Maternity HESI Study

A client with asthma who is 8 hours post-delivery is experiencing postpartum hemorrhage. Which prescription should the nurse administer? 1. Oxytocin (Pitocin). 2. Ibuprofen (Motrin). 3. Fentanyl (Sublimaze). 4. Hemabate (Carboprost).

1. Oxytocin (Pitocin). Oxytocin is the drug of choice, and it will not exacerbate symptoms of asthma (A). Nonsteroidal antiinflammatory drugs (NSAIDs) (B) are not used to treat bleeding. Fentanyl (C) is used to treat pain, not bleeding. Prostaglandin derivatives (D) may exacerbate asthma symptoms.

A multiparous client has been in labor for 8 hours when her membranes rupture. What action should the nurse implement first? 1. Prepare the client for imminent birth. 2. Assess the fetal heart rate and pattern. 3. Document the characteristics of the fluid. 4. Notify the client's primary healthcare provider.

2. Assess the fetal heart rate and pattern. The fetal heart rate and pattern should be assessed (B) to determine compromise of fetal well-being caused by compression or prolapse of the umbilical cord. The intensity and frequency of the uterine contractions often trigger spontaneous rupture of the membranes (SROM), which does not indicate that birth is imminent (A). The healthcare provider should be notified of the client and fetal well-being after evaluation of SROM. Although the characteristics of the amniotic fluid should be documented (C), assessment of fetal response to the SROM is the priority.

An infant in respiratory distress is placed on pulse oximetry. The oxygen saturation indicates 85%. What is the priority nursing intervention? 1. Evaluate the blood pH. 2. Begin humidified oxygen via hood. 3. Stimulate infant crying. 4. Place the infant under a radiant warmer.

2. Begin humidified oxygen via hood. An oxygen saturation of less than 90% (normal oxygen saturation is 96% to 98%) requires oxygen administration (B). (A) is not necessary. (C) may utilize additional oxygen and will not correct the problem. (D) is important because it may decrease energy use for respiratory effort, but it will not correct a low saturation level.

The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply.) 1. Shallow with an irregular rhythm. 2. Chest breathing with nasal flaring. 3. Diaphragmatic with chest retraction. 4. Abdominal with synchronous chest movements. 5. Heart rate of 158 beats per minute. 6. Grunting heard with a stethoscope.

2. Chest breathing with nasal flaring. 3. Diaphragmatic with chest retraction. 6. Grunting heard with a stethoscope. Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are signs of respiratory distress in the infant.

What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta? 1. Maternal bradycardia. 2. Hard, board-like abdomen. 3. Decrease in fundal height. 4. Decrease in abdominal pain.

2. Hard, board-like abdomen. Abruptio placenta causes concealed intrauterine hemorrhage when the placenta separates and its edges do not. The formation of a hematoma behind the placenta and subsequent infiltration of the blood manifests as a firm, board-like abdomen (B), which should be reported immediately to the healthcare provider. As bleeding occurs, fetal oxygenation and maternal stability are compromised leading to fetal and maternal tachycardia, not (A). With abruptio placenta, fundal height and abdominal pain increase, not (C and D).

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? 1. Avoid alcohol because it is excreted in breast milk. 2. Avoid spicy foods to prevent infant colic. 3. Increase caloric intake by approximately 500 calories/day. 4. Double prenatal milk intake to improve Vitamin D transfer to the infant.

1. Avoid alcohol because it is excreted in breast milk. Alcohol should be avoided while breastfeeding because, when consumed by the mother, it is excreted in breast milk (A). It also adversely effects the milk ejection reflex. While (B) may cause some gastric upset in some babies, it does not cause colic. (C) should also be included in diet teaching for a breastfeeding mother, but because it does not involve safety to the infant it does not have the same degree of importance as (A). Recent research has shown that infants receive very little Vitamin D via the breastmilk and some sources recommend Vitamin D supplementation in exclusively breastfed babies to prevent rickets.

During an assessment of a multiparous client who delivered an 8-lb 7-oz infant 4 hours ago, the nurse notes the client's perineal pad is completely saturated within 15 minutes. What action should the nurse implement next? 1. Perform fundal massage. 2. Assess blood pressure. 3. Notify the healthcare provider. 4. Encourage the client to void.

1. Perform fundal massage. Perineal pad saturation within 15 minutes during the early post partum period is indicative of bleeding, which is commonly due to uterine atony and can lead to post-partum hemorrhage. Fundal assessment and massage should be performed (A) first to control bleeding. (B, C, and D) are actions implemented after manually stimulating the fundus to contract.

A primigravida at 12-weeks gestation who just moved to the United States indicates she has not received any immunizations. Which immunization(s) should the nurse administer at this time? (Select all that apply.) 1. Tetanus. 2. Rubella. 3. Diphtheria. 4. Chickenpox. 5. Hepatitis B.

1. Tetanus. 3. Diphtheria. 5. Hepatitis B. Correct selections are (A, C, and E). Vaccines composed of killed viruses may be administered during pregnancy. Rubella (B) and chickenpox (D) consist of live or attenuated live viruses which would be contraindicated during pregnancy due to potential teratogenicity.

At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villi sampling (CVS) procedure. What assessment finding requires immediate intervention? 1. Uterine cramping. 2. Abdominal tenderness. 3. Systolic blood pressure < 100 mmHg. 4. Intermittent nausea.

1. Uterine cramping. The client should be monitored for 1 to 2 hours following the procedure for the occurrence of uterine cramping (A) so that immediate intervention to decrease the risk of miscarriage can be initiated. This procedure (removal of a small piece of tissue from the fetal portion of the placenta) may cause initiation of labor. (B) may occur at the puncture site if the procedure was done transabdominally. (C and D) are normal findings during in the first trimester.

A multiparous client is admitted to the postpartum unit after a rapid labor and birth of an infant weighing 4,000 grams. The client's fundus is boggy, lochia is heavy, and vital signs are unchanged. After having the client void and massaging the uterus, the client's fundus remains difficult to locate, and the rubra lochia remains heavy. What action should the nurse implement next? 1. Recheck the client's vital signs. 2. Notify the healthcare provider. 3. Insert an indwelling urinary catheter. 4. Massage the fundus in 30 minutes.

2. Notify the healthcare provider. Treatment of excessive bleeding requires the collaboration of the healthcare provider. Based on the findings, the healthcare provider should be notified (B) for additional treatment. The nurse should ask another nurse to rechecks the vital signs (A) while the healthcare provider is being called. (C) maybe needed if the client is unable to void. (D) may be implemented to prevent immediate uterine overstimulation by massage, which can lead to uterine atony and rebound hemorrhage.

A nulliparous client telephones the labor and delivery unit to report that she is in labor. What action should the nurse implement? 1. Emphasize that food and fluid intake should stop. 2. Tell the woman to stay home until her membranes rupture. 3. Ask the client to describe why she thinks she is in labor. 4. Suggest the client to come to the hospital for labor evaluation.

3. Ask the client to describe why she thinks she is in labor. Assessment, the first step of the nursing process, should include specific questions to determine if the woman is in labor (C). Current research does not support stopping oral intake (A). Spontaneous rupture of membranes (SROM) may not occur until labor has progressed, so (B) is not indicated. The client can describe over the phone what is happening, so (D) may not be necessary at this time.

A primigravida at 12-weeks gestation tells the nurse that she does not like diary products. Which food should the nurse recommend to increase the client's calcium intake? 1. Canned clams. 2. Fresh apricots. 3. Canned sardines. 4. Spaghetti with meat sauce.

3. Canned sardines. A 3 ounce can of sardines (with bones) provides about the same amount of calcium as 1 cup of milk (C). (A, B, and D) are not good sources for dietary calcium.

A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage? 1. Vaginal bleeding. 2. Complaints of abdominal pain. 3. Changes in fetal heart rate patterns. 4. Alteration in maternal blood pressure

3. Changes in fetal heart rate patterns. Hypoperfusion of the fetus may be present before the onset of clinical signs of maternal compromise or shock in a pregnant woman, so the external fetal monitor tracings should be assessed first to determine signs of fetal hypoxia due to internal bleeding in the mother. (A, B, and D) are not the first findings of internal hemorrhage in the pregnant client.

When assessing the integument of a 24-hour-old newborn, the nurse notes a pink papular rash with superimposed vesicles on the thorax, back, and abdomen. What action should the nurse implement next? 1. Notify the healthcare provider immediately. 2. Move the newborn to an isolation nursery. 3. Document the finding as erythema toxicum. 4. Obtain a culture from one of the vesicles.

3. Document the finding as erythema toxicum. Erythema toxicum, or newborn rash, is a normal, transient rash that is found in term neonates during the first 3 weeks of age. No treatment is required, so (C) should be implemented. (A, B, and D) are not indicated since this is a normal finding.

The nurse is assessing a 12-hour-old infant with a maternal history of frequent alcohol consumption during pregnancy. Which finding should the nurse report that is most suggestive of fetal alcohol syndrome (FAS)? 1. An extra digit on the left hand. 2. Corneal clouding. 3. Flat nasal bridge. 4. Asymmetrical bulging fontanels.

