PrepU Test 5

How should a nurse assess a neonate's rooting reflex?

Stroke the neonate's cheek.

On the second postpartum day after a cesarean birth, the client reports having gas pains. What should the nurse should instruct the client to do?

Ambulate more often.

A male neonate underwent circumcision. What nursing intervention is part of the initial care of a circumcised neonate?

Apply petroleum gauze to the site for 24 hours.

The nurse is caring for a primigravida who gave birth to a viable neonate 2 hours ago under epidural anesthesia. The new mother has a midline episiotomy. Which finding by the nurse would warrant further assessment?

two perineal pads soaked with blood within 30 minutes

A nurse is conducting an assessment of a neonate born 3 hours ago. Which finding makes the nurse suspect a congenital hip dislocation?

unequal gluteal folds

A woman has been diagnosed as having gestational hypertension. Which symptom for this condition is the most typical?

blood pressure elevation

The nurse is assessing a neonate born to a mother with type 1 diabetes. Which finding is expected?

large size

A woman having contractions comes to the emergency department. She tells the nurse that she is at 34 weeks' gestation. The nurse examines her and finds that she is already effaced and dilated 2 cm. What is this woman demonstrating?

preterm labor

The nurse is caring for a client after experiencing a placental abruption (abruptio placentae). Which finding is the priority to report to the health care provider?

45 ml urine output in 2 hours

A multiparous client who has a neonate diagnosed with hemolytic disease of the newborn asks the nurse why the neonate has developed this problem. Which response by the nurse would be most appropriate?

"You are Rh-negative and the baby is Rh-positive."

A nurse has been assigned to assess a pregnant client for placental abruption (abruptio placentae). For which classic manifestation of this condition should the nurse assess?

"knife-like" abdominal pain with vaginal bleeding

The nurse is assessing a client who is 4 hours postpartum. Based on the findings documented by the nurse, which action is most appropriate at this time?

Ask the client to empty her bladder.

While assessing a 2-hour-old neonate, a nurse observes that the neonate has acrocyanosis. Which nursing action should the nurse perform at this time?

Do nothing- acrocyanosis is normal in the neonate.

While preparing to provide neonatal care instructions to a primiparous client who gave birth to a term neonate 24 hours ago, what should the nurse include in the client's teaching plan?

Milia are white papule from plugged sebaceous ducts that disappear by age 2 to 4 weeks.

A multiparous client at 24 hours postpartum is found to have a swelling and pain in her right leg. She demonstrates a positive Homan sign with discomfort. What should the nurse do next?

Notify the client's health care provider (HCP) immediately.

Which measure included in the care plan for a client in the fourth stage of labor requires revision?

Obtain an order for cauterization to protect the bladder from trauma.

A high-risk pregnant client is determined to have gestational hypertension. The nurse suspects that the client has developed preeclampsia with severe features based on which finding?

blurred vision

On the first postpartum day after a cesarean birth, the client is prescribed a full liquid diet as tolerated. Before providing a full liquid breakfast, the nurse should assess which factor?

bowel sounds

Which finding would the nurse expect as common for a multiparous client giving birth to a viable neonate at 41 weeks' gestation with the aid of a vacuum extractor?

caput succedaneum

A 16-year-old client has been in the active phase of labor for 14 hours. An ultrasound reveals that the likely cause of delay in dilation (dilatation) is cephalopelvic disproportion. Which intervention should the nurse most expect in this case?

cesarean birth

A 3-day-old neonate is receiving phototherapy with an overhead bilirubin light to treat jaundice. What measure should the nurse include in the plan of care?

check the vital signs every 2 to 4 hours.

