NU472 HESI Obstetrics/Maternity Practice Exam - 103 Questions

A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? o 3+ deep tendon reflexes. o Periorbital edema. o Epigastric pain. o Decreased urine output.

o Epigastric pain. · Epigastric pain is indicative of an edematous liver or pancreas which is an early warning sign of an impending convulsion in eclampsia and requires immediate attention.

A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? o Length of labor and method of delivery. o Infant's condition at birth and treatment received. o Feeding method chosen by the parents. o History of drugs given to the mother during labor.

o Infant's condition at birth and treatment received. Immediate care is most dependent on the infant's current status (i. e., Apgar scores at 1 and 5 minutes) and any treatment or resuscitation that was indicated.

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? o The client's readiness to learn. o The client's educational background. o The order in which the information is presented. o The extent to which the pregnancy was planned.

o The client's readiness to learn. When teaching any client, readiness to learn is the most important criterion. For example, the client with severe morning sickness in the first trimester may not be "ready to learn" about labor and delivery, but is probably very "ready to learn" about ways to relieve morning sickness.

A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client? o "Which symptom did you experience first?" o "Are you eating large amounts of salty foods?" o "Have you visited a foreign country recently?" o "Do you have a history of rheumatic fever?"

o "Do you have a history of rheumatic fever?" · Obtaining a client's health history is a priority because clients with a history of rheumatic fever may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the increased blood volume that occurs during pregnancy.

A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide? o "Herbs are a cornerstone of good health to include in your treatment." o "Touch is also therapeutic in relieving discomfort and anxiety." o "Your healthcare provider should direct treatment options for herbal therapy." o "It is important that you want to take part in your care."

o "It is important that you want to take part in your care." Clients need to be viewed holistically. By acknowledging the emphasis the client made to alternative and complementary therapies, such as herbal therapy, the client is empowered as an integral member of the healthcare team.

A female client with insulin-dependent diabetes arrives at the clinic seeking a plan to get pregnant in approximately 6 months. She tells the nurse that she wants to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client? o "Your current dose of Insulin should be maintained throughout your pregnancy." o "Maintain blood sugar levels in a constant range within normal limits during pregnancy." o "The course and outcome of your pregnancy is not an achievable goal with diabetes." o "Expect an increase in insulin dosages by 5 units/week during the first trimester."

o "Maintain blood sugar levels in a constant range within normal limits during pregnancy." Maintaining blood sugar within a normal range during pregnancy has a strong correlation with a good outcome.

A 30-year-old multiparous woman who has a 3-year-old boy and a newborn girl tells the nurse, "My son is so jealous of my daughter, I don't know how I'll ever manage both children when I get home." How should the nurse respond? o "Tell the older child that he is a big boy now and should love his new sister." o "Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him." o "Let the older child stay with his grandparents for the first six weeks to allow him to adjust to the newborn." o "Regression in behaviors in the older child is a typical reaction so he needs attention at this time."

o "Regression in behaviors in the older child is a typical reaction so he needs attention at this time." · Preschool-aged children frequently regress in habits or behaviors, such as toileting and sleep habits, as a method of seeking attention, so the parents should distribute their attention between the children and include the preschooler during infant care.

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best? o "This is not an unusual shaped head, especially for a first baby." o "It may look funny to you, but newborn babies are often born with heads like your baby's." o "That is normal; the head will return to a round shape within 7 to 10 days." o "Your pelvis was too small, so the baby's head had to adjust to the birth canal."

o "That is normal; the head will return to a round shape within 7 to 10 days."o "That is normal; the head will return to a round shape within 7 to 10 days." · Reassuring the mother that this is normal for a newborn head to have that appearance and provide correct information regarding the return to a "normal" shape is the best response.

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client? o "Some care is required when touching the large soft area on top of your baby's head until the bones fuse together." o "That's just an 'old wives' tale' so don't worry, you can't harm your baby's head by touching the soft spot." o "The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for your baby." o "There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair."

o "There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair." · The anterior fontanel or "large soft spot" has a strong epidermal membrane present, which can be touched. The posterior fontanel closes at 8-12 weeks. Providing this information to the client will alleviate her anxiety related to knowledge deficit

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which response is best for the nurse provide? o "Weigh the baby daily, and if she is gaining weight, she is eating enough." o "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day." o "Offer the baby extra bottle milk after her feeding, and see if she is still hungry." o "If you're concerned, you might consider bottle feeding so that you can monitor her intake."

o "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day." · An infant is hydrated when the urine is dilute (straw-colored) and frequency of voiding is >6 to 10 times/day. Infants feed 8-12 times in a 24 hour period.

A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? o 3+ deep tendon reflexes and hyperclonus. o Periorbital edema, flashing lights, and aura. o Epigastric pain in the third trimester. o Recent decreased urinary output.

o 3+ deep tendon reflexes and hyperclonus. · Three plus deep tendon reflexes and hyperclonus are indicative of an impending convulsion and require immediate attention.

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. When preparing to document the client's delivery history, it is important for the nurse to document in the client's record which GTPAL history? o 3-1-2-0-3. o 4-1-2-0-3. o 2-1-2-1-2. o 3-1-1-0-3.

o 3-1-1-0-3. · The correct GTPAL is 3-1-1-0-3. The client has been pregnant 3 times which includes the current pregnancy (G-3), in addition, she had one full-term infant (T-1) and also had a preterm (P-1) twin pregnancy (a multifetal gestation is considered one birth when calculating parity). The client denied history of abortions (A-0), so this client has a total of 3 living children.

