Module 33: Reproduction
A nurse is caring for the 1-hour-old newborn of a mother with diabetes mellitus. Which actions will the nurse include in the newborn's plan of care? Select all that apply. A) Assess blood glucose frequently. B) Assess for SGA. C) Assess for hyperthyroidism. D) Assess the newborn's temperature hourly. E) Assess for hyperbilirubinemia.
A) Assess blood glucose frequently. E) Assess for hyperbilirubinemia. Explanation: In a newborn of a mother with diabetes, the onset of hypoglycemia occurs at 1- 3 hours after birth and can continue for several days. Blood glucose levels should be checked frequently during the first several days. The nurse should assess lab results for hypocalcemia, hyperbilirubinemia, and polycythemia. Alterations in temperature and thyroid hormone levels are not associated with newborns of mothers with diabetes. Newborns of mothers with diabetes are often LGA (large for gestational age), not SGA (small for gestational age).
The nurse is caring for a 36-year-old pregnant woman. She has two children, ages 15 and 13, from a previous marriage, and this is her first child from her second marriage. The client has indicated that her two older children seem very upset by her pregnancy and have been increasingly belligerent the closer she gets to delivery. What can the nurse say to support this family? A) "It may help to remind your older children that you will still make time for them and that you won't expect them be responsible for the baby unless they want to." B) "You could tell your older children that the stress and anxiety that comes with a new baby will help improve your family relationships." C) "They are probably just embarrassed because you are pregnant. They'll get over it once you have the baby." D) "Your older children probably just want to know what their new roles will be once the baby is born. You should tell them what their responsibilities will be in caring for the baby."
A) "It may help to remind your older children that you will still make time for them and that you won't expect them be responsible for the baby unless they want to." Explanation: Adolescent children, especially children from a previous marriage, may feel jealous that the new baby will take all the attention of the parent or fear that they will be asked to contribute to the newborn's care. The nurse should help the mother understand these feelings and encourage the mother to address these feelings with her older children. Telling the mother that the older children are just embarrassed and will get over it is inappropriate. Encouraging the mother to give newborn care responsibilities to the older children may make the issue worse. Discussing the role of stress and anxiety in improving relationships is more appropriate for a spouse, not older children.
The nurse is instructing the parents who delivered their first child at 34 weeks' gestation. Which statements made by the parents indicate that additional teaching is needed? Select all that apply. A) "Tube feedings will be required because his stomach is small." B) "Breathing might be harder for our baby because he is early." C) "Our baby will be in an incubator to keep him warm." D) "The growth of our baby will be slower than if he were term." E) "Because he came early, he will not produce urine for 2 days."
A) "Tube feedings will be required because his stomach is small." E) "Because he came early, he will not produce urine for 2 days." Explanation: Preterm infants grow more slowly than do term infants. Although tube feedings might be required, it would be because preterm babies lack sufficient suck and swallow reflexes to prevent aspiration. Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they will make urine. Preterm infants have little subcutaneous fat, and have difficulty maintaining their body temperature. An incubator or radiant warmer is used to keep the baby warm. Surfactant production might not be complete at 34 weeks, which leads to respiratory distress syndrome. In addition, respiratory effort is increased when the ductus arteriosus remains patent, which is common in preterm infants.
A client at 16 weeks' gestation is diagnosed with tuberculosis (TB). Which statement by the nurse is appropriate when instructing the client regarding the needs for both the client and fetus? A) "You have been prescribed isoniazid; therefore, you must also take pyridoxine (vitamin B6)." B) "Your contact with the baby will be limited for several months after delivery." C) "You will not be able to breastfeed your baby because of this diagnosis." D) "You are free to have contact with anyone as TB is not contagious when diagnosed during pregnancy."
A) "You have been prescribed isoniazid; therefore, you must also take pyridoxine (vitamin B6)." Explanation: When teaching a pregnant client diagnosed with TB, the nurse will include information regarding medication administration. Isoniazid, which does cross the placenta but most studies show is not teratogenic, is often the drug of choice to treat TB during pregnancy. When taking isoniazid, the client will also need to take pyridoxine. If TB is active at delivery, the newborn should not have direct contact with the mother while she is infectious. This is not likely going to be the case, as the client is diagnosed early in the pregnancy. If maternal TB is inactive, the mother may breastfeed and care for her infant. Extra rest and limited contact with others are required until the disease becomes inactive.
If a woman had a prepregnancy daily requirement of 1800 calories and she decides to breastfeed her newborn, how many calories should the nurse recommend the woman take in each day? A) 2300 calories B) 2500 calories C) 2000 calories D) 1800 calories
A) 2300 calories Explanation: The breastfeeding mother should take in 500 more calories than her prepregnancy requirements. Therefore, she should take in 2300 calories each day. The woman who is not breastfeeding should return to her prepregnancy requirement of 1800 calories per day.
A client who gave birth to her first child 12 hours ago has the following assessment findings: nausea for 2 hours; boggy fundus that firmed with massage; moderately heavy lochia rubra; ecchymotic and edematous perineum; and pain rating of 6 on a scale of 0-10. The client's partner is present and supportive. Breastfeeding has been successful three times. Based on this data, which is the priority nursing diagnosis? A) Acute Pain related to perineal trauma B) Risk for Deficient Fluid Volume secondary to boggy fundus and nausea C) Deficient Knowledge related to birth of first child D) Readiness for Enhanced Family Coping related to partner involvement
A) Acute Pain related to perineal trauma Explanation: The client has a pain level of 6, so treating pain is a high priority for this client. Pain could contribute to nausea and a decreased desire to drink fluids, so treating the pain could decrease the risk for deficient fluid volume. Actual diagnoses, such as Acute Pain, are almost always higher priority than Risk diagnoses. Although the nursing diagnoses of Readiness for Enhanced Family Coping and Deficient Knowledge fit, they are a lower priority than treating pain.
A premature newborn's neuronal immaturity may contribute to what complication? A) Apnea of prematurity B) Patent ductus arteriosus C) Respiratory distress syndrome D) Anemia of prematurity
A) Apnea of prematurity Explanation: Apnea of prematurity is primarily a result of neuronal immaturity, causing irregular breathing patterns and cessation of breathing for 20 seconds or longer in preterm infants. PDA, respiratory distress syndrome, and anemia of prematurity have other etiologies related to the premature development of the neonate.
The nurse is providing postpartum care to a client from a different culture. What nursing actions are appropriate to include in the client's plan of care? Select all that apply. A) Assess for any assistance required during breastfeeding. B) Ask if there are any specific customs the client wants to follow. C) Assess for any specific foods or fluids to hasten recovery. D) Limit client visitors to the immediate family. E) Restrict interactions with the client.
A) Assess for any assistance required during breastfeeding. B) Ask if there are any specific customs the client wants to follow. C) Assess for any specific foods or fluids to hasten recovery. Explanation: A) When providing postpartum care to a client of a different culture, the nurse should assess for any specific customs the client wants to follow, if there are any foods or fluids in the culture that are believed to hasten recovery, and if the client requires any assistance during breastfeeding. Restricting visitors would not support the postpartum client's needs. Restricting interactions would not support the client's physiologic or psychologic needs.