The nurse is required to assess a client for HELLP syndrome. Which are the signs and symptoms of this condition? Select all that apply.

epigastric pain upper right quadrant pain hyperbilirubinemia

What should the nurse expect to find in a premature female neonate born at 30 weeks' gestation who is small for gestational age?

fine, downy hair over the upper arms and back

A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation?

fundus two finger breadths above the umbilicus

A client has come to the office for a prenatal visit during her 24th week of gestation. On examination, it is noted that her blood pressure has increased to 146/94 mm Hg. Her urine is negative for proteinuria. Blood pressure assessment at 20 weeks' gestation was 142/92 mm Hg and urine was negative for protein. Blood pressure readings at previous visits ranged from 120/76 mm Hg to 126/80 mm Hg. The nurse suspects which condition?

gestational hypertension

A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements?

gestational hypertension

What site should the nurse use to obtain a blood sample to screen a neonate for phenylketonuria (PKU)?

heel

A client in her 20th week of gestation develops HELLP syndrome. What are features of HELLP syndrome? Select all that apply.

hemolysis elevated liver enzymes low platelet count

In the fourth stage of labor, a full bladder increases the risk of what postpartum complication?

hemorrhage

The health care provider (HCP) prescribes an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which problem?

hemorrhage

The nurse should be especially alert for what problem when caring for a term neonate, who weighed 10 lb (4,500 g) at birth, 1 hour after a vaginal birth?

hypoglycemia

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The health care provider (HCP) is notified because the nurse suspects which complication?

hypospadias

After teaching a mother about the neonate's positive Babinski's reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski's reflex indicates which factor?

immaturity of the central nervous system

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings contradicts the estimated gestational age of the newborn?

increased amounts of vernix

When preparing to obtain a neonatal screening test for phenylketonuria (PKU), the nurse understands that the neonate must have been fed what to ensure reliable results?

initial formula or breast milk at least 24 hours before the test

A nurse completes postpartum assessments on every shift. Which parameters should the nurse include in the assessment? Select all that apply.

lochia bowel sounds fundus bladder

A nurse assesses a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown above). Which terms best identifies the discharge?

lochia rubra

A multigravid client in active labor at 39 weeks' gestation has a history of smoking one to two packs of cigarettes daily. Which problem is the nurse most likely to find during the infant's assessment?

low birth weight

What would be the physiologic basis for a placenta previa?

low placental implantation

What terminology would the nurse use to document a newborn who weighs 4,000 grams (8.8 lb) or more at birth?

macrosomia

A nursing student working with a client in preterm labor correctly identifies which medication as being used to relax the smooth muscles of the uterus and for seizure prophylaxis and treatment in clients with preeclampsia?

magnesium sulfate

A primary care provider prescribes intravenous tocolytic therapy for a woman in preterm labor. Which agent would the nurse expect to administer?

magnesium sulfate

On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which nursing intervention takes highest priority?

massaging the uterus gently

After giving birth to a viable term male neonate vaginally under epidural anesthesia, a primiparous client asks the nurse, "Why are my baby's breasts so swollen?" The nurse responds to the client stating that slight breast engorgement in term neonates is due to which factor?

maternal hormonal influences

During a routine prenatal visit, a client is found to have proteinuria and a blood pressure rise to 140/90 mm Hg. The nurse recognizes that the client has which condition?

mild preeclampsia

A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress?

nasal flaring

As part of the respiratory assessment, a nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because

neonates are obligate nose breathers.

When a woman in labor has reached 8 cm dilation, the nurse notices the fetal heat rate suddenly slows. On perineal inspection, the nurse observes the fetal cord has prolapsed. The nurse's first action would be to:

place her in a knee-chest position.

The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss?

placental abruption

A nurse is performing a neurologic assessment on a neonate. Which assessment finding would be normal for a neonate?

positive Babinksi's reflex

On the second postpartum day, a client tells the nurse she feels anxious and tearful. Which assessment finding is most consistent with the client's statement?

postpartum "blues"

A client at 4 weeks postpartum tells the nurse that she cannot cope any longer and is overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she does not want to care for the infant. The nurse should encourage the client and her husband to call their health care provider (HCP) because the mother should be evaluated further for which complication?

postpartum depression

The nurse makes a home visit to a primigravid client on the fourth postpartum day after birth of a term neonate. When the nurse enters the house, the nurse finds the client sitting in a chair, crying inconsolably, while the neonate is crying in another room. The client tells the nurse that she has not been sleeping well and has been hearing voices. The nurse determines that the client is most likely experiencing which condition?