In evaluating the respiratory effort of a one-hour-old infant using the Silverman-Anderson Index, the nurse determines the infant has synchronized chest and abdominal movement, just visible lower chest retractions, just visible xiphoid retractions, minimal and transient nasal flaring, and an expiratory grunt heard only on auscultation. What Silverman-Anderson score should the nurse assign to this infant? (Enter numeral value only.)

o 4 · A Silverman-Anderson Index has five categories with scores of 0, 1, or 2. The total score ranges from 0 to 10. Four of the these assessment findings should receive a score of 1, and the 5th finding (synchronized chest and abdominal movement) receives a score of 0. Therefore, the total score is 4. A total score of 0 means the infant has no dyspnea, a total score of 10 indicates maximum respiratory distress.

The nurse is preparing to give an enema to a laboring client. Which client would require the most caution when carrying out this procedure? o A gravida 6, para 5 who is 38 years of age and in early labor. o A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilatation, and a -1 station. o A gravida 2, para 1 who is at 1 cm cervical dilatation and a 0 station admitted for induction of labor due to post dates. o A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.

o A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged. · When the presenting part is ballottable, it is floating out of the pelvis. In such a situation, the cord can descend before the fetus causing a prolapsed cord, which is an emergency situation.

A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH). The healthcare provide prescribed magnesium sulfate is to control the symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved? o 4+ reflexes. o Urinary output of 50 ml per hour. o A decrease in respiratory rate from 24 to 16. o A decreased body temperature.

o A decrease in respiratory rate from 24 to 16. · Magnesium sulfate is a CNS depressant that helps prevent seizures. A decreased respiratory rate indicates that the drug is effective. (Respiratory rate below 12 indicates toxic effects.) The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl.

A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? o Cervical dilation of 5 cm with 90% effacement. o White blood cell count of 12,000/mm3. o Hemoglobin of 12 mg/dl and hematocrit of 38%. o A platelet count of 67,000/mm3.

o A platelet count of 67,000/mm3. · Thrombocytopenia (low platelet count) should be reported to the healthcare provider because it places the client at risk for bleeding when an epidural is administered.

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) o Litmus paper. o Fetal scalp electrode. o A sterile glove. o An amnihook. o Sterile vaginal speculum. o Lubricant.

o A sterile glove. o An amnihook. o Lubricant. · A single sterile glove, an amnihook, and lubricant are the necessary equipment for performing an amniotomy.

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) o Litmus paper. o Fetal scalp electrode. o A sterile glove. o An amniotic hook. o Sterile vaginal speculum. o A Doppler.

o A sterile glove. o An amniotic hook. o A Doppler. · A single sterile glove, an amniotic hook , and Doppler are needed to check fetal heart tones are the necessary equipment for performing an amniotomy.

The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.) o Admission weight of 4 pounds, 15 ounces ( 2244 grams). o Head to heel length of 17 inches (42.5 cm). o Frontal occipital circumference of 12.5 inches (31.25 cm). o Skin smooth with visible veins and abundant vernix. o Anterior plantar crease and smooth heel surfaces. o Full flexion of all extremities in resting supine position.

o Admission weight of 4 pounds, 15 ounces ( 2244 grams). o Head to heel length of 17 inches (42.5 cm). o Frontal occipital circumference of 12.5 inches (31.25 cm). · The normal full-term, appropriate for gestational age (AGA) newborn should fall between the measurement ranges of weight, 6-9 pounds (2700-4000 grams); length, 19-21 inches (48-53 cm); FOC, 13-14 inches (33-35 cm).

The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention? o Emptying the bladder during delivery is difficult because of the position of the presenting fetal part. o An over-distended bladder could be traumatized during labor, as well as prolong the progress of labor. o Urine specimens for glucose and protein must be obtained at certain intervals throughout labor. o Frequent voiding minimizes the need for catheterization which increases the chance of bladder infection.

o An over-distended bladder could be traumatized during labor, as well as prolong the progress of labor. · A full bladder can impair the efficiency of the uterine contractions and impede the descent of the fetus during labor because of the close proximity of the bladder to the uterus, in addition, the bladder can be traumatized by the descent of the fetus.

A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take? o Apply cold compresses to both breasts for comfort. o Instruct the client run warm water on her breasts. o Wear a loose-fitting bra to prevent nipple irritation. o Express small amounts of milk to relieve pressure.

o Apply cold compresses to both breasts for comfort. · The client is experiencing engorgement even though she is bottle-feeding her infant, and applying cold compresses may help reduce discomfort.

A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement? o Discontinue the oxytocin (Pitocin) infusion. o Place the client in a semi-Fowler's position. o Inform the healthcare provider. o Apply firm pressure to sacral area.

o Apply firm pressure to sacral area. · The discomfort of "back labor" can be minimized by the application of firm pressure to the sacral area.

The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take? o Check the client for urinary bladder distention. o Notify the healthcare provider of the nonreactive results. o Have the mother stimulate the fetus to move. o Ask the client if she has felt any fetal movement.

o Ask the client if she has felt any fetal movement. The client should be asked if she has felt the fetus move. An NST is used to determine fetal well-being, and is often implemented when postmaturity is suspected. A "reactive" NST occurs if the FHR accelerates 15 bpm for 15 seconds in response to the fetus' own movement, and is "nonreactive" if no FHR acceleration occurs in response to fetal movement.