The nurse is providing care to a pregnant client who will undergo chorionic villus sampling. The client is currently 10 weeks pregnant. When teaching the client about this genetic testing, which layer of the embryonic membrane will the nurse say is tested during this procedure? A) Chorion B) Amnion C) Ectoderm D) Endometrium
A) Chorion Explanation: The chorion is the outermost embryonic membrane and develops into chorionic villi, which can be used for early genetic testing of the embryo at 10 to 11 weeks' gestation by chorionic villus sampling. The endometrium is the lining of the uterus and will not be used for genetic testing of the embryo. The ectoderm is a germ layer and will develop into specific structures within the developing fetus. The amnion will develop into amniotic fluid, which can also be sampled for genetic testing but may not be developed by 8 weeks' gestation.
A client delivers a newborn son and plans to breastfeed. When the nurse attempts to help the newborn latch on for breastfeeding, the client states, "I would like to bottle feed my baby for the first few days." Which reason might the nurse hear regarding why the client wants to delay breastfeeding? A) Colostrum is bad for the baby. B) The birthing process spoils breast milk. C) It will cause "evil eye." D) Newborns require feeding on demand.
A) Colostrum is bad for the baby. Explanation: Some Asian, Haitian, Hispanic, Eastern European, and Native American cultures believe breastfeeding should be delayed because colostrum is bad for the baby. A Haitian client may believe that strong emotions, not the birthing process, spoil breast milk. Some Latin American cultures do not believe that breastfeeding causes evil eye but rather that touching the head or the face of the baby when admiring it will ward off the "evil eye." Many Cambodian refugees practice breastfeeding on demand or provide a comfort bottle between feedings.
The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110 bpm and is at 120 bpm by the end of the contraction. Which nursing action is appropriate? A) Documenting the fetal heart rate B) Preparing for imminent delivery C) Applying oxygen via mask at 10 liters per minute D) Assisting the client into the Fowler position
A) Documenting the fetal heart rate Explanation: The described fetal heart rate has a normal baseline, the presence of accelerations indicates adequate fetal oxygenation, and early decelerations are normal. No intervention is necessary. The fetal heart rate tracing is normal; oxygen is not indicated. There is no indication that delivery will be occurring soon. The client does not need to be assisted into the Fowler position.
The nurse is planning care for a client who had a cesarean birth 4 hours ago. Which actions should be included in this client's plan of care? Select all that apply. A) Encourage the use of breathing, relaxation, and distraction. B) Encourage deep breathing and coughing every 2 to 4 hours. C) Encourage to ambulate to the bathroom to void. D) Discourage leg exercises. E) Withhold all analgesics.
A) Encourage the use of breathing, relaxation, and distraction. B) Encourage deep breathing and coughing every 2 to 4 hours Explanation: A) Encouraging deep breathing and coughing every 2 to 4 hours and encouraging the use of breathing, relaxation, and distraction all address the client's nursing care needs, which are similar to those of other surgical clients. Encouraging the client to ambulate to the bathroom to void might be an intervention done on the first or second day postpartum, but not in the first 4 hours. Leg exercises should be encouraged. Withholding analgesics may leave the client in pain.
Which symptom would the nurse recognize as being consistent with postpartum endometritis at 4 weeks postpartum? A) Foul-smelling lochia B) Bright red lochia C) Upper abdominal pain D) Bradycardia
A) Foul-smelling lochia Explanation: Assessment findings consistent with endometritis are foul-smelling lochia, sawtooth fever, uterine tenderness, lower abdominal pain, tachycardia, and chills. Bright red lochia might indicate postpartum hemorrhage at 4 weeks postpartum.
Because of the immature development of the kidney, the nurse needs to assess preterm infants for what condition?' A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis
A) Metabolic acidosis Explanation: The buffering capacity of the kidney is reduced in a preterm infant, predisposing the neonate to metabolic acidosis. Bicarbonate is excreted at a lower serum level, and acid is excreted more slowly. Therefore, the neonate is at higher risk for metabolic acidosis than metabolic alkalosis. Respiratory acidosis or alkalosis would be due to changes in lung physiology, not kidney physiology.
The nurse is teaching childbirth exercises to a pregnant client with a history of back pain. Which is most appropriate for this client? A) Perform the pelvic rock exercise only in the standing position. B) Exercise in the supine position throughout the pregnancy. C) Perform the pelvic rock exercise while in the hands and knees position. D) Soak in a hot tub for approximately 30 minutes after exercise.
A) Perform the pelvic rock exercise only in the standing position. Explanation: The pelvic tilt or pelvic rock exercise helps prevent or reduce back strain, as it strengthens the abdominal muscles. The client with a history of back pain should be instructed to perform the exercise in the standing position only. Doing the exercise on the hands and knees may aggravate back strain and cause pain. Pregnant clients should be instructed to avoid exercising in the supine position after the first trimester because it could hinder uterine blood flow and harm the fetus. Pregnant clients should be instructed to avoid hot tubs because of the possible teratogenic effects of hyperthermia on the developing fetus.
A pregnant adolescent client asks for information about the pregnancy and the baby because she cannot afford prenatal care. Which action by the nurse is the most appropriate? A) Provide the client with information on resources to assist with medical care during the pregnancy and after delivery. B) Instruct the client on aspects of pregnancy, fetal development, and labor and delivery. C) Ask the client if her parents are aware that she is pregnant and if she is covered by their medical insurance. D) Tell the client that the father of the baby is responsible to pay for medical care for her during the pregnancy and after delivery.
A) Provide the client with information on resources to assist with medical care during the pregnancy and after delivery. Explanation: Poverty and low education levels are associated with adolescent pregnancy. The nurse should support the client by providing information on resources to assist with medical care during the pregnancy and after delivery. The nurse should not instruct the client on all aspects of the pregnancy, including fetal development, labor, and delivery, as this can be overwhelming to the client. The nurse should not ask the client if the parents are aware of the pregnancy nor tell the client that the baby's father is responsible for her medical care; these actions do not address the client's needs.
The nurse is proving care to a 1-hour-old newborn who was born at 39 weeks' gestation. Which assessment data is cause for concern? Select all that apply. A) Respiratory rate of 82 breaths per minute B) Negative Babinski reflex C) Mean blood pressure of 52 mmHg D) AcrocyanosisE) Presence of soft heart murmur
A) Respiratory rate of 82 breaths per minute B) Negative Babinski reflex Explanation: Assessment data that would cause this nurse concern include a respiratory rate of 82 breaths per minute and a negative Babinski reflex. Respirations within 2 hours of delivery are expected to be between 60 and 70 breaths per minute but can be as high as 80 breaths per minute. Anything above this is abnormal. A positive Babinski reflex is an expected finding. A negative Babinski could indicate neurologic compromise. The nurse would expect a mean blood pressure of 52 mmHg (normal range is 31-61 mmHg), acrocyanosis, and the presence of a soft heart murmur.