postpartum psychosis

A woman in labor has sharp fundal pain accompanied by slight vaginal bleeding. What would be the most likely cause of these symptoms?

premature separation of the placenta

After birth, a direct Coombs test is performed on the umbilical cord blood of a neonate with Rh-positive blood born to a mother with Rh-negative blood. The nurse explains to the client that this test is done to detect which information?

presence of maternal antibodies

A client presents to the emergency department reporting regular uterine contractions. Examination reveals that her cervix is beginning to efface. The client is in her 36th week of gestation. The nurse interprets the findings as suggesting which condition is occurring?

preterm labor

A multiparous client, 28 hours after cesarean birth, who is breastfeeding has severe cramps or afterpains. The nurse explains that these are caused by which factor?

release of oxytocin during the breastfeeding session

A woman who has given birth to a healthy neonate is being discharged. As part of discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the health care provider (HCP) for which finding?

saturating a pad in less than an hour

A woman in labor is at risk for abruptio placentae. Which assessment would most likely lead the nurse to suspect that this has happened?

sharp fundal pain and discomfort between contractions

A breastfeeding primiparous client who gave birth 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which guideline should the nurse include in the teaching plan as evidence of adequate intake?

six to eight wet diapers by the fifth day

Which assessment finding should a nurse interpret as abnormal for a 38-week gestation neonate who is 1 hour old?

slight yellowish hue to the skin

Twenty-four hours after a client has given birth, the nurse documents that involution is progressing normally after palpating the client's fundus at which location?

slightly below the level of the umbilicus

Which observation is expected when the nurse is assessing the gestational age of a neonate born at term?

sole creases covering the entire foot

A mother is instructed to stimulate the rooting reflex when attempting to breast-feed her baby. Which action shows that the mother understands these instructions?

stroking the neonate's cheek

A client gave birth to a healthy full-term girl 2 hours ago by cesarean birth. When assessing this client which finding requires immediate nursing action?

tachycardia and hypotension

The nurse is caring for a multigravida woman who is 1 day postpartum following a vaginal birth. Which finding indicates a need for further assessment?

temperature of 100.8*F (38.2*C)

A client is concerned that her 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if:

the neonate latches onto the areola and swallows audibly.

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation?

thin, wasted appearance

When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assess for which complication?

urinary retention

A nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care?

using a peri bottle to clean the perineum after each voiding or bowel movement

During the first hour after a precipitous birth, the nurse should monitor a multiparous client for signs and symptoms of which complication?

uterine atony

A woman in active labor with a history of two previous cesarean births is being monitored frequently as she tries to have a vaginal birth. Suddenly, the woman grabs the nurse's hand and states, "Something inside me is tearing." The nurse notes her blood pressure is 80/50 mm Hg, pulse rate is 130 bpm and weak, the skin is cool and clammy, and the fetal monitor shows bradycardia. The nurse activates the code team because the nurse suspects the client may be experiencing which complication?

uterine rupture

While the nurse is conducting a teaching session on breast-feeding, a client asks why she should put her newborn to the breast within the first 30 minutes of birth. The nurse's best response will be

"The neonate will be responsive and eager to suck at this time."

According to the antenatal record, a newborn is 12 days post-mature. A nurse completes the initial assessment of the newborn and notes increased amounts of vernix. The mother asks why the nurse seems concerned about the presence of the vernix. Which of the following statements by the nurse is most appropriate?

"The vernix indicates a different gestational age than expected."

The nurse is preparing to administer vitamin K intramuscularly to a term neonate of a primipara who has just given birth. After explaining the purpose of the drug to the mother, which statement by the mother indicates effective teaching?

"Vitamin K will help my baby's blood to clot properly."

A postpartum client gave birth 6 hours ago without anesthesia and just voided 100 ml. The nurse palpates the fundus two fingerbreadths above the umbilicus and off to the right side. What should the nurse do first?

Catheterize the client.

A woman with a positive history of genital herpes is in active labor. Assessment reveals vesicles in the perineum area, membranes are ruptured, dilated 5 cm, and effaced 70%. The nurse should prepare the client for which type of birth?

