Maternity Practice Questions 2 (Dr. Hernandez)

A nurse is caring for a postpartum client. Medical History Gravida 1, Para 1 Spontaneous vaginal birth 39 weeks of gestation Breastfeeding Nurses Notes Postpartum day 1: Client is breastfeeding newborn every 4 to 5 hr for 30 to 40 minutes each time. Client reports some nipple discomfortduring the feedings. Assisted client with positioning and latch. Recommended the client awaken the newborn to feed every 3 hr during the day. Newborn voided twice and passed two meconium stools in the past 24 hr. Postpartum day 2: Client reports breastfeeding every 3 to 4 hr. Client reports nipple discomfort during some feedings. No physical findings of nipple trauma are noted. Breasts are soft. Client denies feelings of fullness. Newborn voided twice and passed three meconium stools in the second 24 hr of life. Discharge teaching provided to client regarding breastfeeding. Vital Signs Newborn Daily Weights: Birth weight 3,515 gm (7 lb 12 oz) Weight after 24 hr: 3,410 gm (7 lb 8 oz) (3% weight loss) Weight after 48 hr: 3,345 gm (7 lb 4 oz) (5% weight loss) Which of the following statements by the client indicates an understanding of the discharge teaching? Click to highlight the client statements that indicate an understanding of the discharge teaching. "Because of my baby's weight loss, I need to supplement with formula after breastfeeding." "I should make sure that my baby feeds 8 to 12 times per day." "I should cover my sore nipples with plastic-lined breast pads after every feeding." "My baby's stools should turn to a yellow color within the next day or two." "I can increase my milk supply by drinking more water

"I need to make sure that my baby feeds 8 to 12 times per day" is correct. Newborns should feed 8 to 12 times per day, although it may not be on a regular schedule. Some newborns feed every hour for a few hours and then sleep for a longer period of time. During the first few days of life, newborns might need to be awakened to ensure adequate frequency of feedings. "My baby's stools should turn to a yellow color within the next day or two" is correct. The newborn's stools will change in color and consistency as the client's milk comes in. The stools will change from a thick, sticky, dark green color, and consistency to a yellow seedy consistency. If the newborn is still passing meconium stools after day 4 of life, the client should notify the newborn's provider. "I should expect my breasts to become harder, warmer, and more tender when my milk comes in" is correct. Breastmilk typically transitions from low volume colostrum to high volume mature breastmilk between days 3 and 5 postpartum. Clients will note a change in the firmness, temperature, and comfort of their breasts when this occurs.

A nurse is teaching a client who is breastfeeding about dietary recommendations. Which of the following statements by the client indicates understanding of the teaching? "I will decrease my daily fiber intake." "I'll make sure I reduce salt in my diet." "I'll eat more protein at each meal." "I will consume more vitamin D-rich foods."

"I'll eat more protein at each meal." During lactation, clients should consume about 25 g of additional protein per day, which is more than what is required by nonpregnant and nonlactating female clients.

A nurse is providing discharge teaching to a client who has a new prescription for verapamil for angina. Which of the following instructions should the nurse include? "Limit your fluid intake to meal times." "Do not take this medication on an empty stomach." "Increase your daily intake of dietary fiber." "You can expect swelling of the ankles while taking this medication."

"Increase your daily intake of dietary fiber." The nurse should instruct the client to increase his daily intake of dietary fiber to reduce the risk of constipation associated with verapamil.

A nurse is teaching a client who has a new prescription for colesevelam to lower his low-density lipoprotein level. Which of the following instructions should the nurse include? "Take this medication 4 hr after other medications." "Reduce fluid intake." "Take this medication on an empty stomach." "Chew tablets before swallowing."

"Take this medication 4 hr after other medications." The client should take this medication 4 hours after other medications to increase absorption of the medication.

A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate? "The newborn might be actively shedding the virus." "The newborn is at risk for developing a TORCH infection." "The child might develop encephalitis, a complication of rubella." "Exposure to rubella will suppress the newborn's immune response."

"The newborn might be actively shedding the virus." Infants born to mothers who have rubella will continue to shed the rubella virus for up to 18 months postdelivery.

A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone gel. Which of the following statements should the nurse include in the teaching? "This medication promotes softening of the cervix." "This medication is used to treat preeclampsia." "It causes relaxation of the uterine muscles." "It is used to treat genital herpes simplex virus."

"This medication promotes softening of the cervix." Dinoprostone is used to prepare (or ripen) the cervix for the induction of labor in clients who are at term.

A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make? "You need to take pain medications so you are more comfortable." "We can time your pain medication so that you have an hour or two before the next feeding." "All medications are found in breast milk to some extent." "You have the option of not taking pain medication if you are concerned."

"We can time your pain medication so that you have an hour or two before the next feeding." This answer provides the client an option that allows for administration of pain medication but minimizes the effect it will have on the newborn while breastfeeding.

A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer? "You must be feeling scared and powerless." "Everyone worries about her baby when she's in labor." "Your pregnancy is advanced so your baby should be fine." "We have a neonatal unit here that's equipped to handle emergencies."

"You must be feeling scared and powerless." This response illustrates the therapeutic communication technique of restatement. The nurse shows empathy for the client by recognizing that the client is concerned about the safety of the fetus and is powerless to do anything about the situation. This open-ended statement encourages further communication by the client.

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make? "You should place your nipple and some of the areola into her mouth." "Babies know instinctively how much of the nipple to take into their mouth." "Your baby's mouth is rather small so she will only take part of the nipple." "Try to place the nipple, the areola, and some breast tissue beyond the areola into her mouth."

"You should place your nipple and some of the areola into her mouth." Placing the nipple and 2 to 3 cm of areolar tissue around the nipple into the baby's mouth aids in adequately compressing the milk ducts. This placement decreases stress on the nipple and prevents cracking and soreness

A nurse in a prenatal clinic is teaching a group of clients about nutrition requirements during lactation. Which of the following statements should the nurse make? "Calcium intake should be at least 2,000 mg per day." "Zinc intake should be at least 12 mg per day." "The recommended intake of folic acid remains the same as for pregnant women." "The recommended intake of iron increases."