3. Flat nasal bridge. FAS is typically manifested by craniofacial anomalies, including short eyelid opening, flat midface or flat nasal bridge (C), flat upper lip groove, thin upper lip, and microcephaly. (A, B and D) are not usually associated with FAS.

A client in labor receives an epidural block. What intervention should the nurse implement first? 1. Encourage oral fluids. 2. Assess contractions. 3. Monitor blood pressure. 4. Obtain a radial pulse.

3. Monitor blood pressure. The risk for maternal hypotension is commonly increased by an epidural, so blood pressure should be monitored immediately after the first epidural dose (C) and for 15 minutes thereafter. Oral fluids should be encouraged to help keep the client hydrated (A), but the first action is to evaluate the client for side effects of the epidural block. Although (B and D) should be continuously monitored after an epidural, the first objective sign of epidural precipitated vasodilation is hypotension.

A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the priority nursing action? 1. Assess newborn reflexes for signs of neurological impairment. 2. Leave the infant in the room with the mother to foster attachment. 3. Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia. 4. Perform a gestational age assessment to determine if the infant is large-for-gestational-age.

3. Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia. The infant's birth weight falls within the parameter (4000 grams or greater) for a large-for-gestational-age (LGA) infant and should be assessed for hypoglycemia (C) and trauma. Early recognition of hypoglycemia requires immediate intervention and takes precedence over assessing newborn reflexes (A). Although the infant may remain in the room with the mother (B), frequent assessments of the newborn should be performed. Additional assessment tools (D) can be used after serum glucose levels are determined (C).

A client is receiving an oxytocin infusion for induction of labor. When the client begins active labor, the fetal heart rate (FHR) slows at the onset of several contractions with subsequent return to baseline before each contraction ends. What action should the nurse implement? 1. Insert an internal monitor device. 2. Change the woman's position. 3. Discontinue the oxytocin infusion. 4. Document the finding in the client record.

4. Document the finding in the client record. Early FHR decelerations are a normal finding during active labor that occurs due to fetal head compression, so the finding should be documented in the client record (D). Although the client's status should be monitored continuously, this is a reassuring FHR pattern, so (A, B, and C) are not indicated.

Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor? 1. Brighten the lighting so the mother can view the infant. 2. Complete the newborn assessment as quickly as possible. 3. Provide positive reinforcement for maternal care of infant. 4. Encourage early initiation of breast or formula feeding.

4. Encourage early initiation of breast or formula feeding. (D) is the best of the interventions listed to encourage maternal-infant bonding. (A, B, and C) are all methods of promoting maternal-infant bonding but are not usually as effective as initiating infant feeding.

A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. What information should the nurse provide? 1. Many women imagine what their baby is like by interpreting fetal movements. 2. The fetus in utero is capable of hearing and does respond to the mother's voice. 3. The healthcare provider should address her concerns about her baby's hearing function. 4. The interaction between the mother's voice and the fetus's response ensures bonding.

2. The fetus in utero is capable of hearing and does respond to the mother's voice. Fetal hearing and response to sound occurs by 24-weeks gestation, so the fetus can be soothed by the familiar sound of the mother's voice (B). There is no evidence to support the validity of maternal intuition about maternal-fetal relationships (A and D). (C) does not provide the mother with reassuring information.

A client at 39-weeks gestation is admitted to the labor and delivery unit. Her obstetrical history includes 3 live births at 39-weeks, 34-weeks, and 35-weeks gestation. Using the GTPAL system, which designation is the most accurate summary of this client's obstetrical history? 1. 3-1-1-1-3. 2. 4-1-2-0-3. 3. 3-0-3-0-3. 4. 4-3-1-0-2.

2. 4-1-2-0-3. The client with 3 previous gravid experiences and this current pregnancy totals 4 gravid experiences, and 1 term delivery (37-weeks or greater), 2 preterm deliveries (20 to 37 weeks, whether viable or not viable), no spontaneous abortions and 3 living children. (B) best designates this client's obstetrical history. (A, C, and D) are inaccurate for this client's history using the TPAL system.

Which gastrointestinal findings should the nurse be concerned about in a client at 28-weeks gestation? 1. Pica. 2. Pyrosis. 3. Ptyalism. 4. Decreased peristalsis.

1. Pica. Pica (A), the consumption of low- or non-nutrient substances, may cause more nutritious foods to be displaced from the diet, and depending on the substance ingested, may be toxic or interfere with the absorption of nutrients and minerals. Pyrosis or heartburn (B), ptyalism or excessive salivation (C), and decreased peristalsis (D) are normal findings during pregnancy.

A client who is breastfeeding develops engorged breasts on the third postpartum day. Which action should the nurse recommend to relieve breast engorgement? 1. Avoid pumping her breasts. 2. Continue breastfeeding every 2 hours. 3. Skip a feeding to rest the breasts. 4. Decrease fluid intake for at least 24 hours.

2. Continue breastfeeding every 2 hours. Breastfeeding every 2 hours should decrease the engorgement (B) and promote lactation that equals the neonate's demands. Skipping feedings (C) increases the symptoms of engorgement and may subsequently reduce milk production. Using a breast pump increases the amount of milk expressed which decreases engorgement and discomfort, so the client should be encouraged to pump, not (A). Decreasing fluid intake (D) does not alleviate the breast engorgement and is not recommended.

The nurse is discussing the stages of labor with a group of women in the last month of pregnancy and provides examples of different positional techniques used during the second stage of labor. Which position should the nurse address that provides the best advantage of gravity during delivery? 1. Walking. 2. Squatting. 3. Kneeling. 4. Lithotomy.

2. Squatting. Squatting (B) helps to align the fetus with the pelvic outlet and allows gravity to assist in fetal descent and gives the client an adventitious position for birth. Although walking (A) and kneeling (C) also help to align the fetus with the pelvic outlet and allow for gravity to assist in fetal descent, these do not accomodate birth easily. The predominant position in the United States for physician-attended births is the lithotomy position which requires a woman to be in a reclined position with her legs in stirrups in which gravity has little effect in this position (D).

A client delivers twins, one is stillborn and the other is recovering in intensive care nursery. As the nurse provides assistance to the bathroom, the client softly crying, states, "I wish my baby could have lived." Which response is best for the nurse to provide? 1. "Don't be sad. You'll need to be strong to care for your healthy baby." 2. "Do you want to go to the nursery and see your baby?" 3. "I am sorry for your loss. Do you want to talk about it?" 4. "It is always sad to lose a baby. Would you like me to call your minister?"

3. "I am sorry for your loss. Do you want to talk about it?" The nurse should recognize the client's grief and offer an opportunity for the client to discuss her feelings (C). Telling the client not to be sad and that she needs to be strong (A) is invalidating and instructive by the nurse. (B and D) are incorrect responses because they deny the client's expressed grief and attempt to change the subject.

A client at 28-weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client? 1. Contraction stress test. 2. Internal fetal monitoring. 3. Abdominal ultrasound. 4. Lecithin-sphingomyelin ratio.

3. Abdominal ultrasound. Bright red, painless vaginal bleeding occuring after 20-weeks gestation can be an indicator of placenta previa, which is confirmed by abdominal ultrasound (C). (A, B and D) are invasive procedures that increase the risk for premature onset of labor, and are not indicated at this client's gestation.

A client is experiencing "back" labor and complains of intense pain in the lower lumbar-sacral area. What action should the nurse implement? 1. Perform effleurage on the abdomen. 2. Encourage pant-blow breathing techniques. 3. Apply counter pressure against the sacrum. 4. Assist the client in guided imagery.

3. Apply counter pressure against the sacrum. Counter pressure against the sacrum (C) during contractions often provides significant relief for "back labor," which results from occipital posterior position. Effleurage (A) is a helpful distraction strategy many clients use during contractions but does not assist with lower back pain. Back labor can occur throughout labor if the fetus does not rotate, and helpful distractions, such as (B), used during transition, and (D), used during phase one of labor, are not effective for back labor.

A newborn infant who is 24-hours-old is on a 4-hour feeding schedule of formula. To meet daily caloric needs, how many ounces are recommended at each feeding? 1. 2 ounces. 2. 4 ounces. 3. 1.5 ounces. 4. 3.5 ounces.

4. 3.5 ounces. A newborn requires approximately 19 to 21 ounces of formula each day (six feedings per 24-hour period x 3.5 = 21). One-and-a-half to two ounces (A and C) may be insufficient to meet the newborn's calorie needs. (B) may cause the infant to spit-up due to over-feeding.

The nurse notes a pattern of the fetal heart rate decreasing after each contraction. What action should the nurse implement? 1. Give 10 liters of oxygen via face mask. 2. Prepare for an emergency cesarean section. 3. Continue to monitor the fetal heart rate pattern. 4. Obtain an oral maternal temperature.

1. Give 10 liters of oxygen via face mask. Late decelerations occur when there is reduced placental and fetal perfusion. Administering oxygen (A) increases the oxygen saturation in the blood thus increasing oxygen to the fetus. (B, C, and D) are inaccurate.