The nurse is providing care to a client whose last menstrual period was 6 weeks ago. The client believes she is pregnant. Which diagnostic test does the nurse anticipate in order to confirm the pregnancy? A) Serum or urine human chorionic gonadotropin (hCG) B) Fetal heartbeat by Doppler C) Fetal heartbeat by fetoscope D) Fetal movement
A) Serum or urine human chorionic gonadotropin (hCG) Explanation: The most commonly used assay for pregnancy diagnosis is measuring the beta subunit of hCG in either urine or serum. hCG is detectable in more than 97% of clients. A fetal heartbeat is diagnostic for pregnancy and is detectable by Doppler around the 10th to 12th week of gestation and by fetoscope at about the 17th to 20th week. Fetal movement, another objective sign of pregnancy, is palpable around 20 weeks' gestation by a trained examiner; pregnant women may experience movement subjectively, called quickening, around this same time.
The nurse is caring for a 14-year-old client who is pregnant. What will the nurse need to consider that may affect this client more than older adolescents? A) The client may be more concerned about modesty. B) The client may be more concerned with state marriage laws. C) The client may be more concerned about parents finding out about the pregnancy. D) The client may be more concerned about finding a support person.
A) The client may be more concerned about modesty. Explanation: A younger client may be more concerned about modesty than older clients, especially as her body changes and grows rapidly. Older adolescents who are pregnant may be more concerned about state marriage laws, parents finding out about the pregnancy, and finding a support person. Younger clients are more likely to involve parents in the early stages of pregnancy for both emotional and financial support.
A pregnant client presents to the emergency department reporting that she has started labor and is certain the baby is coming "any minute now." After assessing and monitoring the client, the healthcare team determines that the client is in "false" labor, and the nurse prepares her for discharge. Which observations support the conclusion of false labor? Select all that apply. A) The contractions do not have a regular pattern. B) Her cervix has dilated 2 cm over the 2 hours of observation. C) The frequency and intensity of the contractions have stayed about the same. D) Walking seems to increase the strength of the contractions. E) The contractions are mostly in her abdomen.
A) The contractions do not have a regular pattern. C) The frequency and intensity of the contractions have stayed about the same. E) The contractions are mostly in her abdomen. Explanation: A) Signs and symptoms of "false" labor, in contrast to "true" labor, include a pattern of irregular contractions that do not increase in frequency or intensity, a lack of cervical dilation and effacement, discomfort that is felt mostly in the abdomen rather than in the back and radiating to the front, and the fact that activity does not increase contraction intensity.
A client who says she is "about 6 weeks pregnant" hears the baby's heartbeat for the first time through a Doppler. Based on this data, which conclusion by the nurse is the most appropriate? A) The mother is at 8 to 12 weeks' gestation. B) The mother is over 16 weeks' gestation. C) The mother is at 4 to 8 weeks' gestation. D) The mother is at least 20 weeks' gestation.
A) The mother is at 8 to 12 weeks' gestation. Explanation: The ultrasonic Doppler device is the primary tool for assessing fetal heartbeat. It can detect fetal heartbeat, on average, at 8 to 12 weeks' gestation. If an ultrasonic Doppler is not available, a fetoscope may be used. The fetal heartbeat can be detected by fetoscope as early as week 16 and almost always by 19 or 20 weeks' gestation. The mother is not at 4 to 8 weeks' gestation because the Doppler device detected fetal heartbeat. The mother will have likely already heard the heartbeat at least once before 16 to 20 weeks' gestation if her primary care provider has access to a Doppler device.
A client pregnant with her first child tells the nurse that she is concerned that her husband does not want the baby because he has a renewed interest in playing tennis and visiting with college friends after work. When responding to the client, which should the nurse take into consideration? A) This is a normal reaction by fathers that is seen in the second trimester of pregnancy. B) This is a normal reaction by fathers that is seen in the third trimester of pregnancy. C) This is a normal reaction by fathers that is seen in the first trimester of pregnancy. D) This is an atypical reaction of the father to pregnancy that should be further examined.
A) This is a normal reaction by fathers that is seen in the second trimester of pregnancy. Explanation: Pregnancy produces psychological changes in the mother and father of the child. A reaction seen in the father during the second trimester of pregnancy is a renewed interest in hobbies or activities outside of the family and is usually a sign of stress. This behavior is not typical in the first or third trimesters and is not an atypical reaction that should be further examined.
An adolescent client at 34 weeks' gestation states to the nurse, "I am stressed out about becoming a mother. I hope that I can get back to my normal day to day activities after the baby is born, like hanging out with friends and studying." If the nurse wants to assess whether the client is performing normal developmental tasks for this stage of pregnancy, which question by the nurse is the most appropriate? A) "Are your friends excited about the baby coming and planning a shower for you?" B) "Are you prepared to delay some of your own needs and desires for your baby?" C) "Do you miss going out with your friends on the weekends?" D) "Have you been able to get enough rest while keeping up with your studies?"
B) "Are you prepared to delay some of your own needs and desires for your baby?" Explanation: One developmental task for the mother is learning to give of oneself on behalf of the child. The statement by this client that she wants to get back to her normal activities indicates that she is still self-focused. The nurse should assess the client's preparedness for putting aside her own wants and needs temporarily for the good of her child. The nurse should not focus on the client's social life and friends because these are not developmental tasks associated with the pregnancy.
The nurse is instructing a new mother on how to care for the newborn's circumcision site. Which statements indicate that the nurse's education session was effective? Select all that apply. A) "I should not use petroleum jelly on the penis." B) "Every time I change the diaper I am to wash the area with warm water." C) "I should report any pus drainage or change in diaper wetness to the physician." D) "Swelling is expected." E) "I am to use soap and water to remove yellow tissue on the penis."
B) "Every time I change the diaper I am to wash the area with warm water." C) "I should report any pus drainage or change in diaper wetness to the physician." Explanation: B) The nurse should instruct the mother to wash the area with warm water after every diaper change, to use petroleum jelly to protect the penis and prevent bleeding, and to report any pus drainage or change in urine output to the physician. Yellow tissue on the penis is granulation tissue, which is evidence of healing and should not be washed off with soap and water. Swelling is not expected after a circumcision and should be reported to the physician.
The nurse is providing discharge instructions for a healthy 37-year-old first-time mother and her newborn. What should the nurse include in her instructions for this mother and her spouse? A) Information related to contraception and sexually transmitted infections (STIs). B) A reminder that addition of a newborn will alter established routines. C) A referral to a group class that provides information on newborn care. D) A referral for follow-up care with healthcare providers other than the obstetrician.
B) A reminder that addition of a newborn will alter established routines Explanation: Women who are over 35 have life experiences and education that often better prepare them for parenthood. However, older couples must be made aware that the addition of a newborn will alter established routines and practices. A referral for follow-up care with other healthcare providers is appropriate for women over 35 who have preexisting conditions or complications. Information related to contraception and STIs and referral to a group class on newborn care are more appropriate for adolescent mothers.
A nurse is caring for a premature infant with a central line. The otherwise healthy, growing infant suddenly develops apnea, bradycardia, and metabolic acidosis. Which is the most likely condition causing this change in health status? A) Hyperbilirubinemia B) Bacterial sepsis C) Hypoglycemia D) Intracranial hemorrhage
B) Bacterial sepsis Explanation: The sudden onset of apnea, bradycardia, and metabolic acidosis in a premature infant with a central line in place who had previously been growing and doing well is suggestive of bacterial sepsis rather than hyperbilirubinemia, hypoglycemia, or intracranial hemorrhage.
