NSG 312 Lippincott 1
The health care provider (HCP) prescribes an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which problem?
hemorrhage
After instructing a primigravid client about desired weight gain during pregnancy, the nurse determines that the teaching has been successful when the client states which statement?
"Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average."
A nurse demonstrates infant bathing to a primiparous client. Which statement by the client indicates a need for additional teaching?
"I have all kinds of pretty, scented soaps and lotions to bathe the baby with."
During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her neonate, the client tells the nurse that her mother has suggested that she feed the neonate cereal so he will sleep through the night. What would be the nurse's best response?
"It's better to continue feeding only formula until about 4 to 6 months of age."
The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns respond to painful stimuli. What is the nurse's best response?
"Newborns typically move their whole body in response to pain."
A pregnant client at about 29 weeks' gestation asks the nurse "What can I do about this dark brown line running down my stomach?" When teaching the client about this brown line, what should the nurse tell the client?
"This is a linea nigra that will fade after the baby is born."
Which statement by the nurse would be most appropriate when responding to a primigravid client who asks, "What should I do about this brown discoloration across my nose and cheeks?"
"This usually disappears after birth."
A nurse observes a family in the playroom. Which behavior would be considered to be an example of social affective play?
An infant is making happy noises in response to her father speaking to her.
After instructing a female client about the radioimmunoassay pregnancy test, the nurse determines that the client understands the instructions when the client states that which hormone is evaluated by this test?
human chorionic gonadotropin (hCG)
A client who is pregnant with her second child comes to the clinic complaining of a pulling and tightening sensation over her pubic bone every 15 minutes. She reports no vaginal fluid leakage. Because she has just entered her 36th week of pregnancy, she is apprehensive about her symptoms. Vaginal examination discloses a closed, thick, posterior cervix. These findings suggest that the client is experiencing:
Braxton Hicks contractions.
Using Naegele's rule for a client whose last normal menstrual period began on May 10, the nurse determines that the client's estimated date of birth is what date?
February 17
During an annual checkup, a client tells the nurse that she and her partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?
It should begin before conception and end 3 months after childbirth.
A multigravid client who stands for long periods while working in a factory visits the prenatal clinic at 35 weeks' gestation, stating, "The varicose veins in my legs have really been bothering me lately." Which instruction would be most helpful?
Take frequent rest periods with the legs elevated above the hips.
The nurse is developing a community health education program about sexually transmitted infections. Which information about women who acquire gonorrhea should be included?
Women with gonorrhea are usually asymptomatic.
At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. What is this neonate most likely experiencing?
a state of deep sleep
When performing a physical assessment on a postterm neonate, the nurse expects to find
abundant subcutaneous fat.
The nurse conducts the health assessment of a client who is a primigravida in the prenatal clinic. Which presumptive signs of pregnancy should the nurse expect to assess?
amenorrhea and quickening
A male client has been diagnosed as having a low sperm count during infertility studies. After giving instructions about causes of low sperm counts, the nurse determines that the client needs further instructions when the client says low sperm counts may be caused by which health problem?
decreased body temperature
A nulliparous client says that she and her husband plan to use a diaphragm with spermicide to prevent conception. Which should the nurse include as the action of spermicides when teaching the client?
destruction of spermatozoa before they enter the cervix
A nulliparous client tells the nurse that during her last pelvic examination, the health care provider said that her uterus was in a severe retroverted position. The nurse determines that the client may experience which complication?
difficulty conceiving a child
At which time should the nurse anticipate assisting a client to breastfeed her neonate?
during the neonate's first period of reactivity
When teaching a group of pregnant adolescent clients about reproduction and conception, the nurse is correct when stating that fertilization occurs:
in the first third of the fallopian tube.
A 25-year-old client tells the nurse that she would like to become pregnant, but she has been diagnosed with blocked fallopian tubes due to pelvic inflammatory disease. When helping the client explore infertility treatment options, what is most appropriate for this client?
in vitro fertilization
After trying for a year to conceive, a couple consults an infertility specialist. When obtaining a history from the husband, the nurse asks about childhood infectious diseases. Which childhood infectious disease most significantly affects male fertility?
mumps
A female client with infertility related to anovulatory cycles is prescribed menotropins. The nurse should assess the client for which possible adverse effect of this medication?
ovarian enlargement
A primigravid client visits the clinic at 12 weeks' gestation and tells the nurse that she has a cold and her nose is stuffy. The nurse should instruct the client to treat the nasal stuffiness by using which approach?
saline nose drops
The parents of a child with colic are asked to describe the infant's bowel movements. Which description should the nurse expect?
soft, yellow stools
A newly pregnant client tells the nurse that she hasn't been taking her prenatal vitamins because they make her nauseated. In addition to telling the client how important taking the vitamins are, the nurse should advise her to:
take the vitamin on a full stomach.
