OB HESI

During labor, the nurse determine that a full term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions.

1. Reposition the client 2. Provide O2 via face mask 3. Increase IV fluid 4. Call the healthcare provider

State 3 ways to identify the chronological age of a pregnancy (gestation).

10 lunar months, 9 calendar months consisting of 3 trimesters; 40 weeks; 280 days

FHR can be ascultated by Doppler at _____ week's gestation.

10-12

Normal maternal temperature during labor is _____.

100.4 F (38 C)

Normal FHR during labor is _____.

110-160

Ovulation occurs how many days before the next menstrual period?

14 days

The hemodilution of pregnancy peaks at _____ weeks and results in a _____ in a woman's Hct.

28-32 weeks Decrease

During pregnancy, a woman should add _____ calories to her diet and drink _____ of milk per day.

300 3 cups

Normal blood glucose in the term neonate is _____.

40-80 mg/dL

A term newborn needs to take in _____ calories per pound per day. After the initial weight loss is sustained, the newborn should gain _____ per day.

50 calories 1 oz or 30 grams

The newborn transitional period consists of the first _____ days of life.

6-8 hours

What is considered a good APGAR score?

7-10

Normal fetal scalp pH in labor is _____, and values below _____ indicate true acidosis.

7.25-7.35 7.2

The goal for diabetic management during labor is euglycemia. How is it defined?

70-90 mg/dL

Normal maternal pulse during labor is _____.

<100 bpm

Normal maternal BP during labor is _____.

<140/90

A prolonged latent phase for a multipara is _____ and for a nullipara is _____. Multipara's average cervical dilation is _____ cm/hr in the active phase and nullipara's is _____ cm/hr.

>14 hours, >20 hours 1.5, 1.2

WHat is the most common cause of uterine atony in the first 24 hour postpartum?

A full bladder

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.)

A sterile glove. An amnihook. Lubricant.

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? A. Between the time the temperature falls and rises. B. Between 36 and 48 hours after the temperature rises. C. When the temperature falls and remains low for 36 hours. D. Within 72 hours before the temperature falls.

A. Between the time the temperature falls and rises.

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

A. Raise the foot of the bed.

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? A. The client's readiness to learn. B. The client's educational background. C. The order in which the information is presented. .DThe extent to which the pregnancy was planned.

A. The client's readiness to learn.

Magesium sulfate is used to treat preeclampsia. A. What is the purpose of adminstering MgSO4? B. What is the main action of MgSO4? C. What is the antidote? D. List the 3 main assessment findings indicating toxic effects of MgSO4.

A. To prevent seizures by decreasing CNS irritability B. CNS depression (seizure prevention) C. Calcium gluconate D. Reduced urinary output, reduced respiratory rate, decreased reflexes

A multigravida client arrives at the L&D unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal HR is between 140 and 150 beats/min. What action should the nurse implement next? A. complete sterile vag exam B. take maternal temp every 2 hrs C. Prepare for an immediate cesarean bitrh D. Obtain sterile suction equipment

A. complete sterile vag exam

A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate. A. dark,red vaginal bleeding B. lower back pain C. premature rupture of membranes D. increased uterine irritability E. bilateral pitting edema F. Rigid abdomen

A. dark,red vaginal bleeding D. increased uterine irritability F. Rigid abdomen

The healthcare provider prescribes terbutaline for a client in preterm labor. Before initating this prescription, it is most important for the nurse to assess the client for which of condition. A. gestational diabetes B. Elevated BP C. UTI D> Swelling in lower extremities

A. gestational diabetes

A 42 week gestational client is receiving an intravenous infusion of oxytocin(Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for with pattern of contractions? A. transition labor with contractions every 2 mins, lasting 90 seconds each. B. early labor with contractions every 5 min, lasting 40 seconds each. C. Active labor with contractions every 31 mins, lasting 60 seconds each. D. Active labor with contraction every 2 to 3 mins, lasting 70 to 80 seconds each.

A. transition labor with contractions every 2 mins, lasting 90 seconds each.

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? A. yellowish tinge to the skin B. babinski reflex present bilaterally C. pink papular rash on the face D. moro reflex noted after a loud noise

A. yellowish tinge to the skin

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.) A.Admission weight of 4 pounds, 15 ounces (2244 grams) B.Head to heel length of 17 inches (42.5 cm). C.Frontal occipital circumference of 12.5 inches (31.25 cm). D.Skin smooth with visible veins and abundant vernix. E.Anterior plantar crease and smooth heel surfaces. F. Full flexion of all extremities in resting supine position.

A.Admission weight of 4 pounds, 15 ounces (2244 grams) B.Head to heel length of 17 inches (42.5 cm). C.Frontal occipital circumference of 12.5 inches (31.25 cm).

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? A.Come to the clinic today for an ultrasound. B.Go immediately to the emergency room. C.Lie on your left side for about one hour and see if the bleeding stops. D.Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.

A.Come to the clinic today for an ultrasound.

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? A.Complete bedrest decreases oxygen needs and demands on the heart muscle tissue. B.We want your baby to be healthy, and this is the only way we can make sure that will happen. C.I know you're upset. Would you like to talk about some things you could do while in bed? D.Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties.

A.Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.

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? A.Edema, basilar rales, and an irregular pulse. B. Increased urinary output and tachycardia. C.Shortness of breath, bradycardia, and hypertension. D.Regular heart rate and hypertension.

A.Edema, basilar rales, and an irregular pulse.

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? A.Grief related to her perceptions about the loss of this child. B.Relief of ambivalent feelings experienced with this pregnancy. C.Shock because she may not have realized that she was pregnant. D. Guilt because she had not followed her healthcare provider's instructions.

A.Grief related to her perceptions about the loss of this child.

Which nursing intervention is helpful in relieving "afterpains" (postpartum uterine contractions)? A.Using relaxation breathing techniques. B.Using a breast pump. C.Massaging the abdomen. D.Giving oxytocic medications.

A.Using relaxation breathing techniques.

List 3 symptoms of abruptio placentae and 3 symptoms of placenta previa.

Abruptio placentae: fetal distress, rigid/boardlike abdomen, pain, dark-re or absent bleeding Placenta previa: pain free, bright red vaginal bleeding, normal FHR, soft uterus

State the objective signs that signify ovulation.

Abundant, thin, clear cervical mucus; spinnbarkeit (egg white stretchiness) of cervical mucus; open cervical os; slight drop in body temp and then a 0.5-1 degree rise; ferning under a microscope

Name the four periodic changes of the FHR, their causes, and one nursing treatment for each.

