Saunders Maternity antepartum, intrapartum and postpartum and newborn

A licensed practical nurse (LPN) is assisting in the care of a client in preterm labor who is being started on intravenous magnesium sulfate to stop the contractions. The LPN checks to see that which is available on the unit as an antidote to magnesium sulfate?

3.Calcium gluconate

A pregnant client tells the nurse that she has been craving "unusual foods." On further data collection, the nurse discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Which laboratory result indicates a physiological consequence of a result of this practice?

Hemoglobin 9.1 g/dL

A client who is pregnant will be treated by a dermatologist for acne. Which statement if made by the client indicates a need for further teaching?

I will continue to take the prescribed oral tetracycline hydrochloride on a daily basis."

After a newborn infant undergoes circumcision, which should the nurse include in the postprocedure plan of care?

Observing for bleeding and monitoring for pain

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should perform which action?

Prepare an ice pack for application to the area.

Which action, if noted in the new mother, indicates the need for further data collection by the nurse for signs of postpartum depression?

The mother constantly complains of tiredness and fatigue.

The nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by initiating which action?

Warming the crib pad before placing the newborn in the crib

A pregnant client tells the nurse that she has been experiencing pain as a result of hemorrhoids. Which statement by the client identifies the need for further teaching regarding the hemorrhoids?

"Hemorrhoids are caused solely by the changes in hormones during pregnancy. They will go away within a day or two after the baby is born."

The postpartum nurse is collecting data from a client who delivered a viable newborn 2 hours ago. Which statement does the nurse anticipate that the client will make regarding her lochial flow?

"I am having a dark red discharge."

The nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse reinforces instructions to the mother regarding care related to the infection. Which statement by the mother indicates the need for further teaching?

"I need to isolate my infant for 48 hours after starting the antibiotics."

The nurse has reinforced instructions to a new mother about how to perform postpartum exercises. The nurse determines that the client understands the instructions when she makes which statement?

"I should alternately contract and relax the muscles of the perineal area."

The nurse is reinforcing instructions to a mother who is bottle-feeding a baby and who is complaining of breast engorgement. Which statement by the client indicates a need for further teaching?

"I should avoid wearing a bra at this time."

A client who is pregnant has been instructed on prevention of genital tract infections. Which statement by the client indicates an understanding of these prevention measures?

"I should choose underwear with a cotton panel liner."

The nurse is reinforcing instructions to a client who had an episiotomy during the birthing process. Which statement by the client indicates a need for further teaching?

"I should take sitz baths 3 or 4 times a day and test the water temperature to be sure that it is at 115° F."

The nurse reinforces discharge instructions to the mother of a 5-day-old postterm newborn who required ventilatory support for 3 days for meconium aspiration. Which statement indicates that the mother needs further teaching?

"I understand that my baby will be susceptible to contracting all respiratory infections throughout his childhood."

The nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures that will provide comfort. Which statement by the mother indicates an understanding of these measures?

"I will massage the breasts before feeding to stimulate let-down."

The nurse reinforces home care instructions to a postpartum client who had a cesarean delivery. Which statement by the client indicates an understanding of the instructions?

"If I develop a fever, I will call my doctor."

A student nurse examines an Asian-American infant's eyes and notes that the infant's eyes are crossed. Which statement by the student to the nurse indicates an understanding of this finding?

"It probably isn't strabismus but appears that way because of the child's ethnic background."

A new mother is seen in the health care clinic 2 weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu and complains of fatigue and aching muscles. On further data collection the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. Which nursing response is appropriate?

"The infection can occur at any time during breastfeeding."

The nurse is collecting data on a newborn infant with a diagnosis of a hiatal hernia. Which findings should the nurse expect to note in the infant? Select all that apply.

1.Short episodes of apnea 2.Coughing and wheezing,

During initial data collection of a client who is pregnant, the nurse notes that the laboratory report shows leukopenia, thrombocytopenia, anemia, and an elevated erythrocyte sedimentation rate. The nurse suspects human immunodeficiency virus (HIV). Which laboratory study further supports the presence of HIV?

3.T lymphocyte levels

A client experiences subinvolution during the puerperium. The nurse recalls that which factors are the most common causes for this occurrence? Select all that apply.

4.Retained placental fragments 5.Maternal reproductive tract infections

The nurse is providing nutritional counseling to a new mother who is breastfeeding her newborn. The nurse instructs the mother to increase her daily caloric intake by which amount?

500 calories per day

The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates which?

The presence of infection

When collecting data from a pregnant client at risk for disseminated intravascular coagulation (DIC), which factors should the nurse consider significant?

A client who is gravida II who has just been diagnosed with dead fetus syndrome; fetal demise occurred 2 months ago

The nurse is assisting in developing a plan of care for a client preparing to breastfeed. In planning care, which factor is most significant in teaching a client to breastfeed?

A positive nurse-client relationship

A postpartum client is at high risk for infection. A goal has been developed that states, "The client will not develop an infection during her hospital stay." Which data support that the goal has been met?

Absence of fever

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention?

Begin with the eyes and face.

A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint which should the nurse do first?

Check for signs of thrombophlebitis.

The nurse is caring for a client during the immediate recovery phase or fourth stage of labor. Which action is most important for the nurse to take at this time?

Check the uterine fundus and lochia.

The nurse is collecting data on a postpartum client and performs which best intervention when checking for thrombophlebitis in the legs?

Checks the calf areas for redness or swelling

The nurse is gathering data from a prenatal client with heart disease. The nurse carefully evaluates vital signs, monitors for weight gain, and checks the fluid and nutritional status. For which complication is the nurse collecting data?

Increase in circulating volume

The nurse provides explanation to a client prescribed methylergonovine maleate in the immediate postpartum period. Which statement made by the client demonstrates understanding of the rationale for administration?

It will help prevent bleeding and control bleeding if it occurs."

A pregnant client in the prenatal clinic states that her last menstrual period (LMP) began April 5 and ended April 12. According to Nägele's rule, which is the estimated date of delivery (EDD)?

January 12

A woman diagnosed with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication?

Macrosomia

The nurse has assisted in developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan and selects which nursing intervention as the highest priority?

Monitoring fetal status

The nurse is assigned to care for a client experiencing dystocia. Which is the highest priority in planning care?

Monitoring for changes in the physical and emotional condition of the mother and fetus

A second-day postpartum client diagnosed with a stable cardiac condition has scant lochia with a foul odor and a temperature of 102.2° F. The primary health care provider suspects infection and writes prescriptions to treat the client. Which prescription written by the primary health care provider should the nurse implement first?

Obtain culture and sensitivity of lochia and urine.

The nurse is caring for a woman who has delivered a baby after a pregnancy complicated with placenta previa. Which complication is the client most at risk for developing?

Postpartum hemorrhage

The nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily accomplish which goal?

Prevent dehydration and hypoxemia.

A client has just experienced a precipitate delivery. The nurse observes that the mother is lying quietly in bed and touches the infant only briefly and occasionally. How should the nurse be most therapeutic in this situation?

Provide support to the mother.

The nurse is assisting in planning care to meet the emotional needs of a pregnant woman. Which nursing intervention is least likely to assist in meeting her emotional needs?

Providing the mother with pamphlets and booklets to read about the pregnancy

Immediately following the delivery of a newborn, the nurse prepares to assist in the delivery of the placenta. Which action is appropriate to deliver the placenta?

Pull gently on the cord following placental separation as the mother bears down.

If a precipitate delivery is imminent, which is the appropriate nursing action?

Put on sterile gloves, and gently guide the baby's head and shoulders out.

The nurse assists a pregnant client with cardiac disease in identifying resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily to accomplish which tasks?

Reduce excessive maternal stress and fatigue.

A client who consumes alcohol frequently is in the first trimester of pregnancy. Which is the expected outcome when the nurse initiates interventions to assist the client to cease alcohol consumption?

Reducing the risk of teratogenic effects to developing fetal organs, tissues, and structures

A postpartum client asks the nurse when she may resume sexual activity. Which response should the nurse give to the client?

Sexual activity may be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped.

As a part of discharge teaching, a new mother has been provided with instructions about how to perform postpartum exercises. Which response by the client indicates that the client understands the instructions?

She should alternately contract and relax the muscles of the perineal area.

The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client?

The bladder must be full during the examination.

The nurse is monitoring a client with mild gestational hypertension (GH). Which data indicate that GH is a concern?

The client complains of a headache and blurred vision.

While a client is holding and talking to her newborn immediately following delivery, she begins to cry. How does the nurse interpret the client's behavior?

The client is experiencing a normal response to birth.

In providing initial care to the newborn following delivery, what is the nurse's priority action?

Turn the infant's head to the side.

The nurse is assessing a client who is at 32 weeks of gestation. It has been 4 weeks since her last visit. Which assessment needs to be reported to the primary health care provider?

Fundal height, 38 cm

A client who has just been told that she is pregnant asks a clinic nurse when the fetus's heart will be developed and beating. The nurse tells the client that the fetal heart is beating at what gestational week?

Week 5

The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document which as the GTPAL for this client?

G = 2, T = 1, P = 0, A = 0, L = 1

The nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. Which initial intervention in meeting the emotional needs of the client and her spouse is appropriate?

Gather data from the client and spouse about the perception of the event.

The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse should document which gravida and para status on this client?

Gravida II, para I

The nurse is reinforcing instructions to a pregnant client regarding the need to consume folic acid in the diet. The nurse determines that the client understands the instructions when the client states that it is necessary to include which food item in the diet?

Green, leafy vegetables

The nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, "I can't even dress this baby!" After reassuring the client, which nursing action is the most appropriate?

Have the mother place the infant in the bassinet and assist the mother in dressing the baby.

When the client has been given instructions about postoperative complications following cesarean delivery, the nurse interprets that the client requires clarification of the information when the client identifies which situation as a reason to notify her primary health care provider?

Her temperature is 99° F.

A prenatal client diagnosed with anemia has come to the clinic. After reviewing the client's health record, the nurse notes that the laboratory values indicate low hemoglobin and hematocrit levels. Which problem do the data best support?

High risk for infection

The nurse reviews the antenatal history of a client in early labor. The nurse recognizes that which factor noted in the history presents the greatest potential for causing neonatal sepsis following delivery?

History of substance abuse during this pregnancy

A client calls the primary health care provider's office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identified the presence of which in the urine?

Human chorionic gonadotropin (hCG)

The nurse is collecting data on a pregnant woman who is diagnosed with human immunodeficiency virus (HIV) during the thirty-second gestational week. The nurse reviews the data and determines that which finding requires further follow-up?

Increased shortness of breath and bilateral rales

The nurse is assisting in administering beractant to a premature infant who has respiratory distress syndrome. The nurse understands that the medication should be administered by which route?

Intratracheal

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was October 20, 2019. Using Nägele's rule, the nurse determines the estimated date of birth is which date?

July 27, 2020

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action?

Keep the client and her family members informed of her progress.

The nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin. The nurse should include which in the plan of care?

Maintain continuous electronic fetal monitoring.

