N482 Unit 1 HESI

Which information would the nurse include when teaching a client experiencing a postterm pregnancy? SATA. a. Monitor for signs of labor. b. Perform daily fetal movement counts. c. Go to the birthing facility soon after labor begins. d. Call the Primary HCP if the membranes rupture. e. Keep appointments for fetal assessment tests and cervical checks.

a. Monitor for signs of labor. b. Perform daily fetal movement counts. c. Go to the birthing facility soon after labor begins. d. Call the Primary HCP if the membranes rupture. e. Keep appointments for fetal assessment tests and cervical checks.

The nurse is reassessing a newborn who had an axillary temperature of 97° F (36° C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97° F (36° C) after 1 hour of skin-to-skin contact. Which intervention should the nurse implement next? a. Placing the newborn under a radiant warmer and attaching a skin probe b. checking the newborn for a wet diaper and then continuing skin to skin contact c. leaving the infant in skin to skin contact and rechecking the temp in 1 hr d. double-wrapping the newborn in warm blankets and returning the newborn to a crib by the mother's bedside

a. Placing the newborn under a radiant warmer and attaching a skin probe

Which assessment finding indicates that a client at 40 weeks gestation is experiencing true labor? a. cervical dilation b. membrane rupture c. decreased fetal heart rate d. intensification of contractions

a. cervical dilation

Which is the best time for the nurse to teach simple breathing and relaxation techniques to a client in labor that has not attended any childbirth classes? a. during the latent phase of the first stage of labor b. during the active phase of the first stage of labor c. during the active phase of the second stage of labor d. during the transition phase of the first stage of labor

a. during the latent phase of the first stage of labor

The charge nurse is delegating tasks for the nursing assistants regarding the postpartum care of a client. Which task is appropriate to be delegated to an unlicensed assistive personnel (UAP) to provide effective client care? Select all that apply. a. feeding the client b. providing basic hygiene c. teaching care of the infant d. encouraging breast-feeding e. administering IV fluids

a. feeding the client b. providing basic hygiene d. encouraging breast-feeding

Which nursing action would the nurse perform to promote maternal-newborn bonding in the hospital? a. suggesting that the mother choose breast-feeding instead of formula-feeding b. advising the mother to call for the newborn to be taken to the nursery when she's tired c. encouraging the mother to perform simple aspects of her newborn's care d. observing the mother-infant interaction unobtrusively to evaluate the relationship

c. encouraging the mother to perform simple aspects of her newborn's care

What is the optimal method for the nurse to use for assessing a newborn's grasp reflex? a. stroking gently upward along the sole of the newborn's foot b. jarring the crib and watching the movement of the newborn's hands c. pressing the examiner's fingers against the palm of the newborn's hand d. holding the body upright and allowing the newborn's feet to touch a surface

c. pressing the examiner's fingers against the palm of the newborn's hand

The nurse is caring for a client who is in the taking-in phase of the postpartum period. The area of health teaching that the client will be most responsive to is: 1. Perineal care 2. Infant feeding 3. Infant hygiene 4. Family planning

1. Perineal care

A nurse is giving discharge instructions to a new mother. What is the most important instruction to help prevent postpartum infection? 1 "Don't take tub baths for at least 6 weeks." 2 "Eat a balanced diet and get plenty of rest." 3 "Douche with a dilute antiseptic solution twice a day and continue for a week." 4 "Tampons are better than sanitary napkins for inhibiting bacteria in the postpartum period."

2 "Eat a balanced diet and get plenty of rest."

Which finding indicates that a newborn has vernix caseosa? 1 Brown hair on the skin 2 Rosy to yellowish skin 3 Cheese-like substance on the skin 4 Light-pink to reddish-brown skin

3 Cheese-like substance on the skin

A client who has had a cesarean birth appears upset. She has been having difficulty breastfeeding for two days and now asks the nurse to bring her a bottle of formula. What is the nurse's initial reaction? A. obtaining the requested formula B. Administering the prescribed pain medication C. Assessing the client's breastfeeding technique D. Notifying the practicioner of the client's request to switch feeding methods

C. Assessing the client's breastfeeding technique

After 8 postpartum hours the nurse determines that a client's fundus is 3 cm above the umbilicus and displaced to the right. Which statement is most significant in confirming the reason for the location of the uterus? a. "I've been so thirsty the past few hours." b. "I've been to the bathroom but I can't seem to urinate." c. "I've changed my pad since I got to my room." d. "I've had a lot of contractions, especially while I was nursing."

b. "I've been to the bathroom but I can't seem to urinate."