Accelerations: caused by a burst of sympathetic activity, reassuring, require no treatment Early Decels: caused by head compression, benign and alert the nurse to monitor for labor progress/fetal descent Variable Decels: caused by cord compression, change of position tried first Late Decels: caused by UPI and should be treated by placing client on her side and giving oxygen

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.)

Admission weight of 4 pounds, 15 ounces (2244 grams). Head to heel length of 17 inches (42.5 cm). Frontal occipital circumference of 12.5 inches (31.25 cm).

Name 5 maternal variables associated with diagnosis of a high-risk pregnancy.

Age (under 17 or over 34) Parity (over 5 births) <3 months between pregnancies Dx of preeclampsia, diabetes, or cardiac disease

State the normal psychosocial responses to pregnancy in the second trimester.

Ambivalence wanes (stop feeling so unsure) Acceptance of pregnancy occurs Pregnancy becomes "real" Signs of maternal-fetal bonding occur

Prior to anesthesia for c-section delivery, the mother may be given an antacid or a gastric antisecretory drug. State the reasons these drugs are given.

Antacid buffers alkalize the stomach secretions. If aspiration occurs, less lung damage ensues. An antisecretory drug reduces gastric acid, reducing the risk for gastric aspiration.

List 3 nursing interventions for the neonate undergoing phototherapy.

Apply opaque mask over eyes. Leave diaper loose so stools and urine can be monitored but cover genitalia. Turn every 2 hours Watch for dehydration

If meconium was passed in utero, what action must the nurse take in the delivery room?

Arrange for immediate endotracheal tube observation to determine the presence of meconium below the vocal cords (prevents pneumonitis and meconium aspiration syndrome)

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?

Ask the client if she has felt any fetal movement.

What is the major cause of maternal death when general anesthesia is administered?

Aspiration of gastric contents

What are the two best ways to test for correct placement of the gavage tube in the infant's stomach?

Aspiration of stomach contents and pH testing Auscultation of an air bubble injected into stomach

A client feels faint on the way to the bathroom. What nursing assessments should be made?

Assess BP sitting and lying Assess Hgb and Hct for anemia.

What is the priority nursing action after spontaneous or AROM?

Assessment of the FHR

When is the screening test for PKU done?

At 2-3 days of life, or after enough breast or formula (usually after 24 hours) is ingested to allow for determination of body's ability to metabolize amino acid phenylalanine.

Physiologic jaundice in the newborn occurs _____. It is caused by _____.

At 2-3 days of life. Caused by immature liver's inability to keep up with the bilirubin production resulting from normal RBC distribution.

When is cardiac disease in pregnancy most dangerous?

At peak plasma volume increase, between 28-32 weeks GA, and during stage 2 labor.

State the best way to administer IV drugs during labor.

At the beginning of contraction, push a little medication in while uterine blood vessels are constricted, thereby reducing dose to fetus.

At 20 weeks gestation, the fundal height would be _____; the fetus would weigh about _____ and would look like _____.

At the umbilicus 300-400 grams Baby with hair, lanugo, and vernix, but W/O subcutaneous fat

What information should be given to a client regarding resumption of sexual intercourse after delivery?

Avoid until postpartum examination. Use water-soluble jelly. Expect slight discomfort due to vaginal changes.

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? a. Length of labor and method of delivery b. Infant's condition at birth and treatment received. C. Feeding method chosen by the parents. D. History of drugs given to the mother during labor.

B. Infant's condition at birth and treatment received.

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? A. Supplementary iron is more efficiently utilized during pregnancy. B. It is difficult to consume 18 mg of additional iron by diet alone. C. Iron absorption is decreased in the GI tract during pregnancy. D. Iron is needed to prevent megaloblastic anemia in the last trimester.

B. It is difficult to consume 18 mg of additional iron by diet alone.

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? A. Maternal blood pressure and respirations. B.Maternal and fetal heart rates. C.Hourly urinary output. D.Deep tendon reflexes.

B.Maternal and fetal heart rates.

A baby is delivered blue, limp, and with a HR of <100. The nurse dries the infant, suctions the oropharynix, and gently stimulates the infant while blowing O2 over the face. The infant still does not respond. What is the next nursing action?

Begin oxygenation by bag and mask at 30-50 breaths per min. If heart rate is <60 start cardiac massage at 120 events/min (30 breaths and 90 compressions) Assist HCP in setting up for intubation procedure.

List the symptoms of hyperbilirbinema in the neonate.

Bilirubin levels rising 5 mg/day, jaundice, dark urine, anemia, high RBC count, and dark stools

Which woman experience afterpains more than others?

Breastfeeding women Multiparas Woman who experienced overdistention of the uterus

The nurse anticipates which newborns will be at greater risk for problems in the transitional phase. State 3 factors that predispose to respiratory depression in the newborn.

C-section delivery Magnesium Sulfate given to mom in labor Asphyxia or fetal distress during labor

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 pads are completely saturated a nd the client is lying in a 6inch diameter pool of blood. A. Cleanse the perineum B. obtain a BP C. palpate the firmness of the fundus D; inspect the perineum for lacerations

C. palpate the firmness of the fundus

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

C.A decrease in respiratory rate from 24 to 16.

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? A.Notify the pediatrician immediately. B.Suction the infant's nares, then the oral cavity. C.Check the infant's oxygen saturation rate. D.Position the infant on the right side.

C.Check the infant's oxygen saturation rate.

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

C.Encourage the mother to breastfeed frequently.

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

C.Feed your baby every 2 to 3 hours or on demand, whichever comes first.

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? A.Provide oral hydration. B.Have a complete blood count (CBC) drawn. C.Obtain a specimen for urine analysis. D.Place the client on strict bedrest.

C.Obtain a specimen for urine analysis.

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

C.Place the woman in a lateral position.

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 postprocedure complaint indicates that the fallopian tubes are patent? A.Back pain B.Abdominal pain. C.Shoulder pain. D. Leg cramps.

C.Shoulder pain.

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

C.Three vessels: two arteries and one vein.

During the physical exam of the newborn, the nurse notes the cry is shrill, high-pitched, and weak. What are the possible causes?

CNS abnormalities brain damage, hypoglycemia, drug withdrawal

In order to prevent rickets in the preterm newborn, what supplements are given?

Calcium and Vitamin D

List 3 signs of positive bonding between parents and newborn.