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV)-positive. The nurse understands that which should be included in the plan of care?

Maintaining standard precautions at all times while caring for the neonate

A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement?

Massage the breasts before feeding to stimulate let-down.

The nurse is caring for a prenatal client who is at risk for placental abruption. Which risk factor documented in the client's record supports this risk factor?

Maternal hypertension

The nurse is caring for a neonate with fetal alcohol syndrome (FAS). The nurse includes which priority intervention in the plan of care for this newborn?

Monitor neonate response to feedings and the weight gain pattern.

The nurse is caring for a client in preterm labor when her membranes rupture. Which is the initial nursing action?

Monitor the fetal heart rate.

The nurse assisting in the care of a woman in labor should focus primarily on which client at the time of delivery?

Newborn

The nurse is caring for a newborn with respiratory distress syndrome (RDS). Which data obtained by the nurse indicate potential complications associated with this disorder?

No audible breath sounds in left lung; heart sounds louder in right side of chest

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). Which is the appropriate nursing action?

Notify the registered nurse (RN), who will then contact the primary health care provider (PHCP).

The nurse is monitoring a newborn infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?

Notify the registered nurse.

The nurse is providing information to a pregnant woman about food items high in folic acid. Which mid-afternoon snack should be recommended to supply folic acid?

Nuts and green, leafy vegetables

A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that which primary hormone stimulates postpartum contractions?

Oxytocin

A pregnant client in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home for progression of the disease process. The home care nurse reinforces teaching the client about the signs that need to be reported to the primary health care provider (PHCP) and tells the client to call the PHCP if which occurs?

Weight increases by more than 1 pound in a week.

The nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery?

White blood cell count of 35,000 mm3

The nurse reviews the results of a bilirubin level on a 2-day-old, jaundiced, term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. On which interpretation of the bilirubin result does the nurse base a response?

Within acceptable ranges

A stillborn was delivered in the birthing suite a few hours ago. After the birth, the family has remained together, touching the baby. Which statement by the nurse should further assist the family in their initial period of grief?

Would you like to hold your baby?"

The nurse is assisting a client who, at 38 weeks of gestation, reports feeling dizzy, lightheaded, and nauseated when attempting to lie down on the examining table. Her skin is pale and is both cool and moist to the touch. Which action should the nurse perform first?

Place a wedge pillow under the client's right side.

The nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure the nurse should take which action?

Place the client in a supine position and place a wedge under the right hip.

The nurse is assisting with care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by performing which?

Placing external fetal monitors so that each fetal heart rate is monitored separately

A mother is breastfeeding her newborn. The mother complains to the nurse that she is experiencing severe nipple soreness. The nurse should provide which suggestion to the client?

Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.

The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy, and the woman asks the nurse about the purpose of progesterone. According to the nurse, what is the purpose of progesterone?

Progesterone maintains the uterine lining for implantation.

A client who is a primigravida is receiving magnesium sulfate for gestational hypertension. The nurse is asked to monitor the client every 30 minutes. Which information should be of concern to the nurse?

Respirations of 10 breaths per minute

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?

Side-lying

The nurse documents the following assessment findings at 1 minute following birth: heart rate, 122 beats/minute; good, lusty cry; well flexed; cries appropriately; and the body is pink with blue extremities. What should the nurse document as this newborn's 1-minute Apgar score?

9

The new breastfeeding mother has been seen in the clinic for the treatment of mastitis. Which comment by the mother indicates a need for further teaching?

My left breast is sore, so I will offer only my right breast frequently for breastfeeding."

he nurse is teaching a pregnant client how to perform Kegel exercises. The nurse should tell the client that these exercises are for which purpose?

Strengthen the pelvic floor in preparation for delivery.

A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs what?

To regain her breathing pattern

A pregnant client is a gravida III, para 0, abortus II. She is placed on bed rest at home because of preterm labor. The nurse provides information to the husband, knowing that which instruction will assist in promoting family adaptation?

Teaching the husband to perform passive range of motion and provide back rubs for his wife

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate?

Tell the client that these are common and they may occur throughout the pregnancy.

Which should be included in the plan of care for a pregnant teenager to reinforce instructions regarding dental care?

Tell the dental office staff that she is pregnant.

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make?

The bright red bleeding is abnormal and should be reported.

The postpartum nurse is caring for a mother following delivery of a newborn infant. The nurse performs a perineal assessment on the mother and notes a trickle of bright red blood coming from the perineum. The nurse checks the mother's fundus and notes that it is firm. On review of the mother's record, the nurse also notes that an episiotomy was performed. Which determination should the nurse make based on this information?

The bright red bleeding is abnormal and should be reported.

The nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which as the priority goal for the client?

The client exhibits no signs of fetal distress.

The nurse in the prenatal clinic is taking a nutritional history from a pregnant adolescent. Which statement by the client should alert the nurse to a potential concern regarding adequate nutritional intake during the pregnancy?

"I need to gain only 10 pounds so that my baby will be small like I am."

During a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client makes which statement?

"I need to increase the fiber in my diet to control my blood glucose and prevent constipation."

A newborn is diagnosed with a hiatal hernia. The mother of the newborn asks the nurse to explain the diagnosis. The nurse recognizes that the mother understands this condition when she makes which statement?

"My baby has a portion of the stomach protruding through the esophageal hiatus of the diaphragm."

A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat a urinary tract infection. The mother expresses concern that her baby will be born with an infection. Which response should the nurse make to help reduce the maternal fears that the newborn will be born with an infection?

"Now that you have taken the medication as prescribed, we will continue to monitor you closely by repeating the urine culture before you leave today."

A client is scheduled for an amniocentesis and tells the nurse, "I'm not sure I should have this test done." Which response by the nurse is appropriate?

"Tell me what concerns you have."

A pregnant anemic client is concerned about her baby's condition following delivery. Which nursing response best supports the client?

"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."

Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery?

"There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth."

The nurse-midwife is conducting a session on the process of conception with a group of nursing students. Which statements reflect that the nursing students understand the process of conception? Select all that apply.

1. "Fertilization occurs in the outer third of the fallopian tube." 2. "Only 1 sperm will penetrate the ovum to produce fertilization." 4. "Implantation occurs in the anterior or posterior fundal region of the uterus." 5. "The ovary produces hormones to maintain the pregnancy before placental development."

The nurse is assisting in performing Leopold's maneuvers. The client asks the purpose of the procedure. How should the nurse respond to the client? Select all that apply.

1. "Leopold's maneuvers are used to determine fetal position." 5. "Leopold's maneuvers assist in determining the degree of descent into the pelvis of the presenting part." 6. "Leopold's maneuvers assist in determining the point of maximal intensity of the fetal heart rate on the maternal abdomen."

The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.

1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions

In order to prevent mastitis, which discharge instructions should the breastfeeding postpartum client receive from the nurse? Select all that apply.

1. Change breast pads frequently. 4. Avoid the use of soap on your nipples. 5. Intermittently expose your nipples to the air.

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.

1. Rest during the acute phase. 2. Wear a supportive, nonunderwire bra. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breastfeed if the breasts are not too sore.

A 26-year-old woman comes to the clinic and asks for a pregnancy test because she thinks she might be pregnant. The nurse assesses for which presumptive signs of pregnancy? Select all that apply.

1.Breast tenderness 2.Early morning nausea 5.No menstruation for the last 8 weeks

The nurse is explaining physiological changes of pregnancy that are related to melanocyte-stimulating hormone (melanotropin). Which pregnancy changes are related to the effects of this hormone? Select all that apply.

1.Chloasma 2.Linea nigra 4.Darkening of areola

The nurse is preparing to teach a pregnant client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the primary health care provider. Which warning signs should the nurse place on the list? Select all that apply.

1.Facial edema 2.Rapid weight gain 3.Visual disturbances 4.Generalized edema

A client presents at her primary health care provider's office 10 weeks pregnant with her first pregnancy. Which are presumptive signs of pregnancy that the client might be expected to have? Select all that apply.

1.Fatigue 2.Breast changes 4.Nausea and vomiting

The nurse is collecting data on a client who is pregnant with twins. Which signs should alert the nurse to potential problems specifically related to the twin pregnancy? Select all that apply.

1.Hypertension 4.Six or more uterine contractions per hour

The nurse is caring for a newborn diagnosed with hyperbilirubinemia. Which action is recommended for a newborn who is being breast-fed when diagnosed with hyperbilirubinemia?

1.Increase the frequency of breastfeeding.

The nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body areas, knowing that venous congestion is commonly noted in which areas? Select all that apply.

1.Legs 2. Vulva

A delivery room nurse collects data on a mother who just delivered a healthy newborn infant. The nurse checks the uterus to determine if the placenta has detached. Which findings indicate to the nurse that placental detachment has occurred? Select all that apply.

1.Lengthening of the umbilical cord 3.Sudden gush of dark blood from the vagina 4.Appearance of fetal membranes at the introitus

A client has had a midline episiotomy. In relation to clients with other types of episiotomies, the nurse anticipates that the client will generally experience which findings? Select all that apply.

1.Less pain 2.Less blood loss 4.More likely to extend with birth of LGA infant

The nurse is collecting data on a client with severe preeclampsia. Which signs and symptoms are noted in severe preeclampsia? Select all that apply.

1.Oliguria 4.Proteinuria 3+ 6.Blood pressure 168/116 mm Hg

Then examining the umbilical cord immediately after birth, which blood vessels are present in a normal umbilical cord? Select all that apply

1.One vein 4.Two arteries

The nurse is collecting data from a client who is pregnant with twins. The nurse understands that which complications are more likely to occur with a twin pregnancy? Select all that apply.

1.Preterm labor 3.Maternal anemia

The nurse is admitting a newborn infant to the nursery and notes that the primary health care provider has documented that the newborn has an omphalocele. Which interventions are appropriate for the nurse to use with this newborn? Select all that apply.

1.Protect defect from trauma. 4.Administer prophylactic antibiotics as prescribed. 5.Keep viscera moist with saline soaked dressings.

The nurse in a prenatal clinic is teaching a group of pregnant clients about physiological adaptations during pregnancy. Which are increased during the first trimester of pregnancy? Select all that apply.

1.Pulse 2.Blood volume 3.Cardiac output 5.Red blood cell mass

During an initial prenatal visit, the nurse notes that the primary health care provider documents that the client is experiencing iron deficiency anemia. Which client data support this finding? Select all that apply.

1.Reports of fatigue 2.Pink mucous membranes

The nurse in the newborn nursery is collecting data on a neonate who was born of a mother addicted to cocaine. Which signs/symptoms should the nurse expect to note in the neonate? Select all that apply.

1.Tremors 2.Irritability 4.Hypertension 6.Exaggerated startle reflex

A pregnant client is newly diagnosed as having gestational diabetes. She cries during the interview and keeps repeating, "What have I done to cause this? If I could only live my life over." Which client problem should initially direct nursing care at this time?

The client is blaming herself.

A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently and requests to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because of which situation?

The client is required to stay on bed rest.

The nurse is assisting in developing goals for the postpartum client who is at risk for infection. Which goal would be appropriate?