A nurse is caring for a postpartum client. Where does the nurse expect the fundus to be located if involution is progressing as expected 12 hours after birth? a. 2 cm below the umbilicus b. 3 cm above the umbilicus c. 1 cm above the umbilicus d. 3 cm below the umbilicus

c. 1 cm above the umbilicus

A mother and her newborn have just been transferred to the postpartum unit from labor and delivery. Which infant safety education should be provided as soon as mom and baby are settled into their room? Select all that apply .1. "Wash your hands before touching the newborn." 2. "Send the newborn to nursery to be monitored during the night." 3. "All client identification bands should remain in place until discharge." 4. "Do not let anyone remove the infant from your sight while you are in the hospital." 5. "Check the identification of staff, and if there is a question of validity, call the nursing station."

1. "Wash your hands before touching the newborn." 3. "All client identification bands should remain in place until discharge." 5. "Check the identification of staff, and if there is a question of validity, call the nursing station."

Which information should the nurse include in the discharge teaching of a postpartum client? 1.The prenatal kegel tightening exercise should be continued 2. The episiotomy sutures will be removed at the first postpartum visit 3. She may not have a bowel movement for up to a week after birth 4. She should schedule a postpartum checkup as soon as her menses returns

1.The prenatal kegel tightening exercise should be continued

An infant born in the 36th week of gestation weighs 4 lb 3 oz (2062 g) and has Apgar scores of 7 and 9. What nursing actions will be performed on the infant's admission to the nursery? (Select all that apply.) 1 Recording of vital signs 2 Administration of nasal cannula oxygen 3 Offering a bottle of dextrose in water 4 Evaluation of the neonate's health status 5 Supportive measures to keep the neonate's body temperature stable

1 Recording of vital signs 4 Evaluation of the neonate's health status 5 Supportive measures to keep the neonate's body temperature stable

A client expresses a desire to breast-feed her preterm neonate, who is in the neonatal intensive care unit (NICU). The client states that she will pump her breasts until her baby is ready to breast-feed. The infant has been sucking on a pacifier for 1 week in accordance with protocol. How should the nurse respond to the mother's request? 1By telling the client that this is unnecessary because the infant is being fed by gavage 2By discouraging the client because of the time and effort it will take to pump her breasts 3By instructing the client that breast milk is inadequate because it does not contain the necessary nutrients 4By supporting the client's decision and explaining that her infant may be unable to finish breastfeeding due to exhaustion

4By supporting the client's decision and explaining that her infant may be unable to finish breastfeeding due to exhaustion

Two days after being discharged a new mother calls the clinic stating that she is not sure that her baby is receiving enough breast milk. What information does the nurse need to determine whether the infant is being fed adequately? A. Voids four times before 2 pm B. Sleeps 3½ to 4 hours between feedings C. Has two or more bowel movements each day D. Nurses 5 minutes on the first breast and 10 on the other

A. Voids four times before 2 pm

Which assessments and interventions are necessary once an epidural catheter has been inserted? SATA. a. Maintain IV fluid administration. b. Have oxygen available in case of hypotension. c. Check the bladder for distention every 2 hours. d. Position the client supine for ease of monitoring. e. Monitor fetal heart rate and labor progress per hospital protocol. f. Administer an oxytocin infusion to maintain the labor pattern.

a. Maintain IV fluid administration. b. Have oxygen available in case of hypotension. c. Check the bladder for distention every 2 hours. e. Monitor fetal heart rate and labor progress per hospital protocol.

Which response would the nurse give to a client who asks what having a fetus in longitudinal lie means in relation to her labor and birth of the baby? a. "A vaginal birth is possible." b. "We're anticipating a cesarean delivery." c. "It has no relevance to the labor and birth." d. "Labor probably will be long, and you might have back pain."

a. "A vaginal birth is possible."

On the second postpartum day a client mentions that her nipples are becoming sore from breastfeeding. What is the nurse's initial action in response to this information? a. Assess her breastfeeding techniques to identify possible causes. b. Provide a nipple shield to keep the infant's mouth off the nipples. c. Instruct her to apply warm compresses 10 minutes before she begins to breastfeed. d. Explain that she should pump her breasts and give milk in a bottle until the soreness subsides.

a. Assess her breastfeeding techniques to identify possible causes.

The nurse instructs a pregnant woman in labor that she must avoid lying on her back. what is the primary reason for this instruction? a. The supine position can prolong the course of labor. b. Decreased placenta perfusion is seen in the supine position. c. This position can lead to transient episodes of HTN. d. Lying on the back interferes with free movement of the coccyx.

b. Decreased placenta perfusion is seen in the supine position.

