OB EAQ 2
A client's membranes rupture, and the nurse immediately detects the presence of a prolapsed umbilical cord. The nurse alerts another nurse, who calls the primary healthcare provider. Place the following nursing interventions in the order in which they should be performed.
1) Moving the presenting part off the cord. 2) placing the client in the Trendelenburg position. 3) Administering oxygen by facemask. 4) Checking the fetal heart rate.
What should be included in a plan of care to limit the development of hyperbilirubinemia in the breastfed neonate?
Encouraging more frequent breastfeeding during the first 2 days
Which finding in a newborn whose temperature over the last 4 hours has fluctuated between 98.0 °F (36.7 °C) and 97.4 °F (36.3 °C) would be considered critical?
Blood glucose level of 26 mg/dL (1.4 mmol/L)
The nurse is preparing to discharge a 3-day-old infant who weighed 7 lb (3175 g) at birth. Which finding should be reported immediately to the healthcare provider?
Weight of 6 lb 4 oz (2835 g)
The nurse is caring for a gravida 2 para 2 client who gave birth the previous day. During the morning assessment the nurse notes that the lochia is rubra and moderately heavy. The picture indicates where the fundus is located. What should the nurse's priority action be at this time? The fundus is located one or two fingerbreadths above the umbilicus and to the right.
have the patient void and reassess
The nurse is assessing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? Select all that apply.
sneezing, hyperactivity, high-pitched cry, exaggerated Moro relfex
A nurse is assessing a postpartum client for signs of hemorrhage by evaluating the degree of perineal pad saturation. What other parameter can the nurse use to estimate blood loss in a postpartum client?
time elapsed between pad changes
A client expresses a desire to breastfeed her preterm infant, who is being cared for in the neonatal intensive care unit. How should the nurse respond to this client's request?
By supporting the client's decision and explaining that her infant may be unable to finish breastfeeding due to exhaustion
One hour postpartum a nurse assesses the amount of vaginal bleeding and determines that a client's uterus has become relaxed and boggy. Which intervention is a priority for the nurse to take in this situation?
Massage the uterus until firm
The nurse is assessing a postpartum client for signs of an impending hemorrhage resulting from laceration of the cervix. Besides monitoring the client for a firm uterus, what other assessment finding is important?
continuous trickling of blood