The client will be able to identify measures to prevent infection.

During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted?

150 beats per minute

The nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy, and the instructor asks the student about the function of progesterone. Which response made by the student indicates an understanding of the function of this hormone? Select all that apply.

2. "It maintains the uterine lining for implantation." 4. "It relaxes all smooth muscle, including the uterus."

The nurse is collecting data from a client during the first prenatal visit at 12 weeks' gestation. The client is anxious to know what the fetus will look like at this time. The nurse correctly responds to the client by providing which information? Select all that apply.

2. Earliest taste buds present. 3. Kidneys able to secrete urine. 5. Sex can be determined as internal and external organs are sex specific.

A client with type 1 diabetes mellitus in the first trimester of pregnancy is scheduled for a primary health care provider's visit. The client asks the nurse whether a change in the medication to treat the diabetes will occur at this time. Which statement is true?

2."Your normal insulin dosage will have to be decreased."

A pregnant client has been diagnosed with placental abruption. The client should be prepared for which intervention or procedure?

2.A cesarean birth

The nurse receives a report at the beginning of the shift regarding a client with an intrauterine fetal demise. Which signs/symptoms should the nurse expect to note when collecting data on the client? Select all that apply.

2.Absence of fetal movement 3.Fetal heart tones not audible 5.Prenatal record indicating no change in fundal height for several weeks

he nurse in the newborn nursery is preparing to feed a non-breastfeeding newborn a first feeding of sterile water. During the feeding, the newborn suddenly begins to cough, choke, and become cyanotic. Based on these signs, the nurse might suspect that the newborn has which condition?

2.Tracheoesophageal fistula

The nurse is working with a woman who has just been diagnosed with gestational diabetes mellitus. The nurse informs the client of which issues that may occur during this pregnancy because of this condition? Select all that apply.

2.Urinary tract infections 3.Increased chance of cesarean birth 4.Delayed lung maturation in the neonate

The nurse is preparing a pregnant client for a transvaginal ultrasound exam. The nurse should tell the client that which will occur?

The client will feel some pressure when the vaginal probe is moved.

When caring for the pregnant client with human immunodeficiency virus (HIV), which goal is appropriate?

The client will not develop an opportunistic infection during the remainder of pregnancy.

The nurse is providing emotional support to a client who experienced a spontaneous abortion. The nurse can best assist the client by planning care that focuses on which psychosocial issue?

The feelings of guilt that is often associated with grief

A pregnant woman visiting a health care clinic for the first prenatal visit hears the primary health care provider discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. What information should the nurse share related to this stage of development? Select all that apply.

3. "The preembryonic period is the first 2 weeks of fetal development following conception." 6. "The preembryonic period includes initial development of the embryonic membranes and establishment of the primary germ layers."

The nurse is caring for a neonate that is 3 hours old and should assess for which signs of cold stress? Select all that apply.

3.Mottling of skin 5.Increased respirations with apnea

A nursing student is conducting a clinical conference regarding the hormones related to pregnancy. The instructor asks the student about the function of thyroxine. Which statements by the student indicate an understanding of this hormone? Select all that apply.

4. "It may play a role in the neural development of the fetus." 5. "It increases during pregnancy to stimulate basal metabolic rate."

A woman diagnosed previously with gestational hypertension is returning to the clinic for her scheduled prenatal appointment. During the assessment, the nurse is concerned that she is developing signs/symptoms that indicate that her mild gestational hypertension is progressing. What assessment findings indicate to the nurse that the mild gestational hypertension is progressing? Select all that apply.

4. Blood pressure (BP) 165/120 mm Hg 5. Complaints of headache for the last 12 hours

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply.

4. Monitor the skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with shields or patches.

A pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Which should the nurse determine is a harmful measure in preventing constipation?

4.Adding 1 tablespoon of mineral oil to a bowl of cereal daily

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply.

4.Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply.

4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age

The nurse is reviewing the record of a newborn infant and notes that the primary health care provider has documented the presence of a cephalhematoma. Based on this documentation, the nurse expects to observe which indications on data collection of the infant? Select all that apply.

4.Edema caused from bleeding below the brain's periosteum 5.Develops 24 to 48 hours following birth and may take 2 to 3 weeks to resolve

The nurse is collecting initial data on a newborn in the delivery room. Which observations should the nurse expect to note in a healthy newborn? Select all that apply.

4.Respiratory rate of 40 breaths/minute 5.Three umbilical cord vessel, two arteries and one vein

The nurse is checking lochia discharge on a client in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. Which interpretation should the nurse make about this finding?

The finding is normal.

The nurse is reviewing the criteria for early discharge of a newborn infant with a new mother. Which data, if noted in the infant, indicate that the criterion for early discharge has not been met?

The infant has evidence of significant jaundice.

The nurse is providing education to the client with gestational diabetes who was recently placed on insulin therapy. Which information should the nurse tell the client about insulin needs during the second and third trimesters of pregnancy?

The insulin needs will increase.

The nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. Which instruction should the nurse provide to the client?

A cesarean section will be necessary if vaginal lesions are present at the time of labor.

A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the client's behavior, the nurse should suspect the client is how far dilated?

8 to 10 cm

A pregnant client in the second trimester of pregnancy is admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding should the nurse expect to note if this condition is present?

Abdominal pain

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS?

Abnormal palmar creases

The nurse is monitoring a client in the active stage of labor. The nurse notes a late deceleration on the fetal monitor. Based on this observation, how should the nurse respond?

Administer oxygen via face mask to the mother.

The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1.8. Which should the nurse anticipate to be prescribed by the primary health care provider?

Administration of a subcutaneous rubella virus vaccine

A client in her twenty-fourth week of pregnancy is admitted to the hospital in preterm labor. She asks the nurse if her baby will live if the labor cannot be stopped. Which diagnostic test should the nurse expect the primary health care provider to prescribe?

Amniocentesis for fetal surfactant level

A perinatal client is at risk for toxoplasmosis. Which instruction should the nurse reinforce with the client to prevent exposure to this disease?

Avoid exposure to litter boxes used by cats.

The nurse is providing health care information to a pregnant client who is human immunodeficiency virus (HIV) positive. The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to accomplish which goal?

Avoid further stress on the maternal immune system.

The nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding indicates which condition?

Bladder distention

The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing action should be to monitor which clinical parameter?

Blood glucose level

A client is brought to the labor unit. As the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. What should be the nurse's immediate action?

Check the fetal heart rate.

The nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse plans care, knowing that which problem should receive highest priority?

Dehydration

After birth the nurse prevents hypothermia as a result of evaporation by performing which action?

Drying the baby with a warm blanket

The nurse is planning for the nursery room admission of a large-for-gestational-age (LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for which diagnostic test?

Heel stick blood glucose

The nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which guideline?

Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dL, which are not abnormal in a 2-day-old neonate.

At 5:00 am a client is admitted to the maternity unit after experiencing 3 hours of labor at home. The assessment determines that the fetal heart rate (FHR) is 140 beats per minute with the fetus at station 0 and strong contractions occurring every 3 minutes. It is now 11:00 am with little progress, and the FHR is decreasing. It is most appropriate for the nurse to anticipate the need to perform which action?

Prepare the client for a cesarean delivery.

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note?

Red

The nurse is reinforcing the positive effects of breathing and relaxation techniques to a pregnant client with cardiac issues who has an 18-month-old child. Which primary outcome is the purpose for these interventions?

Reducing maternal stress and fatigue

A pregnant client with severe uterine bleeding is admitted to the labor and birthing department. Which data should best alert the nurse to early signs of hypovolemic shock?

Restlessness and agitation

The nurse is collecting data from a client with placenta previa during an office visit. The nurse should check which item as first priority?

Signs of fetal distress

The nurse caring for a client who is receiving oxytocin for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, which is the nurse's priority action?

Stop the oxytocin infusion.

The pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects the client will indicate that which medication is prescribed?

Subcutaneous administration of heparin sodium 5000 units daily

The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position?

Supine position with a wedge under the right hip

A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table and the nurse places the client in which position?

Supine with a wedge under the right hip

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened?

Support the mother in her reaction to the newborn.

The nurse is assisting in caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy (DIC). Which finding is least likely associated with DIC?

Swelling of the calf of one leg

A pregnant client asks the nurse about the type of exercises that are allowable during the pregnancy. The nurse should instruct the client that which is the safest exercise?

Swimming

The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings in the newborn should alert the nurse to the possibility of this syndrome?

Tachypnea and retractions

A nursing student prepares a teaching plan for a pregnant client newly diagnosed with diabetes mellitus. The nursing instructor suggests changing the plan if the student includes which information?

To avoid exercise because of the negative effects on insulin production

A postpartum nurse reinforces information provided to a new mother following a vaginal delivery regarding a sitz bath. The nurse determines that the client understands the purpose of the sitz bath when the client makes which statement?

"A sitz bath will promote healing of the perineum."

The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which statement indicates successful learning?

"The iron is needed for the red blood cells."

The advantages of using spinal anesthesia for delivery of a fetus include which reasons? Select all that apply.

1. Ease of administration 2. Absence of fetal hypoxia 3. Immediate onset of anesthesia

Which findings indicate to the nurse that placental separation has occurred? Select all that apply.

1. Lengthening of umbilical cord 2. Sudden trickle or spurt of blood 5. Fetal membranes are seen at the introitus

Which nursing interventions should be implemented for a newborn receiving phototherapy for hyperbilirubinemia? Select all that apply.

1. Monitor the temperature frequently. 2. Protect the eyes with an opaque mask. 5. Monitor and document the number and consistency of stools.

The nurse is monitoring a pregnant client with gestational hypertension (GH) who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? Select all that apply.

1. Proteinuria 2. Hypertension

The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has a platypelloid pelvic shape. The nurse recognizes which characteristics to be present in the platypelloid pelvis? Select all that apply.

1. Shallow depth 2. Wide suprapubic arch 4. Compatible with vaginal delivery 5. Flattened anteroposteriorly and wide transversely

The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is in a cephalic presentation. Which findings while performing Leopold's maneuvers support the identification of a cephalic presentation? Select all that apply.

1. Small parts are located on the left side of the uterus. 2. Small parts are located on the right side of the uterus. 5. A soft, irregular non-ballottable shape is located just above the symphysis pubis.

A client is in the first stage of labor. Which nursing actions are implemented in the first stage of labor? Select all that apply.

1.Encourage frequent urination. 3.Continue maternal and fetal assessments. 4.Review breathing and relaxation techniques.

The nurse assigned to care for a client with mild preeclampsia should anticipate which specific nursing intervention for this client?

1.Monitoring fetal movement

The nurse observes the client following delivery for normal maternal physiological changes that are anticipated. The nurse should document which expected changes? Select all that apply.

1.Slowed pulse rate 3. Elevated blood pressure

A postpartum client with mastitis in the right breast complains that the breast is too sore for her to breastfeed her infant. Which should the nurse tell the client?

"Breastfeed from the left breast and gently pump the right breast."