The nurse will commonly need to work with all except which member of the healthcare team to provide care to the newborn? A) Audiology specialist B) Cardiac surgeon C) Lactation consultant D) Pediatrician
B) Cardiac surgeon Explanation: The healthcare team works together to care for the newborn. The team commonly includes a pediatrician or neonatal specialist, a nurse, a lactation consultant, and an audiology specialist. A cardiac surgeon will only be involved in the newborn's care if the newborn is diagnosed with a congenital cardiac disorder or birth defect.
When administering an intramuscular dose of vitamin K (phytonadione) to a newborn, which actions by the nurse are appropriate? Select all that apply. A) Using a 23-gauge 1/2-inch needle B) Cleaning the skin with an alcohol swab C) Preparing 5 mg of the medication for injection D) Using the middle third of the vastus lateralis muscle E) Washing the skin with soap and water
B) Cleaning the skin with an alcohol swab D) Using the middle third of the vastus lateralis muscle E) Washing the skin with soap and water Explanation: A single dose of vitamin K (phytonadione) is administered to newborns within 1 hour of birth. The nurse should use the middle third of the vastus lateralis muscle, clean the skin with an alcohol swab, and use a 27-gauge 1/2-inch needle. The skin is not to be washed with soap and water before the injection. The medication dosage is between 0.5 and 1.0 mg.
The nurse is caring for a newborn boy who was circumcised an hour ago. Which is the priority nursing diagnosis for the newborn? A) Risk for Injury B) Risk for Infection C) Risk for Imbalanced Nutrition D) Risk for Ineffective Breathing Pattern
B) Risk for Infection Explanation: The client is at increased risk for infection because of the circumcision. Risk for Injury would be appropriate if the client were having difficulty metabolizing bilirubin. Risk for Ineffective Breathing Pattern would be appropriate if the client were demonstrating signs of ineffective breathing. Risk for Imbalanced Nutrition would be appropriate if the client were demonstrating signs of ineffective feeding behaviors.
A client who recently learned of being pregnant tells the nurse that she stopped eating meat years ago and started eating fish daily because it is healthier. Which teaching points are appropriate for this client based on her current diet? Select all that apply. A) Avoid shrimp, salmon, and catfish because these have higher mercury levels. B) Eat up to 12 ounces a week of a variety of fish and shellfish. C) Do not eat more than 6 ounces per week of albacore tuna. D) Eat plenty of fish such as king mackerel while pregnant. E) Follow a complete vegetarian diet while pregnant as an alternative to eating fish.
B) Eat up to 12 ounces a week of a variety of fish and shellfish. C) Do not eat more than 6 ounces per week of albacore tuna. Explanation: B) Nearly all fish contain traces of mercury. Mercury can place the developing nervous system of the fetus at risk and cause negative effects on cognitive functioning. The nurse should instruct the client to eat up to 12 ounces a week of a variety of fish and shellfish. The nurse should advise the client to eat no more than 6 ounces of albacore tuna each week because it has more mercury than other canned tuna. King mackerel should be avoided because it contains high levels of mercury. The nurse should not suggest that the client consume a complete vegetarian diet because this could lead to other nutritional deficiencies. The nurse should encourage the client to consume shrimp, salmon, and catfish because these fish have the least amount of mercury. C) Nearly all fish contain traces of mercury. Mercury can place the developing nervous system of the fetus at risk and cause negative effects on cognitive functioning. The nurse should instruct the client to eat up to 12 ounces a week of a variety of fish and shellfish. The nurse should advise the client to eat no more than 6 ounces of albacore tuna each week because it has more mercury than other canned tuna. King mackerel should be avoided because it contains high levels of mercury. The nurse should not suggest that the client consume a complete vegetarian diet because this could lead to other nutritional deficiencies. The nurse should encourage the client to consume shrimp, salmon, and catfish, because these fish have the least amount of mercury.
The nurse is caring for a 15-year-old pregnant adolescent during the labor and delivery process. The client has no support person with her, and she plans to give up her baby for adoption. What nursing intervention can the nurse implement to facilitate the grieving process for this client? A) Encourage the client to avoid seeing and holding the baby. B) Encourage the client to see and hold the baby. C) Encourage the client to have the adoptive parents present for the birth. D) Encourage the client to sign the adoption papers as soon as possible after the birth.
B) Encourage the client to see and hold the baby. Explanation: The adolescent who is planning to give up her baby for adoption should be given the option of seeing and holding her baby. This facilitates the grieving process. However, seeing or holding the newborn should be her choice. The nurse should not discourage the adolescent from seeing her baby and should not encourage the adolescent to sign adoption papers as soon as possible after the birth. Because of privacy concerns, the nurse should not encourage the adolescent to have the adoptive parents present for the birth except for special circumstances as determined by the client, not the nurse.
Before a first-time mother is discharged from the hospital with her newborn, the nurse notices that the mother is taking directions on newborn care from her parents and in-laws. What stage of maternal role attainment is the new mother in? A) Anticipatory stage B) Formal stage C) Informal stage D) Personal stage
B) Formal stage Explanation: In the formal stage of maternal role attainment, the woman is influenced by the guidance of others and tries to act as she believes others expect her to act. The anticipatory stage occurs during pregnancy. The informal stage occurs when the mother begins to make her own choices about mothering. The personal stage occurs when the mother is comfortable with the notion of herself as "mother."
During which phase of the ovulatory cycle does the ovum get fertilized? A) Follicular phase B) Luteal phase C) Proliferative phase D) Secretory phase
B) Luteal phase: Explanation: The ovum can be fertilized as it moves through the fallopian tube, which occurs after the graafian follicle ruptures. The rupture of the graafian follicle begins the luteal phase. The ovum is still encapsulated in the graafian follicle in the follicular phase, and it cannot be penetrated by sperm. The proliferative phase and secretory phase are phases of the menstrual cycle, not the ovulatory cycle.
The nurse is preparing to provide an enteral feeding to a preterm infant. Which is the priority nursing action prior to administering the feeding? A) Weigh the current diaper. B) Measure abdominal girth. C) Weigh the baby. D) Measure pulse oximetry.
B) Measure abdominal girth. Explanation: Before each feeding, the nurse should measure the abdominal girth to determine abdominal distention, which is seen in necrotizing enterocolitis or paralytic ileus. Weighing the baby and weighing diapers are interventions to assess for fluid volume status. Measuring pulse oximetry is an intervention for assessing oxygenation.
The nurse is providing care to a client with a history of rheumatoid arthritis (RA) who is 5 months pregnant. Which nursing actions are appropriate when providing care to this client? Select all that apply. A) Telling the client there is an increased risk for preterm delivery because of salicylate therapy B) Monitoring the client for anemia due to salicylate therapy C) Suggesting the client begin supplemental pyridoxine D) Educating the client that medication therapy may be discontinued due to remission E) Teaching the client that RA may be contracted by the fetus during pregnancy
B) Monitoring the client for anemia due to salicylate therapy D) Educating the client that medication therapy may be discontinued due to remission Explanation: B) When providing care to a client with RA during pregnancy, the nurse will monitor the client for anemia due to salicylate therapy and educate the client that medication therapy may be discontinued if the client experiences remission during the pregnancy. Salicylate therapy is associated with prolonged gestation and labor. Supplemental pyridoxine is required for clients being treated with isoniazid for TB during pregnancy. RA cannot be contracted by the fetus during pregnancy.