Which finding(s) would the nurse identify as normal for a newborn? Select all that apply. One, some, or all responses may be correct a. The newborn has a flat abdomen. b. The newborn weighs 6 lbs (2700g) c. The newborn's hands and feet appear cyanosed. d. The newborn does not blink in the presence of light. e. The circumference of the head is 33 cm (13 inches).

b. The newborn weighs 6 lbs (2700g) c. The newborn's hands and feet appear cyanosed. e. The circumference of the head is 33 cm (13 inches).

Which postpartum client would the nurse assess first? a. client who vaginally delivered a 7 lb baby 1 hour ago b. client who vaginally delivered a 9 lb baby 1 hour ago c. client who vaginally delivered a preterm baby 1 hour ago d. client who had a planned cesarean delivery of an 8 lb baby 2 hours ago

b. client who vaginally delivered a 9 lb baby 1 hour ago

Which intervention would the nurse suggest to ease back discomfort during labor? a. alternating lying on the back and side b. having support persons use back massage techniques c. using distraction techniques such as abdominal effleurage d. maintaining the knee-chest position before and after assessments of the fetal heart rate

b. having support persons use back massage techniques

During a childbirth class, several participants have questions about the elective induction of labor. One participant states that it is more convenient for a woman with a busy schedule. What evidenced-based information should the nurse provide to the participant? a. "Elective induction rates are dropping nationwide." b. "Elective induction is recommended if the client has a classic uterine incision." c. "There are risks and benefits to elective induction of labor to consider." d. "There is no evidence that elective induction makes any difference in the labor experience."

c. "There are risks and benefits to elective induction of labor to consider."

Now, on admission to the newborn nursery, it is noted that the infant has signs of respiratory distress, and transient tachypnea of the newborn is suspected. The nurse reviews the mother's obstetric history and takes the neonate's vital signs. In light of this information and the nursery routine, what is the most appropriate intervention by the nurse for this newborn?. (Temp: 98, HR 144 Resp 78) a. Feed glucose water. b. Bathe with mild soap. c. Keep in overbed warmer. d. Take to mother's bedside for further bonding.

c. Keep in overbed warmer.

A nurse plans to administer vitamin K to a newborn. What site should the nurse use for the injection? a. Deltoid muscle b. Rectus femoris c. Vastus lateralis d. Gluteus maximus

c. Vastus lateralis

On the third postpartum day after an unexpected cesarean birth, the nurse finds the mother crying. The client says, "I know my baby is fine, but I can't help crying. I wanted natural childbirth so much. Why did this have to happen to me?" Which information would the nurse consider when responding? a. The client's feelings will pass after she has bonded with her infant. b. The client is probably suffering from postpartum depression and needs special care. c. A cesarean birth may be a traumatic experience, but most women know that it is a possible outcome d. A woman's self-concept may be negatively affected by a cesarean birth, and the client's statements may reflect this.

d. A woman's self-concept may be negatively affected by a cesarean birth, and the client's statements may reflect this.

A vaginal examination reveals that a client's cervix is 90% effaced and dilated 6 cm. The fetus's head is at station 0 and the fetus is in an ROA position. The contractions are occurring every 3 to 4 minutes, are lasting 60 seconds, and are of moderate intensity. What should the nurse record about the client's stage of labor? a. early first stage of labor b. transition stage of labor c. beginning second stage of labor d. midway through first stage of labor

d. Midway through first stage of labor

After her baby's birth a client wishes to begin breast-feeding as soon as possible. How can the nurse best assist the client at this time? a. Giving the infant a bottle first to evaluate the sucking reflex b. Positioning the infant to grasp the nipple to express colostrum c. Leaving the infant and parents alone to promote attachment behaviors d. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex

d. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex

Which additional nursing care is needed for the postpartum client after a cesarean birth due to her postsurgical status? a. encouraging early ambulation b. assessing the fundus gently but firmly c. checking vital signs for evidence of shock d. administering the prescribed pain medications in scheduled intervals

d. administering the prescribed pain medications in scheduled intervals

The nurse who works in a birthing unit understands that newborns may have impaired thermoregulation. Which nursing interventions may help prevent heat loss in the newborns? Select all that apply. 1 The nurse keeps the newborn covered in warm blankets. 2 The nurse keeps the newborn under the radiant warmer. 3 The nurse places the newborn on the mother's abdomen. 4 The nurse measures the newborn's temperature regularly. 5 The nurse encourages the mother to feed the newborn well to maintain the fluid balance.

1 The nurse keeps the newborn covered in warm blankets. 2 The nurse keeps the newborn under the radiant warmer. 3 The nurse places the newborn on the mother's abdomen.

A client in active labor is 100% effaced, dilated 3 cm, and at +1 station. Which stage of labor has this client reached? a. first b. latent c. second d. transitional

a. first