's next action when the fundus of a healthy multipara at 16 weeks' gestation is palpated at one fingerbreadth above the umbilicus?

- Check for two distinct fetal heart rates Twins should be suspected with a faster-than-expected increase in fundal height; the nurse should assess the client for two distinct heartbeats. Fundal height, not the size of the fetus, should prompt the nurse to suspect a multiple pregnancy

A client who has had a cesarean birth is being discharged. Which statement indicates to the nurse that further teaching is required?

"I don't need perineal care because I didn't give birth through the vagina." Perineal care is necessary to prevent an ascending infection.

signs and symptoms of Hirschsprung disease

- bilious vomiting (vomiting bile) - abdominal distention - failure to pass meconium (first stool) - failure of internal anal sphincter relaxation (tight anal sphincter)

fetal station

+ below the ischial spine - above the ischial spine

fontanelle stuff for babies

- flat fontanelle is normal - sunken fontanelle is a sign of dehydration - bulging fontanelle is a sign of increasing intracranial pressure

Which of these questions is included on the CAGE screening test for alcoholism?

-Have you ever felt you should cut down on your drinking? -Have people annoyed you by criticizing your drinking? -Have you ever felt bad or guilty about your drinking? -Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?

child car seat info

-age 0-2yrs rear facing car seat - age 2-7yrs forward facing car seat -age 4-12 years booster seat - age 8-adult child uses seat beat * Children younger than 13 years should never ride in a front seat

the nurse is performing an initial assessment of a newborn. which of the following findings should the nurse report to the health care provider?

-decreased muscle tone (hypotonia) which may indicate a congenital neurological abnormality (down syndrome) or spinal cord injury. newborns normally have increased muscle tone - sacral dimple with a 0.4 (1 cm) skin tag sacral dimples with or without tufts of hair or skin tags are associated with spina bifida occult which is an incomplete closure of the vertebrae that cannot be seen externally - normal umbilical cords contain 2 arteries and 1 vein a single umbilical artery which is abnormal is associated with congenital defects specifically the kidneys and heart

The nurse is caring for a client with prolonged rupture of membranes (PROM). Which assessment finding should the nurse identify as a sign that client is experiencing complications related to prolonged rupture of the membranes?

Elevated temperature. Prolonged rupture of membranes (PROM) is considered when the client's membranes have been rupture longer than 24-hours before delivery of the fetus. A client who has experienced prolonged rupture of membranes is at an increased risk for infection which poses a risk for the mother and the unborn infant. The nurse should assess for signs of infection, which include rapid pulse, fever, and foul-smelling vaginal discharge. The healthcare provider will often prescribe blood cultures and complete blood counts in incidents of PROM.

pediatrics anticipatory guidance

For example, one of the most significant areas in pediatrics is injury prevention. Beginning prenatally, parents need specific instructions on home safety. Because of the child's maturing developmental skills, parents must implement home safety changes early to minimize risks to the child.

For women who are experiencing discomfort associated with uterine contractions

For women who are experiencing discomfort associated with uterine contractions, applying warmth (e.g., heating pad) or lying prone may be helpful. Interaction with the infant may also provide distraction and decrease this discomfort. Because afterpains are more severe during and after breastfeeding, interventions are planned to provide the most timely and effective relief. Administering pain medication about 30 minutes before breastfeeding can help minimize afterpains that are enhanced by breastfeeding.

A client with myasthenia gravis begins taking pyridostigmine. Two days later, the client develops loose stools and increased salivation. Which conclusion would the nurse make about these new developments?

The medication is causing cholinergic side effects. Because this medication inhibits the destruction of acetylcholine, parasympathetic activity may increase, resulting in cholinergic side effects such as diarrhea and increased salivation. The signs do not indicate a myasthenic crisis. Myasthenic crisis is characterized by difficulty breathing or speaking, morning headaches, feeling tired during the daytime, waking up frequently at night, not sleeping well, a weak cough with increased secretions (mucus or saliva), an inability to clear secretions, a weak tongue, trouble swallowing or chewing, and weight loss.