Cesarean

A nurse places a neonate with hyperbilirubinemia under a phototherapy lamp, covering the eyes and gonads for protection. The parents asked the nurse to tell them how their baby will benefit from having phototherapy done. Which statement by the nurse is the most appropriate response about phototherapy?

"Phototherapy decreases the serum unconjugated bilirubin level."

A nurse is caring for a woman who gave birth to her baby boy 2 hours ago. The nurse notes the woman's perineal pad contains some small clots and a moderate amount of lochia has accumulated under her buttocks. What is the first action the nurse should take at this time?

Check fundus for position and consistency.

The nurse is assessing a newborn (view the figure). What should the nurse expect the infant to do?

Close the fingers around the nurse's hands.

After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between abruptio placentae and placenta previa. Which statement should the nurse include in the teaching?

"Placenta previa causes painless, bright red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the cervix; abruptio placentae is associated with dark red painful bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor."

The triage nurse in the pediatrician's office returns a call to a mother who is breastfeeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse?

"Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding."

While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which response would be most appropriate?

"Sometime baby girls have this from hormones received from the mother."

On examination of an African newborn, the nurse notes a macular, blue-black area of pigmentation near the buttocks. Which of the following actions of the nurse is appropriate?

Consider the finding as normal in Africans.

The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 g (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 3,572 g (7 lb, 14 oz). Which instruction should the nurse give to the mother?

Continue feeding every 3 to 4 hours since the weight loss is normal.

Which action is most appropriate when noting small, shiny white specks on the neonate's gums and hard palate during assessment?

Continue monitoring because these spots are normal.

While caring for a multiparous client 4 hours after vaginal birth of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/min. Her fundus is firm, midline, and at the level of the umbilicus. What should the nurse do?

Continue to monitor the client's vital signs.

Which practice should a nurse recommend to a client who has had a cesarean birth?

Coughing and deep-breathing exercises

During the immediate postpartum period after giving birth to twins, the client experiences uterine atony. What should the nurse do first?

Gently massage the fundus.

A nurse is assessing a neonate born 1 day ago to a client who smoked one pack of cigarettes daily during pregnancy. Which finding is most common in neonates whose mothers smoked during pregnancy?

Small size for gestational age

A new primiparous client asks the nurse, "Can my baby see?" Which statement about neonatal vision should the nurse include in the explanation?

They can see objects up to 12 inches (30.5 cm) away.

The student nurse correctly anticipates which lochial findings in a client within the first 24 hours after birth?

Vaginal discharge consists of bright red blood.

During the admission assessment of a female neonate, a nurse notes a large lump on the neonate's head. Concerned about making the correct assessment, the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that

a cephalohematoma doesn't cross the suture lines.

A nurse is assessing pregnant clients for the risk of placenta previa. Which client faces the greatest risk for this condition?

a client who had a myomectomy to remove fibroids

A nurse visits a client at home on the 10th postpartum day. When assessing the client's uterus, which finding requires further evaluation?

a fundus palpable at the umbilicus

The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which client should the nurse assess first?

a primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally

A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission?

assessing fetal heart tones by use of external monitor

A postpartum mother has the following lab data recorded: a negative rubella titer. What is the appropriate nursing intervention?

Administer rubella vaccine before discharge.

Which instructions should the nurse give to a client after noting a white, cheese-like substance on the neonate's body creases?

Allow it to remain on the skin.

A client has been admitted to the hospital with a diagnosis of severe preeclampsia. Which nursing intervention is the priority?

Confine the client to bed rest in a darkened room.

The nurse notes that a neonate's Apgar score at 5 minutes was 9. The nurse interprets this as indicating which information about the neonate?

The neonate was in stable condition.

Which finding requires further intervention in a mother who's breast-feeding?

The neonate's lips smack.

A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible asphyxia in utero? Select all that apply.

The neonate's toes do not fan out when soles of the feet are stroked. The neonate doesn't respond when the nurse claps her hands above him. The neonate displays weak, ineffective sucking.