When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? o At 16-weeks gestation. o At 20-weeks gestation. o At 24-weeks gestation. o At 30-weeks gestation.

o At 30-weeks gestation. Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy when they are psychologically ready for the termination of the pregnancy, and the birth of their child is an immediate concern.

A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first? o Bathe the infant with an antimicrobial soap. o Measure the head and chest circumference. o Obtain the infant's footprints. o Administer vitamin K (AquaMEPHYTON).

o Bathe the infant with an antimicrobial soap. · To reduce direct contact with the human immuno-virus in blood and body fluids on the newborn's skin, a bath with an antimicrobial soap should be administered first.

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? o Between the time the temperature falls and rises. o Between 36 and 48 hours after the temperature rises. o When the temperature falls and remains low for 36 hours. o Within 72 hours before the temperature falls.

o Between the time the temperature falls and rises. · In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone making between the time of the temperature fall and rise is the best time to try to conceive.

A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? o Biophysical profile (BPP). o Ultrasound for fetal anomalies. o Maternal serum alpha-fetoprotein (AF) screening. o Percutaneous umbilical blood sampling (PUBS).

o Biophysical profile (BPP). · A BPP (biophysical profile) provides data regarding fetal risk surveillance by examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate. The client's gestation has progressed past the estimated date of confinement, so the major concern is fetal well-being related to an aging placenta, not screening for fetal anomalies.

A client with gestational hypertension is in active labor and receiving an infusion of magnesium sulfate. Which is the most important drug the nurse should have available for signs of potential toxicity? o Oxytocin (PItocin). o Calcium gluconate. o Terbutaline (Brethine). o Naloxone (Narcan).

o Calcium gluconate. · The antidote for magnesium sulfate is calcium gluconate, which should be readily available if the client manifest signs of toxicity.

One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM X 1. What action should the nurse take immediately? o Give the medication as prescribed and monitor for efficacy. o Encourage the client to breastfeed rather than bottle feed. o Have the client empty her bladder and massage the fundus. o Call the healthcare provider to question the prescription.

o Call the healthcare provider to question the prescription. · Methergine is used to treat postpartum hemorrhage, but is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription because the client's elevated blood pressure.

Which assessment finding should the nursery nurse report to the pediatric healthcare provider? o Blood glucose level of 45 mg/dl. o Blood pressure of 82/45 mmHg. o Non-bulging anterior fontanel. o Central cyanosis when crying.

o Central cyanosis when crying. · An infant who demonstrates central cyanosis when crying is manifesting poor adaptation to extrauterine life which should be reported to the healthcare provider for determination of a possible underlying cardiovascular problem. The other options are expected findings in newborn.

A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective? o Slowly increasing urinary output over the last week. o Respiratory rate changes from the 40s to the 60s. o Changes in apical heart rate from the 180s to the 140s. o Change in indirect bilirubin from 12 mg/dl to 8 mg/dl.

o Changes in apical heart rate from the 180s to the 140s. · Epogen, given to prevent or treat anemia, stimulates erythropoietin production, resulting in an increase in RBCs. Since the body has not had to compensate for anemia with an increased heart rate, changes in heart rate from high to normal is one indicator that Epogen is effective.

What action should the nurse implement to decrease the client's risk for hemorrhage after a cesarean section? o Monitor urinary output via an indwelling catheter. o Assess the abdominal dressings for drainage. o Give the Ringer's Lactated infusion at 125 ml/hr. o Check the firmness of the uterus every 15 minutes.

o Check the firmness of the uterus every 15 minutes. · A client's risk of postpartal hemorrhage is decreased when the uterus is firm after delivery of the infant. Assessment of fundus consistency q15 minutes provides frequent intervals to stimulate the fundus to contract and prevent bleeding.

A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first? o Notify the pediatrician immediately. o Suction the infant's nares, then the oral cavity. o Check the infant's oxygen saturation rate. o Position the infant on the right side.

o Check the infant's oxygen saturation rate. · When possible, the nurse should first obtain measurable objective data; an oxygen saturation rate provides such information.

A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit? o Choking, coughing, and cyanosis. o Projectile vomiting and cyanosis. o Apneic spells and grunting. o Scaphoid abdomen and anorexia.

o Choking, coughing, and cyanosis. · The "3 Cs" of esophageal atresia are coughing, chocking and cyanosis. They are caused by the overflow of secretions into the trachea.

A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? o Come to the clinic today for an ultrasound. o Go immediately to the emergency room. o Lie on your left side for about one hour and see if the bleeding stops. o Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.

o Come to the clinic today for an ultrasound. · Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound.

A multigravida client arrives at the labor and delivery unit and tell the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next? o Complete a sterile vaginal exam. o Take maternal temperature every 2 hours. o Prepare for an immediate cesarean birth. o Obtain sterile suction equipment.

o Complete a sterile vaginal exam. · A vaginal exam should be performed after the rupture of membranes to determine the presence of a prolapsed cord.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness? o Wear a cotton bra. o Increase nursing time gradually. o Correctly place the infant on the breast. o Manually express a small amount of milk before nursing.

o Correctly place the infant on the breast. The most common cause of nipple soreness is incorrect positioning of the infant on the breast, e. g., grasping too little of the areola or grasping only the nipple.