The nurse is performing an assessment on a pregnant client who has had a severe asthma attack. The nurse asks the client about prescription and herbal medications she is taking, and the client tells the nurse that she has been taking the herb chamomile. Which statement made by the client demonstrates correct information about this herbal intervention?

"Chamomile should not be used while I am pregnant and because I have asthma."

The nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan?

"Circumcision has been delayed to save tissue for surgical repair."

When collecting data on a pregnant client, the nurse includes which question to determine whether the client is at risk for toxoplasmosis parasite infection?

"Do you have any cats as house pets, and if so, do you ever come in contact with their soiled kitty litter?"

On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urine sample is collected for urinalysis, and the results indicate the presence of a urinary tract infection. The nurse reinforces instructions to the new mother regarding measures to take for the treatment of the infection. Which statement by the mother indicates the need for further teaching?

"Foods and fluids that will increase urine alkalinity should be consumed."

The nurse has provided instructions about measures to clean the penis to the mother of a newborn who is not circumcised. Which statement by the mother indicates an understanding of this procedure?

"I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."

The nurse reinforces instructions to a client with mild preeclampsia on home care. Which comment by the client indicates that teaching is effective?

"I need to check my urine with a dipstick every day for protein and call my health care provider if it is 2+ or more."

The nurse is reinforcing instructions to a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement?

"I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."

A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed?

"I will breastfeed, especially for the first 6 weeks postpartum."

The nurse is reinforcing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further teaching?

"I will change the perineum pads three times a day."

The nurse attempts to encourage a new mother to understand and to accept the cesarean section that was necessary to deliver her baby, rather than to focus on the surgical aspect of the procedure. Which nursing statement provides the best encouragement?

"Tell me about the delivery of your baby."

The nurse is caring for an infant with a diagnosis of hyperbilirubinemia. When explaining to the infant's mother the use of phototherapy, the nurse should make which statement?

"While undergoing phototherapy, your infant should wear an eye shield that is removed during feedings."

The nurse shares with a pregnant client that the result of her rubella screening is positive. Which is the nurse's response when asked by the client if it is safe for her 15-month-old toddler to receive the rubella vaccine?

"You are immune to the virus so it is safe for your toddler to receive the vaccine at this time."

A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse is appropriate?

"You were wise to call. I will check your rubella titer screening results, and we can identify immediately if interventions are needed."

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse should make

- Where fertilization occurs

The nurse is about to reinforce discharge instructions to a postpartum client who delivered a healthy newborn infant. The occurrence of which event should be reported to the primary health care provider?

.Pain, redness, or swelling in the breasts

The nurse is assigned to assist in caring for a client in labor. The nurse determines that which sign/symptom would least likely indicate dystocia?

.Progressive changes in the cervix

A client who is in the second trimester of pregnancy develops melasma during pregnancy. Which statements made by the client indicates an understanding of this condition? Select all that apply.

1."Melasma may reoccur in a subsequent pregnancy. 4."These brown, splotchy patches will most likely disappear after I deliver my baby." 5."The dark patches that are on my nose, cheeks and forehead will most likely darken until the baby is delivered."

A client asks, "What does it mean that the baby is at minus one?" The nurse should explain to the client that the fetal presenting part is which?

1 cm above the ischial spines

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. Which probable signs of pregnancy refer to the softening of the uterus and related structures? Select all that apply.

1.Hegar's sign 3.Goodell's sign 5.McDonald's sign

It has been 12 hours since a client's delivery of a newborn. The nurse assesses the mother for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted at which level? Refer to figure.

1. A blue shirt woman with a pelvis and a bunch of ring around pelvis,

The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing student to identify the functions of the vagina. The student correctly responds by identifying which functions? Select all that apply.

1. Female organ of coitus 2. Discharge of menstrual flow 3. Allows for fetal passage during the process of birth

The nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which interventions are included in the plan of care? Select all that apply.

1. Maintaining bed rest 2. Elevating the affected extremity 5. Applying warm compresses to the affected area as prescribed

The nurse is caring for a woman in labor. The nurse monitors the baseline fetal heart rate (FHR) and would document which findings as a normal FHR pattern?

150 beats per minute, moderate variability

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?

16 and 20 weeks' gestation

A nulliparous woman asks the nurse when she will feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately which week of gestation?

18

The nurse's assignment is to visit a new mother at home who was recently discharged from the hospital. Which finding should the nurse expect to note in a healthy breastfeeding mother and newborn?

A mother breastfeeding with the newborn in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow

The client is informed that she is now in the second stage of labor, the descent phase. Which observations should the nurse make to support this stage of labor? Select all that apply.

3. Bearing down with contractions 4. Making expiratory vocalizations 5. Changing body positions frequently

A newborn has just been circumcised and is being discharged home in 2 hours. Which instructions should be provided by the nurse to the parents? Select all that apply.

3. Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days. 4. Change diaper every 4 hours or more often to inspect the penis for drainage or infection. 5. Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure.

The nurse is monitoring a client at risk for postpartum endometritis. Which observation noted during the first 24 hours after delivery supports this diagnosis?

Abdominal tenderness and chills

The nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative and is refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as likely the result of which situation?

Acute anxiety and the need for support

The goal for the postpartum client with deep thrombophlebitis is to prevent the complication of pulmonary embolism. In planning care to assist in meeting this goal, the nurse should perform which action?

Administer anticoagulants as prescribed.

A client in labor has an underlying diagnosis of sickle cell anemia. During labor the client is at high risk for sickling crisis. The nurse should take which action to assist in preventing a crisis from occurring during labor?

Administer oxygen as prescribed.

A mother experiencing dystocia looks alarmed and asks, "What's going on? Why are you all poking and prodding? Is my baby okay?" Based on the client's questions, the nurse understands that the client is experiencing which problem?

Anxiety and fear

The nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which client problem should the nurse expect to note on the plan of care?

Anxiety related to a slow progress of labor

A pregnant client has just been admitted to the hospital with severe preeclampsia. The nurse knows it is important to monitor for additional complications at this time. Which assessment should be part of the plan of care?

Any bleeding, such as in the gums, petechiae, and purpura

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first?

Baseline fetal heart rate

The nurse is assisting with caring for a client who has a placenta previa. The nurse understands that a cervical examination should not be performed on the client primarily because it could have which consequence?

Cause hemorrhage

Which history places a maternity client at risk for uterine rupture?

Cesarean section birth

The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which assessment finding most likely indicates a hematoma?

Changes in vital signs

A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states which about the ductus venosus?

Connects the umbilical vein to the inferior vena cava

A pregnant client is seen in the health care clinic with reports of morning sickness. When the client asks the nurse about measures to relieve this situation, what is the nurse's appropriate suggestion?

Consume dry crackers before getting out of bed.

The nurse is reinforcing instructions to a maternity client on how to keep a fetal activity diary. Which instruction should the nurse provide the client?

Contact the primary health care provider if the baby's movements are fewer than 10 times in 2 hours.

The nurse is caring for the nullipara woman in labor. The nurse understands that the primary health care provider must be contacted if which condition becomes apparent?

Decreased periods of uterine relaxation between contractions

A multigravida woman with a history of cesarean births is admitted to the maternity unit in labor. The client is having excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which finding is noted if complete rupture occurs?

Decreasing blood pressure

The nurse is caring for a client receiving magnesium sulfate for preeclampsia. During the administration of this medication, which should the nurse specifically monitor?

Deep tendon reflexes

A primigravida's membranes rupture spontaneously. Which action should the nurse take first?

Determine the fetal heart rate.

The nurse in the labor room is caring for a client in the first stage of labor. When monitoring the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action?

Document the findings and continue to monitor the fetal patterns.

The nurse is caring for a newborn following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is appropriate?

Document the findings.

The nurse is changing the diaper of a 1-day-old, full-term female newborn and notes that the genitalia are red and swollen and that a thick, white mucoid vaginal discharge is present. Based on these findings, the nurse determines that which action is the best?

Document the findings.

The nurse is assessing a client during a prenatal visit. The nurse takes the client's temperature and notes that the temperature is 99.2° F. Which nursing action is appropriate?

Document the temperature.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure?

Dorsiflex the client's foot while extending the knee.

The nurse prepares to explain the purpose of effleurage to a client in early labor. Which explanation by the nurse describes effleurage?

Effleurage is light stroking of the abdomen to facilitate relaxation during labor.

A postpartum nurse obtains the vital signs on a mother who delivered a healthy newborn 2 hours ago. The mother's temperature is 100° F (38° C). What is the initial nursing action?

Encourage oral fluid intake.

A client is scheduled to have an elective cesarean delivery. How should the nurse allay the client's feelings of anxiety?

Encourage the client to discuss her concerns and desires regarding anesthesia options.

A primigravida client comes to the clinic and has been diagnosed with a urinary tract infection. She has repeatedly verbalized concern regarding safety of the fetus. Which client problem does the nurse identify as the priority at this time?

Fear about the well-being of the fetus

The nurse is assisting in developing a teaching plan for a pregnant client diagnosed with diabetes mellitus. Which instruction is the priority for this client?

How to check for signs of hypoglycemia and the required treatment

The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement?

I will tell the nurse at the hospital that I had an Rh shot during pregnancy."

The nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. In which position should the nurse place the client?

In a sitting position

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action should be appropriate?

Instruct the client that these are common and may occur throughout the pregnancy.

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action should the nurse take?

Instruct the client that these are common and may occur throughout the pregnancy.

The nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which item(s) at the client's bedside?

Intravenous (IV) supplies

The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse should recommend which measure to help relieve both discomforts?

Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

The nurse is told that a prenatal client is at risk for placental abruption. The nurse expects to note which risk factor documented in the client's record?

Maternal hypertension

The nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which is the most important information for the nurse to document on the strip?

Maternal vital signs

The maternity nurse prepares the client for which techniques commonly used to relieve shoulder dystocia?

McRoberts' maneuver

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate admitted to the newborn nursery. The nurse determines that which additional sign would be consistent with fetal alcohol syndrome (FAS)?

Microcephaly and increased respiratory effort

A pregnant client at 36 weeks' gestation experiences painless bleeding and is admitted to the labor room. In addition to maintaining complete bed rest, which other actions should the nurse include in the plan of care?

Monitor IV fluid intake and monitor the fetal heart rate.

The nurse is assisting in developing a plan of care for a newborn with spina bifida (myelomeningocele type). The nurse includes measures in the plan to monitor for increased intracranial pressure (ICP). Which action will detect the presence of an increase in ICP?

Monitoring the anterior fontanel for bulging

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is appropriate?

Notify the registered nurse (RN).

When performing a postpartum assessment on a client, the licensed practical nurse (LPN) notes clots in the lochia. The LPN examines the clots and notes that they are larger than 1 cm. Which nursing action is appropriate?

Notify the registered nurse (RN).

The nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse should take which action?

Notify the registered nurse of the finding.

The nurse is reinforcing instructions to a client about preterm labor. Which method of teaching should the nurse use?

Palpate for uterine contractions at the same time as the client.