A nurse working in an OB/GYN outpatient clinic finds that on a routine anemia screen, a pregnant client in her second trimester has a hemoglobin of 10 g/dL. The client confirms fatigue, but otherwise feels fine. Which action by the nurse is the priority when providing care to this client? A) Tell the client to rest any time she feels fatigued. B) Recommend the client add supplemental iron to her diet. C) Ask the client to return in 2 months for a repeat check of her hemoglobin. D) Order a screening for sickle cell anemia.
B) Recommend the client add supplemental iron to her diet. Explanation: Iron deficiency anemia is the most common medical complication of pregnancy; thus, low hemoglobin during pregnancy suggests an inadequate intake of dietary iron as the probable cause of her anemia. Given that the client's anemia is likely from iron deficiency, the nurse needs to emphasize the importance of increased iron supplementation. A screening for sickle cell anemia is not indicated given the information presented. The client should return in 1 month for a recheck of her hemoglobin levels; if improvement is not seen, then further evaluation is indicated. Although adequate rest is important, it does not address the client's physiologic iron deficiency that is causing the fatigue.
During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the nurse assesses the following: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood noted from the vagina. Which assessment finding requires immediate follow-up? A) Moderate lochia rubra B) Steady trickle of blood C) Fundus at the umbilical level D) Firm fundus
B) Steady trickle of blood Explanation: The steady trickle of blood could indicate a laceration in the birth canal and should be reported to the healthcare provider for follow-up. A firm fundus is a desired finding and is considered normal. Six hours after birth, the fundus at the umbilicus would not be a concern. Moderate lochia rubra is considered a normal finding.
The nurse is providing care to a pregnant client who is experiencing ptyalism. Which will the nurse include in the plan of care for this client? A) Use a cool-mist vaporizer B) Suck on hard candy C) Avoid use of nasal sprays and decongestants D) Use low-sodium antacids
B) Suck on hard candy Explanation: Ptyalism is excessive, often bitter salivation that can occur during pregnancy. Appropriate interventions for this client include using astringent mouthwashes, chewing gum, or sucking on hard candy. A cool-mist vaporizer and avoiding nasal sprays and decongestants are appropriate interventions for nasal stuffiness and nosebleed (epistaxis). The use of low-sodium antacids is appropriate for pyrosis, or heartburn.
A client who is in the first trimester of pregnancy tells the nurse that she is constantly nauseated and can vomit at any time. To assist this client, the nurse should instruct her to do which of the following? A) Drink a glass of water every time nausea occurs. B) Take a multivitamin each day. C) Take over-the-counter Benadryl for the nausea. D) Eat a snack any time nausea occurs.
B) Take a multivitamin each day. Explanation: Multivitamins may reduce the nausea associated with the first trimester of pregnancy. The nurse should not instruct the client to drink a glass of water every time nausea occurs because this could lead to the ingestion of high quantities of water. The nurse should not instruct the client to eat a snack any time nausea occurs, as this could lead to higher than needed calorie intake and inappropriate weight gain, and it also will not likely help the nausea significantly. The nurse should also not instruct the client to ingest an over-the-counter medication without discussing this with her physician.
A pregnant woman at 41 weeks' gestation has a Bishop score of 5. What does this score indicate? A) The cervix is favorable for a normal vaginal delivery. B) The cervix is unfavorable and induction of labor may be necessary. C) The cervix is unfavorable and a cesarean section may be necessary. D) The cervix is favorable and labor has been successfully induced.
B) The cervix is unfavorable and induction of labor may be necessary. Explanation: A Bishop score less than 6 indicates that the cervix is unfavorable. When a pregnant woman at or near term has an unfavorable cervix, induction of labor may be necessary for medical or obstetric reasons. A Bishop score less than 6 does not indicate that a cesarean section may be necessary.
A postpartum client is experiencing pain from an episiotomy. Which actions will the nurse suggest to the client to decrease discomfort? Select all that apply. A) Washing the area with soap and water every day B) Tightening the buttocks before sitting C) Changing peripads daily D) Performing leg scissor kicks several times a day E) Increasing the intake of meat, cheese, fish, eggs, and nuts
B) Tightening the buttocks before sitting E) Increasing the intake of meat, cheese, fish, eggs, and nuts Explanation: Lysine has been identified as an essential amino acid that decreases the pain of an episiotomy. This amino acid is present in meat, cheese, fish, eggs, and nuts. The nurse should instruct the client to tighten the buttocks before sitting to reduce the pain. The client should wash the area daily and the peripad should be changed four times a day to decrease the risk of infection, not pain. Performing leg scissor kick exercises would put strain on the incision site and should not be done.
The nurse is providing discharge instructions for a first-time mother and her baby. Which statement is appropriate for the nurse to include in the teaching session? A) "Your baby's stools will change to a dark green color when your milk comes in." B) "Your baby may spit up frequently for the first few weeks." C) "Compress the bulb syringe before placing it in your baby's nose or mouth." D) "You can wipe away any green drainage that might form around the umbilical cord."
C) "Compress the bulb syringe before placing it in your baby's nose or mouth." Explanation: A bulb syringe is often used to suction excess secretions from the baby's nose and mouth. The bulb syringe should be compressed before placing it gently in the baby's nose or mouth. Stool color is often seedy and yellow or golden brown in color when breastfeeding. The baby may spit up frequently in the first day or two, but this should not continue for several weeks. Green drainage from the umbilical cord is abnormal and should be reported to the baby's provider.
Which pregnant client would have the greatest need for a nutritional assessment and individualized meal plan? A) A client who is lactose intolerant B) A client who is vegetarian C) A client who requires a Kosher diet D) A client with anorexia nervosa
D) A client with anorexia nervosa Explanation: Although all of these clients will need special considerations related to diet and nutritional requirements, the client with anorexia nervosa, an eating disorder, is at highest risk for inadequate nutrition. When a pregnant woman has an eating disorder, education and individualized meal plans can help the patient increase her dietary intake while maintaining a sense of control.
The nurse is instructing a pregnant client on how the baby's condition is evaluated during labor. Which client statement indicates appropriate understanding of the information presented? A) "During labor, the nurse will verify that my contractions are strong but not too close together." B) "During labor, the nurse will look at the color and amount of bloody show that I have." C) "During labor, the nurse will assess the baby's heart rate with a Doppler ultrasound." D) "During labor, the nurse will regularly check my cervix by doing a pelvic exam."
C) "During labor, the nurse will assess the baby's heart rate with a Doppler ultrasound." Explanation: During labor, the nurse will assess the baby's heart rate with a Doppler ultrasound unless complications are present. This is the statement the client should make to prove that education was successful. The nurse will also monitor contractions, bloody show, and the cervix, but these assessments do not monitor the baby's condition.