"Zinc intake should be at least 12 mg per day." Zinc intake should be increased to 12 mg per day during lactation, which is above the recommended levels for pregnancy and nonpregnant female clients over age 19.

A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor? Decreased vaginal discharge A surge of energy Urinary retention Weight gain of 0.5 to 1.5 kg

A surge of energy Prior to the onset of labor, the pregnant client experiences a surge of energy.

A nurse is caring for a client who is at 32 weeks of gestation. Vital Signs 0800: Oral temperature 36.7 °C (98.0 °F) Heart rate 100/min Respiratory rate 20/min Blood pressure 100/50 mm Hg SaO2 96% on room air (>95%) 0830: Heart rate 105/min Respiratory rate 20/min Blood pressure 90/52 mm Hg SaO2 96% on room air (>95%) 0900: Heart rate 115/min Respiratory rate 22/min Blood pressure 86/50 mm Hg SaO2 95% on room air (>95%) Nurses Notes 0800: Client placed on electronic fetal monitor and positioned to the left lateral side. Fetal heart tone 170/min, minimal variability noted. Abdomen firm/rigid and tender to palpation. Saturated peri pad noted with dark red vaginal bleeding. Peri care provided; pad changed. 0830: Fetal heart tone 180/min, uterine contractions noted every 1 to 2 min, 60 second duration, strong to palpation, uterine tone remains hard between contractions. Client reports pain as 8 on a scale of 0 to 10. Facial grimacing and moaning noted. Peri pad saturated with dark red vaginal bleeding. Peri care provided; pad changed. Provider contacted, report given, prescription received 0845: 16-gauge IV catheter inserted into right hand and connected to lactated Ringer's at 125 mL/hr. Client tolerated procedure well. Blood collected and sent to lab. 0855: Indwelling urinary catheter insert without difficulty, 100 mL of amber urine noted. Fetal heart tone 180's with no variability noted, late decelerations noted. Uterine contractions every 1 to 2 min. 40 to 70 duration and strong to palpation, uterine tone remains hard between contractions. 0900: Provider noted of client's status, vital signs, and diagnostic test. Provider on way to examine the client. Medical History 0800: A client who is gravida 4, para 3, at 32 weeks of gestation presents to the antepartum clinic with reports of dark red vaginal bleeding and saturating two peri pads in the past 2 hr. Client reports abdominal pain. Abdomen is rigid and tender to palpation. Provider's Prescriptions 0800: Admit to antepartum unit Continuous fetal monitoring Vital signs per protocol 0830: Hgb, Hct, and platelet count Strict I&O Initiate 16 gauge IV with lactated Ringer's at 125 mL/hr Insert indwelling urinary catheter 0900: Prepare for cesarean birth Diagnostic Results 0900: Hgb 8 g/dL (12 to 16 g/dL) Hct 27% (greater than 33%) Platelet count 100,000/mm³ (150,000 to 400,000/mm³) A nurse reviews the assessment findings and determines the findings are consistent with which of the following complications? For each finding, click to specify if the assessment findings is consistent with placenta previa or abruptio placentae. Each finding may support more than one disease process. Assessment Findings Placenta Previa Abruptio Placentae Uterine tone Abdominal assessment Abdominal pain level Hemoglobin level Description of vaginal bleeding

Abdominal assessment is consistent with abruptio placentae. This client's abdomen is firm, rigid, and tender to palpation, which is caused by the premature separation or detachment of the implanted placenta from the uterus. Hemoglobin level is consistent with abruptio placentae and placenta previa. Clients who experience abruptio placentae and placenta previa are at an increased risk for hemorrhage and hypovolemia due to the blood loss associated with these conditions. This client's hemoglobin is 8 g/dL, which is below the expected reference range of 12 to 16 g/dL, and is an indicator of excessive blood loss. Uterine tone is consistent with abruptio placenta. The client's abdomen is hard to palpation between contractions, which is consistent with abruptio placentae. The abdomen of a client who has placenta previa will be soft and relaxed when palpated. Abdominal pain level is consistent with an abruptio placenta. Findings associated with an abruptio placentae include moderate to severe pain. This client reports their pain as an 8 on a scale of 0 to 10. Clients who have placenta previa do not report pain. Description of vaginal bleeding is consistent with an abruptio placenta. Clients who have abruptio placentae have dark red bleeding as indicated in the client's medical record. Clients who have placenta previa present with bright red vaginal bleeding.

A nurse is caring for a newborn who is 72 hr old. Vital Signs Medical History Physical Examination Vital Signs 0900: Heart rate 160/min Respiratory rate 80/min Temperature 38.1° C (100.6° F) Oxygen saturation 97% 1000: Heart rate 167/min Respiratory rate 72/min Temperature 38°C (100.4°F) Oxygen saturation 97% 1100: Heart rate 174/min Respiratory rate 79/min Temperature 38° C (100.5° F) Oxygen saturation 98% Medical History 0900: A term newborn 37 weeks of gestation is admitted to the newborn nursery following a precipitous vaginal birth. Birthing parent has a history of heroin use during pregnancy and prenatal care beginning at 34 weeks of gestation. Birthing parent and newborn drug screens positive for heroin. Physical Examination 1100: Neonatal Abstinence Scoring System (NAS) Excessive high-pitched cry=2 Sleeps < 2 hr=2 Hyperactive Moro reflex=2 Moderate- severe tremors disturbed=2 Increased muscle tone=2 Fever < 37.2 to 38.2° C (99 to 100.8° F)=1 Excessive sucking=1 Frequent sneezing=1 Frequent yawning=1 Loose stools=2 Poor feeding=2 Respiratory rate > 60/min=1 Mottling=1 NAS score 20 The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions should the nurse anticipate? Select the 3 interventions the nurse should anticipate. Encourage the birthing parent to breastfeed. Swaddle the newborn. Administer oral morphine. Administer naloxone for NAS scores greater than 24. Continue NAS scoring as prescribed.