What action should the nurse implement when caring for a newborn receiving phototherapy? 1. Reposition every 6 hours. 2. Place an eyeshield over the eyes. 3. Limit the intake of formula. 4. Apply an oil-based lotion to the skin.

2. Place an eyeshield over the eyes. Phototherapy converts unconjugated bilirubin, which is deposited in the skin, to a water-soluble form that is more easily excreted by the liver. Exposure to the light source can increase the risk for ocular damage, so an eyeshield (B) is placed while the infant is under the light source. To ensure all body surfaces are exposed to the lights, the newborn should be reposition every 2 to 4 hours, not every 6 hours (A). Phototherapy can increase insensible water loss, and to prevent dehydration, fluid intake should be encouraged, not restricted (C). Lotions (D) absorb heat and can potentially cause burns and should not be used on the skin while phototherapy is in progress.

A female client who wants to delivery at home asks the nurse to explain the role of a nurse-midwife in providing obstetric care. What information should the nurse provide? 1. Birth in the home setting is the preference for a using a midwife for delivery. 2. The pregnancy should progress normally and be considered low risk. 3. Natural child birth without analgesia is used to manage pain during labor. 4. An obstetrician should also follow the client during pregnancy.

2. The pregnancy should progress normally and be considered low risk. A nurse midwife is an advanced practice nurse who is prepared to provide quality perinatal care for a low-risk obstetric client (B). Nurse-midwife births are managed in hospital settings or birth centers (A) as well as in home settings. Care in a midwifery model is noninterventional in orientation where the client and family are encouraged to be active participants in the natural child birth practices, but this does not imply that analgesia is not prescribed during labor (C). Nurse-midwives practice as independent practitioners and usually work in conjunction with licensed medical backup (D) in case of a complication or surgical emergency.

A client at 29-weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client? 1. Amniocentesis. 2. Ultrasonography. 3. Chorionic villus sampling. 4. Maternal serum alpha-fetoprotein.

2. Ultrasonography. Gestational age, fetal growth, and the status and position of the placenta are monitored by ultrasound.

A client at 28-weeks gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client? 1. It is not necessary to keep such a close watch on weight gain. 2. Try to exercise more because too much weight has been gained. 3. Increase the calories in your diet to gain more weight per week. 4. The weight gain is acceptable for the number of weeks pregnant.

4. The weight gain is acceptable for the number of weeks pregnant. The normal pattern of weight gain is 2 to 4 pounds in the first trimester (by 13-weeks) and 1 pound per week after that. At 28-weeks gestation, a weight gain between 17 and 20 pounds is acceptable (D). (A, B and C) do not provide accurate information.

Which prescription should the nurse administer to a newborn to reduce complications related to birth trauma? 1. Silver nitrate. 2. Erythromycin (Ilotycin ointment). 3. Ceftriaxone (Rocephin). 4. Vitamin K (AquaMEPHYTON).

4. Vitamin K (AquaMEPHYTON). The normal neonate is vitamin K deficient, so to rapidly elevate prothrombin levels and reduce the risk of neonatal bleeding, newborns receive a single injection of vitamin K (AquaMEPHYTON) (D). (A and B) are prophylactic ophthalmic agents used to prevent neonatal ophthalmia. (C) is an antibiotic used to treat neonatal infections.

The father of a newborn tells the nurse, "My son just died." How should the nurse respond? 1. "I am sorry for your loss." 2. "There is an angel in heaven." 3. "I understand how you feel." 4. "You can have other children."

1. "I am sorry for your loss." The nurse should acknowledge the loss with a simple but sincere comment, such as (A), which validates the experience and recognizes the feelings of the parents. Clich s (B and C) or advice (D) do not encourage the bereaved parents to tell their stories but can stifle the further expression of emotion.

Which statement by a client who is pregnant indicates to the nurse an understanding of the role of protein during pregnancy? 1. "Protein helps the fetus grow while I am pregnant." 2. "Gestational diabetes is prevented by eating protein." 3. "Anemia is averted by consuming enough protein." 4. "My baby will develop strong teeth after he is born."

1. "Protein helps the fetus grow while I am pregnant." Adequate protein intake is essential to meet increasing demands of rapid growth of the fetus (A) and maternal changes during pregnancy, such as enlargement of the uterus, mammary glands, and placenta, increase in the maternal blood volume, and formation of amniotic fluid. Protein is essential for anabolism, but its consumption does not prevent gestational diabetes (B). Iron found in high protein foods, such as meat, helps prevent anemia (C), but the basic need for protein is the anabolic growth processes of the fetus. Although calcium is needed for fetal bone and teeth development (D), it is not found in all protein food sources.

A gravid client develops maternal hypotension following regional anesthesia. What intervention(s) should the nurse implement? (Select all that apply.) 1. Administer oxygen. 2. Increase IV fluids. 3. Perform a vaginal examination. 4. Assist client to a sitting position. 5. Place the client in a lateral position. 6. Monitor fetal status.

1. Administer oxygen. 2. Increase IV fluids. 5. Place the client in a lateral position. 6. Monitor fetal status. Correct selections are (A, B, E, and F). Oxygen (A), fluids (B), lateral position (E), and evaluating fetal response (F) effectively manage maternal hypotension following regional anesthesia. Placing the client in a sitting position (D) does not facilitate venous return to the heart and limits perfusion of the fetus. A sterile vaginal examination (C) does not increase blood flow and oxygenation to the placenta and fetus.

What nursing action should be implemented when intermittently gavage-feeding a preterm infant? 1. Allow formula to flow by gravity. 2. Avoid letting infant suck on tube. 3. Insert feeding tube through nares. 4. Apply steady pressure to syringe.

1. Allow formula to flow by gravity. Gavage feeding is commonly used to feed preterm infants who are born at less than 32-weeks gestation, infants who weigh less than 1500 grams, or infants who are unable to tolerate oral feedings. The feeding should flow by gravity (A) to avoid over-distention and a sudden sensation of fullness that may cause vomiting. Allowing the infant to suck on the tube, not (B), permits observation of the sucking response. The feeding tube should be inserted orally, since nasal insertion (C) impedes obligatory nose breathing and may irritate delicate nasal mucosa. (D) can result in vomiting if the rate of administration is too fast.

A woman who is bottle-feeding her newborn infant calls the clinic 72 hours after delivery and tells the nurse that both of her breasts are swollen, warm, and tender. What instructions should the nurse give? 1. Apply ice to the breasts. 2. Wear a loose-fitting bra. 3. Run warm water on the breasts during a shower. 4. Express small amounts of milk from the breasts.

1. Apply ice to the breasts. Since the baby is receiving bottled formula, suppression of breast milk production is desired. Ice applications to the breast cause vasoconstriction which reduces engorgement and provides topical pain relief. A well-fitted support bra or breast binder , not (B), should be recommended to reduce stimulation of the nipples and breast tissue, which often stimulates breast milk production and engorgement. Applying heat to the breast causes vasodilation and increased engorgement (C). Expressing milk from the breast will stimulate additional milk production (D) and contribute to engorgement.

Which cardiovascular findings should the nurse assess further in a client who is at 20-weeks gestation? 1. Decrease in pulse rate. 2. Decrease in blood pressure. 3. Increase in heart sounds (S1, S2). 4. Increase in red blood cell production.

1. Decrease in pulse rate. Between 14 and 20 weeks gestation, the pulse increases about 10 to 15 beats/minute, which persists to term, so a decrease (A) should be assessed further. During the second trimester, both systolic and diastolic pressures decrease by about 5 to 10 mm Hg (B), a more audible splitting of S1 and S2 occurs (C), and there is an accelerated production of red blood cells (D).

A multiparous client is experiencing bleeding 2 hours after a vaginal delivery. What action should the nurse implement next? 1. Determine the firmness of the fundus. 2. Give oxytocin (Pitocin) intravenously. 3. Inform the healthcare provider of the bleeding. 4. Assess the vital signs for indicators of shock.

1. Determine the firmness of the fundus. The first step in recognizing the potential cause of postpartum bleeding is to evaluate the contractility of the uterus (A). (B) should not be implemented until the cause of the bleeding is determined. The nurse should implement (C) after completing the assessment of the potential cause for bleeding. (D) is important, but (A) is a higher priority.

While monitoring a client in active labor, the nurse observes a pattern of a 15-beat increases in the fetal heart rate that lasts 15 to 20 seconds and returns to baseline. Which information should the nurse report during shift change? 1. Fetal well being with labor progression. 2. Signs of uteroplacental insufficiency. 3. Episodes of fetal head compression. 4. Occurrences of cord compression.

1. Fetal well being with labor progression. Fetal heart rate accelerations that last 15 to 20 seconds are a sign of fetal well-being, so continuous external fetal monitoring should be continued (A). Uteroplacental insufficiency (B) causes late decelerations. Compression of the fetal head (C) results in early decelerations. Compression of the umbilical cord (D) is evidenced by variable decelerations.