The spouse of a pregnant client tells the nurse that he is not sure he is ready to be a father and wishes his wife had not gotten pregnant. Which response by the nurse is appropriate? A) "Do you think your wife got pregnant on purpose, without your consent?" B) "Have you considered giving the baby up for adoption?" C) "Tell me more about why you feel this way." D) "Every husband has these feelings, and many times they never go away."
C) "Tell me more about why you feel this way." Explanation: The nurse needs to include the care of the father when providing care to a pregnant client. The husband is expressing uncertainty about his ability to be a father and regrets the pregnancy. The best response by the nurse is to explore the father's feelings. The nurse should not minimize the husband's feelings by stating every husband has these feelings. It is inappropriate for the nurse to say that the feelings may never go away. The nurse should not suggest that the baby be given up for adoption or that the client became pregnant on purpose because neither of these statements supports the client or husband at this time.
The nurse is planning for several women who are pregnant for the first time who are in the labor and delivery process. Which woman has the highest risk of labor and delivery complications? A) A healthy 38-year-old woman B) A 24-year-old woman with asthma C) A 36-year-old woman with diabetes D) A 31-year-old woman with hypertension
C) A 36-year-old woman with diabetes Explanation: Women over the age of 35 have an increased risk for complications during labor and delivery, especially when the woman already has preexisting medical conditions such as hypertension or diabetes. However, risks are much lower for women under the age of 35 or women over the age of 35 who do not have preexisting medication conditions.
When palpating the fundus of a woman on her first day postpartum, the nurse finds that the woman's uterus is higher than expected and is deviated to the right. She is not having excessive uterine bleeding. Which is the priority nursing action for this client? A) Notify the client's midwife of this condition. B) Ask another nurse to assess the client to verify the findings. C) Ask the client to void and then reassess fundal height. D) Perform a straight catheterization on the client and then reassess fundal height.
C) Ask the client to void and then reassess fundal height. Explanation: The cause of a distended fundus in a recently delivered woman is likely due to a distended bladder causing a temporary upward displacement of the uterus. Having the woman empty her bladder and then reassessing fundal height is the priority action for the nurse to take at this time. If the client is unable to void, a straight catheterization to empty the bladder is indicated, after which fundal height would then be reassessed. The nurse would not notify the client's midwife about the data unless the assessment remains unchanged after the client voids. Asking another nurse to verify the assessment findings is not an appropriate action.
The nurse is providing care to the client during the second stage of labor. Which nursing action is appropriate? A) Assessing maternal temperature every 1-2 hours after amniotic membranes have ruptured B) Encouraging the client to void every 1-2 hours C) Assessing fetal heart rate every 5 minutes D) Administering antibiotics for a positive group beta strep
C) Assessing fetal heart rate every 5 minutes Explanation: The second stage of labor is reached when the cervix is completely dilated. At this time, it is appropriate for the nurse to assess fetal heart rate every 5 minutes or after every contraction. Assessing temperature every 1 to 2 hours after amniotic membranes have ruptured, encouraging the client to void, and administering antibiotics are all nursing actions that are appropriate during the first stage of labor.
The nurse is providing care to a client in labor who experiences spontaneous rupture of membranes. The fetus is in the vertex position. The nurse notes that the amniotic fluid is meconium stained. Based on this data, which is the priority action by the nurse? A) Notifying the healthcare provider that birth is imminent B) Changing the client's position in bed C) Beginning continuous fetal heart rate monitoring D) Administering oxygen at 2 liters per minute
C) Beginning continuous fetal heart rate monitoring Explanation: Meconium-stained amniotic fluid is an abnormal fetal finding and is an indication for continuous fetal monitoring. Changing the client's position is not indicated. Meconium-stained amniotic fluid does not indicate that birth is imminent. Oxygen administration is not indicated.
The nurse is caring for a pregnant client who has asthma. The client has a cold and has an exacerbation of asthma symptoms, including mild wheezing. To help avoid hypoxia-related complications in the fetus, which medication prescription does the nurse anticipate? A) IV corticosteroid (e.g., prednisone) B) Oral pseudoephedrine (e.g., Sudafed) C) Inhaled beta2-agonist (e.g., albuterol) D) Oral acetylsalicylic acid (e.g., aspirin)
C) Inhaled beta2-agonist (e.g., albuterol) Explanation: Albuterol, a beta2-agonist, is the medication recommended to treat asthma exacerbations during pregnancy. Steroids, decongestants such as pseudoephedrine, and aspirin should be avoided in pregnancy because of potential harmful effects to the fetus.
A client who is at 12 weeks' gestation is experiencing nausea, breast tenderness, and fatigue. She tells the nurse her husband is upset with her constant complaints. Which is the priority nursing diagnosis based on this data? A) Ineffective Breastfeeding B) Dysfunctional Family Processes C) Nausea D) Fatigue
C) Nausea Explanation: Of the three physiologic complaints, the one that has the highest priority is nausea because it could directly impact the developing fetus. Breast tenderness does not mean that the client will experience ineffective breastfeeding. Fatigue is a common symptom of pregnancy and would not negatively impact the developing fetus. The husband being upset with the client's complaints does not necessarily mean that she and her husband have dysfunctional family processes.
The nurse is instructing a client who is at 10 weeks' gestation on avoiding substance abuse. Which is the rationale for why substances of abuse should be avoided during pregnancy? A) Interferes with hormone excretion of the fetus B) Facilitates the transfer of viruses and other diseases into the developing fetus C) Passes into the developing fetus through the placenta very easily D) Stops the synthesis of protein in the developing fetus
C) Passes into the developing fetus through the placenta very easily Explanation: Substances of abuse pass from the mother to the fetus through the placenta via simple diffusion. These substances have adverse effects on the developing fetus. Substances of abuse do not interfere with the hormone excretion of the fetus or stop the synthesis of protein in the fetus. They do not facilitate the transfer of viruses and other diseases into the developing fetus.
Upon delivery of the newborn, which nursing intervention promotes parental attachment? A) Placing the newborn under the radiant warmer B) Placing the newborn on the bed next to the mother C) Placing the newborn on the maternal chest D) Taking the newborn to the nursery for the initial assessment
C) Placing the newborn on the maternal chest Explanation: Placing the baby on the maternal chest promotes attachment and bonding and gives the mother a chance to interact immediately with her baby. Removing the baby to the radiant warmer, allowing the mother a chance to rest immediately after delivery, and taking the newborn to the nursery for the initial assessment do not promote attachment.
The nurse is reviewing the immunization record for a client who just learned she is pregnant. Which vaccine is not safe to give during pregnancy? A) Pertussis B) Annual influenza C) Rubella D) Tetanus
C) Rubella Explanation: Rubella vaccine should never be given to pregnant women (or women trying to conceive) because the vaccine contains the attenuated live virus, which has teratogenic effects on the developing fetus. Pertussis, tetanus, and annual influenza vaccines can safely be given in pregnancy. Safe vaccine recommendations for pregnant women are available from the Centers for Disease Control and Prevention website (http://www.cdc.gov).