Calling infant by name Exploring newborn head to toe Using en face position

State the advantage of CVS over amniocentesis.

Can be done between 8-12 weeks gestation Results are returned within 1 week. so.... Allows for decision about termination while still in the 1st trimester

When is preterm labor able to be arrested?

Cervix is <4 cm dilated, <50% effacement, and membranes are intact and not bulging out of the cervical os.

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?

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 (C) is one indicator that Epogen is effective.

A woman's WBC count is 17,000; she is aferbile and has no symptoms of infection. What nursing action is indicated?

Continue routine assessments. Normal leukocytosis occurs during postpartal period because of placental site healing.

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing hx, the client indicates that she has delivered premature twins, one full term baby and has had no abortions. Which GTPAL should the nurse document in this client's record? A. 3-1-2-0-3 B. 4-1-2-0-3 C. 2-1-2-1-2 D. 3-1-1-0-3

D. 3-1-1-0-3

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

D. Take prescribed multivitamin and mineral supplements.

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? A.Assess the husband's feelings about his wife's decision to breastfeed their baby. B.Ask the client to describe why she was unsuccessful with breastfeeding her last child. C.Encourage the client to develop a positive attitude about breastfeeding to help ensure success. D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

D.Provide assistance to the mother to begin breastfeeding as soon as possible 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? A.Use a thread to tie off the umbilical cord. B.Provide as much privacy as possible for the woman. C.Reassure the husband and try to keep him calm. D.Put the newborn to breast

D.Put the newborn to breast

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

D.There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.

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

D.Urine output 90 ml/4 hours.

What interventions should the nurse implement to reduce CNS irritability in the preeclampsia client?

Darken room, limit visitors, private room, do all nursing interventions at the same time for fewer disturbances

What specific information should the nurse include when teaching about HPV detection and treatment?

Detection of dry, wartlike growths on the vulva or rectum. Need for Pap smear in the prenatal period. Treat with laser ablation. Associated with cervical carcinoma in mother and respiratory papillomatosis in neonate. Teach about immunization for females 9-30 with Gardasil.

Nurses often weigh diapers in order to determine exact urine output in the high-risk neonate. Explain this procedure.

Diaper is weighed in grams before being applied to the infant. Diaper is weighed after infant has wet it. Each gram of added weight is calculated and recorded as 1 mL of urine.

What contraceptive technique is recommended for diabetic women?

Diaphragm with spermicide, clients should avoid birth control pills, which contain estrogen, and IUDs which are an infection risk.

State 4 risk factors for or predisposing factors to postpartum hemorrhage.

Dystocia or prolonged labor, overdistention of the uterus, abruptio placentae, and infection

What condition should the nurse suspect if a woman of childbearing age presents to an ER room with bilateral or unilateral abdominal pain, with or without bleeding?

Ectopic Pregnancy

State 3 nursing interventions during forceps delivery.

Ensure empty bladder. Auscultate FHR before application and again between traction periods. Observe for maternal lacerations and newborn cerebral or facial trauma

How often should the nurse check the fundus during the 4th stage of labor?

Every 15 minutes for 1 hour Every 30 minutes for 2 hours if normal

State the most important action to take when a cord prolapse is determined.

Examiner should position the mother to relieve pressure on the cord (Tredenburg) or push the presenting part off the cord with fingers until emergency delivery is accomplished.

What is a reactive nonstress test?

FHR acceleration of 15 bpm for 15 seconds in response to fetal movement

What is the most important indicator of fetal autonomic nervous system integrity & health?

FHR variability

Neonates who are "sick" are prone to receive too much stimulation in the form of invasive procedures and handling and too little developmentally appropriate stimulation and affection. How might such an infant respond?

Failure to thrive, absence of crying

True of false: The newborn's head is usually smaller than the chest.

False. The head is usually 2 cm larger unless severe molding occured.

What does the BPP determine?

Fetal well-being

What immediate nursing actions should be taken when a postpartum hemorrhage is detected?

Fundal massage. Notify HCP is massage does not firm fundus. Count pads to estimate blood loss. Assess and record VS. Increase IV fluids and administer oxytocin infusion as prescribed.

List the symptoms of a full bladder that might occur in the 4th stage of labor.

Fundus above umbilicus, dextroverted (to the right side of abdomen), increased bleeding (uterine atony)

What are the common SE of antibodies used to treat puerperal infection?

GI adverse reactions: N/V, diarrhea, and cramping Hypersensitivity reactions: rashes, urticaria, and hives

Why are PO medications avoided in labor?

Gastric activity slows or stops in labor, decreasing absorption from PO route; it may cause vomiting

When should the postpartum dosage of oxytocin (Pitocin) be administered? Why is it administered?

Give immediately after placenta is delivered to prevent postpartum hemorrhage and atony

List 3 signs of placental separation.

Gush of blood, lengthening of cord, and globular shape of uterus

A SGA newborn is identified as one who _____.

Has a weight below the 10th percentile for estimated GA.

List 3 necessary nursing actions prior to a US examination for a woman in the first trimester of pregnancy.

Have a full bladder! Do not allow client to void. Position client supine with uterine wedge.

A breastfeeding mother complains of very tender nipples. What nursing actions should be taken?

Have her demonstrate infant position on breast (incorrect positioning can cause tenderness) Leave bra open to air-dry nipples for 15 minutes 3 times daily Express colostrum and rub on nipples

Identify 3 ways to determine the presence of congenital hip dislocation in the newborn.

Hip click Asymmetric gluteal folds Unequal limb lengths

What complications are associated with TPN?

Hyperglycemia, electrolyte imbalances, dehydration, and infection.

State one contraindication to the use of ergot drugs (Methergine).

Hypertension

What is the danger associated with regional blocks?

Hypotension resulting form vasodilation below the block, which pulls blood in the periphery, reducing venous return

Name 4 causes of decreased FHR variability.

Hypoxia, acidosis, drugs, fetal sleep

To promote comfort, what nursing interventions are used for a 3rd degree episiotomy that extends into the anal sphincter?

Ice pack Witch hazel compresses No rectal manipulation

When may a VBAC be considered by a woman with a previous c-section?

If a low uterine transverse incision was performed and can be documented and if teh origional complication does not recur, such as CPD

Identify 2 reasons to withhold anesthesia and analgesia until the midactive phase of stage 1 labor.

If analgesia and anesthesia are given too early, they can retard labor; if given too late, they can cause fetal distress

What are the major symptoms of preeclampsia?