A full-term neonate is admitted to the normal newborn nursery. When lifting the baby out of the crib the nurse notes the baby's arms move sideways with the palms up and the thumbs flexed. What should the nurse do next?
Identify this reflex as a normal finding.
A nurse is providing care for a pregnant 16-year-old. The client says that she is concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying:
"Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems."
Which client statement indicates a need for additional teaching about self-care during pregnancy?
"I should sit in a hot tub for 20 minutes to relax after working."
A nurse is teaching a client who gave birth to a full-term female neonate how to change the neonate's diaper. Which of the following statement by the client would indicate to the nurse that learning has taken place?
"I will clean and dry the neonate's perineal area from front to back."
A pregnant client is seeking information from the nurse about a home birth with registered midwives. Which of the following statements lets the nurse know that the client has considered the risks and benefits of using a midwife? Select all that apply.
"I will develop a list of questions to use in interviewing potential midwives." "I understand the complications that could occur in a home birth setting." "I realize that I may need to be transferred to a hospital if complications develop."
A nurse is teaching a female client, who is positive for human immunodeficiency virus, about pregnancy. The nurse should know more teaching is necessary when the client says:
"I'll need to have a cesarean birth if I become pregnant and have a baby."
A client is scheduled to have in vitro fertilization (IVF) as an infertility treatment. Which client statement about IVF indicates that the client understands this procedure?
"IVF involves bypassing the blocked or absent fallopian tubes."
A client who tells the nurse that she would like to use the basal body temperature method for family planning receives instructions about the method. Which client statement indicates to the nurse that the teaching has been successful?
"It's important to take my temperature at about the same time every morning before arising."
Which statements made by a pregnant woman in the first trimester are consistent with this stage of pregnancy? Select all that apply.
"My husband told his friends we'll have to give up the convertible for a minivan." "Oh my, how did this happen? I don't need this now." "I wonder how it will feel to buy maternity clothes and be fat."
While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which response would be most appropriate?
"Sometimes baby girls have this from hormones received from the mother."
During a visit to the clinic, a mother who's breast-feeding her 2-month-old infant expresses concern over the infant's bowel movements. Which statement by the mother would lead the nurse to believe that the infant's bowel movements are normal?
"The baby's stools are bright yellow and soft."
While the nurse is conducting a teaching session on breast-feeding, a client asks why she should put her newborn to the breast within the first 30 minutes of birth. The nurse's best response will be
"The neonate will be responsive and eager to suck at this time."
The parents of a child with sickle cell disease ask the nurse why their child's hemoglobin was normal at birth but now the child has S hemoglobin. Which response by the nurse is appropriate?
"The newborn has a high concentration of fetal hemoglobin in the blood for some time after birth."
According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the initial assessment of the newborn and notes increased amounts of vernix. The mother asks why the nurse seems concerned about the presence of the vernix. Which of the following statements by the nurse is most appropriate?
"The vernix indicates a different gestational age than expected."
A pregnant client is experiencing a thin, odorless, vaginal discharge. What should the nurse instruct the client to do to prevent vaginal infections?
"Try wearing a panty liner and discarding it after every urination."
The nurse is preparing to administer vitamin K intramuscularly to a term neonate of a primipara who has just given birth. After explaining the purpose of the drug to the mother, which statement by the mother indicates effective teaching?
"Vitamin K will help my baby's blood to clot properly."
A nurse is administering vitamin K to a neonate following birth. The medication comes in a concentration of 2 mg/ml, and the ordered dose is 0.5 mg to be given subcutaneously. How many milliliters would the nurse administer? Record your answer using two decimal places.
0.25
During a health-teaching session, a pregnant client asks the nurse how soon the fertilized ovum becomes implanted in the endometrium. Which answer should the nurse supply?
7 days after fertilization
A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, what would be the most appropriate outcome for the couple to accomplish by the end of this visit?
Describe each of the potential causes and possible treatment modalities.
A primiparous client with a neonate who is 36 hours old asks the nurse, "Why does my baby spit up a small amount of formula after feeding?" The nurse explains that the regurgitation is thought to result from which factor?
an immature cardiac sphincter
While assisting a primiparous client with her first breastfeeding session, the nurse should instruct the mother to perform which action in order to stimulate the neonate to open the mouth and grasp the nipple?
