OB hesi

a new mother asks the nurse about the swelling on her baby's head near the posterior fontanel that lies across the suture line. how should the nurse response?

"that is called caput succedaneum. it will absorb and cause no problems."

during a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. which action should the nurse implement?

inform her that this is a normal physiological change

a women who delivered a 9 pounds (4082 gram) baby boy by c/s under spinal anesthesia is recovering in the post anesthesia care unity. her fundus is firm, at the umbilicus, and a continuous trickle of bright red blood with no clots from the vagina is observed by the nurse. which action should the nurse implement?

assess her blood pressure

baby has a cephalohematoma, what does the nurse do?

measure bilirubin levels

the nurse is assessing a newborn who was precipitously delivered at 38 weeks gestation. the newborn is tremulous, tachycardic, and hypertensive. which assessment action is most important for the nurse to implement?

obtain a drug screen for cocaine

following a minor motor vehicle collision, a client at 36 weeks gestation is brought to the emergency center. she is lying supine on a backboard, is aware, and denies any complaints. her blood pressure is 80/50mmHg and heart rate is 130 beats/min. which action should the nurse implement first?

tilt the backboard sideways to displace the uterus laterally

a client who is receiving oxytocin to augment early labor begins to experience tachysystole or tetanic contractions with variable fetal heart decelerations. which action should the nurse implement?

turn off the oxytocin

a client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. which information should the nurse provide this client?

use an alternate form of contraception until a new diaphragm is obtained

at a prenatal visit, a primigravida client confides to the nurse that her partner is abusive. which information should the nurse provide?

visit summary documenting the report of abuse

a woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. which method provides the greatest degree of accuracy?

visualization of implantation by vaginal ultrasound

a client at 33 weeks gestation is admitted with a moderate amount of vaginal bleeding, no contractions are noted on the external monitor. which intervention should the nurse implement?

weigh perineal pads

the nurse is reviewing a women's health care record during her first prenatal visit. the client has a history of chicken pox as a child and syphilis as a teenager. what action is most important for the nurse to take?

obtain blood and urine for prenatal screens

following the vaginal delivery of a 10 pound (4536 gram) infant, the nurse assesses a new mothers vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. which action should the nurse implement?

perform fundal massage until firm

the nurse is caring for a postpartum client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?

place procedure equipment at bedside

upon admission to the nursery, the nurse places a newborn supine under a radiant warmer, an external heat source. what intervention should the nurse implement to ensure thermoregulation?

place temperature probe on the abdomen in line with the radiant heat source

a father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infants eyes. he asks the nurse what the purpose of the ointment is. the nurse would be correct in stating that the purpose for using the ointment is to

prevent eye infection

which type of anesthesia is used with a client in labor, produces a loss of sensation only to the vagina and perineum?

pudendal block

which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

pulse rate of 56 beats/minute

a postpartum client who is giving her new baby formula feedings asks the nurse when she should expect to start menstruating again. what information should the nurse tell the client?

six to eight weeks after birth

a client at 40 weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive, which actions should the nurse plan to perform? SATA

-give antiviral medication intravenously -use standard precautions -encourage the mother to bottle feed

a women is brought to the labor and delivery unit after delivering a term infant and the placenta in the hospital parking lot 10 minutes ago. which action should the nurse perform first?

massage the fundus and give oxytocic agent

assessment findings of a 4-hour old newborn include: axillary temperature of 96.8F (35.8C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic, and weak cry. based on these findings, which action should the nurse implement?

obtain a heel stick blood glucose level

a women is 36 weeks gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. she is placed on strict bedrest and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. two hours after admission, the nurse notes a large amount of bright red vaginal bleeding. which nursing intervention has highest priority?

assess the fetal heart rate and client's contraction pattern

the nurse notes on the fetal monitor that a laboring client has a variable deceleration. which action should the nurse implement?

change the clients position

A client at 35 weeks gestation complains of a "pain whenever the baby moves". on assessment, the nurse notes the clients temperature to be 101.2 (38.4), with severe abdominal or uterine tenderness on palpation. the nurse knows that these findings are indicative of which condition?

chorioamnionitis

the nurse is caring for a client who is 10 weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis. the client reports nausea, vomiting, and scant dark brown vaginal discharge. which action should the nurse take?