A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? Select all that apply. o Dark, red vaginal bleeding. o Lower back pain. o Premature rupture of membranes. o Increased uterine irritability. o Bilateral pitting edema. o A rigid abdomen.

o Dark, red vaginal bleeding. o Increased uterine irritability. o A rigid abdomen. · The symptoms of abruptio placentae include dark red vaginal bleeding (A), increased uterine irritability (D), and a rigid abdomen (F). (B, C, and E) are findings not associated with abruptio placentae.

A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain? o Gravidity and parity. o Time and amount of last oral intake. o Date of last normal menstrual period. o Frequency and intensity of contractions.

o Date of last normal menstrual period. Evaluating the gestation of the pregnancy takes priority due to the risks involved when the fetus is preterm. If preterm labor is imminent and a reassuring fetal heart pattern is assessed, the healthcare provider may attempt to prolong the pregnancy by administering corticosteroids to mature the lungs of the fetus.

A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? o Describe diet changes that can improve the management of her diabetes. o Inform the client that oral hypoglycemic agents are teratogenic during pregnancy. o Demonstrate self-administration of insulin. o Evaluate the client's ability to do glucose monitoring.

o Describe diet changes that can improve the management of her diabetes. Diet modifications are effective in managing Type 2 diabetes during pregnancy, and describing the necessary diet changes is the most important intervention for the nurse to implement with this client.

A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement? o Notify the healthcare provider. o Move the newborn to an isolation nursery. o Document the finding in the infant's record. o Obtain a culture of the vesicles.

o Document the finding in the infant's record. · Erythema toxicum (or erythema neonatorum) is a newborn rash that is commonly referred to as "flea bites," but is a normal finding that is documented in the infant's record, and requires no further action.

A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurse's response should be based on what information? o Males inherit the disorder with a greater frequency than females. o Each pregnancy carries a 50% chance of inheriting the disorder. o The disorders can occur in 25% of pregnancies. o All children will be carriers of the disorder.

o Each pregnancy carries a 50% chance of inheriting the disorder. · According to the laws of inheritance, an autosomal dominant disorder has a 50% chance of being transmitted with each pregnancy, and if transmitted, the disorder will appear in the child.

The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? o Edema, basilar rales, and an irregular pulse. o Increased urinary output and tachycardia. o Shortness of breath, bradycardia, and hypertension. o Regular heart rate and hypertension.

o Edema, basilar rales, and an irregular pulse. · Edema, basilar rales, and an irregular pulse indicate cardiac decompensation and require immediate intervention.

The nurse is planning preconception care for a new female client. Which information should the nurse provide the client? o Discuss various contraceptive methods to use until pregnancy is desired. o Provide written or verbal information about prenatal care. o Ask the client about risk factors associated with complications of pregnancy. o Encourage healthy lifestyles for families desiring pregnancy.

o Encourage healthy lifestyles for families desiring pregnancy. Preconception care has an overall goal to prepare the client for a healthy pregnancy. It begins with encouraging healthy lifestyle choices in the family and should focus on measures to assist the client in reducing lifestyle variables that may increase the risk for problems in pregnancy.

The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement? o Provide phototherapy for 30 minutes q8h. o Feed the newborn sterile water hourly. o Encourage the mother to breastfeed frequently. o Assess the newborn's blood glucose level.

o Encourage the mother to breastfeed frequently. The normal total bilirubin level is 6 to 12 mg/dl after Day 1 of life. This infant's bilirubin is beginning to climb and the infant should be monitored to prevent further complications. Breast milk provides calories and enhances GI motility, which will assist the bowel in eliminating bilirubin.

A client in active labor complains of cramps in her leg. What intervention should the nurse implement? o Ask if she takes a daily calcium tablet. o Extend the leg and dorsiflex the foot. o Lower the leg off the side of the bed. o Elevate the leg above the heart.

o Extend the leg and dorsiflex the foot. · Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is capable) (B), and putting the heel of the foot on the floor is the best means of relieving leg cramps. (A) is not related to leg cramps caused by reduced circulation to the foot. (C) is not likely to be helpful. (D) is used to promote venous return, but is not indicated for leg cramps.

The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class? o Begin as soon as your baby is born to establish a four-hour feeding schedule. o Resting helps with milk production. Ask that your baby be fed at night in the nursery. o Feed your baby every 2 to 3 hours or on demand, whichever comes first. o Do not allow your baby to nurse any longer than the prescribed number of minutes.

o Feed your baby every 2 to 3 hours or on demand, whichever comes first. · Breastfeeding infants should be kept in the room with the mother and fed every 2 to 3 hours or on demand--whichever comes first.

The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition? o Gestational diabetes. o Elevated blood pressure. o Urinary tract infection. o Swelling in lower extremities.

o Gestational diabetes. · The nurse should evaluate the client for gestational diabetes because terbutaline (Brethine) increases blood glucose levels.

The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? o Herpes. o Staphylococcus. o Gonorrhea. o Syphilis.

o Gonorrhea. · Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmica neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by chlamydia.

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate? o Grief related to her perceptions about the loss of this child. o Relief of ambivalent feelings experienced with this pregnancy. o Shock because she may not have realized that she was pregnant. o Guilt because she had not followed her healthcare provider's instructions.

o Grief related to her perceptions about the loss of this child. Clients can experience Grief/loss response at all stages of pregnancy loss.