Which action should the nurse implement when caring for a newborn immediately after birth? 1. Keep the newborn's airway clear. 2. Foster parent-newborn attachment. 3. Administer eye prophylaxis and vitamin K. 4. Dry the newborn and wrapping in a blanket.

1. Keep the newborn's airway clear. The immediate care after birth should focus on assessment and stabilization of the newborn's respiratory effort and airway clearance (A). When is the infant is warm and identification is ensured, then the opportunity to foster parental attachment (B) should be provided. Eye prophylaxis and a vitamin K supplementation (C) is given after the newborn is stabilized and assessed. To facilitate respiratory stabilization, the newborn's skin is dried and covered with a warmed blanket (D) to prevent cold stress.

The nurse administers meperidine (Demerol) 25 mg IV push to a laboring client, who delivers the infant 90 minutes later. What medication should the nurse anticipate administering to the infant? 1. Naloxone (Narcan). 2. Nalbuphine (Nubain). 3. Fentanyl (Sublimaze). 4. Promethazine (Phenergan).

1. Naloxone (Narcan). Demerol is a CNS depressant, which moves across the placenta and can cause respiratory depression in the infant, so Narcan (A), a narcotic antagonist, is administered to the infant to reverse CNS effects. Nubain (B), Fentanyl (C), and Phenergan (D) are analgesics and not indicated for the infant.

A client at 35-weeks gestation visits the clinic for a prenatal check-up. Which complaint by the client warrants further assessment by the nurse? 1. Periodic abdominal pain. 2. Ankle edema in the afternoon. 3. Backache with prolonged standing. 4. Shortness of breath when climbing stairs.

1. Periodic abdominal pain. Abdominal pain (A) may indicate preterm labor or placental abnormalities, so specific information should be gathered about the intensity, location, and circumstances surrounding the pain. (B, C, and D) are expected findings at 35-weeks.

Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routine standing order for methylergonovine maleate (Methergine)? 1. Pregnancy induced hypertension. 2. Placenta previa. 3. Gestational diabetes. 4. Postpartum hemorrhage.

1. Pregnancy induced hypertension. Methergine is used for post-partum bleeding. A client's history of pregnancy-induced hypertension (A) is a contraindication for Methergine which causes vasoconstriction and increases blood pressure, so the routine standing order should be withheld and reported to the healthcare provider. (B, C, and D) are not contraindications for the use of Methergine.

Which nursing intervention is the priority during the fourth stage of labor? 1. Promote bonding. 2. Assess for hemorrhage. 3. Provide comfort measures. 4. Monitor uterine contractions.

2. Assess for hemorrhage. The fourth stage of labor starts after delivery of the placenta which leaves open uterine wall sinuses subject to bleeding. The main focus of the fourth stage is to monitor vital signs and assess for vaginal hemorrhage (B). Although promoting bonding (A) and providing comfort measures (C) are important, assessing for bleeding during the first hours after delivery is the highest priority. Although "after-pains" can occur after delivery, regular uterine contractions have ceased during the fourth stage (D).

While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document? 1. Molding. 2. Cephalohematoma. 3. Caput succedaneum. 4. Bulging fontanel.

2. Cephalohematoma. A cephalohematoma (B) should be documented because it is a collection of blood beneath the periosteum of the cranial bone causing scalp swelling that does not cross the suture line. Molding (A) is overlapping of cranial bones that occurs as the fetal head accommodates for the descent through the vaginal vault. Caput succedaneum (C) is differentiated from a cephalohematoma by generalized edematous swelling of the presenting part of the head. Fontanel tension should feel slightly concave and well defined against the edges of the cranial bones, whereas a bulging anterior fontanel (D) is tense and distends from an increased intracranial pressure, such as seen in congenital hydrocephalus.

The nurse tells a client in her first trimester that she should increase her daily intake of calcium to 1,200 mg during pregnancy. The client responds, "I don't like milk." What dietary adjustments should the nurse recommend? 1. Increase organ meats in the diet. 2. Eat more green, leafy vegetables. 3. Add molasses and whole-grain breads to the diet. 4. Choose more fresh citrus and other fruits daily.

2. Eat more green, leafy vegetables. For pregnant women who do not like milk, other sources of calcium include enriched cereals, legumes, nuts, dried fruits, green leafy vegetables (B), and canned salmon and sardines that contain bones. (A, C, and D) are not significant sources of calcium.

Which behavior should the nurse anticipate for a new mother with an uncomplicated vaginal birth on the third postpartum day? 1. Request help with ambulation and perineal care. 2. Exhibit interest in learning more about infant care. 3. Sleep most of the time when the baby is not present. 4. Be very excited and talkative about the birth experience.

2. Exhibit interest in learning more about infant care. By the third postpartum day, the new mother should start to "take hold" of caring for her infant, by asking questions about infant care and initiating care of her infant (B). This client should be independent with self-care (A). Excessive sleeping (C) is more indicative of immediate post-delivery behavior when the new mother is tired from the process of labor. Being excited and talkative about the birth is more characteristic of "taking in" behavior, seen in the first 24 to 48 hours after delivery (D).

The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the nurse, "Wait! I don't want my baby to have a shot." Which response would be best for the nurse to make? 1. Inform the mother that the injection was prescribed by the healthcare provider. 2. Explore the mother's concerns about the infant receiving an injection of vitamin K. 3. Explain that vitamin K is required by state law and compliance is mandatory. 4. Remind the mother that all babies receive this shot and it is relatively painless.

2. Explore the mother's concerns about the infant receiving an injection of vitamin K. This mother's concerns should be explored (B) and any misconceptions cleared up before the vitamin K is injected. (A and C) are true but do not communicate the importance of vitamin K administration. Also, parents have the right to refuse the injection by signing a refusal form. (D) is providing false reassurance--all injections cause pain.

The nurse observes a male newborn who is displaying a rigid posture with his eyes tightly closed and grimacing as he is crying after an invasive procedure. The baby's blood pressure is elevated on the Dinamap display. What action should the nurse implement? 1. Obtain a serum glucose level. 2. Give the infant medication for pain. 3. Feed the newborn 1 ounce of formula. 4. Request a genetic consultation.

2. Give the infant medication for pain. A cry face (or crying with the eyes squeezed or closed tightly), a rigid posture, and an increase in blood pressure are indicative of pain in the neonate, so analgesia should be given for pain (B). The symptoms of hypoglycemia (A) are jitteriness and mottling. The signs of hunger include rooting, tongue extrusion and possibly crying (C). A high-pitched shrill cry is associated with neurologic and genetic anomalies (D).

A client in the first stage of active labor is using a shallow pattern of rapid breaths that is twice the normal adult breathing rate. The client complains of feeling light-headed, dizzy, and states that her fingers are tingling. What action should the nurse implement? 1. Notify the healthcare provider. 2. Help her breathe into a paper bag. 3. Administer oxygen via nasal cannula. 4. Tell the client to slow her breathing.

2. Help her breathe into a paper bag. Hyperventilation can precipitate respiratory alkalosis and cause light-headedness, dizziness, tingling of the fingers, and circumoral numbness. Breathing into a paper bag held tightly around the mouth and nose (B) enables the client to rebreathe carbon dioxide, which reduces depletion of carbonic acid. and compensates for the respiratory alkalosis. (A) is unnecessary, and (C and D) are less effective than (B).

A client comes in to the clinic for her six week postpartum check up and complains that her left breast is eythematous and painful. The client asks, "Can I still breastfeed my baby?" What is the best response for the nurse to provide? 1. Advise to stop breastfeeding until the infection clears. 2. Inform the client to continue breastfeeding. 3. Begin all feedings with the infected breast. 4. Tell the client to pump then discard the milk from the affected breast.

2. Inform the client to continue breastfeeding. The client should be encouraged to continue breastfeeding (B) because emptying the breast helps alleviate the pain and prevents abscess formation. (A, C, and D) are inaccurate instructions for a breastfeeding client with mastitis.

A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An intrauterine pressure catheter (IUPC) is in place when the client's membranes rupture after 5 hours of active labor. Which finding should require the nurse to implement further action? 1. Labor has progressed at 1 cm/hr dilation. 2. Intensity of contractions is 130 mm Hg. 3. Contractions are lasting 60 to 80 seconds. 4. Oxytocin is infusing at a rate ot 30 mU/min.

2. Intensity of contractions is 130 mm Hg. The goal of induction of labor with oxytocin is to produce an effective labor, which can be measured by an IUPC reading of 40 to 90 mm Hg for contractions when giving oxytocin, so (B) requires further intervention. (A, C, and D) are goals for induction of labor using oxytocin.

During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide? 1. Discontinue all forms of contraception. 2. Make sure to include adequate folic acid in the diet. 3. Lose weight so more weight is gained during pregnancy. 4. Continue to take any medications that are taken regularly.

2. Make sure to include adequate folic acid in the diet. A healthy diet before conception is the best way to ensure that adequate nutrients are available for the developing fetus. Folate or folic acid intake in the periconception period (B) reduces the risk of neural tube defects. Recommendations to stop or continue medications (A and D) during pregnancy should be evaluated on an individual basis. Losing weight so more can be gained during pregnancy (C) is not indicated as a generalization and may place the client at risk for nutritional deficiencies.