A 16-year-old has just given birth, and she plans to keep and care for the baby. However, the nurse determines that the young mother has low self-esteem, and she does not appear to have adequate social support. The nurse should encourage adequate follow-up care for this young mother for what reason? A) She is at risk for postpartum hemorrhage. B) She is at risk for postpartum endometritis. C) She is at risk for postpartum depression. D) She is at risk for postpartum weight gain.
C) She is at risk for postpartum depression. Explanation: Young mothers with low self-esteem, family conflict, and few social supports are more likely to encounter postpartum depression. The nurse should carefully assess the young mother for risk factors and provide appropriate referrals for follow-up. Having low self-esteem and no social support does not increase the adolescent's risk for postpartum hemorrhage. There is not enough information to determine if she is at risk for postpartum endometritis. She may be at higher risk for inadequate nutrition rather than excessive weight gain.
The nurse is assessing a premature newborn who is being cared for in the newborn intensive care unit (NICU). Which assessment finding indicates the newborn is experiencing respiratory distress? A) Acrocyanosis B) Respiratory rate of 58 breaths per minute C) Substernal and intercostal retractions D) Abdominal breathing
C) Substernal and intercostal retractions Explanation: A premature newborn who is experiencing retraction may indicate respiratory distress. Acrocyanosis, a respiratory rate of 58 breaths per minute, and abdominal breathing are considered normal assessment findings in the premature newborn.
The nurse is providing care to a client who is experiencing nausea and vomiting during the first trimester of pregnancy. Which actions by the nurse are appropriate based on this data? Select all that apply. A) Notify the healthcare provider that the client is experiencing hyperemesis gravidarum. B) Educate the client to notify the healthcare provider if she vomits once per day. C) Suggest the client use acupressure to pressure points on the wrist. D) Teach the client that ginger may relieve her symptoms. E) Caution the client against using over-the-counter medications such as over-the-counter antihistamines.
C) Suggest the client use acupressure to pressure points on the wrist. D) Teach the client that ginger may relieve her symptoms. Explanation: C) Nausea and vomiting is a common experience during the first trimester of pregnancy. Acupressure and ginger are two complementary therapies that the nurse can suggest to the client to relieve the symptoms. There is no evidence that the client is experiencing hyperemesis gravidarum. The client should be taught to notify the healthcare provider if vomiting occurs more than once a day. Over-the-counter antihistamines are safe to use during pregnancy to decrease the occurrence of nausea and vomiting if recommended by the doctor. D) Nausea and vomiting is a common experience during the first trimester of pregnancy. Acupressure and ginger are two complementary therapies that the nurse can suggest to the client to relieve the symptoms. There is no evidence that the client is experiencing hyperemesis gravidarum. The client should be taught to notify the healthcare provider if vomiting occurs more than once a day. Over-the-counter antihistamines are safe to use during pregnancy to decrease the occurrence of nausea and vomiting if recommended by the doctor.
During an assessment, the nurse notes the client in the fourth stage of labor is experiencing intense shaking and chills. Based on this data, which conclusion by the nurse is appropriate? A) This is evidence of incomplete expulsion of the placenta. B) The client has a full bladder. C) This is a normal reaction to the ending of the physical exertion of labor. D) The client has a fever from a postpartum infection.
C) This is a normal reaction to the ending of the physical exertion of labor. Explanation: Many clients experience a shaking chill in the fourth stage of labor, which is thought to be associated with the ending of the physical exertion of labor. The nurse would need to assess the client's temperature to determine the presence of a fever. Indications of a full bladder would most likely be a displaced uterus. Shaking chills after delivery is not evidence of incomplete expulsion of the placenta.
A client in the fourth stage of labor is experiencing perineal trauma. Which nursing diagnosis is the priority at this time? A) Health-Seeking Behaviors B) Fear C) Anxiety D) Acute Pain
D) Acute Pain Explanation: Many clients experience perineal trauma during the childbirth process, which causes acute pain in the fourth stage of labor. Therefore, Acute Pain is a more appropriate nursing diagnosis related to this condition than Fear or Anxiety. The diagnosis of Health-Seeking Behaviors does not address the client experiencing perineal trauma during labor.
When planning the care for a preterm infant with ineffective thermoregulation, the nurse should include which intervention? A) Keep the baby's head uncovered. B) Rinse hands with cold water before providing care to the infant. C) Place incubator near a window or source of fresh air. D) Allow skin-to-skin contact with the mother to maintain warmth.
D) Allow skin-to-skin contact with the mother to maintain warmth. Explanation: The nurse needs to plan for a neutral thermal environment to minimize oxygen consumption, prevent cold stress, and facilitate growth of the preterm infant. To do this, the nurse should plan for the infant to have skin-to-skin contact with the mother to maintain warmth. The hands should be rinsed with warm water before providing care to the infant. The baby's head should be covered because the head is 25% of the baby's size and is prone to evaporative heat loss. Incubators should be moved away from drafts or open windows to reduce radiative and conductive heat loss.
The nurse is providing care to a pregnant client and her spouse. The client requires an amniocentesis. Which client statement indicates appropriate understanding of the information presented? A) "The test has to be done before the 14th week of pregnancy." B) "If the test determines our baby has Down syndrome, we will not need to take childbirth classes." C) "It is not unusual for amniocentesis to misdiagnose a problem with the baby." D) "The results of the amniocentesis will take up to 2 weeks."
D) "The results of the amniocentesis will take up to 2 weeks." Explanation: For couples having an amniocentesis, the first few months of pregnancy can be difficult because the test cannot be performed until the 14th week of pregnancy, and not before. The results of the amniocentesis will not be available for up to 2 weeks, which is evidence that instruction regarding the test has been understood by the client and spouse. Childbirth classes are important in promoting adaptation to the event of childbirth for expectant couples of any age or situation. The results of an amniocentesis are 99% accurate in diagnosing genetic abnormalities.
The nulliparous client states, "I have been in labor for 4 hours and I am still only 2 cm dilated. Why is this happening? I feel like I should be ready to push by now." Which is the best response by the nurse? A) "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." B) "The hormones that cause labor to begin are just getting to the levels that will change your cervix." C) "What did you expect? You've only had contractions for a few hours. Labor takes time." D) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."
D) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress." Explanation: Cervical effacement must be nearly complete before cervical dilation takes place in primiparas. This is why the labor and birth of a first baby usually take much more time than for subsequent labor and births. The perineal body thinning primarily occurs during the second stage of labor; it is not expected early in labor. The reply "what did you expect" is not therapeutic. Although it is true that this client has only been in early labor for a short time, and it is true that labor for a nullipara averages 12-24 hours, the nurse must always be therapeutic in all communication. The hormones that cause labor contractions do not directly cause cervical change; the contractions cause the cervix to change.
The nurse is reviewing exercises with a pregnant woman to help the client maintain physical fitness and appropriate weight gain throughout the pregnancy. After the teaching session, the client tells the nurse that she was taught never to reach over the head because this will harm the baby. Based on this data, which action by the nurse is appropriate? A) Provide dietary instruction instead to ensure the client does not gain excessive weight. B) Tell the client to just perform the exercises that don't require her to reach over her head. C) Provide alternative activities to do instead of exercise. D) Assure the client that reaching over the head will not harm the baby.