The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? o Administer oxygen by face mask. o Notify the healthcare provider of the client's symptoms. o Have the client breathe into her cupped hands. o Check the client's blood pressure and fetal heart rate.

o Have the client breathe into her cupped hands. · Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hand.

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client? o Have the client empty her bladder. o Request the client lie on her left side. o Perform Leopold's maneuvers first. o Give the client some cold juice to drink.

o Have the client empty her bladder. · To avoid an elevation of the uterus, the client must empty the bladder prior to obtaining an accurate fundal height measurement.

When evaluating maternal bonding, which of the following maternal behaviors exhibited by the client would the nurse most likely expect to see when a new mother receives her infant for the first time? o She eagerly reaches for the infant, undresses the infant, and examines the infant completely. o Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. o Her arms and hands receive the infant and she then cuddles the infant to her own body. o She eagerly reaches for the infant and then holds the infant close to her own body.

o Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. Attachment/bonding theory indicates that most mothers will demonstrate behaviors such as tracing the infant's profile with her fingertips during the initial visit with the newborn, which may be at delivery or later.

A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin? o Dehydration. o Hyperstimulation. o Galactorrhea. o Fetal tachycardia.

o Hyperstimulation. · Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the client is at risk for hyperstimulation which can lead to tetanic contractions, uterine rupture, and fetal distress or demise.

At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next? o Check the hematocrit results. o Administer pain medication. o Increase the rate of IV fluids. o Monitor client for contractions.

o Increase the rate of IV fluids. · The client is demonstrating symptoms of blood loss, probably the result of an ectopic pregnancy, which occurs at approximately 14-weeks gestation when embryonic growth expands the fallopian tube causing its rupture, and can result in hemorrhage and hypovolemic shock. Increasing the IV infusion rate provides intravascular fluid to maintain blood pressure.

Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse perform next? o Initiate positive pressure ventilation. o Intervene after the one minute Apgar is assessed. o Initiate CPR on the infant. o Assess the infant's blood glucose level.

o Initiate positive pressure ventilation. · According to the neonatal resuscitation guidelines, the nurse should immediately begin positive pressure ventilation because this infant's vital signs are not within the normal range, and oxygen deprivation leads to cardiac depression in infants. (The normal newborn pulse is 100 to 160 beats/minute and respirations are 40 to 60 breaths/minute.)

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? o Supplementary iron is more efficiently utilized during pregnancy. o It is difficult to consume 18 mg of additional iron by diet alone. o Iron absorption is decreased in the GI tract during pregnancy. o Iron is needed to prevent megaloblastic anemia in the last trimester.

o It is difficult to consume 18 mg of additional iron by diet alone. Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and to meet the demands of pregnancy is difficult so iron supplements are often recommended.

The nurse is counseling a client who wants to become pregnant. The client tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. Which date accurately reflects the calculation of the client's next fertile period? o January 14-15. o January 22-23. o January 30-31. o February 6-7.

o January 30-31. · This client can expect her next period to begin 36 days from the first day of her last menstrual period. A menstrual cycle begins at the first day of the cycle and continues to the first day of the next cycle, therefore if January 8 was the first day on her last menstrual cycle, her next period would begin on February 13. Ovulation occurs 14 days before the first day of the menstrual period so this client would be ovulating on January 30- 31.

An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? o Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse. o Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed. o Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit. o Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

o Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement. · These behaviors are positive signs of maternal/fetal bonding and do not reflect ambivalence. No intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks gestation and begins a new phase of prenatal bonding during the second trimester.

When assisting a client to relieve postpartum uterine contractions, which nursing intervention would be most helpful for the nurse to take? o Lying client prone with a pillow on the abdomen. o Asking the client to express milk via breast pump. o Massaging the client's abdomen. o Giving oxytocic medications.

o Lying client prone with a pillow on the abdomen. · Lying prone keeps the fundus contracted and is especially useful with multiparas, who commonly experience afterpains due to lack of uterine tone.

A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous. Which assessment is the highest priority for the nurse to monitor during the administration of this drug? o Maternal blood pressure and respirations. o Maternal and fetal heart rates. o Hourly urinary output. o Deep tendon reflexes.

o Maternal and fetal heart rates. · Monitoring maternal and fetal heart rates is most important when terbutaline is being administered because Terbutaline acts as a sympathomimetic agent that stimulates both beta 1 receptors (causing tachycardia, a side effect of the drug) and beta 2 receptors (causing uterine relaxation, a desired effect of the drug).

A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug? o Maternal blood pressure and respirations. o Maternal and fetal heart rates. o Hourly urinary output. o Deep tendon reflexes.

o Maternal and fetal heart rates. · Terbutaline has effects on receptors. It acts as a sympathomimetic agent stimulating beta 1 receptors which cause tachycardia as a side effect and that is a reason why monitoring maternal and fetal heart rates is most important when terbutaline is being administered. It also affects beta 2 receptors which relaxes the uterus and that is the reason for its administration.

A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2016. Based on Naegele's rule, what is the estimated date of delivery? o April 25, 2017. o May 9, 2017. o May 29, 2017. o June 2, 2017.

o May 9, 2017. · Since this client's first day of her last normal menstrual period occurred on August 2, 2017, the estimated date of delivery is May 9, 2018. Nägele's rule is used to calculate the expected date of delivery and is obtained by subtracting 3 months and adding 7 days beginning from the first day of the last normal menstrual period.