The nurse notes an irregular bluish hue on the sacral area of a 1-day old Hispanic infant. How should the nurse document this finding? 1. Acrocyanosis. 2. Mongolian spots. 3. Erythema toxicum. 4. Harlequin sign.

2. Mongolian spots. Mongolian spots (usually in the sacral, lumbar, and gluteal regions) are a common skin variation in newborns of African, Asian, Native American, and Hispanic descent (B). (A) refers to cyanosis of the hands and feet, a normal finding in newborns soon after birth. (C) is a pink, papular rash that may appear on the thorax, back, buttocks, and abdomen within 24 to 48 hours after birth. (D) is visible when an infant lies on the side and the lower half of the body is pink or red and the upper half is pale.

An infant with hyperbilirubinaemia is receiving phototherapy. What intervention should the nurse implement? 1. Maintain NPO status. 2. Monitor temperature. 3. Apply skin lotion as prescribed. 4. Change T-shirt every 3 hours.

2. Monitor temperature. Minor side effects of phototherapy include loose, green stools, transient rashes, hyperthermia, increased metabolic rate, dehydration, electrolyte disturbances, and priapism. Regular monitoring of the infant's temperature (B) allows evaluation of hyperthermia and dehydration. Extra oral fluids are provided to reduce the risk of dehydration, so NPO status is not necessary (A). Skin lotion is contraindicated (C) to prevent increased tanning or an increase in heat or skin "frying" effect. Clothing reduces the area of exposed skin to the lights, so T-shirts (D) should not be worn during phototherapy.

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take? 1. Ask the mother why she won't look at the infant. 2. Observe the mother for other attachment behaviors. 3. Examine the newborn's eyes for the ability to focus. 4. Recognize this as a common reaction in new mothers.

2. Observe the mother for other attachment behaviors. Parent-infant bonding or attachment is based on a mutual relationship between parent and infant and is commonly established by the "enface position," which is demonstrated by the mother's and infant's eyes meeting in the same plane. To assess for other attachment behaviors, continued observation of the new mother's interactions with her infant (B) helps the nurse determine problems in attachment. (A) may cause undue confusion, stress, or impact the mother's self-confidence. (C) is not indicated. The "enface position" is a significant, early behavior that leads to the formation of affectional ties and should be encouraged (D).

What action should the nurse implement with the family when an infant is born with anencephaly? 1. Ensure that measures to facilitate the attachment process are offered. 2. Prepare the family to explore ways to cope with the imminent death of the infant. 3. Inform the family about multiple corrective surgical procedures that will be needed. 4. Provide emotional support to facilitate the consideration of fetal organ donation.

2. Prepare the family to explore ways to cope with the imminent death of the infant. Anencephaly, a neural tube congenital malformation, is the incomplete embryological formation of both cerebral hemispheres, which often results in death due to respiratory failure. While comfort measures are provided, there is no resuscitation effort or successful treatment available, so the family should be prepared for the infant's imminent death (B) and encouraged to explore ways to cope with the loss and express grief. Providing opportunities with the infant promote a realistic experience of connectedness and facilitates parental closure, not attachment (A). (C) is not warranted. Although (D) may be considered, it may not be the most therapeutic family-centered intervention when initially confronting the parents with the infant's prognosis.

What action should the nurse implement to prevent conductive heat loss in a newborn? 1. Place the infant under a radiant warming system. 2. Put a blanket on the scale when weighing the infant. 3. Dry the newborn with a warmed blanket. 4. Position the crib away from the windows.

2. Put a blanket on the scale when weighing the infant. Placing a blanket on the scale (B) provides a barrier to prevent conductive heat loss when the infant's body comes in contact with a cooler solid surface. (A) prevents convection heat loss from the infant's body to the surrounding air. (C) prevents heat loss by evaporation when the infant's body cools as moisture present on the skin evaporates. (D) prevents radiant heat loss when the body loses heat to solid items that are not in contact with the body but are in close proximity.

Which finding indicates to the nurse that a 4-day-old infant is receiving adequate breast milk? 1. Gains 1 to 2 ounces per week. 2. Saturates 6 to 8 diapers per day. 3. Rests for 6 hours between feedings. 4. Defecates at least once per 24 hours.

2. Saturates 6 to 8 diapers per day. Breastmilk "comes in" usually on day 3 or 4, so an infant should have six to eight wet diapers every 24 hours (B) for adequate hydration. An infant typically gains 15 to 30 gm/day, not 30 to 60 gm (A). Sleeping 6 hours (C) is not an indication of adequate breast milk intake for a 4-day-old infant. An infant should have a minimum of three bowel movements per day, not (D).

A neonate who is receiving an exchange transfusion for hemolytic disease develops respiratory distress, tachycardia, and a cutaneous rash. What nursing intervention should be implemented first? 1. Inform the healthcare provider. 2. Stop the transfusion. 3. Administer calcium gluconate. 4. Monitor vital signs electronically.

2. Stop the transfusion. Exchange blood transfusion is a standard mode of therapy for treatment for severe hyperbilirubinemia unresponsive to phototherapy and hydrops caused by Rh incompatibility. If the neonate demonstrates signs of a blood transfusion reaction, such as tachycardia or bradycardia, respiratory distress, dramatic change in blood pressure, temperature instability, and rash, the transfusion should be stopped immediately (B). Then, the healthcare provider should be informed (A) of the findings, and (C and D) implemented as needed.

A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide? 1. This is a demonstration of the fetus's acoustical reflex. 2. The fetus can respond to sound by 24-weeks gestation. 3. It is a coincidence the fetus responded at the same time. 4. Report the fetus's behavior to the healthcare provider.

2. The fetus can respond to sound by 24-weeks gestation. At 24-weeks gestation, the fetus's ability to hear loud environment sounds can illicit a startle response (B). Acoustic stimulations can evoke a fetal heart rate response and fetal movement, but (A and C) are inaccurate. (D) is not indicated.

A 31-year-old woman uses an over-the-counter (OTC) pregnancy test that is positive one week after a missed period. At the clinic, the client tells the nurse she takes phenytoin (Dilantin) for epilepsy, has a history of irregular periods, is under stress at work, and has not been sleeping well. The client's physical examination and ultrasound do not indicate that she is pregnant. How should the nurse explain the most likely cause for obtaining false-positive pregnancy test results? 1. Having an irregular menstrual cycle. 2. Using an anticonvulsant for epilepsy. 3. Taking the pregnancy test too early. 4. Being under too much stress at work.

2. Using an anticonvulsant for epilepsy. Anticonvulsants may yield false-positive pregnancy test results (B). Although over-the-counter pregnancy tests can yield positive results as soon as 4 days after implantation, the client's menstrual cycle dates indicate she is 3 weeks late, so implantation, which occurs 6 to 10 days after conception, has not occurred (C). Normal hormonal and menstrual cycles (A) may be influenced by stress (D), but hCG levels and positive pregnancy results are not affected.

A multiparous client is bearing down with contractions and crying out, "The baby is coming!" Which immediate action should the nurse implement? 1. Obtain a precipitous delivery tray. 2. Visualize the perineum for bulging. 3. Call the healthcare provider for a STAT delivery. 4. Instruct the client's partner to stay for the delivery.

2. Visualize the perineum for bulging. The perineum should be visualized (B) for bulging or the presentation of the baby so assistance with the impending birth can be immediately rendered. A precipitous delivery tray (A) should be brought to the labor room by another staff member. The healthcare provider should be called (C), but the nurse should prepare to deliver. Although the client's partner should be instructed to stay for the delivery, the nurse should assess the client first.

An infant born at 37-weeks gestation, weighing 4.1 kg (9.02 pounds) is 2 hours old and appears large for gestational age, flushed, and tremulous. What procedure should the nurse follow to implement a glucose screening? (Arrange the examination process from first on top to last on the bottom.) 1. Restrain the newborn's foot with your free hand. 2. Wrap the infant's foot with a heal warmer for 5 minutes. 3. Collect a spring-loaded automatic puncture device. 4. Cleanse puncture site on the lateral aspect of the heal.

2. Wrap the infant's foot with a heal warmer for 5 minutes. 3. Collect a spring-loaded automatic puncture device. 1. Restrain the newborn's foot with your free hand. 4. Cleanse the puncture site on the lateral aspect of the heal. Obtaining capillary blood for the glucose screening for a infant that is macrosomic and at risk for hypoglycemia should begin with wrapping the infant's foot with a heel warmer for 5 to 10 minutes to facilitate vasodilation to obtain an adequate blood sample volume. Next, a spring loaded automatic puncture device should be obtained to puncture the skin because it is less traumatic than a manual lancet. Then, the nurse's hand is used to restrain the foot as the puncture site on the lateral aspect of the heel is cleansed.

The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide? 1. The kidneys and renal function are not fully developed. 2. Warmth promotes sleep so the infant will grow quickly. 3. A large body surface area favors heat loss to the environment. 4. The thick layer of subcutaneous fat is inadequate for insulation.