For which reason is a client with heavy bleeding from a complete placenta previa placed in a lateral Trendelenburg position?

To prevent shock The Trendelenburg position shunts blood to the upper body and vital organs.

The nurse is caring for a client who reports painful, cracked nipples due to breastfeeding. Which action should the nurse recommend to the client?

Use breast shells for protection. Breastfeeding clients often experience cracked, sore nipples during breastfeeding. The nurse should encourage the client to use breast shells to decrease irritation to the nipples.

While caring for a woman who has had a positive contraction stress test (CST), which complication would the nurse suspect?

Uteroplacental insufficiency

uterine atony

failure of the uterus of contract after the fetus is delivered and is the most common cause of postpartum hemorrhage. risk factors for the development of uterine atony include multiparty, multiple gestations, fetal macrosomia (large fetus) prolonged labor and chrioamnionitis (Chorioamnionitis is a condition that can affect pregnant women. In this condition, bacteria infects the chorion and amnion (the membranes that surround the fetus) and the amniotic fluid (in which the fetus floats). This can lead to infections in both the mother and fetus. In most cases, this may mean the fetus has to be delivered as soon as possible.)

a client breastfeeding her child reports a painful swollen breast with cracked and sore nipple on the right side. what should the nurse instruct the client?

feed the child every 2 to 4 hours and empty each breast completely the client has developed mastitis. the nurse should recommend frequent feedings and complete emptying of the breasts as this will prevent milk stasis and bacterial growth

signs of neonatal abstinence syndrome

- irritability - hypertonia - jittery movements - diarrhea - vomiting - poor feeding - nasal congestion - frequent sneezing - pupillary dilation

Which complication of severe preeclampsia necessitates diligent monitoring of the client's blood pressure?

Stroke The likelihood of a stroke increases with a rising blood pressure reading.

breastfeeding info

Little preparation is needed during pregnancy for breastfeeding. The mother should avoid soap on her nipples to prevent removal of the natural protective oils from the Montgomery tubercles of the breasts. The use of creams and nipple rolling, pulling, and rubbing to "toughen" nipples does not decrease nipple pain after birth and may cause irritation or uterine contractions from the release of oxytocin. The breasts should be assessed during pregnancy to identify flat or inverted nipples. Flat nipples appear soft, like the areola, and do not stand erect unless stimulated by rolling them between the fingers. Inverted nipples are retracted into the breast tissue. Both conditions may make it difficult for infants to draw the nipples into the mouth. Some nipples appear normal but draw inward when the areola is compressed in the infant's mouth. Compressing the areola between the thumb and forefinger determines whether the nipple projects normally or becomes inverted. Nipples that appear flat or inverted early in pregnancy may improve near term (Wambach & Riordan, 2015). Normal everted nipple and other types of nipples that may cause the infant difficulty in latching on. Nipples shown after stimulation. The helpfulness of breast shells for flat or inverted nipples is debated. Some authors find them helpful for some women, and others feel they decrease motivation to breastfeed and do not improve nipple eversion (Lawrence & Lawrence, 2011; Wambach & Riordan, 2015). These dome-shaped devices are worn during the last weeks of pregnancy and between feedings after birth. The shells are placed in the bra with the opening over the nipple. They exert slight pressure against the areola to help the nipples protrude. A breast pump used just before feedings to help bring the nipples out may be more effective.

The nurse is educating a client who is unsure if she is releasing an adequate supply of milk during breastfeeding. Which maternal sign indicates that the teaching has been effective?

Tingling sensation with milk ejection. Many breastfeeding mothers are concerned their infants are not receiving adequate nutrition. Although infant output is the best indicator of adequate feeding, a maternal sign that breastfeeding has been effective is a tingling sensation with milk ejection.

The nurse has administered Rh immune globulin to a client. The nurse should report which adverse effect of this medication to the health care immediately?

hypertension Rh immune globulin works to suppress the immune response in a client with Rh negative blood who may have been exposed to Rh positive blood from a previous Rh positive fetus. The nurse should assess for hypertension in a client who has been administered Rh immune globulin, as this is a potentially adverse effect of this treatment.