The nurse is working with a pregnant client regarding how to identify the existence of preterm contractions. The nurse plans to use which strategy as an effective teaching method?

Palpate for uterine contractions at the same time as the client.

The nurse is assisting in collecting data on a large-for-gestational age (LGA) newborn who was delivered in a vertex presentation. Which technique should the nurse anticipate being used to check for evidence of birth trauma?

Palpating the clavicles for a fracture

A pregnant client who has a positive pulmonary identification of the tuberculosis (TB) organism has been prescribed both isoniazid and rifampin. The nurse plans to implement which intervention?

Reviewing daily nutritional intake with the client

The nurse is assisting in performing a prenatal examination on a client in the third trimester of pregnancy. The primary health care provider performs Leopold's maneuvers on the client. Which maneuver indicates the position of the fetus?

Second

The mother of a premature baby asks the nurse why the baby is receiving a caffeine-type medication. Which answer should the nurse give to the mother?

The medication primarily decreases the number of apnea occurrences.

A postpartum nurse has reinforced instructions to a new mother on how to bathe her newborn. The nurse demonstrates the procedure to the mother and on the following day asks the mother to perform the procedure. Which observation made by the nurse indicates that the mother is performing the procedure correctly?

The mother begins to wash the newborn by starting with the eyes and face.

The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care?

The process of keeping the cord clean and dry will decrease bacterial growth.

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client?

The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

The nurse is caring for a client who had a cesarean section to deliver a nonviable fetus as a result of abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, "I lost my baby and now my wife! What am I going to do?" Which appropriately describes the situation?

The spouse lacks hope because of the loss of the baby and illness of his wife.

A client in the prenatal clinic presents with a blood pressure reading of 140/90 mm Hg, which is an elevation from last month's reading of 114/66 mm Hg. Which additional sign or symptom suggests to the nurse that the client has mild preeclampsia?

Trace amount of protein

The nurse is assisting in teaching a series of classes on maintaining a healthy pregnancy. The goal for the class is "The pregnant woman will verbalize measures that may prevent physical traumatic conditions distressing to the fetus." Based on this goal, which topic should be a part of the teaching plan for this class?

Travel precautions and use of shoulder seat belts

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which components?

Two umbilical arteries and one umbilical vein

Oxytocin is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for which effective response from the medication?

Uterine contractions

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placentae is accompanied by which additional finding?

Uterine tenderness on palpation

The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. Which clinical finding supports the documentation of Chadwick's sign?

Violet bluish color of vaginal mucosa and cervix

A postpartum client who delivered at 32 weeks of gestation would like to breastfeed her preterm infant. At this time, the infant is receiving tube feedings only. What is the nurse's best response to the mother?

You can begin pumping as soon as possible after delivery with an electric breast pump."

A client is 8 weeks pregnant and has waves of nausea accompanied by vomiting throughout the day. Food odors consistently precipitate the nausea. Her husband has an important business dinner planned, and she is reluctant to attend because of the nausea and vomiting. This has placed a strain on the husband-wife relationship. Which statement by the nurse indicates an understanding of the problem?

You feel you are having difficulty fulfilling your role as a wife."

A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which informative statement should the nurse provide to the client?

"An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly."

A pregnant client who has gestational diabetes mellitus tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response best supports the client?

"Better blood glucose control means fewer effects; let's review your plan of care."

The nursing instructor asks the nursing student to identify the reason that the pulse rate of a client in the second trimester of pregnancy has increased since the last visit. Which response indicates that the student understands the rationale of this physiological response?

"Blood volume and cardiac output increase resulting in a faster pulse."

A pregnant client tests positive for the hepatitis B virus (HBV), and the client asks the nurse whether she will be able to breastfeed the baby as planned after delivery. The nurse makes which response to the client?

"Breastfeeding is allowed once the baby has been vaccinated."

The nurse is caring for a pregnant client who was diagnosed with acquired immunodeficiency syndrome (AIDS) and asks the nurse if she will be able to breastfeed the infant after delivery. Which response by the nurse is appropriate?

"Breastfeeding is contraindicated."

A pregnant client is positive for the human immunodeficiency virus (HIV). The nurse educates the client and determines that there is a need for further teaching if the client makes which statement?

"Breastfeeding my newborn will be the best option for my baby."

A young pregnant woman with diabetes mellitus has lost 10 pounds during the first 15 weeks of gestation. The client tells the nurse, "I do not eat regular meals." Based on the client's statement, which is the best response by the nurse?

"Can you tell me more about what you are eating?"

The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn. Which statement should the nurse make to the client?

"Hands should be washed thoroughly before holding the infant."

During a routine prenatal visit, a client complains of gingivitis and gums that bleed easily with brushing. When assisting to plan the care for the client, the nurse includes a goal that addresses proper nutrition to minimize this problem. The nurse determines that the goal has been achieved when the client makes which statement?

"I am eating fresh fruits and vegetables for snacks and for dessert each day."

A pregnant client tests positive for hepatitis B virus (HBV). The nurse determines that the client understands this infection when the client makes which statement?

"I am so glad that I can breastfeed my baby after she has been vaccinated."

The nurse provides home care instructions to a postpartum client following a vaginal birth with episiotomy. Which statement by the client indicates the need for further teaching?

"I can resume sexual activity at any time."

The nurse is reinforcing instructions to a postpartum cesarean delivery client who is preparing for discharge. Which statement by the client indicates a need for further teaching

"I can start doing abdominal exercises as soon as I get home."

The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which statement by the mother is most likely to occur at this time related to her birth experience?

"I do not feel any urges yet to empty my bladder."

The nurse is gathering data from a 16-year-old pregnant client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which client statement indicates a need for further investigation?

"I don't like my face anymore. I always look like I have been crying."

A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement?

"I don't need birth control because I will be breastfeeding."

The nurse employed in a primary health care provider's office is collecting information from a pregnant client. Which statement made by the client indicates the need for psychological referral?

"I hate the way I look and feel. The baby has done this to me and I wish I were not pregnant."

The nurse collects data from a pregnant client diagnosed with iron deficiency anemia during her third trimester for additional risk factors associated with the anemia. Which statement made by the client should the nurse question to receive more information?

"I have had mild vaginal spotting twice since my last prenatal visit."

A client is pregnant, has a history of heart disease, and has been instructed on care at home. Which statement by the client indicates that she understands her needs?

"I should avoid stressful situations."

The nurse is caring for a client diagnosed with preeclampsia. Which statement by the client suggests the need for further teaching regarding possible complications of preeclampsia?

"I should expect that my urine output will decrease."

The nurse is caring for a client in labor. The nurse reviews the primary health care provider's prescriptions and notes that the client has a prescription for butorphanol tartrate. Which client statement indicates that the client understands the purpose of receiving this medication?

"I should experience at least some pain relief shortly after receiving this medication."

A maternity nurse is caring for a client who is admitted to the hospital with a diagnosis of gestational diabetes. This is the client's first pregnancy. Which statement by the client indicates a knowledge deficit regarding gestational diabetes?

"I shouldn't have eaten so many sweets before I became pregnant."

The nurse is reinforcing instructions to the mother of an infant about postcircumcision care. The nurse determines that teaching has been effective when the mother states which?

"I will observe for signs of bleeding with each diaper change."

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?

"It is the fetal movement that is felt by the mother."

The nurse is assigned to care for a client who received methylergonovine maleate in the immediate postpartum period. The nurse determines the medication is effective when the client makes which statement?

"My afterpains are really strong."

The nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client makes which statement?

"My cervix is completely dilated."

A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione). The nurse should make which statement to the client?

"Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding."

The nurse is assisting in conducting a prenatal session with a group of expectant parents. Which comment related to female hormones made by a parent indicates the need for further teaching?

"Prolactin is the hormone responsible for the initiation of labor."

The nurse is conducting a prenatal session with a group of expectant parents. The nurse recognizes that teaching regarding hormones has been successful if a parent makes which statement?

"Prolactin is the hormone responsible for the secretion of milk."

A concerned mother of a newborn with a cleft lip asks the nurse when the surgical repair will occur. Which is an appropriate nursing response?

"Surgical repair is usually around 6 to 12 weeks of age."

A client at 32 weeks of gestation with a diagnosis of severe preeclampsia is admitted to the maternity department. The client is alone and appears very anxious. Which statement by the nurse is therapeutic?

"Tell me about your concerns."

A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." Which is the appropriate response by the nurse?

"Tell me what you mean when you say that your baby has moved."

A pregnant client is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. Which response is appropriate for the nurse to make?

"The breast changes are a result of the secretion of estrogen and progesterone."

The nurse is caring for a newborn in the nursery and notes that the primary health care provider has documented that the child has gastroschisis. The parents ask the nurse about the treatment for the disorder. Which statement should the nurse make to the parents?

"The defect will be closed surgically after all of the contents have been returned to the abdominal cavity."

A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test?

"The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation."

A woman at 20 weeks of gestation calls the primary health care provider's office and speaks to the nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which is the least helpful response to the client?

"This is an emergency; you should come to the clinic within the hour."

A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure?

"What an efficient way to record my baby's heart rate."

A postpartum client diagnosed with gestational diabetes is scheduled for discharge. During the discharge, the client asks the nurse, "Do I have to worry about this diabetes anymore?" The nurse should make which response to the client?

"You will be at risk for developing gestational diabetes with your next pregnancy and developing overt diabetes mellitus."

The nurse is reviewing the health care record of a pregnant client at 24 weeks' gestation. The nurse should anticipate that the fundus should be located at which level?

.22 cm to 26 cm

A client delivers a viable neonate who is given Apgar scores of 8 and 9 at 1 and 5 minutes. The nurse recognizes that this score is based on which factors? Select all that apply.

1. Color 2.Heart rate 3.Muscle tone 4.Reflex irritability 6.Respiratory effort

The nurse working in a prenatal clinic reviews a client's chart and notes that the primary health care provider documents that the client has a gynecoid pelvis. The nurse plans care understanding that which findings are characteristic of this type of pelvis? Select all that apply.

1. Round shape 4. Diagonal conjugate measures 12.5 cm to 13 cm 5. Blunt, somewhat widely separated ischial spines

A postpartum nurse is reinforcing instructions to a mother regarding how to provide a bath to the newborn. Which statement by the mother indicates the need for further teaching?

1."I need to bathe my newborn after a feeding."

The nurse working in a prenatal clinic receives a telephone call from a client at 22 weeks of gestation. The client reports some vaginal discharge and has started to experience menstrual-like cramps and diarrhea. Which responses by the nurse indicate an understanding of the implications of the client's signs/symptoms? Select all that apply.

1."Lie on your left side for an hour and try to drink some fluids." 2."It is important that you urinate frequently to keep your bladder empty." 4."Palpate for contractions and call back if there are more than four contractions in the next hour." 5."Can you identify what you ate and drank, what medications you took, and your activity during the past 24 hours?"

A blood glucose screening measurement is performed on a pregnant client, and the results indicate that the blood glucose is elevated. Which prescription should the nurse anticipate for the client?