Increase in BP of 30 mmHg systolic and 15 diastolic Proteinuria CNS disturbances

What factor places the postpartum client at risk for thromboembolism?

Increased clotting factors

What factors does a nurse look for in determining a newborn's ability to take in nourishment by nipple and mouth?

Infant has good suck, has coordinated suck-swallow, takes less than 20 minutes to feed, gains 20-30 grams/day

List 4 nursing interventions to enhance family and parent adjustment to a high-risk newborn.

Initiate early visitation at ICU. Provide daily info to family. Encourage participation in support group for parents. Encourage all attempts at caregiving (enhances bonding)

Describe the maternal changes that characterize the transition phase of labor.

Irritability and unwillingness to be touched, but does not want to be left alone; n/v, and hiccuping

List the symptoms of neonatal narcotic withdrawal.

Irritability, hyperactivity, high-pitched cry, frantic sucking, coarse flapping tremors, and poor feeding

NEC results from _____ and is manifested by _____, ischemia/hypoxia results in _____.

Ischemic hypoxia, abdominal distention, sepsis, and a lack of absorption from intestines; injury to the intestinal mucosa.

What is the danger to the newborn of heat loss in the 1st few hours of life?

It can lead to depletion of glucose; body begins to use brown fat for energy, producing ketones and causing subsequent ketoacidosis and shock

The nurse notes a swelling over the back part of the newborn's head. Is this a normal newborn variation?

It depends on the finding. If it crosses suture lines and is a caput (edema) then its normal. If is does not cross suture lines, it is a cephaloheamtoma with bleeding between the skull and periosteum. This could cause hyperbuilirubinema which is abnormal.

Why is regular insulin used in labor?

It is short-acting, predictable, can be infused IV, and can be discontinued quickly if needed.

List 3 nursing interventions to ease the discomfort of afterpains.

Keep bladder empty. Provide a warm blanket for abdomen. Administer analgesics prescribed by the HCP.

What maternal position provides optimum fetal and placental perfusion during pregnancy?

Knee-chest position but the ideal position for comfort is the side-lying position.

What is the most important determinant of fetal maturity for extrauterine survival?

L/S Ratio (lung maturity and lung surfactant development)

What are the two most difficult times for control in the pregnant diabetic?

Late in the 3rd trimester and in the postpartum period when insulin needs drop sharply.

List 5 signs/symptoms new parents should be taught to report immediately to a doctor or clinic.

Lethargy Temperature > 100 Vomiting Green Stools Refusal of 2 feeds in a row

List the major CNS danger signals that occur in the neonate.

Lethargy, high-pitched cry, jitteriness, seizures, and bulging fontanels

What are the cardinal symptoms of sepsis in a newborn?

Lethargy, temperature instability, difficulty feeding, subtle color changes and behavioral changes, and hyperbilirubemia

List 5 prodromal signs of labor that the nurse might teach the client.

Lightening, Braxton Hicks contractions, increased bloody show, loss of mucous plug, burst of energy, and nesting behaviors

What symptoms are common to most newborns with Down Syndrome?

Low set ears, simian crease on palm, protruding tongue, Brushfield spots in iris, epicanthal folds.

What instructions should the nurse give the woman with a threatened abortion?

Maintain strict bedrest for 24-48 hours. Avoid sexual intercourse for 2 weeks

What are the major goals of nursing care related to pregnancy-induced hypertension with preeclampsia?

Maintenance of uteroplacental perfusion, prevention of seizures, prevention of complications such as HELLP syndrome, and abruption

List four nursing actions for the 2nd stage of labor.

Make sure cervix is completely dilated before pushing is allowed. Assess FHR with each contraction. Teach woman to hold breath for no longer than 10 seconds. Teach pushing technique.

if the first day of a woman's last normal menstrual period was May 28th, what is the EDB using the Nagele rule?

March 7 (count back 3 months and add 7 days)

What actions can the nurse take to assist in preventing postpartum hemorrhage?

Massage the fundus (gently) and keep the bladder emptied

Name 3 maternal and 3 fetal complications of gestational diabetes.

Maternal hypoglycemia, hyperglycemia at birth, fetal anomalies

Gentle counterpressure against the perineum during an emergency delivery prevents _____ and _____.

Maternal lacerations, fetal cerebral trauma

How should a nurse determine the length of a tube needed for the oral gavage feeding of a newborn?

Measure from the bridge of the nose to the earlobe and then to a point halfway between the xiphoid and the umbilicus

What are the nursing actions for endometritis and parametritis?

Measures to promote lochial drainage, antipyretic measures (acetaminophen, cool cloths); administration of analgesics and antibiotics as prescribed, increase in fluids with attention to high-protein and high-vitamin C diet.

What characteristics would the nurse expect to see in a neonate with FAS?

Microcephaly, growth retardation, short palpebral fissures, maxillary hypoplasia, abnormal palmar creases, irregular hair, poor suck, cleft lip, cleft palate, small teeth.

State 3 priority nursing actions in the postdelivery period for the client with preeclampsia.

Monitor for signs of blood loss. Continue to assess BP and DTRs every 4 hours. Monitor for uterine atony.

What special actions should the nurse take during the intrapartum period if preterm labor is unable to be arrested?

Monitor the FHR continously and limit drugs that cross placental barriers so as to prevent fetal depression or further compromise.

All pregnant woman should be taught preterm labor recognition. Describe the warning symptoms of preterm labor.

More than 5 contractions per hour, cramps Low, dull backache Pelvic pressure Change in vaginal discharge

List the symptoms of water intoxication resulting form the effect of Pitocin (oxytocin) on the ADH.

N/V Headache Hypotension

Name the major discomforts of the 1st trimester and one suggestion for amelioration of each.

N/V= crackers before standing/moving Fatigue= rest periods, naps, 7-8 hours of sleep at night

Hypotension commonly occurs after the laboring client receives a regional block. What is one of the 1st signs the nurse might observe?

Nausea

State 2 ways to determine whether the membranes have truly ruptured

Nitrazine testing: Paper turns dark blue/black Demonstration of fluid ferning under microscope

May women with a positive HIV antibody try to breastfeed?

No, HIV has been found in breast milk.

Are psycho prophylactic breathing techniques prescribed for use according to the stage and phase of labor?

No. Clients should use these techniques according to their discomfort level and should change techniques when one is no longer working on relaxation.

Is one ultrasound examination useful in determining the presence of IUGR?

No. Serial measurements are needed to determine IUGR.