Administer oral morphine is correct. The nurse should administer oral morphine to assist with decreasing the withdrawal findings in the newborn. The dosage of the medication is adjusted based on the NAS scores of the newborn. Swaddle the newborn is correct. The nurse should swaddle the newborn and reduce the environmental stimuli for newborns with NAS to assist with decreasing the manifestations the newborn is experiencing. Continue NAS scoring as prescribed is correct. The nurse should continue conducting NAS scoring as prescribed in order to evaluate the newborn's clinical findings and status. The score obtained will assist with determining the dosage of morphine to administer.

A nurse is planning to administer ceftriaxone IM to an adult client. Which of the following actions should the nurse plan to take? Administer the medication using a 5/8-inch needle. Administer the medication at a 45° angle. Administer the medication in the deltoid muscle. Administer the medication using a Z-track technique.

Administer the medication using a Z-track technique. The Z-tract technique is used to reduce pain and prevent medication to leak into subcutaneous tissue.

A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take? Administer oxygen via nasal cannula. Assist the client to breathe into a paper bag. Have the client tuck her chin to her chest. Instruct the client to increase her respiratory rate to more than 42 breaths per min.

Assist the client to breathe into a paper bag. This client is experiencing respiratory alkalosis due to hyperventilation. The client should be assisted to breathe into a paper bag or to cup her hands over her mouth to increase the carbon dioxide level, which replaces the bicarbonate ion.

A nurse caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions? Asthma Glaucoma Depression Migraines

Asthma Propranolol, a beta-blocker, is contraindicated in clients who have asthma because it can cause bronchospasms. Propranolol blocks the sympathetic stimulation, which prevents smooth muscle relaxation.

A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus? At the level of the umbilicus 2 cm above the umbilicus One fingerbreadth above the symphysis pubis To the right of the umbilicus

At the level of the umbilicus Within 12 hr, the fundus should be palpable at the level of the umbilicus and then recede 1 to 2 cm each day.

A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority? Platelets 200,000/mm3 Bilirubin 19 mg/dL Blood glucose 45 mg/dL Hemoglobin 22 g/dL

Bilirubin 19 mg/dL Bilirubin 19 mg/dL is above the expected reference range for a newborn at 4 hr of age. A bilirubin level greater than 15 mg/dL or an increase by more than 6 mg/dL in 24 hr is pathologic or nonphysiologic jaundice. Pathologic jaundice is a result of an underlying disease and occurs before 24 hr of age; therefore, this is the nurse's priority finding.

A nurse is caring for a newborn who is 30 min old. Medical History Spontaneous vaginal birth with dark brown-greenish amniotic fluid noted during labor 42 weeks gestation Apgar scores: 8 at 1 min; 9 at 5 min Nurses' Notes 1030: Newborn placed on the birth parent's abdomen immediately following birth. Mouth and nose suctioned with bulb syringe. Dried and stimulated. Strong cry noted. Moving all extremities. Flexed tone noted. Acrocyanosis present. 1100: Newborn is alert and active. Respirations rapid and shallow with occasional expiratory grunting. Fine crackles auscultated throughout lung fields. Small amount of green-stained vernix present in skin folds. Fingernails stained green. Molding of skull and generalized soft occipital swelling noted. Vital Signs 1030: Axillary temperature 36.9° C (98.4° F) Heart rate 170/min Respiratory rate 72/min 1100: Birth weight 4,025 gm (8 lb 14 oz) (Appropriate for Gestational Age) Axillary temperature 36.7° C (97.8° F) Heart rate 162/min Respiratory rate 80/min Drag 1 condition and 1 client finding to fill in each blank in the following sentence. After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk?The condition that poses the greatest risk to the newborn is Condition due to Finding. Condition jaundice meconium ileus cold stress hypoglycemia meconium aspiration syndrome Finding gestational age color of amniotic fluid birth weight Apgar scores acrocyanosis

Condition Meconium aspiration syndrome is correct. The nurse should identify that meconium aspiration syndrome is the complication that poses the greatest risk to the newborn because this can result in both a mechanical obstruction in the airways and a chemical pneumonitis. The presence of meconium-stained amniotic fluid at birth increases the risk that the fetus could inhale the meconium into their lungs while in utero or during the birth process. The nurse should monitor the newborn for signs of respiratory distress frequently and intervene if there are any unexpected findings. Finding Color of amniotic fluid is correct. The presence of meconium in the amniotic fluid at delivery increases the risk for meconium aspiration syndrome and meconium ileus.

A nurse in an antepartum clinic is caring for a client who is pregnant. Vital Signs 0800: Temperature 36.6° C (97.9° F) Pulse 85/min Respiratory rate 20/min Blood pressure 180/99 mm Hg 0815: Pulse 88/min Respiratory rate 16/min Blood pressure 178/106 mm Hg 0830: Pulse 84/min Respiratory rate 18/min Blood pressure 174/105 mm Hg Medical History 0815: Gravida 4 Para 3 33 weeks of gestation Allergies: Sulfa Height 165 cm (66 in) Weight 82 kg (180 lb) BMI 30.6 3.2 kg (7 lb) weight gain over the last 2 weeks Nurses' Notes Client reports, "I have had a headache for 2 days. Tylenol does not relieve it. I have blurred vision and dizziness." Client reports swelling of their feet. 2+ pitting edema of the lower extremities noted bilaterally Deep tendon reflexes 3+, absent clonus Fetal heart tones (FHT) 150/min Select the 4 assessment findings the nurse should report to the provider. Deep tendon reflexes Visual disturbances Fetal heart rate Blood pressure Weight

Deep tendon reflexes is correct. The client has deep tendon reflexes of 3+, which is above the expected reference range and requires immediate follow-up. Hyperreflexia occurs due to increased central nervous system irritability that is caused from vasospasms and decreased organ perfusion, which cause cortical brain spasms. The nurse should report this finding to the provider. Visual disturbances is correct. The client reports blurred vision, which is caused from vasospasms and decreased organ perfusion, causing retinal arteriolar spasms. Increased central nervous system irritability can manifest as visual disturbances. The nurse should report this finding to the provider. Blood pressure is correct. The client's blood pressure is above the expected reference range and requires immediate follow-up to rule out preeclampsia. One criterion for evaluating the client's blood pressure is a systolic blood pressure greater than 30 mm Hg and a diastolic blood pressure greater than 15 mm Hg above the client's prepregnancy blood pressure value. The nurse should report this finding to the provider. Weight is correct. The client has gained 3.2 kg (7 lb) over the past 2 weeks. This is above the expected weight gain of 0.45 kg (1 lb) per week. The nurse should report this to the provider.