3. A large body surface area favors heat loss to the environment. Thermoregulation, heat regulation, is critical to the survival of a neonate because the newborn's larger surface area (C) per unit of weight predisposes to heat loss. While keeping the infant warm may help the infant to sleep, it promotes transitional homeostasis, not growth (B). (A) is unrelated to cold stress of the newborn. (D) does not support the metabolic cascade that results from neonatal heat loss.

The nurse on the postpartum unit receives report for 4 clients during change of shift. Which client should the nurse assess for risk of postpartum hemorrhage (PPH)? 1. A primigravida who had a spontaneous birth of preterm twins. 2. A multigravida who delivered a 8 pound 2 ounce infant after an 8-hour labor. 3. A multiparous client receiving magnesium sulfate during induction for severe preeclampsia. 4. A primiparous client who had an emergency cesarean birth due to fetal distress.

3. A multiparous client receiving magnesium sulfate during induction for severe preeclampsia. Magnesium sulfate administration during labor acts as a smooth muscle relaxant and contributes to uterine relaxation and atony, which poses a risk for early PPH (C). Although there are many causes and risk factors associated with postpartum hemorrhage (PPH), (A, B, and D) are not at higher risk for PPH.

The nurse is teaching a primigravida at 10-weeks gestation about the need to increase her intake of folic acid. Which explanation should the nurse provide that supports preventative perinatal care? 1. The risk for neonatal cerebral palsy increases with folic acid deficiencies during pregnancy. 2. Folic acid can significantly reduce the incidence of mental retardation. 3. Adequate folic acid during embryogenesis reduces the incidence of neural tube defects. 4. The incidence of congenital heart defects is related to folic acid intake deficiencies.

3. Adequate folic acid during embryogenesis reduces the incidence of neural tube defects. Folic acid can significantly reduce neural tube defects (C) if taken during early pregnancy. (A, B, or D) are not valid explanations.

The nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics. The infant expels a bloody stool. What nursing action should the nurse implement? 1. Institute contact precautions. 2. Obtain a rectal temperature. 3. Assess for abdominal distention. 4. Decrease the amount of the feeding.

3. Assess for abdominal distention. Etiological factors playing an important role in the development of necrotizing enterocolitis (NEC), a complication common in premature infants, include intestinal ischemia, colonization by pathogenic bacteria, and substrate (formula feeding) in the intestinal lumen. Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of NEC. Nursing responsibilities include measuring the abdomen (C) and listening for bowel sounds. Contact precautions (A) are necessary if a contagious gastrointestinal infection is suspected. Rectal temperatures are contraindicated (B) because of the risk for perforation of the bowel. Oral or gavage feeding is stopped, not (D), until necrotizing enterocolitis is ruled out.

The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first? 1. Check the infant's arterial blood gases. 2. Notify the pediatrician of the infant's vital signs. 3. Assess the infant's blood glucose level. 4. Encourage the infant to take the breast or sugar water.

3. Assess the infant's blood glucose level. The nurse should first assess the infant's blood glucose level (C), because the infant is displaying signs of hypothermia (normal newborn axillary temperature is 96 to 98 F) and hypoglycemia may occur as glucose is metabolized in an effort to meet cellular energy demands. The infant's respiratory and heart rates are within normal limits, so (A) is not a priority. (B and D) would be implemented after information regarding the blood sugar level has been obtained.

A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon fundal assessment, the nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement next? 1. Document the color of the lochia. 2. Observe maternal vital signs. 3. Assist the client to the bathroom. 4. Notify the healthcare provider.

3. Assist the client to the bathroom. Fundus displacement commonly occurs in the early hours of the postpartum period due to urinary retention, so assisting the client to the bathroom (C) to void should be implement next. (A and B) can be completed after the client's bladder is emptied. (D) should only be implemented if the fundus does not become firm or lochial bleeding continues after the bladder is emptied.

A multigravida client at 35-weeks gestation is diagnosed with pregnancy-induced hypertension (PIH). Which symptom should the nurse instruct the client to report immediately? 1. Backache. 2. Constipation. 3. Blurred vision. 4. Increased urine output.

3. Blurred vision. Blurred vision, headache, visual changes, and epigastric discomfort are the most common symptoms experienced by a client with PIH and may indicate impending seizures and should be reported.

When assessing a newborn infant's heart rate, which technique is most important for the nurse to use? 1. Quiet the infant before counting the heart rate. 2. Listen at the apex of the heart. 3. Count the heart rate for at least one full minute. 4. Palpate the umbilical cord

3. Count the heart rate for at least one full minute. It is most important for the nurse to count the heart rate for at least one full minute (C) so that irregularities or murmurs can be detected. (A) is not necessary for the heart rate to be correctly auscultated. The heart rate can be heard clearly over any point of an infant's chest, not just (B). Immediately after delivery, (D) will allow the nurse to assess the rate, but (B) is the most accurate method of obtaining a newborn's heart rate.

The nurse is planning for the care of a 30-year-old primigravida with pre-gestational diabetes. What is the most important factor affecting this client's pregnancy outcome? 1. Mother's age. 2. Amount of insulin required prenatally. 3. Degree of glycemic control during pregnancy. 4. Number of years since diabetes was diagnosed.

3. Degree of glycemic control during pregnancy. Clients with tight glucose control and no blood vessel disease should have positive pregnancy outcomes (C). Risk assessment is best done by evaluating the woman's blood glucose and blood vessels, not by evaluating mother's age (A), number of years since diabetes was diagnosed (D), or the amount of insulin required prenatally (B).

Which action is most important for the nurse to implement for a client at 36-weeks gestation who is admitted with vaginal bleeding? 1. Monitor uterine contractions. 2. Apply disposable pads under the client. 3. Determine fetal heart rate and maternal vital signs. 4. Obtain blood samples for hemoglobin hematocrit levels.

3. Determine fetal heart rate and maternal vital signs. The priority nursing action is assessment of the fetal heart rate and maternal vital signs (C) to evaluate the impact of blood loss in the mother and fetus. Although monitoring uterine activity (A), applying pads to assess bleeding amount (B), and obtaining samples for hemoglobin and hematocrit levels (D) should be implemented, these are not as important as assessing maternal and fetal well-being.

The nurse is giving discharge instructions for a client following a suction curettage for hydatidiform mole. The client asks why oral contraceptives are being recommended for the next 12 months. What information should the nurse provide? 1. Oral contraceptives prevent a reoccurrence of a molar pregnancy. 2. Pregnancy within 1 year decreases the chances of a future successful pregnancy. 3. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy. 4. Molar reoccurrences are higher if conception occurs within 1 year after an initial mutation.

3. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy. The major risk after a molar pregnancy is the development of choriocarcinoma, which is detected by measuring the same hormone (hCG) that the body produces during pregnancy. Continued elevated hCG levels may be either from choriocarcinoma or a subsequent pregnancy making diagnosis and treatment difficult, so oral contraceptives are prescribed to prevent pregnancy for a year since it interferes with monitoring the return of hCG levels (C) to normal. (A, B, and D) are inaccurate.

The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at 32-weeks gestation who has severe preeclampsia with pulmonary edema. As the PAC enters the right ventricle, what is the priority nursing assessment? 1. Assess fetal response to the procedure. 2. Note any complaint of sudden chest pain. 3. Monitor for premature ventricular contractions. 4. Observe for maternal blood pressure changes.

3. Monitor for premature ventricular contractions. During and following the insertion of a pulmonary artery catheter (PAC), ECG activity should be monitored for the occurrence of any ventricular ectopy (C). Although fetal well-being (A) is important, the primary nursing assessment at this time is monitoring for immediate cardiac changes in the mother. Adverse cardiac responses to PAC insertion should first identify changes in the client's heart rhythm before the client complains of chest pain (B). Manual blood pressures (D) evaluate systemic perfusion, but the primary purpose in monitoring pulmonary artery pressures is to detect early cardiac changes due to left ventricular failure.

A client who is stable has family members present when the nurse enters the birthing suite to assess the mother and newborn. What action should the nurse implement at this time? 1. Ask to meet with the client and infant without family members present. 2. Do a brief assessment for only the infant while family members are present. 3. Observe interactions of family members with the newborn and each other. 4. Reschedule the visit so that the mother and infant can be assessed privately.

3. Observe interactions of family members with the newborn and each other. An opportunity to assess the emotional adjustment of individual family members to birth and lifestyle changes is presented, so the nurse should first observe the interaction of the family members (C). Although family members can remain during the assessment of the newborn (B), the mother should be assessed also. Privacy to assess the mother should be assured (A and D), but evaluation of the family dynamics provides essential data about mother-child bonding and should be determined at this time.

A client who is at 24-weeks gestation presents to the emergency department holding her arm and complaining of pain. The client reports she fell down the stairs. Which observation should alert the nurse to a possible battering situation? 1. The woman and her partner are having a loud and hostile argument. 2. The woman avoids eye contact and hesitates while answering questions. 3. Other parts of her body have injuries that are in different stages of healing. 4. Examination reveals a fracture to the right humerus and multiple bruises.