A woman on Orinase (oral hypoglycemic) asks the nurse if she can continue this medication during pregnancy. How should the nurse respond?

No. She cant. oral hypoglycemic medications are teratogenic to the fetus. Insulin will be used.

Does insulin cross the placenta-breast barrier?

No. Therefore, insulin dependent woman may breastfeed.

Must women diagnosed with mastitis stop breastfeeding?

No. Women who stop breastfeeding abruptly may make the situation worse by increasing congestion and engorgement and providing further media for bacterial growth. Client may have to discontinue breastfeeding if pus is present or if antibiotics are contraindicated for neonate.

State 3 principles pertinent to counseling and teaching a pregnant adolescent.

Nurse must establish trust and rapport before counseling and teaching begin. Adolescents do not respond to an authoritarian approach. Consider the developmental tasks of identity and social and individual intimacy.

Describe the schedule of prenatal visits for a low-risk pregnant women.

Once every 4 weeks until 28 weeks Every 2 weeks from 28-36 weeks Then once a week until delivery

State 4 risk factors for or predisposing factors to postpartum infection.

Operative delivery, intrauterine manipulation, anemia or poor physical health, traumatic delivery, and hemorrhage

In order to prevent problems with oxygenating the newborn, what parameters can the nurse observe?

PO2 50-90; SVO2 60-80 mmHg

What are the symptoms of hypovolemic shock?

Pallor, clammy skin, tachycardia, lightheadedness, and hypotension

Clients who have had a c-section are prone to what postoperative complications?

Paralytic ileus, infection, thromboembolism, respiratory complications, and impaired maternal-infant bonding

What action should the nurse take when a soft, boggy uterus is palpated?

Perform fundal massage

A nurse discovers a postpartum client with a boggy uterus that is displaced above and to the right of the umbilicus. What nursing action is indicated?

Perform immediate fundal massage. Ambulate to the bathroom or use bedpan to empty bladder because cardinal signs of bladder distention are present.

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?

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

The nurse records a temperature below 97 F on admission of the newborn. What nursing actions should be taken?

Place newborn in isolette or under warmer and attach a temperature skin probe to regulate temperature in isolette/warmer. Double wrap the newborn and put cap on head if warmer/isolette isn't available. Watch for signs of hypothermia and hypoglycemia.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take?

Place the woman in a lateral position. The nurse should immediately turn the woman to a lateral position (C), 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.

A premature baby is born and develops hypothermia. State the major nursing interventions to treat hypothermia.

Place under warmer or in an incubator with temperature skin probe over liver. Warm all items toughing newborn, place plastic wrap over neonate

What interventions can the nurse implement to maintain cardiac perfusion in a laboring client?

Position client in a semi- or high-Fowlers position. Prevent Valsalva maneuvers. Position client in a side-lying position for regional anesthesia. Avoid stirrups because of possible popliteal vein compression and decreased venous return.

Should the normal newborn have a positive or negative Babinski reflex?

Positive; the transient reflex is present until 12-18 months of age.

What complications are pregnant adolescents particularly prone to develop?

Preeclampsia IUGR CPD STDs Anemia

List 3 conditions clients with diabetes mellitus are more prone to develop.

Preeclampsia, hydramnios, infection

IVH is more common in _____ and results in symptoms of _____.

Premature neonates and VLBW babies; increased ICP

Describe the discharge counseling for a woman after hydatidiform mole exacuation by D&C.

Prevent prgnancy for 1 year. Return to clinic or MD for monthly hCG levels for a year. Post-op instructions: call if bright-red vaginal bleeding or foul smelling vaginal discharge occurs or temperature spikes over 104.

How does the nurse differentiate the symptomatology of cystitis from that of pyelonephritis?

Pyelonephritis has the same symptoms as cystitis (dysuria, frequency, and urgency) with the addition of flank pain, fever, and pain at costovertebral angle.

What conditions make oxygenation of the newborn more difficult?

RDS; alveolar prematurity and lack of surfactant; anemia; and polycythemia

What are the two major complications of O2 toxicity?

RLF and BPD

Hyperventilation often occurs in the laboring client. What results from hyperventilation , and what actions should the nurse take to relieve the condition?

Respiratory alkalosis occurs; it is caused by blowing off CO2 and is relieved by breathing into a paper bag or cupped hands

What does the Silverman-Anderson index measure?

Respiratory difficulty

List the risk factors for hyperbilirubinemia.

Rh incompatibility, ABO incompatibility, prematurity, sepsis, preinatal asphyxia

Write one nursing diagnosis generated from the data pertinent to hyperilirubinemia.

Risk for injury r/t predisposition of bilirubin for fat cells in brain.

Three days postpartum, a lactating mother has full, warm, taut, tender breasts. What nursing actions should be taken?

She is engorged; have newborn suckle frequently Take measures to increase milk flow like warm water, breast massage, and a supportive bra.

Name the 3 most common complications of amniocentesis.

Spontaneous abortion, fetal injury, infection

What are some signs of endometritis?

Subinvolution (boggy, high uterus), lochia returning to rubra with possible foul smell, temperature 100.4 or higher, ususual fundal measurement

What is the major side effect of beta-adrenergic tocolytic drugs (Terbutaline)?

Tachycardia

List the symptoms of cardiac decompensation in a laboring client with cardiac disease.

Tachycardia, tachypnea, dry cough, rales in lung bases, dyspnea, and orthopnea

State 5 symptoms of respiratory distress in the newborn.

Tachypnea, dusky color, flaring nares, retractions, and grunting

A woman has decided to take birth control pills as her contraceptive method. What should she do if she misses taking the pill for 2 consecutive days?

Take 2 pills for 2 days and use an alternative form of birth control.

Normal newborn temperature is _____. Normal newborn HR is _____. Normal newborn respiratory rate is _____. Normal newborn BP is _____.

Temp 97.7-99.4 HR 110-160 R 30-60 BP 80/50

Upon admission to the postpartum room, 3 hours after delivery, a client has a temperature of 99.5 F. What nursing actions are indicated?

Temp is probably elevated due to dehydration and work of labor. Force fluids and retake temperature in an hour. Notify physician if it is above 100.4.

What is the most common complication of oxytocin augmentation or induction of labor? List 3 actions the nurse should take if this occurs?

Tetany, Turn off Pitocin, Turn pregnancy woman onto side, Administer O2 by mask.

How is the 4th stage of labor defined?

The first 1-4 hours after delivery of placenta

What are the dangers of the nipple-stimulation stress test?