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take? Discontinue the medication infusion. Prepare for an emergency cesarean birth. Assess maternal blood glucose. Place the client in Trendelenburg position.

Discontinue the medication infusion. Magnesium toxicity is manifested by bradypnea (respiratory rate less than 12/min) and absent deep tendon reflexes. The magnesium sulfate infusion should be discontinued and calcium gluconate administered via IV.

A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.) Document fundal height. Massage a firm fundus. Observe the lochia during palpation of fundus. Determine whether the fundus is midline. Administer methylergonovine maleate if uterus is boggy.

Document fundal height is correct.Fundal height should be documented each time it is assessed. The return of the uterus to a nonpregnant state following birth is called involution, which begins immediately after birth. At the end of the third stage of labor, the uterus should be midline approximately 2 cm below the level of the umbilicus. Within 12 hr postpartum, the fundus might rise to approximately 1 cm above the umbilicus. The nurse must monitor and palpate the fundus for location and tone to detect the risk of postpartum hemorrhage. Observe the lochia during palpation of fundus is correct. During palpation of the fundus, the nurse should expect and observe an increase in lochia. The appearance of lochia changes as the client progresses in the postpartum period. Lochia is initially red (rubra: 1 to 3 days); pink/brown (serosa: 4 to 10 days); and yellow/white (alba: 11 days to 6 weeks). The color and amount of lochia indicates sloughing of the lining of the uterus. An increase in the amount of lochia and the presence of large clots might indicate postpartum hemorrhage. Determine whether the fundus is midline is correct. The nurse must monitor and palpate the fundus for location and tone. The fundus should be firm and midline. A full bladder can cause the uterus to be displaced to one side. Administer methylergonovine maleate if uterus is boggy is correct. The nurse should assist the client with urination immediately followed by uterine massage to stimulate uterine contraction. If the uterus is boggy, the nurse should massage the uterus to stimulate the uterus to contract. Methylergonovine maleate is an ergot alkaloid used to promote uterine contractions and prevent hemorrhage. The nurse should monitor hypertension with the administration of this medication because of smooth muscle vasoconstriction. This medication can be prescribed as scheduled or PRN to meet the needs of the client. This medication is given intramuscularly (IM).

A nurse is preparing to administer medications to a client who states, "I don't want to take those drugs." Which of the following actions should the nurse take? Tell the client the physician wants him to take the medications. Ask the client why he is refusing to take the medications. Explain the purpose for the medications. Document that the client refuses the medications.

Document that the client refuses the medications. The client has the right to refuse the medication. It is appropriate for the nurse to document the client's refusal of the medications. The nurse should then inform the provider of the client's refusal.

A nurse is caring for a client who is in labor. Medical History Gravida 2, Para 1 28 weeks of gestation Previous cesarean section Asthma Vital Signs 1300: Temperature 37.2° C (98.9° F) Heart rate 84 /min Respiratory rate 18 /min Blood pressure 108/84 mm Hg Oxygen saturation 98% Nurses Notes 1300: Client reports increased clear vaginal leakage for the past 12 hr. Client denies cramping or contractions. Client reports fetal movement is present and unchanged. Client also reports a temporal headache for the past few hours and rates it as 2 on scale of 0 to 10. Moderate amount of clear vaginal drainage noted on client's perineal pad. Bilateral lower extremity non-pitting edema noted. Deep tendon reflexes 2+. Fundal height at 30 cm External fetal monitor applied. 1400: Fetal heart rate Category I at 150/min. Moderate variability. No accelerations or decelerations noted. No contractions noted. Diagnostic Results 1400: Speculum examination by provider: Cervix appears closed. Nitrazine test: blue-gray, pH 7.0, positive for rupture of membranes Microscopic examination of vaginal fluid: Crystalline ferning pattern After reviewing the information provided in the client's medical record, which of the following complications should the nurse identify that the client is at risk of developing? Complete the following sentence by using the list of options. The client is at great risk for developing Select... as evidenced by the client's Select... .

Drop Down 1: Chorioamnionitis is correct. The client is at risk for developing chorioamnionitis as evidenced by the client's leakage of vaginal fluid. Chorioamnionitis is a bacterial infection within the uterus during pregnancy. It occurs most often following the rupture of the amniotic membranes, which allows bacteria from the vagina to ascend into the amniotic cavity. Drop Down 2: Leakage of vaginal fluid is correct. The client is at risk for developing chorioamnionitis as evidenced by the client's leakage of vaginal fluid. Chorioamnionitis is a bacterial infection within the uterus during pregnancy. It occurs most often following the rupture of the amniotic membranes, which allows bacteria from the vagina to ascend into the amniotic cavity.

A nurse is caring for a newborn who is 4 hr old. Vital Signs 0800: Axillary temperature 36.5° C (97.7° F) Heart rate 132/min Respiratory rate 52/min Nurses Notes 0800: The newborn is alert and active with an occasional strong cry. Skin color is consistent with the newborn's genetic background. Anterior fontanel even and soft. Molding of skull noted with overlapping of sutures. Generalized soft swelling noted to the occipital area. Respirations easy and unlabored. Newborn is breastfeeding at least every 2 to 3 hr. Diagnostic Results 0900: ABO/Rh: A positive Coombs test, indirect: positive (negative) Urine toxicology screen: positive for cocaine Medical History Spontaneous vaginal delivery 4 hr ago Pregnancy complicated by maternal history of illicit drug use Birth weight 2,948 gm (6 lb 8 oz) Gestational age 38 weeks Maternal prenatal laboratory results: ABO/Rh: O+ Urine toxicology screen: positive for cocaine and marijuana (negative) After reviewing the information in the newborn's medical record, the nurse should recognize that the newborn is at risk for developing which of the following complications? Complete the following sentence by using the list of options. The newborn is at risk for developing Select... as evidenced by the Select... .