1.A 3-hour glucose tolerance test

The nurse is collecting data from a client and is reviewing the client's health record to determine the risk for preterm labor. Which finding places the client at risk for preterm labor?

1.A urinary tract infection

Oxytocin is utilized in multiple ways in the labor and delivery unit. The nurse correctly identifies which purposes for administering this medication? Select all that apply.

1.Aids milk let down 2.Controls uterine atony 4.Augments labor contractions 5.Stimulates uterine contractions

The nurse assisting with monitoring a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client will reflect which attitudes? Select all that apply.

1.Alertness 3. Excitement

A woman who is 8 weeks pregnant complains to the nurse about nausea. Which advice should the nurse provide to this client about ways to assist with this problem? Select all that apply.

1.Avoid greasy foods. 2.Eat 5 to 6 small meals each day. 3.Do not drink fluids with meals.

A client is admitted to the hospital and is in the first stage of labor. She tells you that her "bag of waters" broke. Which assessments of the amniotic fluid are considered to be normal? Select all that apply.

1.Clear fluid 4.White flecks in the amniotic fluid 5.Presence of glucose and protein in the amniotic fluid

For the previous 4 hours, a client in labor has been experiencing hypertonic labor as documented by the primary health care provider. The nurse recognizes which findings to be characteristic of this type of labor? Select all that apply.

1.Contractions typically occur in the latent phase of labor. 3.Contractions occurring every 2 minutes, lasting 70 seconds 5.Contraction force is felt in the midsection of the uterus rather than the fundus.

The nurse is preparing a woman with gestational hypertension for discharge and shares with the client directions to follow which instructions? Select all that apply.

1.Curtail exercise. 3.Measure your blood pressure daily. 4.Rest frequently by lying on your side. 5.Call the primary health care provider if you develop dizziness.

nurse is monitoring a pregnant client for the warning signs/symptoms of gestational hypertension. Which are signs/symptoms of this complication of pregnancy? Select all that apply.

1.Edema 3.Proteinuria 4.Thrombocytopenia

The nurse is assigned to care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother's temperature and notes that it is 100.4° F (38° C). Which nursing action is appropriate?

1.Encourage oral fluids.

During the intrapartum period, the nurse is caring for a laboring client diagnosed with sickle cell disease. The nurse recognizes that which conditions are most likely to lead to a sickling crisis? Select all that apply.

1.Exertion 2.Infection 3.Hypoxemia 4.Dehydration

A postpartum nurse is reinforcing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instructions should the nurse provide to the mother?

1.Increase the frequency of the breastfeeding.

A prenatal client has acquired the sexually transmitted infection, condyloma acuminatum (human papillomavirus). When assisting in planning care, which treatment should the nurse consider to be safe for this client?

1.Laser therapy

The nurse is reading the primary health care provider's documentation regarding a pregnant client and notes that the primary health care provider has documented that the client has an android pelvic shape. Which descriptions apply to an android pelvis? Select all that apply

1.Narrow wedge shape. 5.Unfavorable for a vaginal birth.

The nurse in a prenatal clinic is teaching a group of pregnant clients about anemia and foods high in iron. Which foods are high in iron content? Select all that apply.

1.Peanut butter 3.Whole grain bread 4.Omelet with cheese

Which nursing actions should decrease the discomfort of an episiotomy? Select all that apply.

1.Performing sitz baths 4.Applying ice packs to the perineum for the first 12 to 24 hours

The nurse is preparing to collect data on a client with a possible diagnosis of ectopic pregnancy. Which should the nurse check first?

1.Pulse

The nurse is caring for a woman in the labor room. The primary health care provider prescribes an oxytocic medication for the woman to augment her labor. Which finding indicates a need to discontinue the oxytocic medication?

1.Resting interval of 50 seconds

The nurse has a prescription to give a dose of Rho(D) immune globulin to a client who has delivered an infant. Which criteria need to be met in order to administer this medication? Select all that apply.

1.Rh negative mother. 4.Negative Coombs' test.

The nurse is collecting data from a client on her first prenatal visit. Which factor indicates that the client is at risk for developing gestational diabetes during this pregnancy?

1.She has a history of chronic hypertension.

The nurse is monitoring the status of a client in active labor. The nurse interprets that which findings are consistent with dystocia? Select all that apply.

1.Signs of fetal distress 2.High level of maternal anxiety 3.Failure of the fetus to descend

In caring for a preterm newborn, what knowledge related to skin care should the nurse consider when providing nursing care? Select all that apply.

1.Skin of the preterm baby is thinner than that of the full-term infant. 2.A preterm baby has less subcutaneous fat than the full-term infant. 3.The posture of the preterm infant will expose more skin to potential heat loss. 4.The preterm infant has a high body surface area in relation to their body weight.

The nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented findings are associated with this disorder? Select all that apply.

1.Stenosis of the anorectal canal 2.Failure to pass meconium stool 3.The presence of stool in the vagina 4.The presence of an anal membrane

The nurse is reviewing the health history of a pregnant client. Which data noted in the client's health history would indicate a risk for spontaneous abortion?

1.Syphilis

The nurse in the newborn nursery is assisting in monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings, if noted in the newborn, should alert the nurse to the possibility of this syndrome? Select all that apply.

1.Tachypnea 2.Retractions 4.Nasal flaring

The nurse is monitoring a newborn who was born to a drug-addicted mother. Which findings should the nurse expect to note during data collection for this newborn? Select all that apply.

1.The newborn is irritable. 4.The newborn cries incessantly. 5.The newborn is difficult to console. 6.The newborn hyperextends and postures.

A client in the first trimester of pregnancy arrives at the health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse reinforces a list of instructions for the client regarding management of care. Which instructions should the nurse place on the list? Select all that apply.

1.To note the color of blood on each perineal pad 2.To watch for the evidence of the passage of tissue 3.To note the quantity of blood on each perineal pad 4.To count the number of perineal pads used on a daily basis

The nurse is discussing prenatal testing with a woman who is approximately 6 weeks pregnant. The nurse shares which tests are expected to be conducted during the first trimester? Select all that apply.

1.Urinalysis 2.Rubella titer 4.Complete blood count

A pregnant client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the gender of the fetus can usually be determined by which range of weeks?

12 to 16

The nurse is monitoring a new mother for signs of postpartum depression. Which observations in the mother indicate the need for further data collection related to this form of depression? Select all that apply.

2.Shows a lack of interest in eating 3.Lacks the ability to concentrate on tasks 4.Complains of feeling tired all of the time

Which statements made by a nursing student indicate that the student has an appropriate knowledge base regarding the pregnancy hormone human chorionic gonadotropin (hCG)? Select all that apply.

2. "Human chorionic gonadotropin is the hormone responsible for a positive pregnancy test." 3. "Human chorionic gonadotropin may be present as early as 8 to 10 days following conception." 4. "Human chorionic gonadotropin is produced by the trophoblastic cells that surround the developing embryo." 5. "Human chorionic gonadotropin preserves the function of the ovarian corpus luteum so that estrogen and progesterone are produced before placental functioning."

The nurse is caring for a postpartum client who is being treated for thrombophlebitis. The client is receiving an anticoagulant by intravenous infusion. The nurse monitors for adverse effects of the anticoagulant by checking the client for which signs/symptoms? Select all that apply.

2. Epistaxis 4. Hematuria 5.Ecchymosis

The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has an android pelvic shape. The nurse understands that which characteristics are included with this pelvic shape? Select all that apply.

2. Heart shaped 4. Convergent sidewalls 6. Narrow interspinous diameter

The nurse in the delivery room is assisting with the delivery of a newborn. Which observations indicate that the placenta has separated from the uterine wall and is ready for delivery? Select all that apply.

2. The umbilical cord lengthens 3. Changes in the shape of the uterus 5. A trickle or gush of blood escapes from the introitus

The nurse is assisting in caring for a client in labor. Which data collection finding by the nurse places the client at risk for uterine rupture?

2.Shoulder dystocia

A perinatal client with a history of heart disease has been instructed on care at home. Which statement made by the client indicates the need for further teaching?

2."It is best to rest on my right side."

Which safety measures should be implemented at delivery and when working in the newborn nursery? Select all that apply.

2.Adhere to standard precautions during delivery and in the nursery. 4.Instruct the parents to not release their newborn infant to anyone wearing improper identification. 5.Fingerprint the mother and footprint the infant on the identification card before removing the infant from the delivery room.

The parents of a neonate who is not circumcised asks the nurse why the foreskin should not be retracted. The nurse explains that retracting the foreskin should be avoided because which complication may occur?

2.Adhesions

Which documentation concerning the characteristics of amniotic fluid supports the determination that the fluid is normal? Select all that apply.

2.Amniotic fluid pH is basic. 5.It is pale, straw-colored with flecks of vernix. 6.A volume of 1000 mL is an acceptable amount of amniotic fluid

client in active labor with intact membranes is complaining of back discomfort. An analgesic was administered 1 hour ago but has not relieved the discomfort. The nurse should avoid which measure at this time to assist in relieving the back discomfort?

2.Assist the client to ambulate in the room.

A licensed practical nurse (LPN) is assisting in gathering data on a client who is scheduled for a cesarean delivery. Which findings indicate a need to contact the registered nurse (RN)? Select all that apply.

2.Blood pressure reading of 144/94 3.Fetal heart rate of 180 beats per minute

A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data indicate to the nurse the presence of concealed bleeding? Select all that apply.

2.Boardlike abdomen 4.Increase in fundal height

A woman who is 36 weeks pregnant arrives at the labor and delivery unit complaining of vaginal bleeding. Which signs/symptoms indicate that the client's bleeding is caused by placenta previa? Select all that apply.

2.Bright red vaginal bleeding 3.Lack of uterine contractions

A client asks the nurse to describe how her developing baby will get enough blood and oxygen. The nurse responds that the fetal circulatory system accomplishes this task by which means? Select all that apply.

2.Bypassing the fetal lungs to circulate oxygen rich blood 4.Using the fetus's beating heart to pump blood in the circulatory system 5.Carrying more oxygen on fetal hemoglobin than maternal hemoglobin 6.Making the fetal cardiac output higher per unit of body weight than the maternal cardiac output

The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. The prenatal client asks the nurse to explain Chadwick's sign. Which information provided by the nurse is accurate? Select all that apply.

2.Chadwick's sign is a probable sign of pregnancy. 3.Chadwick's sign may be present as early as 6 weeks' gestation. 4.Chadwick's sign is a bluish discoloration of the vagina and cervix

Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which signs as an indication of placental separation? Select all that apply.

2.Change in uterine shape 4.Lengthening of the umbilical cord 6.Sudden gush of dark blood from the introitus

The nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse should perform which action?

2.Clap the hand or slap on the mattress.

Two weeks following delivery, a client experiences subinvolution of the uterus. Which findings indicate subinvolution? Select all that apply.

2.Constant fever of 101° F 4.Persistent pelvic heaviness 5.Foul-smelling vaginal discharge

The nurse is monitoring the vital signs of a client after delivery of a healthy newborn one day ago and notes that the mother's apical pulse is 56 beats/min. Which nursing action is appropriate related to this finding?