3. Other parts of her body have injuries that are in different stages of healing. A battered woman often has multiple injuries in various stages of healing (C). Hostile arguing, avoiding eye contact and traumatic injuries (A, B, and D)) are not always indications of battering.

A client in active labor at 39-weeks gestation tells the nurse she feels a wet sensation on the perineum. The nurse notices pale, straw-colored fluid with small white particles. After reviewing the fetal monitor strip for fetal distress, what action should the nurse implement? 1. Escort the client to the bathroom. 2. Offer the client a bed pan. 3. Perform a nitrazine test. 4. Clean the perineal area.

3. Perform a nitrazine test. The normal characteristic of amniotic fluid is pale, straw-colored fluid, which may contain white flecks of vernix, with an alkaline pH, so (C) should be done to confirm the pH of the fluid. (A or B) may be indicated if the fluid is urine. (D) should be done after determining the type of fluid expelled.

The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart rate occurring with the peak of each contraction. What action should the nurse implement? 1. Notify the healthcare provider of fetal status. 2. Give oxygen at 10 L per nasal cannula. 3. Place the client in a side-lying position. 4. Increase the flow rate of intravenous fluids.

3. Place the client in a side-lying position. Variable decelerations are caused by compression of the umbilical cord and are evidenced by V shape appearance, characterized by a rapid descent and ascent to and from the depth of the deceleration. To alleviate the pressure on the umbilical cord, the nurse should reposition the client into a side-lying position (C). Once the client is repositioned and evaluated, then (A, B, and D) should be implemented.

A primigravida at 37-weeks gestation tells the nurse that her "bag-of-water" has broken. While inspecting the client's perineum, the nurse notes the umbilical cord protruding from the vagina. What action should the nurse implement first? 1. Administer 10 L of oxygen via face mask. 2. Give the healthcare provider a status report. 3. Place the client in the knee-chest position. 4. Wrap the cord with gauze soaked in saline.

3. Place the client in the knee-chest position. Until an emergency delivery is accomplished, the client should be placed in a knee-chest position (C) to relieve compression of the presenting part on the umbilical cord, which can compromise fetal oxygenation. (A, B, and C) are implemented after the client is positioned to relieve pressure on the umbilical cord.

A woman, whose pregnancy is confirmed, asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide? 1. Excretes prolactin and insulin. 2. Produces nutrients for fetal nutrition. 3. Secretes both estrogen and progesterone. 4. Forms a protective, impenetrable barrier.

3. Secretes both estrogen and progesterone. One of the early functions of the placenta as an endocrine gland is the production of four hormones, hCG, hPL, estrogen, and progesterone (C), necessary to maintain the pregnancy and support the embryo and fetus. The placenta does not excrete prolactin and insulin (A). The placenta functions as a means of metabolic exchange between the maternal and fetal blood supplies, but it does not produce nutrients (B), and is not impenetrable (D) because many bacteria and viruses can cross the placental membrane.

A client in her second trimester of pregnancy asks if it is safe for her to have a drink with dinner. How should the nurse respond to the client? 1. During second trimester beer can be consumed without harm to the fetus. 2. Wine can be consumed several times a week after the first trimester. 3. Only one drink with the evening meal is not harmful to the fetus. 4. Abstinence is strongly recommended throughout the pregnancy.

4. Abstinence is strongly recommended throughout the pregnancy. A safe level of alcohol consumption during pregnancy has not yet been established, so although the consumption of occasional alcoholic beverages may not be harmful to the mother or her developing fetus, complete abstinence is strongly advised (D). Beer (A), wine (B) or any alcoholic drink (C) consumption is not recommended during the pregnancy.

A newborn infant is jaundiced due to Rh incompatibility. Which finding is most important for the nurse to report to the healthcare provider? 1. Bruising. 2. Oral intake. 3. Hemoglobin. 4. Bilirubin.

4. Bilirubin. Neonatal erythrolysis due to Rh incompatibility causes rapid release of unconjugated bilirubin (D), which results in serum levels (hyperbilirubinemia) that place the infant at risk for neurological damage (kernicterus). (A, B, and C) may influence the serum bilirubin level, but the most significant finding is the serial bilirubin levels that determines the need for early intervention.

While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross the suture lines. How should the nurse document this finding? 1. Molding. 2. Hemangioma. 3. Cephalohematoma. 4. Caput succedaneum.

4. Caput succedaneum. Caput succedaneum (D) is characterized by swelling of the soft tissues of the scalp that extends across suture lines. Molding (A) of the head results from adjustment of the infant's skull structure, which allows for the passage of the infant's head through the birth canal and is a common occurence in vaginal deliveries. Hemangioma (B) is a collection of blood vessels close to the skin. Cephalohematoma (C) is an edematous area caused by extravasation of blood between the skull bone and periosteum and does not cross the suture lines, which differentiates it from caput succedaneum.

A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to 70 mm Hg at the peak of a contraction and the resting tone is 6 to 10 mm Hg. Based on this information, what action should the nurse implement? 1. Notify the client's healthcare provider. 2. Bring the delivery table to the room. 3. Prepare to administer an oxytocic. 4. Document the findings in the client record.

4. Document the findings in the client record. This labor pattern indicates that the client is in the active phase of the first stage of labor and has a normal labor pattern, so the findings should be documented in the client's medical record (D). There is no indication to notify the healthcare provider (A) or bring the delivery table into the room (B) at this time. Oxytocin augmentation (C) is not needed for this labor pattern.

The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37-weeks gestation. What nursing action should be implemented first? 1. Provide tactile stimulation. 2. Administer flow by 100% oxygen. 3. Asses the functionality of the monitoring device. 4. Evaluate the newborn's color and respirations.

4. Evaluate the newborn's color and respirations. Monitors are an effective method for continual appraisal of a neonate's respirations, but a visual assessment of the infant oxygenation and respiratory status (D) should be implemented first. If the infant is not breathing, then tactile stimulation (A) should be given for no longer than 10 to 15 seconds before initiating CPR. Oxygen should be administered or increased (B) after determining the neonate's respiratory status. If there is normal color and presence of respirations after assessment, then possible causes of a false alarm (C) should be investigated for mechanical malfunction of the device.

Which client finding should the nurse document as a positive sign of pregnancy? 1. Last menstrual cycle occurred 2 months ago. 2. A urine sample with a positive pregnancy test. 3. Presence of Braxton Hicks contractions. 4. Fetal heart tones (FHT) heard with a doppler.

4. Fetal heart tones (FHT) heard with a doppler. Fetal heart tones (D) are a positive sign of pregnancy because these signs are attributed to the presence of a fetus. (A) is a presumptive sign of pregnancy as described by the client. (B and C) are probable signs of pregnancy that are best evaluated by the healthcare provider.

A preterm infant with an apnea monitor experiences an apneic episode. Which action should the nurse implement first? 1. Ventilate with an Ambu bag. 2. Perform nasal and airway suctioning. 3. Administer supplemental oxygen. 4. Gently rub the infant's feet or back.

4. Gently rub the infant's feet or back. Gentle stimulation of the infant's feet and back (D) can cause an infant to resume spontaneous respirations. If the infant does not respond to manual stimulation, resuscitative measures should be implemented using Ambu bag ventilation (A), suctioning (B), and the administration of oxygen (C).

When discussing birth in a home setting with a group of pregnant women, which situation should the nurse include about the safety of a home birth? 1. Only the woman and her midwife should be present during the delivery. 2. The woman should live no more than 15 minutes from the hospital. 3. The woman's extended family should be allowed to attend the home birth. 4. Medical backup should be available quickly in case of complications.

4. Medical backup should be available quickly in case of complications. Access to quick emergency care should be available in the event that an unforeseen complication arises (D) during a home birth. Although the nurse-midwife should be a competent healthcare provider during a home birth (A), access to emergency, surgical, and resuscitation assistance should be readily available. A 15-minute drive to the hospital is ideal, but (B) does not ensure the safest situation. The presence and support of family during the home birth (C) does not necessarily ensure a safe home birth.

Which procedure evaluates the effect of fetal movement on fetal heart activity? 1. Sonography. 2. Contraction test. 3. Biophysical profile. 4. Non-stress test (NST).

4. Non-stress test (NST). A non-stress test (NST) (D) evaluates the ability of the fetal heart to accelerate either spontaneously or in association with fetal movement. Sonographic examinations visualize the fetus (A) and are done for various reasons. A contraction test evaluates the fetal reaction to contractions (B). The biophysical profile evaluates fetal status using many variables (C).

Which finding for a client in labor at 41-weeks gestation requires additional assessment by the nurse? 1. Cervix dilated 2 cm and 50% effaced. 2. Score of 8 on the biophysical profile. 3. Fetal heart rate of 116 beats per minute. 4. One fetal movement noted in an hour.