Drop Down 1: Jaundice is correct. The newborn has a risk of developing jaundice as evidenced by the indirect Coombs test. A positive indirect Coombs test indicates the presence of anti-A and anti-B maternal antibodies within the newborn's blood. These antibodies will result in an accelerated destruction of the newborn's type A blood cells. The by-product of red blood cell hemolysis is bilirubin. The accelerated breakdown of the red blood cells can lead to excess bilirubin, accumulating within the newborn's skin, mucus membranes, and sclera, and result in jaundice. Drop Down 2: Indirect Coombs test results is correct. The newborn's results were positive, which indicates the presence of anti-A and anti-B maternal antibodies within the blood, and increases the risk for jaundice.

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? Maintain the client in the lithotomy position. Perform vaginal examinations frequently. Remind the client to bear down with each contraction. Encourage the client to empty her bladder every 2 hr.

Encourage the client to empty her bladder every 2 hr. A client in labor should be encouraged to empty her bladder every 2 hr. Bladder distention can impede the descent of the fetus and slow the progression of labor. It can also contribute to uterine atony after delivery, increasing the client's risk of postpartum hemorrhage.

A nurse is caring for a client who is pregnant. Vital Signs 1100: Temperature 37.2° C (98.9° F) Pulse rate 80/min Respiratory rate 16/min Blood Pressure 136/79 mm Hg 1200: Pulse rate 90/min Respiratory rate 20/min Blood Pressure 134/82 mm Hg Medical History 1100: Gravida 4 Para 3 32 weeks of gestation BMI 32 History of two newborns weighing over 4.5 kg (10 lb) Family history of type one diabetes mellitus (maternal) Fetal heart tones 140/min via doppler Diagnostic Results 1115: Fasting blood glucose 138 mg/dL (60 to 105 mg/dL) 1200: Fasting blood glucose 142 mg/dL (60 to 105 mg/dL) 1200: HbA1c 12 % (less than 6.5%) 1220: Urinalysis Appearance: clear Color: amber yellow pH: 8.0 (4.6 to 8.0) Positive urine glucose (expected negative) 3+ ketones (expected negative) Urine specific gravity 1.020 (1.005 to 1.030) Nurses' Notes Contacted the provider to notify of client's status. Which of the following provider prescriptions should the nurse plan to implement? Select the 3 actions the nurse should plan to take. Encourage the client to limit carbohydrate intake to 40% of their daily calories. Instruct the client to check a random blood glucose level once daily. Anticipate a prescription for metformin. Conduct a non-stress test twice per week. Tell the client to refrain from exercise until after delivery.

Encourage the client to limit carbohydrate intake to 40% of their daily calories is correct. The nurse should encourage the client to limit carbohydrate intake to 33% to 40% of daily calorie intake. This can prevent excessive weight gain and post-meal hyperglycemia. Anticipate a prescription for metformin is correct. The nurse should anticipate a prescription for metformin. Oral hypoglycemic therapy is frequently prescribed. Metformin and glyburide are commonly used for glucose control for clients who have gestational diabetes mellitus. Conduct a non-stress test twice per week is correct. The nurse should conduct a non-stress test twice per week beginning at 32 weeks of gestation to assess for fetal well-being.

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first? Evaluate the firmness of the uterus. Initiate oxygen therapy by nonrebreather mask. Administer oxytocin infusion. Obtain a type and crossmatch.

Evaluate the firmness of the uterus. The first action the nurse should take using the nursing process is to assess the client. A blood pressure of 60/50 mm Hg can indicate postpartum hemorrhage; therefore, the first action the nurse should take is to evaluate the firmness of the uterus to determine if there is uterine atony.

A nurse is caring for an adolescent client who has pneumonia and a prescription for cefpodoxime 5 mg/kg PO every 12 hr for 5 days. The client weighs 88 lb. How many mg should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) _________mg

Follow these steps for the Ratio and Proportion method of calculation: Step 1: What is the unit of measurement the nurse should calculate? kg Step 2: Set up an equation and solve for X. 2.2 lbClient's weight in lb = 1 kgX kg 2.2 lb88 lb = 1 kgX kg X kg = 40 kg Step 3: What is the unit of measurement the nurse should calculate? mg Step 4: Set up an equation and solve for X. DoseClient's weight in kgX mg = × kg1 5 mg40 kgX mg = × kg1 X mg = 200 mg Step 5: Round, if necessary. Step 6: Determine whether the amount to administer makes sense. If the provider prescribed cefpodoxime 5 mg/kg/dose and the client weighs 40 kg, it makes sense to administer 200 mg per dose. The nurse should administer cefpodoxime 200 mg PO every 12 hr.

A nurse is preparing to administer buspirone 7.5 mg PO every 12 hr to a client. The amount available is buspirone 15 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) ______tablet(s)

Follow these steps for the Ratio and Proportion method of calculation: Step 1: What is the unit of measurement the nurse should calculate? tablet(s) Step 2: What is the dose the nurse should administer? Dose to administer = Desired 7.5 mg Step 3: What is the dose available? Dose available = Have 15 mg Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 tablet Step 6: Set up an equation and solve for X. HaveDesired = QuantityX 15 mg7.5 mg = 1 tabletX tablet(s) X tablet(s) = 0.5 tablet Step 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there are 15 mg/tablet and the prescription reads 7.5 mg, it makes sense to administer 0.5 tablet. The nurse should administer buspirone 0.5 tablet PO.

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions? Cephalic Transverse Posterior Frank breech

Frank breech With a frank breech presentation, the fetal heart is generally above the level of the client's umbilicus.