Brush the neonate's lips lightly with the nipple.
While assessing a multigravid client at 10 weeks' gestation, the nurse notes a purplish color to the vagina and cervix. The nurse documents this as what finding?
Chadwick's sign
Which recommendation would be the most appropriate preventive measure to suggest to a primigravid client at 30 weeks' gestation who is experiencing occasional heartburn?
Eat smaller and more frequent meals during the day.
A client is planning to be treated for infertility with the zygote intrafallopian transfer (ZIFT) method. Which information should the nurse include when teaching the client about this type of treatment method?
Fertilization takes place outside of the body.
What information should the nurse include in a teaching plan for first-time parents of a bottle-feeding term newborn? Select all that apply.
Fill the entire nipple of the bottle with formula. Do not prop the bottle. The husband can feed the baby the bottle whenever possible.
A nurse is performing a physical examination of a primigravid client who's 8 weeks pregnant. At this time, the nurse expects to assess:
Hegar's sign.
A client calls to schedule a pregnancy test. The nurse knows that most pregnancy tests measure which hormone?
Human chorionic gonadotropin (hCG)
While preparing to provide neonatal care instructions to a primiparous client who gave birth to a term neonate 24 hours ago, what should the nurse include in the client's teaching plan?
Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks.
Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea?
Moist mucous membranes.
A client comes to the office for her first prenatal visit. She reports that January 3 was the first day of her last menstrual period. According to Naegele's rule, what date should the nurse record as the estimated date of delivery (EDD)?
October 10
A client's prenatal record shows a gravida 2, para 0111. From this information, the nurse knows that the client has been pregnant twice. What else does this information reveal about the client's obstetric history?
One pregnancy resulted in an abortion and one resulted in a preterm neonate who's living.
The nurse plans care for a neonate to prevent neonatal heat loss immediately after birth. What action should the nurse take to conserve heat and help the infant maintain a stable temperature?
Place the infant skin to skin with the mother.
A primigravid client at 36 weeks' gestation tells the nurse that she has been experiencing insomnia for the past 2 weeks. Which suggestion would be most helpful?
Practice relaxation techniques before bedtime.
The newborn nurse has just received shift report about a group of newborns and is to receive another admission in 30 minutes. In order to provide the safest care and plan for the new admission, the nurse should do which tasks in order of first to last? All options must be used.
Review notes from shift report, and prioritize all clients; make rounds on the most critical first. Move quickly from room to room, and assess all clients. Log on to the clinical information system, and determine if there are new orders. Check the room to which the new client will be admitted to ensure all supplies and equipment are available.
The nurse in a postpartum couplet room is making rounds prior to ending the shift. Which findings indicate that the safety needs of the clients have been met? Select all that apply.
Security tags in place. Identification system on mother and infant. Bulb syringe within sight. Someone in room able to care for infant
A client has been trying to achieve a pregnancy for 3 years and has just recently sought the assistance of an infertility specialist. Which tests may be conducted to analyze the causes of this client's infertility? Select all that apply.
Semen analysis. Hysterosalpingogram. Basal body temperature graph. Hypothalamic pituitary levels
A newly hired nurse on unit orientation prepares to administer vitamin K to a neonate. The nurse draws up 1 mg of vitamin K and prepares to administer a subcutaneous injection in the left, lateral anterior thigh. Which action by the nurse preceptor is best?
Stop the nurse and ask that the injection techniques be reevaluated.
A client is seeking infertility treatment after attempting pregnancy for 2 years. Of the following data from the client's history, which has the greatest impact on infertility?
The client is a gymnast weighing 105 lb (47.6 kg).
Which statement describes the rationale for administering vitamin K to every neonate?
The neonate lacks intestinal flora to make the vitamin.
A primigravida at 8 weeks' gestation tells the nurse that she wants an amniocentesis because there is a history of hemophilia A in her family. The nurse informs the client that she will need to wait until she is at 15 weeks' gestation for the amniocentesis. Which is the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation?
The volume of amniotic fluid needed for testing will be available by 15 weeks.
A pregnant client in her third trimester asks why she needs to urinate frequently again, as she did during the first trimester. What should the nurse tell her?
This symptom is normal and results from the fetus exerting pressure on the bladder.
A client, 11 weeks pregnant, is admitted to the facility with hyperemesis gravidarum. The client tells the nurse she has never known anyone who had such severe morning sickness. The nurse understands that hyperemesis gravidarum results from:
an unknown cause.