2.Document the finding.

A nurse is reinforcing instructions to a client in the first trimester of pregnancy about measures to help with morning sickness. Which should the nurse include in the instructions? Select all that apply.

2.Eat a low-fat diet. 3.Stop or decrease smoking. 4.Eat smaller, more frequent meals. 5.Consume adequate fluid between meals.

A client is seen in the health care clinic for complaints of vaginal bleeding and mild abdominal cramping. On further data collection, the nurse notes that the client's last menstrual period was 10 weeks ago. The client reports that a home pregnancy test was performed and the results were positive. On physical examination, it is noted that the client has a dilated cervix. The nurse understands that the client is at risk for which type of abortion?

2.Inevitable

The nurse in the prenatal clinic is collecting data regarding the client's nutritional knowledge. The nurse determines that the client understands the food items that are high in folic acid when the client states that she will be sure to eat which food items? Select all that apply.

2.Liver 3.Beans

The nurse is reviewing the record of a client in the labor room. Which documented notation refers to the relationship of the presenting part to the maternal ischial spines?

2.Minus (-) 1 station

The nurse assisting in the care of a newborn has a standing prescription to administer the hepatitis B vaccine to the infant. The nurse should plan to perform which action when carrying out this prescription?

2.Obtain written parental consent.

A client who experienced abruptio placentae is at risk for disseminated intravascular coagulopathy (DIC). The nurse should monitor this client for which symptom of this complication?

2.Oozing from injection sites

A client asks the nurse to describe how her baby is developing at 12 weeks gestation. Which milestones should the nurse identify as present at this time? Select all that apply.

2.Sex recognizable 3.Blood forming in marrow 5.Kidneys able to secrete urine

The nurse is assisting in the admission of a woman for induction of labor. The nurse should contact the primary health care provider before proceeding with the induction if which conditions are noted during the assessment? Select all that apply.

2.The fetus is in the breech position. 3.Lesions are present on the perineum. 4.The fetus is not settled into the pelvis.

The clinic nurse is preparing to discuss cardiovascular changes of pregnancy in a prenatal class. Which information is appropriate for the nurse to present to this group? Select all that apply.

2.The number of red blood cells will be increased during pregnancy. 3.At term, the heart rate has increased by 15 to 20 beats per minute. 6.In a supine position, some degree of compression of the vena cava will occur.

A prenatal client with vaginal bleeding is admitted to the labor unit. Which signs or symptoms indicate placenta previa? Select all that apply.

2.Uterus soft to palpation 5.Bright red vaginal bleeding

The nurse is assigned to care for a pregnant client being admitted to the nursing unit. Laboratory and diagnostic studies have confirmed a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse collects data on the client and reviews the results of the laboratory and diagnostic studies, knowing that which findings are associated with this diagnosis? Select all that apply.

2.Vaginal bleeding 3.Excessive vomiting 4.No fetal heart activity 5.Larger than normal uterine size 6.Elevated levels of human chorionic gonadotropin (hCG)

The primary health care provider is performing a vaginal examination on a pregnant woman. Which assessments are considered to be normal physiological changes in the vagina? Select all that apply.

2.Vaginal secretions increase. 4.Bluish discoloration of the vagina. 5.Higher levels of glycogen in vaginal secretions.

The nurse is collecting data from a pregnant client who is currently at 28 weeks' gestation. At her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in centimeters and should expect which finding?

26 cm

The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the purposes of estrogen. Which responses should the nurse make to the client? Select all that apply.

3."It stimulates the breasts to prepare for lactation." 6."It stimulates uterine development to provide an environment for the fetus."

A nursing instructor instructs the nursing students that surfactant is a substance needed to facilitate neonatal breathing. Which statements made by the nursing students indicate understanding regarding the presence of surfactant? Select all that apply.

3."Surfactant, which is needed for lung expansion, is present beginning at 28 weeks." 4."With decreased surfactant, more pressure must be generated to produce inspiration." 5."Surfactant lowers surface tension, reducing the pressure required to keep the alveoli expanded."

The father of a newly delivered full-term newborn is observing admission of the infant to the nursery. He asks the nursing student performing the admission why a cover is being placed on the baby scale to weigh and measure the newborn? The response that the nursing student should make is based on understanding the mechanism of heat loss in the newborn. This nursing intervention is designed to protect the newborn against which heat loss mechanism?

3.Conduction

The nurse is adding to a plan of care for a postpartum client. Which intervention should promote parent-infant bonding?

3.Encourage her to hold the infant even when the infant is crying.

The nurse is collecting data from the client about the presence of presumptive, probable, and positive signs of pregnancy. Which are the positive signs of pregnancy? Select all that apply.

3.Fetal heart tones 6.Fetal movements felt by examiner

The nurse is reviewing the health care record of a pregnant client at 16 weeks of gestation. Which assessment findings are most likely present at this time? Select all that apply.

3.Fetal heart tones can be heard by Doppler. 4.Braxton Hicks contractions may be felt by the mother. 5.The fundus is located midway between the symphysis pubis and the umbilicus.

The nurse is teaching a prenatal class on the anatomy and physiology of the female reproductive system including hormones. Estrogen produces which effects, either directly or indirectly, during pregnancy? Select all that apply.

3.Increases blood flow to the uterine vessels 4.Stimulates development of the breast ducts 5.Causes vascular changes in the mucous membranes of the nose and mouth

The nurse is reviewing the procedure for vitamin K injection in the newborn with a nursing student. Which information should the nurse provide to the student?

3.Inject into skin that has been cleansed with alcohol.

The nurse is evaluating the effectiveness of meperidine hydrochloride for pain management for a client in labor. The client describes her pain level as "9" during contractions. The nurse determines that the medication was effective if the client exhibited which reasonable goal for pain relief?

3.Pain level is "4" while a progressive labor pattern continues.

A client was admitted to the maternity unit 12 hours ago at station 0 and has been experiencing strong contractions every 3 minutes, and the fetus is currently still at station 0. The fetal heart rate on admission was 140 beats per minute and regular. The fetal heart rate is decreasing and a persistent nonreassuring fetal heart rate pattern is present. Which nursing action is appropriate?

3.Prepare the client for a cesarean delivery.

A blood glucose screening measurement is going to be performed on a pregnant client. Which instructions should the nurse give to the client before this test?

3.There is no restriction for caffeine before the test.

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated?

A change in the uterine contour

The perinatal client is admitted to the obstetrical unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse should consult with the dietitian to ensure which dietary measure?

A diet that is high in fluids and fiber to decrease constipation

The nurse is collecting data from a prenatal client. The nurse determines that which situation places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?

A history of intravenous (IV) drug use in the past year

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated?

A manual pelvic examination

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for the presence of an infection. The nurse should tell the mother that which is a sign of infection?

A moist cord with discharge

A nonstress test is performed on a client, and the results are documented in the chart. The results are documented as a reactive nonstress test. Which interpretation should the nurse make of these results?

A negative test

The nurse palpates the anterior fontanel of a newborn and notes that it feels soft. What does this datum indicate to the nurse?

A normal finding

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which change that occurs with pregnancy?

A softening of the cervix

The nurse is performing a postpartum fundal assessment on a client 6 hours after delivery. The nurse finds the fundus above the umbilicus and displaced to the right. Which intervention should the nurse do first?

Assist the client to the bathroom to void and then reassess the fundus.

During the intrapartum period, the nurse assists the health care team to ensure appropriate intravenous (IV) fluid intake and oxygen consumption for the laboring client with sickle cell disease. Which rationale should the nurse provide to the client for these interventions?

Administering adequate IV fluids and oxygen during your labor will assist in preventing dehydration and hypoxemia, which can lead to sickling."

The nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal heart rate pattern shows multiple late decelerations on the monitor strip. Based on this information, the nurse prepares for which appropriate nursing action?

Administering oxygen via face mask

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. Which does the nurse anticipate to be prescribed?

Administration of immune globulin and vaccine in the infant soon after birth

The nurse is caring for a client diagnosed with abruptio placentae. During labor, the priority nursing action is to monitor which criteria?

All vital signs, especially heart rate and blood pressure

When planning care for a woman with gestational hypertension (GH), the nurse plans to encourage which maternal behavior?

Expression of hope for a positive outcome

The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action?

Ambulate frequently.

The nurse in a postpartum unit identifies which client as being at risk for developing endometritis following delivery?

An adolescent experiencing an emergency cesarean delivery for fetal distress

The clinic nurse is reviewing the records of the pregnant clients who will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection?

An adolescent with multiple heterosexual contacts

The nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which sign noted in the mother indicates an early sign of excessive blood loss and shock?

An increase in the pulse rate from 88 to 102 beats per minute

The nurse is assisting in caring for a newborn whose mother is Rh negative. Which is important for the nurse to include when planning the newborn's care?

Ask about the newborn's blood type and direct Coombs.

The nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?

Ask the client to urinate and empty her bladder.

A newborn is transferred to the neonatal intensive care unit with an admitting diagnosis of esophageal atresia accompanied by a distal tracheoesophageal fistula (TEF). When assisting with care for the newborn, which should be the priority concern?

Aspiration

The nurse instructs a pregnant client diagnosed with human immunodeficiency virus (HIV) to report immediately to the primary health care provider any early signs of vaginal discharge or perineal tenderness. Which is the primary expected outcome for this intervention?

Assists in identifying infections that may need to be treated

After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note?

At the level of the umbilicus

A client who is breastfeeding her newborn infant is experiencing nipple soreness. To relieve the soreness, which action should the nurse suggest to the client?

Begin feeding on the less sore nipple.

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements should be noted at which time interval?

Between 16 and 20 weeks' gestation

During a routine prenatal visit the client states, "I have not been able to get my wedding ring off for the past 2 days. I guess the heat is making my fingers swell." Which should the nurse check further?

Blood pressure changes and the presence of protein in the urine

The nurse discusses infant feeding options with a client following a vaginal delivery of a 6-pound full-term infant. The mother has been diagnosed with human immunodeficiency virus (HIV). Which is the appropriate method of feeding for this client?

Bottle-feeding with a tolerated formula

A newborn infant has coarctation of the aorta (COA). The nurse should expect to note which findings in the infant?

Bounding radial pulses and absent or weak femoral and pedal pulses

The nurse is caring for a client with a diagnosis of dystocia. The nurse specifically collects data regarding which issue?

Characteristics of contractions

The nurse is caring for a 3-hour-old infant and notes that the infant has not eaten since birth, is jittery, and has a weak cry. The mother states that she can't get the baby to eat. Which action should the nurse take first?

Check the blood glucose level.

The client is having moderate contractions that are occurring every 5 minutes and lasting 60 seconds. The fetal heart rate (FHR) is 150 beats per minute and regular. Based on these findings, what is the appropriate nursing action?

Continue to monitor the client.

The nurse is assisting in providing a class to new mothers on newborn care. In teaching cord care, the nurse makes which suggestion to the new mothers?

Clean around the cord with plain water as needed until the cord falls off.