A nurse in the labor and delivery unit is caring for a client who is pregnant. Medical History 0900: Gravida 4 Para 3 31 weeks of gestation FHT 140/min Client reports cramping and low back pain that started last night. Vital Signs 0900: Temperature 36.9° C (98.4° F) Pulse rate 87/min Respiratory rate 20/min Blood Pressure 129/70 mm Hg Oxygen saturation 98% Nurses' Notes 0900: Client placed on external electronic fetal monitor. Fetal heart tones (FHT) 160/min. Client reports pain as 6 on a scale of 0 to 10. Reports needing pain medicine. Vaginal examination 2 cm, 80% effaced, -1 station Uterine contractions every 2 to 4 min, lasting 60 to 80 seconds , noted on fetal monitor tracing. 1000: FHT 158/min. Uterine contractions every 2 min, lasting 80 seconds in duration, noted on fetal monitor tracing. Provider notified of client status, prescriptions received. The nurse is contacting the provider regarding the client's status. Which of the following findings should the nurse report to the provider? Select the 4 findings the nurse should report. Gestational age Vaginal examination Uterine contractions Birthing parent's blood pressure Birthing parent's report of pain Fetal heart rate

Gestational age is correct. The client's gestational age is 31 weeks of gestation which is preterm.. Based on other assessment data collected, the nurse should report this finding to the provider. Vaginal examination is correct. The client's cervix is dilated and effaced, which are findings of preterm labor. Therefore, the nurse should report this finding to the provider. Uterine contractions is correct. The client is experiencing regular uterine contractions that are increasing in frequency and duration. This is a manifestation of preterm labor. The nurse should report this finding to the provider. Birthing parent's report of pain is correct. The client is reporting pain and requesting pain medication. The nurse should report this finding to the provider.

A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include? Wash the cord daily with mild soap and water. Cover the cord with the diaper. Apply petroleum jelly to the cord stump. Give a sponge bath until the cord stump falls off.

Give a sponge bath until the cord stump falls off. Immersing the umbilical cord stump in water can delay the process of drying, separation, and healing. Sponge baths are appropriate until the stump falls off.

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication? Orthostatic hypotension Fundus palpable at the umbilicus Urine output of 3,000 mL in 12 hr Heart rate 110/min

Heart rate 110/min A rapid or increasing heart rate can be a manifestation of fluid volume depletion related to hemorrhage. The nurse should further evaluate the client for evidence of postpartum hemorrhage.

A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive? Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days

Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth A newborn whose mother is positive for the hepatitis B surface antigen should receive both the hepatitis B vaccine and the hepatitis B immune globulin within 12 hr of birth.

A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action? Insert an indwelling urinary catheter. Initiate IV access. Witness the signature for informed consent for surgery. Prepare the abdominal and perineal areas.

Initiate IV access. Insertion of a large-bore IV catheter is the priority nursing action. The client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops.

A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first? Assess client's blood pressure. Assess the bladder for distention. Massage the client's fundus. Prepare to administer a prescribed oxytocic preparation.

Massage the client's fundus. The initial management of excessive uterine bleeding is firm massage of the uterine fundus. This action stimulates contraction of the uterine muscles, which constrict the maternal uterine blood vessels.

A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take? Apply fundal pressure. Observe for the presence of a nuchal cord. Observe for crowning. Prepare to administer oxytocin.

Observe for crowning. In the descent phase of the second stage of labor, crowning occurs when the fetal head is at +2 to +4 station. Because this is the client's third childbirth experience, it is reasonable to assume that delivery is imminent.

A nurse is caring for a client who was recently diagnosed with endometriosis. History & Physical 6/28/XX: Client presented to clinic reporting pelvic pain, dysmenorrhea, dyspareunia, and pain with defecation. Vaginal examination reveals fixed, palpable nodules with retroverted uterus. Imaging reveals endometrial lesions on the ovaries, uterosacral ligaments, and round ligaments. Endometriosis diagnosed. Provider's Prescriptions 6/28/XX: Nafarelin 200 mcg 1 spray intranasally every morning and 1 spray in the opposite nostril every evening. Nurses' Notes 8/28/XX: Client returns to clinic today for follow-up after beginning nafarelin treatment due to an endometriosis diagnosis 2 months ago. Reports that they have been taking the nafarelin as prescribed and has not missed any scheduled doses. Reports that their nasal mucosa has become irritated with treatment. Verbalizes they are feeling better and experiencing less dyspareunia and decreased pain during bowel movements. Also reports that they have decreased pelvic pain and that they did not have a period last month. Client also verbalizes that they have experienced headaches, an increase in acne lesions, and a decrease in sex drive since beginning the nafarelin. Client verbalizes that they also feel like their breasts are decreasing in size. Which of the following manifestations reported by the client should the nurse identify as a therapeutic effect of the nafarelin? (Select all that apply.) CNS manifestations Nasal mucosa changes Dermatological manifestations Pain level during sexual intercourse Breast changes Missed previous month's menstrual cycle

Pain level during intercourse is correct. Nafarelin is a gonadotropin-releasing hormone agonist that decreases ovarian function resulting in medical-induced menopause. Cessation of menstruation allows for shrinkage of endometrial lesions resulting in decreased pain during sexual intercourse, Therefore, the client reporting a decrease in pain with sexual intercourse is a therapeutic effect of the medication. Missed previous month's menstrual cycle is correct. Nafarelin is a gonadotropin-releasing hormone agonist that decreases ovarian function, resulting in medically-induced menopause. The induction of menopause allows for shrinkage of endometrial lesions, resulting in decreased pain during sexual intercourse, decreased pelvic pain, decreased episodes of dysmenorrhea, and decreased episodes of constipation. Therefore, the client reporting they did not have a period the previous month is a therapeutic effect of the medication.

A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis? Moderate amount of dark red lochia with a bloody odor A localized area of breast tenderness Pelvic pain Hematuria

Pelvic pain Indications of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain.

A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions? Postpartum infection Hypertension Postpartum hemorrhage Thromboembolic events

Postpartum hemorrhage Methylergonovine is an oxytocic medication. It causes uterine contractions, which control postpartum bleeding.