A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? o Encourage the mother to provide total care for her infant. o Provide privacy so the mother can develop a relationship with the infant. o Encourage the father to provide most of the infant's care during hospitalization. o Meet the mother's physical needs and demonstrate warmth toward the infant.

o Meet the mother's physical needs and demonstrate warmth toward the infant. · It is most important to meet the mother's requirement for attention to her needs so that she can begin infant care-taking. Nurse theorist Reva Rubin describes the initial postpartal period as the "taking-in phase," which is characterized by maternal reliance on others to satisfy the needs for comfort, rest, nourishment, and closeness to families and the newborn.

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? o Insert an internal fetal monitor. o Assess for cervical changes q1h. o Monitor bleeding from IV sites. o Perform Leopold's maneuvers.

o Monitor bleeding from IV sites. Monitoring bleeding from peripheral sites is the priority intervention. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruptio, characterized by abnormal bleeding.

When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? Select all that apply. o Mood swings. o Panic attacks. o Tearfulness. o Decreased need for sleep. o Disinterest in the infant.

o Mood swings. o Tearfulness. · "Postpartum blues" is a common emotional response related to the rapid decrease in placental hormones after delivery and include mood swings, tearfulness, feeling low, emotional, and fatigued.

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? o Wear support stockings. o Reduce salt in her diet. o Move about every hour. o Avoid constrictive clothing.

o Move about every hour. · Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will straighten out the pelvic veins and increase venous return.

On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) would be o November 22. o November 8. o December 22. o October 22.

o November 22. · November 22 is the answer. The RN correctly applied N gele's rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15+7=22).

The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? o Elicit a positive scarf sign on the affected side. o Observe for an asymmetrical Moro (startle) reflex. o Watch for swelling of fingers on the affected side. o Note paralysis of affected extremity and muscles.

o Observe for an asymmetrical Moro (startle) reflex. · The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fractured clavicle should be suspected if an infant has limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex, crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first? o Provide oral hydration. o Have a complete blood count (CBC) drawn. o Obtain a specimen for urine analysis. o Place the client on strict bedrest.

o Obtain a specimen for urine analysis. · Obtaining a urine analysis should be done first because preterm clients with uterine irritability and contractions are often suffering from a urinary tract infection thus it should be ruled out first.

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately? o Heart rate of 100 beats/minute. o Variable fetal heart rate. o Onset of uterine contractions. o Burning on urination.

o Onset of uterine contractions. · Total (complete) placenta previa involves the placenta covering the entire cervical os (opening). The onset of uterine contractions places the client at risk for dilation and placental separation, which causes painless hemorrhaging. The risk of hemorrhage is the priority.

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pad are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next? o Cleanse the perineum. o Obtain a blood pressure. o Palpate the firmness of the fundus. o Inspect the perineum for lacerations.

o Palpate the firmness of the fundus. · A firm uterus is needed to control bleeding from the placental site of attachment on the uterine wall. The nurse should first assess for firmness and massage the fundus as indicated.

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? o Patellar reflex 4+. o Blood pressure 158/80. o Four-hour urine output 240 ml. o Respiration 12/minute.

o Patellar reflex 4+. A 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia, which is an indication of an impending seizure.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action will the nurse take? o Notify the healthcare provider or anesthesiologist immediately. o Continue to assess the blood pressure q5 minutes. o Place the woman in a lateral position. o Turn off the continuous epidural.

o Place the woman in a lateral position. · The nurse should immediately turn the woman to a lateral position, place a pillow or wedge under the right hip to deflect the uterus, increase the rate of the main line IV infusion, and administer oxygen by face mask at 10-12 L/min. If the blood pressure remains low, especially if it further decreases, the anesthesiologist/healthcare provider should be notified immediately.

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first? o Assess the husband's feelings about his wife's decision to breastfeed their baby. o Ask the client to describe why she was unsuccessful with breastfeeding her last child. o Encourage the client to develop a positive attitude about breastfeeding to help ensure success. o Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

o Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery.

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? o Use a thread to tie off the umbilical cord. o Provide as much privacy as possible for the woman. o Reassure the husband and try to keep him calm. o Put the newborn to breast.

o Put the newborn to breast. · The most important intervention is placing the newborn to the mother's breast. This action serves two purposes as it will help contract the uterus thus preventing a postpartum hemorrhage and avoid infant "cold-stress" because skin to skin will maintain the infant's thermoregulation.

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? o Raise the foot of the bed. o Assess for vaginal bleeding. o Evaluate the fetal heart rate. o Take the client's blood pressure.

o Raise the foot of the bed. These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed will increase venous return and provide blood to the vital areas.

The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do? o Reduce activity level and notify the healthcare provider. o Go to bed and assume a knee-chest position. o Massage the uterus and go to the emergency room. o Do not worry as this is a normal occurrence.

o Reduce activity level and notify the healthcare provider. Lochia should progress in stages from rubra (red) to serosa (pinkish) to alba (whitish), and not return to red. The return to rubra usually indicates subinvolution or infection. If such a sign occurs, the mother should notify the clinic/healthcare provider and reduce her activity to conserve energy.