Hirschsprung's disease

is a condition that affects the large intestine (colon) and causes problems with passing stool. The condition is present at birth (congenital) as a result of missing nerve cells in the muscles of the baby's colon. Hirschsprung disease (HSCR) is a birth defect. This disorder is characterized by the absence of particular nerve cells (ganglions) in a segment of the bowel in an infant. The absence of ganglion cells causes the muscles in the bowels to lose their ability to move stool through the intestine (peristalsis).

the nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery . which the following are expected findings?

- capillary glucose of 60 (optimal glucose levels are 70-100 but >40 is considered normal - respirations of 56 bpm normal respiratory rate is 30-60 bpm

The nurse is conducting the admission assessment of a client who is positive for group B streptococcus (GBS). Which finding is of concern to the nurse?

Spontaneous rupture of membranes 3 hours ago Rupture of the membranes before intrapartum treatment of GBS increases the chances that infection will ascend into the uterus.

A client suspected of having myasthenia gravis is scheduled for an edrophonium chloride test. To treat a common complication associated with the test, the nurse will have which medication available?

atropine Atropine, an anticholinergic, should always be available to treat a cholinergic crisis (sudden, severe episode of muscle weakness that affects breathing and swallowing) should the edrophonium chloride test trigger this response

while assessing a postpartum client the practical nurse determines that the funds is boggy. what action should the practical nurse take?

massage the fundus as a boggy uterus is a risk factor for increased postpartum bleeding the practical nurse should massage the fundus. * note because the fundus is not displaced to the left or right which typically indicates a full bladder.

Necrotizing enterocolitis (NEC)

occurs mostly in premature (preterm infants) Necrotizing enterocolitis (NEC) is a devastating disease that affects mostly the intestine of premature infants. The wall of the intestine is invaded by bacteria, which cause local infection and inflammation that can ultimately destroy the wall of the bowel (intestine). *measuring the client's abdominal girth daily is an important nursing intervention to note nay worsening intestinal gas associated swelling. clients are made NPO and receive nasogastric suction to decompress the stomach and intestines parenteral hydration and nutrition and IV antibiotics are given

the nurse is planning care for a newborn client at term gestation who is large for gestational age. which of the following are appropriate interventions to include in the plan of care? select all that apply

- assess newborn for birth related injuries - discuss the need for feeding supplementation if symptoms of hypoglycemia occur - encourage the mother to breastfeed the newborn every 2-3 hours - notify the health care provider if capillary blood glucose is <45 - perform capillary blood glucose check

a pregnant woman with hyperemesis gravid arum has been vomiting excessively and lab results reveal hypokalemia. what other abnormalities should the nurse expect to find?

- increased serum bicarbonate - decreased serum chloride excessive vomiting results in the loss of potassium, chloride, and stomach acid. this results in the development of a hypokalemic hypochloremic metabolic alkalosis

signs of hypoglycemia for a newborn born to a mother with diabetes mellitus

- jitteriness - irritability - hypotonia ( medical term for decreased muscle tone. Healthy muscles are never fully relaxed. They retain a certain amount of tension and stiffness) -

some expected changes in 39 week (9 months) neonate (newborn)

- plantar creases up the entire sole (plantar creases on the bottom of the feet indicates the neonate's age. the more creases over the greater proportion of the foot the more mature the neonate) - toes fan outward when the lateral sole surface is stroked (the babinski reflex is present at birth and disappears at 1 year the toes hyperextend and fan out when the lateral surface of the sole is stroked in an upward motion. absent or weak babinski reflex may indicate a neurological defect - white pearl like cysts on gum margins (Epstein's pearls are white pearl like epithelial cysts on gum margins and the palate they are benign and usually disappear within a few weeks

the father of newborn baby tells the nurse " I wouldn't think a baby would have hair on their back". upon assessment the nurse notes a tuft of hair just above the baby's buttocks. what is most important for the nurse to assess?

- presence of a sacral dimple a small patch of hair at the base of the spine just above the buttocks can be an indication of spina bifida. spinal bifida is a neural tube defect in which the vertebral arch