A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following? Ballottement Lightening Quickening Chloasma

Quickening Clients describe quickening as a fluttering sensation, which can be felt as early as the 14th week of gestation. It reflects fetal movement.

A nurse is preparing to administer 1 mg vitamin K to a newborn. The medication is available in 1 mg/0.5 mL. How much should the nurse administer? (Round to the nearest tenth. Use a leading zero when applicable. Do not use a trailing zero.) ______mL

Ratio and Proportion STEP 1: What is the unit of measurement the nuse should calculate? mL STEP 2: What is the dose the nurse should administer? Dose to administer= Desired 1 mg STEP 3: What is the dose available? Dose available = Have 0.5 mg STEP 4: Should the nurse convert the units of measurement? no STEP 5: What is the quantity of the dose available? 1 mL STEP 6: Set up an equation and solve for X. Have/Quantity = Desired/X 0.5 mg/1 mL = 1 mg/X mL X = 0.5 mL STEP 7: Round if necessary. STEP 8: Reassess to determine whether the amount to give makes sense. If there are 0.5 mg/mL and the amount prescribed is 1 mg, it makes sense to administer 0.5 mL. The nurse should administer hydroxyzine HCL 0.5 mL IM.

A nurse is preparing to administer desmopressin 0.2 mg daily to a client. Available is desmopressin 0.1 mg tablets. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______tablet(s)

Ratio and ProportionSTEP 1: What is the unit of measurement the nurse should calculate? Tablet STEP 2: What is the dose the nurse should administer? Dose to administer= Desired 0.2 mg STEP 3: What is the dose available? Dose available = Have 0.1 mg STEP 4: Should the nurse convert the units of measurement? No STEP 5: What is the quantity of the dose available? 1 tablet STEP 6: Set up an equation and solve for X. Have/Quantity = Desired/X 0.1 mg/1 tablet = 0.2 mg/X tablet X = 2 tablets STEP 7: Round if necessary. STEP 8: Reassess to determine whether the amount to administer makes sense. If there is 0.1 mg/tablet and the prescription reads 0.2 mg, it makes sense to administer 2 tablets. The nurse should administer 2 tablets desmopressin PO.

A nurse is caring for a client who is breastfeeding her newborn and asks the nurse about the changes she should make in her diet. Which of the following dietary changes should the nurse suggest? Increase her caloric intake by 600 kcal/day. Increase her fluid intake to 2.5 L/day. Reduce her intake of iron. Avoid shellfish.

Reduce her intake of iron. Recommendations for some nutrients, such as iron and folic acid, are less during lactation than during pregnancy. Because maternal blood volume decreases after childbirth, the client's need for these nutrients also diminishes.

A nurse is teaching a client about taking an expectorant to treat a cough. The nurse should explain that this type of medication has which of the following actions? Reduces inflammation Suppresses the urge to cough Dries mucous membranes Stimulates secretions

Stimulates secretions Expectorants act by increasing secretions to improve a cough's productivity.

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority? Suction the nose with a bulb syringe. Suction the mouth with a bulb syringe. Use a suction catheter with low negative pressure. Turn the newborn on his side.

Suction the mouth with a bulb syringe. The greatest risk to the newborn is aspiration of secretions. Removing the secretions from the mouth first is the priority action.

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects? Tardive dyskinesia Parkinsonism Dystonia Akathisia

Tardive dyskinesia These findings indicate tardive dyskinesia, which can develop in clients during long-term therapy with chlorpromazine. For many clients, the manifestations are irreversible.

A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn's Apgar score. ______points

The Apgar score is 6 out of a possible 10. It is based on 5 signs evaluated at 1 and 5 min after delivery that indicate the physiologic state of the newborn as he transitions from intrauterine life to extrauterine life: heart rate over 100/min = 2; slow, weak cry = 1; some flexion of extremities = 1; grimace in response to suctioning of the nares = 1; body pink in color with blue extremities = 1. A score of 4 to 6 indicates moderate difficulty adjusting to life outside of the womb.

A nurse is caring for a client who is admitted to the labor and delivery unit. Vital Signs Temperature: 37.1° C (98.7° F) Heart rate: 108/min Respiratory rate: 22/min Blood pressure: 100/60 mm Hg Oxygen saturation: 98% Diagnostic Results Urinalysis: Glucose: Negative (negative) Blood: None (none) WBC: None ( none) Ketones: +3 (none ) Laboratory Results: Hemoglobin: 11 g/dL (greater than 11g/dL) Hematocrit: 38% (greater than 33%) Glucose: 68 mg/dL (60 to 90 mg/dL) Platelets: 220,000mm3 (150,000 to 400,000 mm3) Nurses Notes Client is a 20-year-old primigravida who is at 18 weeks of gestation and has a past medical history of pyelonephritis. Client is alert and oriented to person, place, time, and situation. Oral mucosa is dry. Turgor without tenting. Client reports 2.3 kg (5 lb) weight loss within the past 2 weeks. Fetal Heart Rate (FHR) 145 in lower suprapubic area via external Doppler ultrasound stethoscope. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Actions to Take 1 Actions to Take 2 Potential Condition Parameters to Monitor 1 Parameters to Monitor 2 Actions to Take Insert urinary catheter. Check blood glucose. Apply internal fetal monitor. Encourage small frequent meals. Administer IV fluids. Potential Condition Hypothyroidism Urinary tract infection Gestational diabetes Hyperemesis gravidarum Parameters to Monitor Contraction frequency Level of consciousness Intake and output Cervical dilation

The nurse should administer IV fluids and encourage the client to eat small frequent meals because the client is most likely experiencing hyperemesis gravidarum. The client is exhibiting symptoms of dehydration such as hypotension, tachycardia, dry mucous membranes, delayed skin turgor, and has experienced significant weight loss within the last 2 weeks. The client's urinalysis shows a moderate number of ketones which could indicate dehydration as well. Therefore, the nurse should monitor the client's vital signs, laboratory studies such as hematocrit and intake and output which would provide information about the client's hydration status.