During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Place the first action on top and last action on the bottom.) o Reposition the client. o Call the healthcare provider. o Increase IV fluid. o Provide oxygen via face mask.

o Reposition the client. o Increase IV fluid. o Provide oxygen via face mask. o Call the healthcare provider. · To stabilize the fetus, intrauterine resuscitation becomes the first priority. In order to enhance the fetal blood supply, the laboring client should be repositioned to displace the gravid uterus and improve fetal perfusion. Secondly, the IV fluids should be increased to expand the maternal circulating blood volume. The next step to optimize oxygenation of the circulatory blood volume is to apply oxygen via face to the mother. Finally, the last step is to notify the primary healthcare provider for additional interventions to resolve the fetal stress.

The nurse should explain to a 30-year-old primigravida client that alpha fetoprotein testing is recommended for which purpose? o Detect cardiovascular disorders. o Screen for neural tube defects. o Monitor the placental functioning. o Assess for maternal pre-eclampsia.

o Screen for neural tube defects. Alpha-fetoprotein (AFP) is a screening test used in pregnancy to rule out neural tube defects. Elevated AFP may indicate an increased risk of neural tube defects such as anencephaly and spinal bifida.

The nurse is calculating the estimated date of confinement (EDC) using Nägele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? o August 1. o August 10. o September 3. o September 8.

o September 8. · Calculation of a client's EDC provides baseline data to monitor fetal gestation. Nägele's rule uses the formula: subtract 3 months and add 7 days to the first day of the last normal menstrual period, so December 1 minus 3 months + 7 days is September 8.

A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which complaint would indicate to the nurse that the woman's fallopian tubes are patent? o Back pain. o Abdominal pain. o Shoulder pain. o Leg cramps.

o Shoulder pain. If the tubes are patent (open), pain is referred to the shoulder from a subdiaphragmatic collection of peritoneal dye/gas.

A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. Which assessment finding would provide the nurse the earliest indication that the client is experiencing primary side effects of terbutaline sulfate? o Drowsiness and bradycardia. o Depressed reflexes and increased respirations. o Tachycardia and a feeling of nervousness. o A flushed, warm feeling and a dry mouth.

o Tachycardia and a feeling of nervousness. · Terbutaline sulfate (Brethine), a beta-sympathomimetic drug which stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of "nervousness".

A client who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client? o Elevate lower legs while resting. o Increase caloric intake by 200 to 300 calories per day. o Increase water intake to 8 full glasses per day. o Take prescribed multivitamin and mineral supplements.

o Take prescribed multivitamin and mineral supplements. · A client who has had a spontaneous abortion or still birth in the last 1 years should take multivitamin and mineral supplements and maintain a balanced diet because the previous pregnancy may have left her nutritionally depleted.

A 23-year-old client who is receiving Medicaid benefits is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client? o Refer the client to a social worker to arrange for home care. o Recommend perinatal care from an obstetrician, not a nurse-midwife. o Teach the client why keeping prenatal care appointments is important. o Advise the client that neonatal intensive care may be needed.

o Teach the client why keeping prenatal care appointments is important. Regular prenatal visits should begin early in pregnancy to monitor health of the mother and development of the fetus.

A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? o The length of labor and method of delivery. o The infant's condition at birth and treatment received. o The feeding method chosen by the parents. o The history of drugs given to the mother during labor.

o The infant's condition at birth and treatment received. · Immediate care is most dependent on the infant's current status (i.e., Apgar scores at 1 and 5 minutes) and any treatment or resuscitation that was indicated.

After each feeding, a 3-day-old newborn is spitting up large amounts of a non-dairy based Newborn formula. The pediatric healthcare provider changes the neonate's formula to a soy protein isolate based infant formula. What information should the nurse provide to the mother about the newly prescribed formula? o The new formula is a coconut milk formula used with babies with impaired fat absorption. o The new formula is prescribed for infants with malabsorption syndromes. o The new formula is a casein protein source that is low in phenylalanine. o The prescribed formula is well tolerated by lactose intolerant infants.

o The prescribed formula is well tolerated by lactose intolerant infants. · The nurse should explain that the newborn's feeding intolerance may be related to the lactose found in cow's milk formula and is being replaced with the soy-based formula that contains sucrose, which is well-tolerated in infants with milk allergies and lactose intolerance.

While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother? o The infant should be positioned to reduce the swelling. o The swelling is a subperiosteal collection of blood. o The pediatrician will aspirate the blood if it gets larger. o The scalp edema will subside in a few days after birth.

o The scalp edema will subside in a few days after birth. · Caput succedaneum is edema of the fetal scalp that crosses over the suture lines and is caused by pressure on the fetal head against the cervix during labor; it subside in a few days after birth without treatment.

During a prenatal visit, the client is concerned about the effects smoking can have on the fetus. Which response by the nurse is most accurate regarding infants of mothers who smoke during pregnancy? o these infants have lower Apgar scores when born. o These infants have lower birth weights. o Respiratory distress is seen initially. o a higher rate of congenital anomalies.

o These infants have lower birth weights. · Smoking is associated with low-birth-weight infants, therefore mothers are encouraged not to smoke during pregnancy.

A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child? o Exercise regimen of both partners includes running four miles each morning. o History of having sexual intercourse 2 to 3 times per week. o The woman's menstrual period occurs every 35 days. o They use lubricants with each sexual encounter to decrease friction.

o They use lubricants with each sexual encounter to decrease friction. · The use of lubricants has the potential to affect fertility because some lubricants interfere with sperm motility.