4. One fetal movement noted in an hour. A count of less than three fetal movements within 1 hour (D) warrants further evaluation using nonstress or contraction stress testing, biophysical profile, or a combination of these tests. A cervical exam of 2 cm and 50% effacement (A) and a fetal heart rate of 116 (C) are normal findings. A score of 8 on a biophysical profile (B) indicates a normal infant with low risk for chronic asphyxia.

Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate? 1. Tactile stimulation. 2. Commercial warm packs. 3. Skin-to-skin contact with parent. 4. Oral sucrose and nonnutritive sucking.

4. Oral sucrose and nonnutritive sucking. Studies of nonpharmacologic interventions for pain in the newborn most frequently indicate that the administration of oral sucrose and nonnutritive sucking (D), such as the provision of a pacifier, are effective in reducing objective indicators of pain after an invasive procedure. Other interventions, such as tactile stimulation (A) during apnea and bradycardic episodes and warm packs (B) for thermoregulation, have not been shown to reduce pain responses. Skin-to-skin contact (C) fosters neurobehavioral development and supporting parent-infant intimacy and attachment, but sucking behaviors provide the most effective pain-comfort responses.

Which client should the nurse report to the healthcare provider as needing a prescription for Rh Immune Globulin (RhoGAM)? 1. Woman whose blood group is AB Rh-positive. 2. Newborn with rising serum bilirubin level. 3. Newborn whose Coombs test is negative. 4. Primigravida mother who is Rh-negative.

4. Primigravida mother who is Rh-negative. RhoGAM is indicated during pregnancy for a woman who is Rh-negative or within 72 hours of birth of a Rh-positive infant (D). RhoGAM is not indicated for (A, B,and C).

The nurse assesses a high-risk neonate under a radiant warmer who has an umbilical catheter and identifies that the neonate's feet are blanched. What nursing action should be implemented? 1. Place socks on infant. 2. Elevate feet 15 degrees. 3. Wrap feet loosely in prewarmed blanket. 4. Report findings to the healthcare provider.

4. Report findings to the healthcare provider. Vasoconstriction of peripheral vessels, which can seriously impair circulation, is triggered by arterial vasospasm caused by the presence of the catheter, the infusion of fluids, or the injection of medication. Blanching of the buttocks, genitalia, or the legs or feet is an indication of vasospasm and should be reported immediately to the healthcare provider (D). (A, B, and C) do not provide effective resolution of this potentially serious complications.

The nurse is providing discharge teaching for a gravid client who is being released from the hospital after placement of cerclage. Which instruction is the most important for the client to understand? 1. Plan for a possible cesarean birth. 2. Arrange for home uterine monitoring. 3. Make arrangements for care at home. 4. Report uterine cramping or low backache.

4. Report uterine cramping or low backache. Uterine cramping and low back pain (D) are symptoms of preterm labor and should be reported to the healthcare provider immediately because the cerclage may need to be removed. A cesarean birth can be planned (A) or the cerclage can be removed at 37-weeks gestation to prepare for a vaginal birth. Home uterine activity monitoring (B) is used to limit the woman's need for visits and to safely monitor her status at home. Bed rest is an element of care so the client should make arrangements for care at home (C) and someone to do household chores. (A, B, and C) do not have the priority of (D).

A 36-week gestation client with pregnancy-induced hypertension (PIH) is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider? 1. Blood pressure of 100/60 mm Hg. 2. Fetal heart rate of 120 to 125 beats/minute. 3. Contractions occurring every 30 minutes. 4. Respiratory rate of 11 breaths/minute.

4. Respiratory rate of 11 breaths/minute. A sign of magnesium toxicity is respiratory depression, so the client's respiration rate of 11 breaths/minute (D) should be reported to the healthcare provider. (A, B, and C) are expected findings for a 36-week gestation client with PIH.

What information should the nurse include about perineal self-care for a client who is 24-hours post delivery? 1. Use cool water to decrease swelling of the perineum. 2. Perineal care should be done at least twice per day. 3. Reapply ice packs to perineum after each voiding. 4. Spray warm water from front to back using a squeeze bottle.

4. Spray warm water from front to back using a squeeze bottle. A postpartum client should use a squeeze bottle after each void and clean from front to back (D). Use of cool water (A) in the perineal bottle does not significantly reduce edema after the first 24 hours post partum. Perineal care (B) should be implemented each time the client toilets, not BID (B). Ice applications (C) are not usually indicated after the first 24 hours post delivery.

A client delivers her first infant and asks the nurse if her skin changes from pregancy are permanent. Which change should the nurse tell the client will remain after pregnancy? 1. Pruritus. 2. Chloasma. 3. Vascular spiders. 4. Striae gravidarum.

4. Striae gravidarum. Striae gravidarum (D), or "stretch marks," occur on the lower abdomen of pregnant women during the second half of pregnancy fade after delivery but do not disappear entirely because they reflect separation within the underlying connective (collagen) tissue of the skin. Pruritis (A) is a temporary skin condition most commonly caused by cholestasis. Chloasma (B), or "mask of pregnancy," is a temporary, blotchy, brownish hyperpigmentation caused by hormonal levels of pregnancy. Vascular spiders (C), or "angiomas," are small, pulsating end arterioles, found on the upper body, that occur as a result of increased circulating estrogen, which usually disappear soon after delivery.

What nursing action should be included in the plan of care for a newborn experiencing symptoms of drug withdrawal? 1. Play soft music and talk to soothe the infant. 2. Administer chloral hydrate for sedation. 3. Feed every 4 to 6 hours to allow extra rest. 4. Swaddle the infant snugly and hold tightly.

4. Swaddle the infant snugly and hold tightly. An infant experiencing drug withdrawal should be swaddled, wrapped snugly, or placed in a "kangaroo pouch" to reduce self-stimulation behaviors and protect skin from abrasions that may occur due to muscular irritability (D). Music or talking to the infant is more likely to stimulate the infant and increase CNS irritability and should be minimized (A). Phenobarbital or diazepam are used to decrease central nervous system (CNS) irritability, not (B). To diminish aspiration and maintain hydration, the infant should be given small, frequent feedings followed by successful burping or bubbling.

The nurse is caring for a client whose labor is being augmented with oxytocin (Pitocin). Which finding indicates that the nurse should discontinue the oxytocin infusion? 1. The client needs to void. 2. Amniotic membranes rupture. 3. Uterine contractions occur every 8 to 10 minutes. 4. The fetal heart rate is 180 bpm without variability.

4. The fetal heart rate is 180 bpm without variability. A fetal heart rate (FHR) without variability (D) is a non-reassuring finding that indicates the oxytocin should be discontinued, and the healthcare provider should be notified. A client's urge to void (A) is not an indication to discontinue the oxytocin infusion used for induction. The oxytocin infusion should not be discontinued when the amniotic membranes rupture (B) unless there are non-reassuring changes in the FHR pattern or uterine hyperstimulation occurs, and (C) does not qualify as uterine hyperstimulation.

A client states, "During the three months I've been pregnant, it seems like I have had to go to the bathroom every five minutes." Which explanation should the nurse provide to this client? 1. The client may have a bladder or kidney infection. 2. Bladder capacity increases during pregnancy. 3. During pregnancy a woman is especially sensitive to body functions. 4. The growing uterus is putting pressure on the bladder.

4. The growing uterus is putting pressure on the bladder. Urinary frequency is a normal discomfort (D) during the first trimester, when the enlarging uterus is still low in the pelvis. It encroaches on the bladder, reducing its capacity. Although urinary frequency is a symptom of bladder infection, it is usually accompanied by other symptoms such as burning on urination, and a kidney infection is usually accompanied by pain and fever (A). Bladder capacity does increase to about 1,500 ml during pregnancy (B), but increased capacity does not cause urinary frequency. There is not enough data to reach the conclusion in (C).

A client at 8-weeks gestation ask the nurse about the risk for a congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur? 1. It depends on what the causative factors are for a CHD. 2. We don't really know what or when CHDs occur. 3. They usually occur in the first trimester of pregnancy. 4. The heart develops in the third to fifth weeks after conception.

4. The heart develops in the third to fifth weeks after conception. The cardiovascular system is the first organ system to develop and function in the embryo. The blood vessel and blood formation begin in the third week, and the heart is developmentally complete in the fifth week (D). Regardless of the etiological factor, the heart is vulnerable during its period of development -- the third to fifth weeks. (A, B, and C) are inaccurate.

An infant who weighs 3.8 kg is delivered vaginally at 39-weeks gestation with a nuchal cord after a 30-minute second stage. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide the parents about this finding? 1. Further assessment is indicated. 2. Petechiae occurs with forceps delivery. 3. An increased blood volume causes broken blood vessels. 4. The pinpoint spots are benign and disappear within 48 hours.

4. The pinpoint spots are benign and disappear within 48 hours. Rapid delivery and a tight nuchal cord cause the presenting parts (head) to have bruising and pin point hemorrhages (petechiae), which are benign and usually disappear within two days after birth (D). (A) is not indicated. Birth injuries caused by forceps (B) present as linear configuration across both sides of the face and outline the placement of the forceps. (C) is inaccurate.