The inability to control oxytocin "dosage" and the change of tetany/hyperstimulation

When suctioning the newborn with a bulb syringe, which should be suctioned first, the mouth or the nose?

The mouth; stimulating the nares can initiate inspiration, which could cause aspiration of mucus in oral pharynx.

Why does the newborn need vitamin K in the first hour after birth?

The sterile gut at delivery lacks intestinal bacteria necessary for the synthesis of Vit K. It is needed in the clotting cascade to prevent hemorrhagic disorders.

Define cervical effacement.

The taking up of the lower cervical segment into the upper segment; the shortening of the cervix expressed in percentages from 0-100%, or complete effacement

A new mother asks the nurse whether circumcision is medically indicated for the newborn. How should the nurse respond?

There is controversy concerning this issue. But we do know that is causes pain and trauma to the newborn, and the medical indications (prevention of penile and cervical canver) may be unfounded.

What should be the fundal height be at 3 days postpartum for a woman who has had a vaginal delivery?

Three fingerlengths/cm below the umbilicus

Where is the FHR best heard?

Through the fetal back in vertex, OA positions

Why are serum or amniotic AFP levels done prenatally?

To determine whether AFP levels are elevated, which may indicate the presence of neural tube defects; or whether they are low, which may indicate Trisomy 21

What is the purpose of eye prophylaxis in the newborn?

To prevent ophalmia neonatorum, which results from exposure to gonorrhea in the vagina (pretty sure chlaymidia too)

What is the purpose of giving docusate sodium (Colace) to the postpartum client?

To soften the stool in mothers with 3rd-4th degree episiotomies, hemorrhoids, or c-section delivery.

State three principles relative to the pattern of weight gain in pregnancy.

Total gain should be 25-35 lbs. Gain should be consistent through pregnancy 1 lb/week should be gained in the 2nd and 3rd trimesters

How is true labor differentiated from false labor?

True labor: regular, rhythmic contractions that intensify with ambulation, pain in the abdomen sweeping around from the back, and cervical changes

State 3 actions the nurse should take when hypotension occurs in a laboring client.

Turn client of left side Administer O2 by mask at 10 L/min Increase speed of IV infusion (if it doesn't contain medication)

List the factors predisposing a woman to preterm labor.

UTIs Overdistention of uterus Diabetes Preeclampsia Cardiac Disease Placenta previa Psychosocial factors (stress)

A woman asks why she is urinating so much in the postpartum period. The nurse bases the response on what information?

Up to 3000 mL per day can be voided because of the reduction in the 40% plasma volume increase during pregnancy

When should a laboring client be examined vaginally?

Vaginal exams should be done prior to analgesia and anesthesia to rule out cord prolapse, to determine labor progress if it's questioned, and to determine when pushing can begin.

What is the cause of preeclampsia?

We have NO idea!!!

Identify the nursing plans and interventions for a woman hospitalized with hyperemesis gravidarum.

Weigh daily; check urine ketone 3 times daily; give progressive diet; check FHR every 8 hours; monitor for electrolyte imbalances.

When is it dangerous to administer butorphanol (Stadol), an agoinsit/antagonist narcotic?

When the client is undiagnosed drug abuser of narcotics, it can cause immediate withdrawal symptoms.

When should the nurse hold the dose of MgSO4 and call the physician?

When the client's respirations are <12/min, DTRs are absent, or Urinary Output is <100 mL/4hr

What nursing interventions are used to enhance maternal-infant bonding during the 4th stage of labor?

Withhold eye prophylaxis for up to 1 hour. Perform newborn admission and routine procedures in room with parents. Encourage early initiation of breastfeeding. Darken room to encourage newborn to open eyes.

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?

Yellowish tinge to the skin.

A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited? a. Choking, coughing, and cyanosis. b. Projectile vomiting and cyanosis. c. Apneic spells and grunting. d. organomegaly.

a. Choking, coughing, and cyanosis.

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? a. Describe diet changes that can improve the management of her diabetes. b.Inform the client that oral hypoglycemic agents are teratogenic during pregnancy. c. Demonstrate self-administration of insulin. d. Evaluate the client's ability to do glucose monitoring.

a. Describe diet changes that can improve the management of her diabetes.

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? a.Biophysical profile (BPP). t b.Ultrasound for fetal anomalies. c.Maternal serum alpha-fetoprotein (AF) screening d.Percutaneous umbilical blood sampling (PUBS).

a.Biophysical profile (BPP).

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.) a.Mood swings. b.Panic attacks. c.Tearfulness d.Decreased need for sleep. e. Disinterest in the infant

a.Mood swings. c.Tearfulness

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) is a.November 22. b.November 8. c.December 22. d.October 22.

a.November 22.

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

a.Transition labor with contractions every 2 minutes, lasting 90 seconds each.

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? a.Yellowish tinge to the skin. b. Babinski reflex present bilaterally. c.Pink papular rash on the face. d.Moro reflex noted after a loud noise.

a.Yellowish tinge to the skin.

hich maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? a. She eagerly reaches for the infant, undresses the infant, and examines the infant completely. b. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. c. Her arms and hands receive the infant and she then cuddles the infant to her own body. She eagerly reaches for the infant and then holds the infant close to her own body.

b. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.

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? a.Males inherit the disorder with a greater frequency than females. b.Each pregnancy carries a 50% chance of inheriting the disorder. c.The disorder occurs in 25% of pregnancies. d.All children will be carriers of the disorder.

b.Each pregnancy carries a 50% chance of inheriting the disorder.

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? a.Dehydration. b.Hyperstimulation. c. Galactorrhea. d.Fetal tachycardia.

b.Hyperstimulation.

tells the nurse that she want to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client? a.Your current dose of Insulin should be maintained throughout your pregnancy. b.Maintain blood sugar levels in a constant range within normal limits during pregnancy. c.The course and outcome of your pregnancy is not an achievable goal with diabetes. d.Expect an increase in insulin dosages by 5 units/week during the first trimester.

b.Maintain blood sugar levels in a constant range within normal limits during pregnancy.

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take? a.Ask the mother why she won't look at the infant. b.Observe the mother for other attachment behaviors. c.Examine the newborn's eyes for the ability to focus. d.Recognize this as a common reaction in new mothers.

b.Observe the mother for other attachment behaviors.

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period is a.January 14-15. b.January 22-23. c.January 30-31. d.February 6-7.

c. January 30-31.