A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. Which pattern of contractions should alert the nurse to discontinue the oxytocin infusion? o Transition labor with contractions every 2 minutes, lasting 90 seconds each. o Early labor with contractions every 5 minutes, lasting 40 seconds each. o Active labor with contractions every 31 minutes, lasting 60 seconds each. o Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each.

o Transition labor with contractions every 2 minutes, lasting 90 seconds each. The RN should discontinue the oxytocin infusion when it causes uterine hyperstimulation as evidenced by inadequate resting time between contractions. The oxytocin infusion should be discontinued because placental perfusion is impeded.

A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data would indicate to the nurse that the client is experiencing magnesium sulfate toxicity? o Deep tendon reflexes 2+. o Blood pressure 140/90. o Respiratory rate 18/minute. o Urine output 90 ml/4 hours.

o Urine output 90 ml/4 hours. A client experiencing urine outputs of less than 100 ml/4 hours, absent DTRs, and a respiratory rate of less than 12 breaths/minute is exhibiting symptoms of magnesium sulfate toxicity and requires immediate attention.

The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider? o Yellowish tinge to the skin. o Babinski reflex present bilaterally. o Pink papular rash on the face. o Moro reflex noted after a loud noise.

o Yellowish tinge to the skin. · Cephalohematomas are characterized by bleeding between the bone and its covering, the periosteum. Due to the breakdown of the red blood cells within a hematoma, the infant is at a greater risk for jaundice thus it should be reported.

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. Which answer accurately reflects the nurse's understanding of the the variation of an accumulation of blood between the periosteum and skull that does not cross the suture line? o a cephalhematoma, caused by forceps trauma and may last up to 8 weeks. o a subarachnoid hematoma, which requires immediate drainage to prevent further complications. o molding, caused by pressure during labor and will disappear within 2 to 3 days. o a subdural hematoma which can result in lifelong damage.

o a cephalhematoma, caused by forceps trauma and may last up to 8 weeks. · A cephalhematoma is a slight abnormal variation of the newborn which usually arises within the first 24 hours after delivery and is more likely to occur by trauma or if birth assisting tools were utilized during the delivery. The trauma causes capillary bleeding between the periosteum and the skull.

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is appropriate? o "A home pregnancy test can be used right after your first missed period." o "These tests are most accurate after you have missed your second period." o "Home pregnancy tests often give false positives and should not be trusted." o "The test can provide accurate information when used right after ovulation."

o "A home pregnancy test can be used right after your first missed period." · Home urine tests are based on the chemical detection of human chorionic gonadotrophin, which begins to increase 6 to 8 days after conception, and is best detected at 2 weeks gestation or immediately after the first missed period.

The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching? o Cuddles the baby close to her. o Rocks and soothes the infant in her arms. o Places the infant prone in the bassinet. o Wraps the baby in a warm blanket after bathing.

o Places the infant prone in the bassinet. The mother should be instructed to avoid placing the infant prone which is associated with an increased incidence of sudden infant death syndrome (SIDS).

The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? o Two vessels: one artery and one vein. o Two vessels: two arteries and no veins. o Three vessels: two arteries and one vein. o Three vessels: two veins and one artery.

o Three vessels: two arteries and one vein. · The normal umbilical cord contains three vessels: two arteries and one vein.

When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation? o Milia are red marks made by forceps and will disappear within 7 to 10 days. o Meconium is the first stool and is usually yellow gold in color. o Vernix is a white, cheesy substance, predominantly located in the skin folds. o Pseudostrabismus found in newborns is treated by minor surgery.

o Vernix is a white, cheesy substance, predominantly located in the skin folds. · The vernix is found in the folds of the skin, is a characteristic of term infants.

The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs o two weeks before menstruation. o immediately after menstruation. o immediately before menstruation. o three weeks before menstruation.

o two weeks before menstruation. · Because menstruation varies for many women, the nurse should explain that ovulation occurs 14 days before the first day of the menstrual period.

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client? o "Complete bedrest decreases oxygen needs and demands on the heart muscle tissue." o "We want your baby to be healthy, and this is the only way we can make sure that will happen." o "I know you're upset. Would you like to talk about some things you could do while in bed?" o "Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties."

o "Complete bedrest decreases oxygen needs and demands on the heart muscle tissue." · The healthcare provider prescribed activity restriction and complete bedrest to this client in order to help preserve cardiac reserves.

A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is o shortness of breath. o joint pain. o a persistent cold. o organomegaly.

o a persistent cold. · Respiratory tract infections commonly occur in the pediatric population. However, the child with AIDS has a decreased ability to defend the body against these infections and often the presenting symptom of a child with AIDS is a persistent cold. The others are symptoms of complications which may occur later in the disease process.

In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the o anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week. o anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week. o anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. o anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.

o anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month. · In the normal infant the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel by the end of the second month .

When evaluating a laboring client's progress, which finding would be an indicative to the RN to encourage the client to begin pushing o there is only an anterior or posterior lip of cervix left. o the client describes the need to have a bowel movement. o the cervix is completely dilated. o the cervix is completely effaced.

o the cervix is completely dilated. · Pushing begins with the second stage of labor, i.e., when the cervix is completely dilated at 10 cm. If pushing begins prior to the cervix being completely dilated, the cervix can become edematous and may never completely dilate thus resulting in an operative delivery.