D) Assure the client that reaching over the head will not harm the baby. Explanation: Clients of European, African, and Mexican descent may believe that reaching over the head during pregnancy can harm the baby. The nurse should assure the client that this is not accurate. Providing activities to do instead of exercise or telling the client to avoid the exercises that require her to reach over her head will not address the misconception that reaching over the head will harm the baby. Dietary instruction during pregnancy is important to ensure a healthy weight gain for a healthy baby, not to ensure the client does not gain excessive weight because of lack of exercise.
The mother of a preterm infant tells the nurse that she was not looking forward to having a baby and now that the baby is sick, she feels worse. Which nursing diagnosis is appropriate based on this data? A) Parental Role Conflict B) Impaired Parenting C) Dysfunctional Family Processes D) Compromised Family Coping
D) Compromised Family Coping Explanation: Compromised Family Coping is the nursing diagnosis most appropriate for this situation at this time because the mother is expressing anger and guilt at having given birth to a premature baby. Parental Role Conflict is seen if the role of parent is in conflict with other expectations. Impaired Parenting is seen if the mother is unable to fulfill the role of mother to the baby. Dysfunctional Family Processes is seen if the addition of a baby leads to the family's inability to function as a family.
During the fourth stage of labor, a client's blood pressure is 110/60 mmHg, pulse 90, and the fundus is firm, midline, and halfway between the symphysis pubis and the umbilicus. Based on this data, which is the primary action by the nurse? A) Massage the fundus. B) Turn the client onto the left side. C) Place the bed in the Trendelenburg position. D) Continue to monitor.
D) Continue to monitor. Explanation: The client's assessment data are normal for the fourth stage of labor, so monitoring is the only action necessary. During the fourth stage of labor, the mother experiences a slight drop in blood pressure and a slightly increased pulse. A left lateral position is not necessary with a BP of 110/60 and a pulse of 90. The Trendelenburg position is not necessary with a BP of 110/60 and a pulse of 90. The uterus should be midline and firm; massage is not necessary.
Which factor contributes to increased respiratory complications in the preterm infant? A) Increased constriction of blood vessels B) Decreased prostaglandin E levels C) Absence of muscular coat on pulmonary blood vessels D) Inadequate surfactant
D) Inadequate surfactant Explanation: The preterm neonate is unable to produce adequate amounts of surfactant in the lungs, decreasing compliance and increasing the pressure needed to expand the lungs with air. Collapsed alveoli do not facilitate exchange of oxygen and carbon dioxide, leading to hypoxia, inefficient pulmonary blood flow, and energy depletion. In preterm infants, the muscular coat on pulmonary blood vessels is incompletely developed, not absent, leading to decreased constriction of blood vessels. Prostaglandin E levels are increased, not decreased.
After giving birth to a preterm infant who is being cared for in the neonatal intensive care unit (NICU), a client says, "My baby doesn't seem real because she's in the hospital and I'm at home." What can the nurse do to promote parent-infant attachment? A) Limit visits to the intensive care unit so as not to disrupt care the baby needs. B) Explain that once the baby is discharged to home, she will have evidence that the baby is real. C) Have the mother visit when the baby is asleep or resting. D) Provide a picture of the infant including a footprint and current weight and length.
D) Provide a picture of the infant including a footprint and current weight and length. Explanation: Nurses need to take measures to promote positive parental feelings toward the preterm infant. One way to do this would be to provide the mother with a picture of the infant, including a footprint and current weight and length. This promotes bonding. The mother needs to begin bonding with the infant now, not wait until the baby is discharged to home. Visits to the intensive care unit should be encouraged and supported. The mother should try to visit with the infant when the baby is awake to encourage interaction.
The nurse conducting a 5-minute Apgar assessment on a newborn assigns the following ratings: Heart rate <100 beats per minute (1 point); slow, irregular respirations (1 point); some flexion of the extremities (1 point); a vigorous cry with flicking of the baby's foot (2 points); and a pink body with blue extremities (1 point). Based on this data, which nursing action is appropriate? A) Having the aide reassess the newborn's heart rate and respiratory rate when admitted to the nursery B) Swaddling the newborn to decrease the risk of increased energy expenditure C) Placing the newborn in the mother's arms and asking her to monitor her baby's breathing D) Repeating the assessment every 5 minutes for up to 20 minutes
D) Repeating the assessment every 5 minutes for up to 20 minutes Explanation: With a 5-minute Apgar of 6, this newborn is at increased risk for complications compared to those with Apgar scores in the range of 7 to 10. The nurse will reassess the client every 5 minutes for up to 20 minutes. The nurse should have resuscitative equipment ready for use. The other actions are not appropriate based on the data provided.
The nurse receives shift change report on infants born within the last 4 hours. Which newborn should the nurse assess first? A) Newborn born at 37 weeks' gestation. Respiratory rate of 45 breaths per minute. B) Term newborn, 2 hours old, who has not passed a meconium stool. C) Term newborn born 3 hours ago. Heart rate is 150 beats per minute. D) Term newborn born 1 hour ago who is exhibiting grunting respirations.
D) Term newborn born 1 hour ago who is exhibiting grunting respirations. Explanation: Grunting respirations are an indication of respiratory distress. This infant needs further assessment and possibly immediate intervention. A normal respiratory rate is 30-60 breaths per minute. A normal pulse is 110-160 beats per minute. If a meconium stool is not passed within the first 24 hours, this would be cause for concern.
The nurse is providing care to a newborn born at 37 2/7 weeks' gestation. The newborn's weight is 1750 g (3 pounds, 10 ounces). What statement would the nurse use to describe these assessment findings? A) Preterm appropriate for gestational age B) Term appropriate for gestational age C) Preterm small for gestational age D) Term small for gestational age
D) Term small for gestational age Explanation: The infant is term at 37 2/7 weeks. Because the weight is below the 10th percentile, the infant is not appropriate for gestational age but is considered small for gestational age.
The nurse is monitoring the intake and output for a preterm infant. Which action by the nurse indicates correct assessment technique when monitoring urine output? A) Document "unable to obtain" on the graphic sheet. B) Apply an external condom catheter. C) Insert an indwelling urinary catheter. D) Weigh diapers using the estimate that 1 mL = 1 gram of weight.
D) Weigh diapers using the estimate that 1 mL = 1 gram of weight. Explanation: Weight change is one of the most sensitive indicators of fluid balance. Weighing diapers is the intervention used to accurately measure the output of an infant. The estimate is that 1 g of diaper weight is equal to 1 mL of fluid. The nurse should not insert an indwelling urinary catheter or apply an external condom catheter on the infant. Documenting "unable to obtain" on the graphic sheet does not support the need to accurately measure the infant's output.
The nurse is providing care to a newborn during the first 24 hours of life. Which is an abnormal finding? A) Respiratory rate of 58 breaths per minute B) Heart rate of 140 beats per minute C) Presence of meconium stool D) Yellowing of the skin
D) Yellowing of the skin Explanation: Yellowing of the skin within the first 24 hours of life is caused by pathologic jaundice and often requires treatment with phototherapy. All of the other assessment findings are considered normal during the first 24 hours of life.