collect urine sample for urinalysis

a client at 10 week gestation calls the clinic reporting a low-grade fever with moderate cramping and heavy bright red bleeding. which instruction should the nurse provide the client?

come in for an immediate evaluation

the nurse is assessing a 38 week gestation newborn infant immediately following a vaginal birth. which assessment finding best indicates that the infant is transitioning well to extrauterine life?

cries vigorously when stimulated

the home health nurse visits a client who delivered a full-term baby three days ago. the mother reports that the infant is waking up every 2 hours to bottle feed. the nurse notes white, curd-like patches on the newborns oral mucous membranes. what action should the nurse take?

discuss the need for medication to treat curd-like oral patches

a 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. the nurse knows that assessment for what complication has the highest priority?

disseminated intravascular coagulation

at 6 weeks gestation, the rubella titers of a client indicate she is non-immune. when is the best time to administer a rubella vaccine to this client?

early postpartum, within 72 hours of delivery

an ambulatory client at 39 weeks gestation presents to the emergency center with an obvious injury to her arm that occurred as the result of a fall. which concurrent symptom is a priority for the nurse?

ecchymotic knees

the nurses caring for a client whose fetus died in uterine at 32 weeks gestation. after the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures. which action is important for the nurse to take?

encourage the mother to hold and spend time with her baby

the nurse is caring for a client who delivered 6 hours ago. assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. which action should the nurse take?

encourage voiding

a client at 18 weeks gestation was informed this morning that she has an elevated alpha fetoprotein (AFP) level. after the healthcare provider leaves the room, the client asks what she should do next. what information should the nurse provide?

explain that a sonogram should be scheduled for definitive results

the nurse is caring for a client who is 24 weeks gestation and reports increased thirst and urination. which diagnostic test result should the nurse report to the healthcare provider?

fasting blood glucose

a primipara at 20 weeks gestation for an ultrasound. in preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?

fetal growth and gestational age

while assessing a 40 week gestation primigravida in active labor, the clients membranes rupture spontaneously and the nurse notes that the amniotic fluid is meconium stained. what additional finding is most important for the nurse to report to the healthcare provider?

fetal heart rate of 100 to 110 beats/min

the nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. her fundus is firm, and she has a moderate lochia flow. on inspection, the nurse finds that a perineal hematoma is beginning to form. which assessment finding should the nurse obtain first?

heart rate and blood pressure

the nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (2.2kg) has a head circumference of 13 inches (33cm), and has a chest circumference of 10 inches (24.5cm). based on these findings, assessment for which condition is the highest priority?

hypoglycemia

which action should the nurse take if an infant who was born yesterday weighing 7.5 pounds (3,402 grams), weighs 7 pounds (3,175) today?

inform and assure the mother that this is a normal weight loss

at 0600 while admitting a women for a scheduled repeat c-section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. which action should the nurse take first?

inform the anesthesia care provider

a client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. on examination, the nurse notes that the client has an elevated blood pressure. which action should the nurse implement next?

inspect the clients face for edema

a woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3cm. the nurse assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia and the healthcare provider prescribes an oxytocin drip. which data is most important for the nurse to monitor?

intensity, interval, and length of contractions

a nurse is speaking with a client who is addicted to heroin who just learned that she is pregnant. the client states "I just started taking methadone, is there anything else I can do to make sure my baby is healthy"? which information should the nurse provide?

start a prenatal care plan as soon as possible

after two miscarriages, a client is instructed to increase daily intake of foods that includes folic acid. the client does not like green leafy vegetables and states she is allergic to soy. which food should the nurse suggest that the client eat to obtain folic acid?

strawberries

a multiparous client is involuntarily pushing while being wheeled into the labor triage. the nurse observes the fetal head presenting at the perineum. which action should the nurse take?

support the infant as it emerges

during a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment. which technique should the nurse implement to calculate the leakage?

test the fluid with a nitrazine strip

the nurse is caring for a 2-day old neonate who has not passed meconium and has a swollen abdomen. the health care provider reviews the flat plate x-ray of the abdomen and makes a tentative diagnosis for Hirschsprung's disease. which pathophysiological process is consistent with neonates clinical picture?

the congenital absence of parasympathetic ganglion cells to large intestine produces no peristalsis