When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which point?
at about the level of the client's umbilicus
A client diagnosed with testicular cancer expresses concerns about fertility. The client and his spouse desire to eventually have a family, and the nurse discusses the option of sperm banking. What should the nurse tell the couple about the best time to donate the sperm?
before treatment is started
A nurse is developing a teaching plan for a primigravid client who's 2 months pregnant. The nurse should tell the client that fetal movement can be felt beginning at which time?
between 18 and 20 weeks' gestation
A nurse is assessing the legs of a client who's 36 weeks pregnant. Which finding should the nurse expect?
bilateral dependent edema
When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which problem?
blindness secondary to gonorrhea
A nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings?
breast sensitivity
A primiparous woman has just given birth to a term infant. What topic should the nurse teach the client about first?
breastfeeding
A client with human papillomavirus (HPV) infection is being treated by a colposcopy. The client asks the nurse if this procedure is really necessary. The nurse can tell the client that if the HPV infection is not treated which health problem is likely to occur?
cervical cancer
An infant diagnosed with Hirschsprung's disease is scheduled to receive a temporary colostomy. When the nurse is initially discussing the diagnosis and treatment with the parents, which action by the nurse would be most appropriate?
encouraging them to ask questions
Which findings are considered positive signs of pregnancy?
fetal heartbeat and fetal movement on palpation
A nursery nurse just received the shift report. Which neonate should the nurse assess first?
four-hour-old term neonate with jaundice
The client gives birth to a neonate who is given a score of 9 at 5 minutes on the Apgar rating system. How does the nurse interpret the neonate's physical condition?
good
A dilatation and curettage (D&C) is scheduled for a primigravid client admitted to the hospital at 10 weeks' gestation with abdominal cramping, bright red vaginal spotting, and passage of some of the products of conception. The nurse should assess the client further for the expression of which feeling?
guilt
A client who's 12 weeks pregnant attends a class on fetal development as part of a childbirth education program. The nurse anticipates that at 16 weeks' gestation, the client's fetus will:
have audible heart sounds.
The nurse is witnessing the client's signature on the informed surgical consent for an abdominal hysterectomy. The nurse should be certain the client understands that what will be the outcome of this surgery?
infertility.
A pregnant client complains of nausea every morning and again before meals. As a result of the nausea, the client has been unable to eat enough and has lost weight. Which nonpharmacologic intervention should the nurse recommend?
keeping crackers at the bedside to eat before getting out of bed
A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise the client to use which body position?
left lateral
After completing discharge instructions for a primiparous client who is bottle-feeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the pediatrician if the neonate exhibits which sign or symptom?
passage of a liquid stool with a watery ring
A primiparous client who is beginning to breastfeed her neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with which factor?
passive immunity from maternal antibodies
A 30-year-old multigravid client has missed three periods and now visits the prenatal clinic because she assumes she is pregnant. She is experiencing enlargement of her abdomen, a positive pregnancy test, and changes in the pigmentation on her face and abdomen. These assessment findings reflect this woman is experiencing a cluster of which signs of pregnancy?
probable
A 15-year-old primigravid client at approximately 16 weeks' gestation tells the nurse that she has been experiencing an occasional sharp pain from the fundus to her pubic bone on the left side. The nurse determines that the client is most likely experiencing which complication?
round ligament pain
A couple is visiting the clinic because they have been unable to conceive a baby after 3 years of frequent coitus. The nurse determines that the couple needs further instruction when they identify which factor as a cause of male infertility?
seminal fluid with an alkaline pH
A breastfeeding primiparous client who gave birth 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which guideline should the nurse include in the teaching plan as evidence of adequate intake?
six to eight wet diapers by the fifth day
Which observation is expected when the nurse is assessing the gestational age of a neonate born at term?
sole creases covering the entire foot
A mother is instructed to stimulate the rooting reflex when attempting to breast-feed her baby. Which action shows that the mother understands these instructions?
stroking the neonate's cheek
After instructing a primigravid client about the functions of the placenta, the nurse determines that the client needs additional teaching when she says that which hormone is produced by the placenta?
testosterone
A client and her partner, both 25 years old, are having trouble conceiving. Infertility in this couple is defined as:
the inability to conceive after 1 year of unprotected attempts.
A client in the first trimester of pregnancy joins a childbirth education class. During this trimester, the class is most likely to cover which physiologic aspect of pregnancy?
warning signs of complications
A client has undergone a vasectomy. The nurse instructs the client that he can begin having unprotected intercourse at what time following the surgery?
when the sperm count reflects sterilization
When assessing a postterm neonate, what is considered a normal finding?
wrinkled, peeling skin