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling finger and dizziness. What action should the nurse take? a. administer o2 by face mask b. notify the HCP for the client's syndrome c. have the client breathe into her cupped hands d. check the client's BP and fetal HR/

c. have the client breathe into her cupped hands.

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? a.Notify the healthcare provider. b.Move the newborn to an isolation nursery. c.Document the finding in the infant's record. d.Obtain a culture of the vesicles.

c.Document the finding in the infant's record.

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? a.Herpes. b.Staphylococcus c.Gonorrhea. d. Syphilis.

c.Gonorrhea.

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? a.Heart rate of 100 beats/minute. b.Variable fetal heart rate. c.Onset of uterine contractions. d.Burning on urination.

c.Onset of uterine contractions.

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 pads are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next? a.Cleanse the perineum. b.Obtain a blood pressure. c.Palpate the firmness of the fundus d. Inspect the perineum for lacerations.

c.Palpate the firmness of the fundus

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

c.Places the infant prone in the bassinet.

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? a.Refer the client to a social worker to arrange for home care. b.Recommend perinatal care from an obstetrician, not a nurse-midwife. c.Teach the client why keeping prenatal care appointments is important. d.Advise the client that neonatal intensive care may be needed.

c.Teach the client why keeping prenatal care appointments is important.

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? a.Cervical dilation of 5 cm with 90% effacement. b.White blood cell count of 12,000/mm3. c.Hemoglobin of 12 mg/dl and hematocrit of 38%. d.A platelet count of 67,000/mm3.

d.A platelet count of 67,000/mm3.

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

d.Central cyanosis when crying.

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

d.Check the firmness of the uterus every 15 minutes.

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

d.Encourage healthy lifestyles for families desiring 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? a.Herbs are a cornerstone of good health to include in your treatment. b.Touch is also therapeutic in relieving discomfort and anxiety. c.Your healthcare provider should direct treatment options for herbal therapy. d.It is important that you want to take part in your care.

d.It is important that you want to take part in your care.

A 30-year-old multiparous woman who has a 3-year-old boy and an 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? a.Tell the older child that he is a big boy now and should love his new sister. b.Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him. c.Let the older child stay with his grandparents for the first six weeks to allow him to adjust to the newborn. d.Regression in behaviors in the older child is a typical reaction so he needs attention at this time.

d.Regression in behaviors in the older child is a typical reaction so he needs attention at this time.

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? a.August 1. b.August 10. c.September 3. d.September 8.

d.September 8.

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? a.The infant should be positioned to reduce the swelling. b.The swelling is a subperiosteal collection of blood. c.The pediatrician will aspirate the blood if it gets larger. d.The scalp edema will subside in a few days after birth.

d.The scalp edema will subside in a few days after birth.

The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?

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 (B), crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take?

Observe the mother for other attachment behaviors.

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?

Obtain a specimen for urine analysis. Obtaining a urine analysis (C) should be done first because preterm clients with uterine irritability and contractions are often suffering from a urinary tract infection, and this 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. A.heart rate of 100 beats min B. variable fetal HR C. Onset of uterine contractions D. Burning on urination

Onset of uterine contractions.

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?

Onset of uterine contractions.

The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is recommended for which purpose?

Screen for neural tube defects.

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?

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 (A).

During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Arrange in order.)

Reposition the client. Provide oxygen via face mask. Increase IV fluid. Call the healthcare provider.

The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?

A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged. When the presenting part is ballottable (D), 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.

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.)

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.

A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?

A decrease in respiratory rate from 24 to 16. Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory rate (C) indicates that the drug is effective. (Respiratory rate below 12 indicates toxic effects.)

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 best? A. home pregnancy test can be used right after your first missed period. B.These tests are most accurate after you have missed your second period. C. Home pregnancy tests often give false positives and should not be trusted. D . The test can provide accurate information when used right after ovulation.

A. A home pregnancy test can be used right after your first missed period.

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 HR of 80 beats/minute and respirations of 20 breaths/min. What action should be performed next? A. Initiate positive pressure ventilation B . Intervene after one min Apgar is assessed. C. Initiate CPR on the infant D. Assess the infant's blood glucose level

A. Initiate positive pressure ventilation

Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?" A. Using relaxation breathing techniques B. Using a breast pump. C. Massaging the abdomen. Incorrect D. Giving oxytocic medications.

A. Using relaxation breathing techniques

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

A.Bathe the infant with an antimicrobial soap.

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

A.two weeks before menstruation.

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? A.At 16-weeks gestation. B.At 20-weeks gestation. C.At 24-weeks gestation. D.At 30-weeks gestation.

D.At 30-weeks gestation.

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?

Apply cold compresses to both breasts for comfort. The client is experiencing engorgement even though she is bottle-feeding her infant, and cold compresses (A) may help reduce discomfort. Lactation begins about the third day after delivery, so the mother should avoid any breast stimulation,

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?

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

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?

At 30-weeks gestation is closest to the time parents would be ready for such classes. 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.

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? A. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part. B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor. C.Urine specimens for glucose and protein must be obtained at certain intervals throughout labor. D. Frequent voiding minimizes the need for catheterization which increases the chance of bladder infection.

B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor.

A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse implement? A. Massage the calf and foot. B. Extend the leg and dorsiflex the foot C. Lower the leg off the side of the bed. D. Elevate the leg above the heart.

B. Extend the leg and dorsiflex the foot

28 year old client in active labor complains of cramps in her leg.What intervention should the nurse implement. A. massage the calf and foot B. extend the leg and dorsiflex the foot C. lower the leg off the side of the bed D. elevate the leg above the heart.

B. Extend the leg and dorsiflex the foot.

A client with gestational htn is an active labor and receiving an infusion of magnesium sulfate. Which drug should the nurse available for signs of potential toxicity? A. oxytocin B. calcium gluconate C. terbutaline D. naloxone 9

B. calcium gluconate

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

B.Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day.

The nurse should explain to a 30 year old gravid client that alpha fetoprotein testing is recommended for which purpose? A.detect cardiovascular disorders B.screen for neural tube defects c .monitor the placental functioning d. assess for maternal pre-eclampsia

B.screen for neural tube defects

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?

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. Therefore, intercourse between the time of the temperature fall and rise (A) is the best time for conception.

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?

Biophysical profile (BPP). BPP (A) provides data regarding fetal risk surveillance by examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate.

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? A.Wear support stockings. B. Reduce salt in her diet. C. Move about every hour. D. Avoid constrictive clothing.