A woman who is Rh negative has given birth to an Rh-positive infant. The nurse explains to the client that she will receive Rho(D) immune globulin. The nurse determines that the client understands the purpose of the treatment when she reports that Rho(D) immune globulin has which action?

preventing antibody formation in her blood

The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be

red and moderate.

A nurse is providing discharge teaching to a postpartum client. Which instruction is the priority to include in the teaching?

"If you have excessive vaginal bleeding, massage your fundus and call the physician."

A nurse is teaching the parents of a newborn about the timing of fontanel closure. The nurse explains that the anterior fontanel closes by age 18 months. Indicate on the illustration (view figure) the location of the anterior fontanel.

Between frontal and parietal bones

When the nurse accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which reflex?

Moro reflex

A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?

Premature separation of the placenta

A nurse is assessing a client on the second postpartum day. Upon palpation, the nurse discovers that the fundus is deviated to the right. To further investigate this finding, what should the nurse ask the client?

"Have you voided recently?"

A postpartum client tells the nurse she is constipated. Which response by the nurse is best?

"Add more fruits, vegetables and fluid to each meal"

After explaining to a primiparous client about the causes of her neonate's cranial molding, which statement by the mother indicates the need for further instruction?

"Brain damage may occur if the molding does not resolve quickly."

A primiparous client planning to breastfeed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth, breasts begin to produce milk within what time period?

2 to 4 days

A nurse is teaching a postpartum client who has decided to breast-feed her neonate. She has questions regarding her nutritional intake and wants to know how many extra calories she should eat. What number of additional calories should the nurse instruct the client to eat per day? Record your answer using a whole number.

500

A primiparous client who underwent a cesarean birth 30 minutes ago is to receive Rho(D) immune globulin. The nurse should administer the medication within which time frame after birth?

72 hours

A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize?

A dipstick value of 2+ for protein

A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client?

Assess fetal heart sounds.

A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take?

Assess the fundus and massage it if it's boggy.

Which postoperative intervention should a nurse perform when caring for a client who has undergone a cesarean birth?

Assess uterine tone to determine fundal firmness.

The nurse is assisting a client who has just undergone an amniocentesis. Blood results indicate the mother has type O blood and the fetus has type AB blood. The nurse should point out the mother and fetus are at an increased risk for which situation related to this procedure?

Baby developing post birth jaundice

The nurse is orientating in the Labor and Delivery unit and asks her preceptor how to differentiate a client with preeclampsia from one with eclampsia. Which symptoms would the preceptor describe to the new nurse as indicative of severe preeclampsia? Select all that apply.

Blood pressure above 160/110 mm Hg Nondependent edema Hyperactive deep tendon reflexes

While assisting a primiparous client with her first breastfeeding session, the nurse should instruct the mother to perform which action in order to stimulate the neonate to open the mouth and grasp the nipple?

Brush the neonate's lips lightly with the nipple.

The heart rate of a newly born neonate is regular at 142 bpm. What should the nurse do next?

Document this as a normal neonatal finding.

Twelve hours after a vaginal birth with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. What should the nurse do next?

Encourage the client to ambulate to the bathroom and void.

The nurse has assisted a multigravida with a precipitous birth of a term neonate. Because a precipitous birth can lead to decreased uterine tone, what nursing action should help to prevent this complication?

Encourage the mother to breast food the infant.

While a mother is feeding her full-term neonate 1 hour after birth, she asks the nurse, "What are these white dots in my baby's mouth? I tried to wash them out, but they're still there." After assessing the neonate's mouth, the nurse explains that these spots indicate which condition?

Epstein's pearls

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby?

Express a small amount of breast milk.

A pregnant woman has been admitted to the hospital due to preeclampsia with severe features. Which measure will be important for the nurse to include in the care plan?

Institute and maintain seizure precautions.

After a lengthy labor, a primigravid client gives birth to a healthy newborn boy with a moderate amount of skull molding. What information would the nurse include when explaining to the parents about this condition?

It usually lasts a day or two before resolving.

Which instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy?

Keep the neonate's eyes completely covered.

A nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Physiologic jaundice is caused by which characteristic?

Large, immature liver

The nurse is caring for a client suspected to have a uterine rupture. The nurse predicts the fetal monitor will exhibit which pattern if this is true?

Late decelerations

A primiparous client expresses concern, asking the nurse why her neonate's eyes are crossed. Which information would the nurse include when teaching the mother about neonatal strabismus?

Neonates commonly lack eye muscle coordination.

A nurse is eliciting reflexes in a neonate during a physical examination. Identify the area that the nurse would touch to elicit a plantar grasp reflex.

On toes of left foot

When assessing a client who gave birth 24 hours ago, the post partum nurse expects to find the top of the client's fundus at which anatomic location?

One finger breadth below the umbilicus

A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next?

Palpate the fundus and check fetal heart rate.

The nurse is caring for a client 24 hours postpartum from a normal, vaginal delivery, and identifies which assessment finding and requiring immediate intervention?

Patient reports pain and warmth behild left knee

During the initial assessment, the nurse notes that the neonate's hands and feet appear blue while the neonate's torso appears pale pink. What should the nurse do next?

Place the infant skin to skin with the mother.

The nurse plans care for a neonate to prevent neonatal heat loss immediately after birth. What action should the nurse take to conserve heat and help the infant maintain a stable temperature?

Place the infant skin to skin with the mother.

A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note, which postpartum complication has the client developed?

Postpartum hemorrhage.

When caring for a neonate, what is the most important step the nurse can take to prevent and control infection?

Practicing meticulous hand washing

The nurse is monitoring a client in labor who has had a previous cesarean section and is trying a vaginal birth with an epidural. The nurse observes a sudden drop in blood pressure, increased heart rate, and deep variable deceleration on the fetal monitor. The client reports severe pain in her abdomen and shoulder. What should the nurse prepare to do?

Prepare the client for a cesarean birth.

The nurse is admitting a client in labor. The care provider determines that the fetus is in a transverse lie and not responsive to Leopold maneuvers. What intervention should the nurse provide for the client?

Prepare the client for cesarean birth.

A client at 27 weeks' gestation is admitted to the obstetric unit after reporting headaches and edema of her hands. Review of the prenatal notes reveals blood pressure consistently above 136/90 mm Hg. The nurse anticipates the health care provider will prescribe magnesium sulfate to accomplish which primary goal?

Prevent maternal seizures

A G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something "came out" when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina?

Put her in bed immediately, call for help, and hold the presenting part of the cord.

A term neonate's mother is O-negative, and cord studies indicate that the neonate is A-positive. Which finding indicates that the neonate developed hemolytic disease?

Signs of kernicterus

A neonate born by elective cesarean birth weighs 7 lb, 3 oz. (3,267 g). The nurse places the neonate under the warmer unit. In addition to routine assessments, the nurse should closely monitor this neonate for which sign?

Respiratory distress caused by lack of contractions

When caring for a post partum client, the student nurse correctly recalls which expected progression of lochia?

Rubra, then serosa, then alba

A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which information would the nurse include when explaining to the client about the increased lochia on ambulation?

The increased lochia occurs from lochia pooling in the vaginal vault.

A nurse is performing a psychosocial assessment on a first-time mother and her neonate. Which behavior indicates a need for further evaluation?

The mother makes little eye contact with the neonate.

While caring for a neonate 2 days after birth, the nurse observes a swelling on the neonate's head that does not cross the cranial suture line. What should the nurse tell the client about the swelling?

The swelling will resolve without treatment by 6 weeks of age.

When developing a teaching plan for the parents of a neonate who is to receive phototherapy, the nurse should give the parents which information? Select all that apply.

Their baby's eyes will be covered. The vital signs will need to be monitored frequently. They will be able to visit and care for their baby.

A primipara calls the birthing unit 3 days after a vaginal birth. She tells the nurse that she is bottle-feeding and her breasts are swollen and painful. Which instructions would be appropriate?

Use ice packs for 20 minutes every 3 to 4 hours.

Which finding is considered normal in the neonate during the first few days after birth?

weight loss then return to birth weight