A nurse on an antepartum unit is caring for a client who is at 24 weeks of gestation. Vital Signs BP: 132/84 mm Hg Pulse: 96/min Respiratory rate: 22/min Temperature: 39.2° C (102.6° F) tympanic Oxygen saturation: 98% room air Diagnostic Results Urine culture and sensitivity: Pending Urinalysis: Appearance: Cloudy (Clear) Color: Yellowish red pH: 8.1 (4.6 to 8.0) Protein: 2 mg/dL (0 to 8 mg/dL) Specific gravity: 1.020 (1.010 to 1.025) Leukocyte esterase: Positive (negative) Nitrites: Positive (none) Ketones: Trace (none) Bilirubin: None Glucose: None WBC: 8/lpf (0 - 4 lpf) RBC: 7/hpf (≤2) Nurses Notes Client is Gravida 1 Para 0 at 24 weeks of gestation and reports bilateral flank pain, urinary frequency, dysuria, chills, and nausea for past 24 hr. Denies epigastric pain, vomiting, leakage of fluid or bleeding from vagina. Reports active fetal movement. Fundal height is 24 cm. FHR is 156/min. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Actions to Take 1 Actions to Take 2 Potential Condition Parameters to Monitor 1 Parameters to Monitor 2 Actions to Take Assess for signs of sepsis. Decrease environmental stimuli. Administer ceftriaxone as prescribed. Assess client for abdominal pain following a high-fat meal. Prepare the client for suction curettage. Potential Condition Pyelonephritis Cholelithiasis Preeclampsia Molar pregnancy Parameters to Monitor Daily fat intake Uterine contractions Urine output Deep tendon reflexes hCG levels for 12 months

The nurse should administer ceftriaxone as prescribed and assess for signs of sepsis because the client is most likely experiencing pyelonephritis as evidenced by bilateral flank pain, dysuria, and chills. Because pyelonephritis is an extension of a UTI or might have spread from some other area, the client is at risk for sepsis. The nurse should monitor the client's urine output and for uterine contractions because pyelonephritis can increase the risk of preterm labor.

A nurse is caring for a client who is in the second stage of labor. Medical History 0800: 28-year-old client; G2 P1; at 39 weeks of gestation. Client has history of insulin dependent gestational diabetes mellitus with current pregnancy. Client admitted to the facility in the latent phase of labor at 4 cm, 70% effaced, and -1 station. Nurse's Notes 1300: Client reports need to have a bowel movement. Sterile vaginal examination (SVE) performed; 10 cm, 100% effaced, and +1 station. Fetal heart rate 130's with moderate variability, occasional variable decelerations observed. Provider notified of cervical assessment. Client actively pushing with contractions. 1503: Provider at bedside. Fetal head crowning. The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Action to Take 1 Action to Take 2 Condition Most Likely Experiencing Parameter to Monitor 1 Parameter to Monitor 2 Actions to Take Perform external cephalic version Apply suprapubic pressure Place the client in Trendelenburg position Flex the client's legs against the abdomen Press down on uterine fundus Potential Condition Precipitous labor Umbilical cord prolapse Malpresentation Shoulder dystocia Parameters to Monitor Presence of the neonatal plantar reflex Movement of the newborn's upper extremities Increasing neonatal head circumference Maternal perineum for trauma

The nurse should flex the client's legs against the abdomen and apply suprapubic pressure because the client is most likely experiencing shoulder dystocia. Flexing the clients legs against the abdomen straightens the maternal pelvis, helping to free the trapped anterior shoulder of the fetus. Applying suprapubic pressure also helps free the anterior shoulder, allowing for birth of the newborn's body. The nurse should monitor the movement of the newborn's upper extremities because newborns who experience a shoulder dystocia are at a greater risk for brachial plexus injuries. The nurse should also monitor the maternal perineum because mothers who experience shoulder dystocia are at a greater risk for trauma to the vagina, perineum, and rectum.

A nurse is caring for a newborn who is 12 hr old. Medical History 39 weeks gestation Vacuum-assisted birth to deliver a large-for-gestational-age newborn Uncomplicated pregnancy Nurses Notes Newborn is very fussy and difficult to console. Displays little interest in feeding. Vital Signs Temperature: 37.1° C (98.8° F) axillary Pulse: 188/min Respiratory rate: 56/min Weight: 4139 grams (9 lb 2 oz) Physical Examination Lips and mucus membranes pale and moist. Respirations easy and unlabored. Lungs clear. Firm raised area with extensive bruising noted over posterior scalp area. Scalp soft and boggy to palpation. Anterior fontanel full and tense. Abdomen soft with active bowel sounds. General flexed positioning and spontaneous movement of all extremities. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Actions to Take 1 Actions to Take 2 Potential Condition Parameters to Monitor 1 Parameters to Monitor 2 Actions to Take Feed the newborn. Decrease environmental stimuli. Measure head circumference. Inspect posterior neck for swelling. Palpate for crepitus. Potential Condition Neonatal abstinence syndrome Hypoglycemia Clavicle fracture Subgaleal hemorrhage Parameters to Monitor Hematocrit level Muscle tone Moro reflex Glucose level Level of consciousness

The nurse should measure the newborn's head circumference and inspect the posterior neck for swelling because the newborn is most likely experiencing bleeding into the inner layer of the scalp, a subgaleal hemorrhage, due to the vacuum assisted birth. The nurse should monitor the newborn's level of consciousness and hematocrit levels because the hemorrhage can cause increased intercranial pressure and result in anemia.

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider? Respirations 16/min Headache for 30 min Urinary output 40 mL in 2 hr Fetal heart rate 158/min

Urinary output 40 mL in 2 hr Urinary output is critical for the excretion of magnesium from the body. The nurse should report an hourly output below 30 mL/hr to the provider immediately and discontinue the medication.

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following? Uteroplacental insufficiency Maternal bradycardia Umbilical cord compression Fetal head compression

Uteroplacental insufficiency The pattern of the fetal heart rate during labor is an indicator of fetal well-being. Late decelerations are the result of uteroplacental insufficiency and the fetus becomes hypoxemic. They are an ominous sign if they cannot be corrected and place the fetus at risk for a low Apgar score.