C. Move about every hour.

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. The nurse plans to monitor for which primary side effect of terbutaline sulfate? A. Drowsiness and bradycardia. B. Depressed reflexes and increased respirations. C. Tachycardia and a feeling of nervousness. D. A flushed, warm feeling and a dry mouth

C. Tachycardia and a feeling of nervousness.

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? A.This is not an unusual shaped head, especially for a first baby. B.It may look funny to you, but newborn babies are often born with heads like your baby's. C. That is normal; the head will return to a round shape within 7 to 10 days. D.Your pelvis was too small, so the baby's head had to adjust to the birth canal.

C. That is normal; the head will return to a round shape within 7 to 10 days.

A 4 week old premature infant has been receiving epoetin alfa for the last 3 weeks. WHich assessment finding indicates to the nurse that the drug is effective. A.slowly increasing urinary output over the last week B.rr changes from 40s to the 60s C. changes in apical HR from the 180 to the 140 D.Change in indirect bilirubin from 12mg/dl to 8mg/dl.

C. changes in apica HR from the 180 to the 140

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

C.Correctly place the infant on the breast.

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?A. Check the hematocrit results. B. Administer pain medication. C.Increase the rate of IV fluids. D.Monitor client for contractions.

C.Increase the rate of IV fluids.

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

C.Vernix is a white, cheesy substance, predominantly located in the skin folds.

The nurse should encourage the laboring client to begin pushing when A.there is only an anterior or posterior lip of cervix left. B.the client describes the need to have a bowel movement. C.the cervix is completely dilated. D.the cervix is completely effaced.

C.the cervix is completely dilated.

What action should the nurse implement to decrease the client's risk for hemorrhage after a cesarean section?

Check the firmness of the uterus every 15 minutes.

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?

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).

A multigravida client arrives at the labor and delivery unit and tells 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?

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

When assessing a client who is at 12 week 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? A. at 16 weeks gestation B.at 20 weeks gestation C. at 24 weeks gestation D. at 30 weeks gestation

D. At 30 weeks gestation.

What action should the nurse implement to decrease the client's risk for hemorrhage after c-section. A. Monitor urinary output via an indwelling catheter. B. assess the abdominal dressings for drainage. C. Give the Ringer's lactated infusion at 125ml D. Check the firmness of the uterus every 15mins.

D. Check the firmness of the uterus every 15mins.

After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil® Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac® Soy Isomil® Formula, a soy protein isolate based infant formula. What information should the nurse provide to the mother about the newly prescribed formula? A.The new formula is a coconut milk formula used with babies with impaired fat absorption. B.Enfamil® Formula is a demineralized whey formula that is needed with diarrhea. C. The new formula is a casein protein source that is low in phenylalanine. D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.

D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.

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

D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month

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 A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week. B.anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week. C.anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.

D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.

A 40 week gestation primigravida client is being induced with an ocytocin secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement? A. Discontinue the oxytocin infusion B. place the client in a semi-fowler's position C. inform the healthcare provider D. apply firm pressure to sacral area

D. apply firm pressure to sacral area

Which assessment finding should the nursery nurse report to the pediatric healthcare provider? A. blood glucose level of 45mg/dl B. blood pressure of 82/45 mmHG C. Non bulging anterior fontanel D. central cyanosis when crying

D. central cyanosis when crying

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? A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse. B.Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed. C. 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. D.Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

D.Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

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? A. Encourage the mother to provide total care for her infant. B. Provide privacy so the mother can develop a relationship with the infant. C. Encourage the father to provide most of the infant's care during hospitalization. D.Meet the mother's physical needs and demonstrate warmth toward the infant.

D.Meet the mother's physical needs and demonstrate warmth toward the infant.

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.)

Dark, red vaginal bleeding. Increased uterine irritability. A rigid abdomen.

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?

Date of last normal menstrual period. Evaluating the gestation of the pregnancy (C) takes priority. If the fetus is preterm and the fetal heart pattern is reassuring, the healthcare provider may attempt to prolong the pregnancy and administer 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?

Describe diet changes that can improve the management of her diabetes. Diet modifications (A) 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 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?

Do you have a history of rheumatic fever? Clients with a history of rheumatic fever (D) may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the increased blood volume that occurs during pregnancy, so obtaining information about this client's health history is a priority.

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?

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 (C).

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?

Grief related to her perceptions about the loss of this child.

The nurse is planning preconception care for a new female client. Which information should the nurse provide the client?

Encourage healthy lifestyles for families desiring pregnancy. Planning for pregnancy begins with healthy lifestyles in the family (D) which is an intervention in preconception care that targets an overall goal for a client preparing for 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?

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 (C)

A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?

Epigastric pain (C) is indicative of an edematous liver or pancreas which is an early warning sign of an impending convulsion (eclampsia) and requires immediate attention.

A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse implement?

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.

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?

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 hands (C)

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?

Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.

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 postprocedure complaint indicates that the fallopian tubes are patent?

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

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?

Increase IV rate. 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 hemorrage and hypovolemic shock. Increasing the IV infusion rate (C) 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?

Initiate positive pressure ventilation. The nurse should immediately begin positive pressure ventilation (A) 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.) Waiting until the infant is 1 minute old to intervene may worsen the infant's condition. According to neonatal resuscitation guidelines, CPR is not begun until the heart rate is 60 or below or between 60 and 80 and not increasing after 20 to 30 seconds of PPV.

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?

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 (B) so iron supplements are often recommended.

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?

It is important that you want to take part in your care.

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period is

January 30-31

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?

Monitor bleeding from IV sites. Monitoring bleeding from peripheral sites (C) 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.

During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have A. lower Apgar scores. B. lower birth weights. C. respiratory distress. D. a higher rate of congenital anomalies.

Move about every hour.

Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?"

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

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?

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 (D).

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 × 1. What action should the nurse take immediately?

Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription (D).

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 pads are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next?

Palpate the firmness of the fundus.

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?

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

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?

Provide assistance to the mother to begin breastfeeding as soon as possible 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?

Put the newborn to breast. Putting the newborn to breast (D) will help contract the uterus and prevent a postpartum hemorrhage--this intervention has the highest priority.

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?

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 (A) will increase venous return and provide blood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrose solution and ensuring that the client is in a lateral position are also appropriate interventions.

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?

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

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?

There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair.

A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions?

Transition labor with contractions every 2 minutes, lasting 90 seconds each.

A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?

Urine output 90 ml/4 hours. Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation should the nurse provide?

Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day. The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day) (B), if the infant is adequately hydrated.

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

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 (D).