A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse should take which approach as the first step to support the client psychologically?

Collect data regarding how the client perceived the event.

The nurse assists the nurse-midwife in examining the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (-) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which activity for the client?

Complete bed rest

The nurse reviews the results of an ultrasound performed on a woman admitted to the maternity unit. The results indicate that the placenta is covering the entire internal cervical os. The nurse understands that the client is experiencing which condition?

Complete placenta previa

While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of which reason?

Compression of the vena cava

The nurse is reinforcing dietary instructions to a pregnant client with a history of lactose intolerance. The nurse should instruct the client to consume which best food item to ensure an adequate source of calcium in the diet?

Dried fruits

The nurse is caring for a client in labor. The fetal heart rate is 156 beats per minute and regular. The client's contractions are occurring every 4 minutes with a duration of 42 seconds and moderate intensity. The nurse should do which at this time?

Continue monitoring the client because the data reflect acceptable progress.

The client is in the second stage of labor. As the baby begins to crown, the primary health care provider administers a pudendal nerve block in preparation for an episiotomy. Which action should the nurse take?

Continue to assess vital signs and fetal heart rate the same as before the nerve block.

A 30-week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure?

Contraction stress test

A client arrives to the postpartum unit following the delivery of her newborn premature infant. On data collection, the nurse notes that the client is shaking uncontrollably. Which nursing action is appropriate?

Covering her with a warm blanket

A nursing instructor is observing a nursing student caring for a newborn with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by which action?

Covering the bladder with a sterile, nonadhering moist dressing

The nurse is assigned to care for a primigravida who is having a precipitate delivery. Which maternal finding does the nurse expect to note?

Decreased periods of uterine relaxation between contractions

The nurse is reinforcing a teaching session to a group of adolescent pregnant clients and is discussing the importance of nutrition. The nurse includes which information in the discussion?

Describing the appropriate amount of weight gain required during the pregnancy

The nurse is monitoring a client in labor whose membranes rupture spontaneously. Which is the initial nursing action?

Determine the fetal heart rate.

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action should the nurse take initially?

Determine the maternal and fetal vital signs.

A client has just delivered a viable newborn. The first nursing action to initiate attachment is which?

Determine the parents' desires for contact with the newborn.

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse helps determine whether this method of family planning is appropriate?

Do you plan to have any other children?"

The nurse is collecting data on a pregnant client in her twenty-second week. The nurse prepares to use a fetoscope to auscultate the fetal heart rate. The nurse hears a fetal heart rate of 115 beats per minute. Which action should the nurse take?

Document the assessment.

The nurse performs a blood glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 50 mg/dL. Which action should the nurse implement based on this finding?

Document the finding because it is within the normal range.

The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure?

Drink decaffeinated coffee and tea.

An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with what problem?

Drug withdrawal

The nurse suspects that the client has a pulmonary embolism when the client exhibits which signs and symptoms?

Dyspnea, tachypnea, and tachycardia

The nurse is assisting in caring for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and parents?

Encourage the parents to touch their newborn.

he nurse who is caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. Which intervention should best facilitate the client's participation in infant care?

Encouraging the client to take pain medication as prescribed

The nursing student is preparing to administer a medication to a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication and placement for the prophylaxis of ophthalmia neonatorum caused by gonococcal or chlamydia infection. The student correctly identifies which medication and location?

Erythromycin, eyes

In the prenatal clinic, the nurse is gathering data from a new client for the health history information. Which action is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections?

Establish a therapeutic relationship between the nurse and pregnant client.

The nurse is teaching a pregnant client about the physiological effects and hormone changes that occur in pregnancy. The client asks the nurse about the purpose of estrogen. Which description explains the purpose of estrogen?

Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

The nurse is preparing to care for a woman in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the woman's vital signs at which time intervals?

Every 15 minutes for the first hour and then every 30 minutes for the next 2 hours

Rho(D) immune globulin is prescribed for a client after delivery of a full-term infant. Before administering the medication, the nurse reviews the client's history, recognizing which circumstance as a contraindication for administering this medication?

Experiencing a severe reaction to prior administered human globulin

During an office visit, a prenatal client with mitral stenosis states she has been under a lot of stress lately. During data collection, the client questions everything the nurse does and behaves in an anxious manner. Which is the appropriate nursing response or action at this time?

Explain the purpose of the nurse's actions and answer all questions.

The nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which appropriately describes the mother's problem at this time?

Fear about what is happening

The nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as indicative of which response?

Fear of losing control

A client who is 6 months pregnant is attending her first prenatal visit. On the first prenatal visit, the nurse notes that the client is gravida 4, para 0, abortion 3. The client is 5 feet, 6 inches tall, weighs 130 pounds, and is 25 years old. She states, "I get really tired after working all day and can't keep up with my housework." Which factor in the above data should lead the nurse to suspect gestational diabetes?

Fetal demise

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which occurrence indicates an abnormal physical finding that necessitates further testing?

Fetal heart rate of 180 beats per minute

The nurse is monitoring a client who is receiving oxytocin to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which is noted?

Fetal tachycardia

The nurse is caring for a client with placenta previa who is at high risk for infection and hemorrhage. The nurse plans care based on which information related to the condition?

Fewer muscle fibers in the lower segment of the uterus will result in poor contractions.

The nurse is instructing a pregnant client on dietary sources of iron. Which client food selection demonstrates an understanding of teaching?

Fresh spinach

A woman is 24 weeks pregnant. She had a previous stillborn neonate at 38 weeks' gestation and a pregnancy that ended at 34 weeks with the birth of a stillborn girl. She states she has a 4-year-old son and an 8-year-old daughter who live with her at home and were both born at 38 weeks. What is her gravidity and parity, using the five-digit system (GTPAL)?

G (5) T (0) P (4) A (0) L (2)

Which is the appropriate method to use to deliver the placenta after a precipitate delivery?

Gently guide the placenta out after a spontaneous separation.

The nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?

Have the client empty her bladder.

During a prenatal visit of a client diagnosed with placenta previa, the primary health care provider defers doing a vaginal examination. The nurse understands that this examination is avoided in this situation because of what potential risk?

Initiating severe hemorrhag

The nurse is reviewing the laboratory results of a pregnant client and notes that the hemoglobin level is decreased. Physiological dilutional anemia is documented in the client's record by the primary health care provider. The nurse plans care, knowing that this type of anemia is a result of which situation?

Increased blood volume of the mother during pregnancy

A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that this procedure will most likely have which effect?

Increased efficiency of contractions

The nurse is collecting data on a client who is 6 hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action is appropriate?

Instruct the mother to request help when getting out of bed.

The nurse is reinforcing instructions to a pregnant client about the warning signs in pregnancy that require the need to notify the primary health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the primary health care provider if which occurs?

Irregular, painless contractions

A pregnant woman reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. Following an assessment, tuberculosis is suspected. A sputum culture is obtained and identifies the Mycobacterium tuberculosis in the sputum. The nurse reinforces instructions to the client regarding therapeutic management of tuberculosis. Which statement is included in therapeutic management?

Isoniazid plus rifampin will be required for a total of 9 months.

The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormonal changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?

It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action?

Keep the client in a side-lying position.

In formulating the plan of care, which problem is most important to address for a postpartum client who has expressed concerns about not knowing how to care for her newborn?

Lack of knowledge regarding ability to care for the newborn

The nurse is caring for a woman in labor who is experiencing a precipitate delivery. Until help arrives, the nurse places the client into which optimal position?

Lateral Sims'

A client in preterm labor is placed on bed rest. The nurse assists the client to which advantageous position?

Left lateral

The nurse is preparing to monitor a fetal heart rate. The nurse locates a round, ballottable shape just above the symphysis pubis. Fetal small parts are located on the right side of the uterus with a concave shape located on the left side of the uterus. Where should the nurse listen to hear the strongest fetal heart tones?

Left lower quadrant

A pregnant client asks the prenatal clinic nurse what the fetal period of development means. Which is correct information about the fetal period?

Longest period of fetal development

The nurse is assisting in conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by taking which action?

Massaging the abdomen during contractions using both hands in a circular motion

The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to document that the fundus of the uterus is located at which area?

Midway between the symphysis pubis and the umbilicus

The nurse encourages the childbearing woman diagnosed with human immunodeficiency virus (HIV) to avoid alcohol and cigarettes during pregnancy and to obtain adequate rest. Which outcome is specific to this client?

Minimize the potential for developing infections.

The nurse is assigned to care for a client admitted with severe preeclampsia. Which is the priority nursing intervention for this client?

Minimizing the client's exposure to external stimuli

The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse should suspect DIC if which is observed?

Petechiae, oozing from injection sites, and hematuria

The nurse notes that a client in labor has foul-smelling amniotic fluid, a maternal temperature of 101° F, and a urine output of 150 mL during the past 2 hours. The nurse should do which action at this time?

Notify the registered nurse of a possible maternal infection.

The nurse is caring for a newborn whose mother had an elevated temperature during a prolonged labor. Which intervention should be important to include in the newborn's plan of care?

Observe vital signs and central nervous system status frequently during the first 2 days.

The nurse is reinforcing instructions to a pregnant client regarding measures that will strengthen the perineal floor muscles. Which should the nurse include in the instructions?

Perform Kegel exercises in 10 repetitions, three times per day.

The nurse should prepare to give a prescribed oxytocic medication after delivery of which?

Placenta

A pregnant woman who is at 38 weeks' gestation arrives at the emergency department. She reports the presence of bright red vaginal bleeding and denies the presence of any pain. Based on this information, what does the nurse determine the client may be experiencing?

Placenta previa

The nurse is caring for the postpartum client who is diagnosed with a low-lying placenta. The nurse monitors the client carefully for which complication?

Postpartum hemorrhage

The nurse is caring for a pregnant client with a history of human immunodeficiency virus (HIV). Which problem has the highest priority for this client?

Potential for infection

The nurse is instructing a pregnant client in her first trimester about nutrition. The nurse should correct which misunderstanding on the part of the client about nutrition during pregnancy?

Pregnancy greatly increases the risk of malnourishment for the mother.

The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action?

Prepare the client for surgery.

A client in the postpartum unit complains of sudden, sharp chest pain. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action?

Prepare to administer oxygen at 8 to 10 L by tight face mask.

The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which is noted?

Presence of accelerations

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes and the mother asks the nurse why this is done. The nurse should give which response to the client?

Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

A term client is being seen for a final prenatal appointment. The clinic nurse is making arrangements for the client to be admitted to the labor and delivery unit for an oxytocin induction. The nurse reviews the client's chart and should contact the primary health care provider regarding which documented finding to verify the oxytocin induction?

Previous classical vertical uterine incision

The nurse is caring for a client following a precipitate delivery. In addition to fundal massage, which nursing action can the nurse implement that will promote the birth of the placenta?

Putting the baby to the mother's breast and letting the baby suck

A new mother is attempting to breastfeed for the first time. The nurse notices that the client has inverted nipples. What nursing action can the nurse take to assist the client in breastfeeding the newborn?

Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp

The nurse is planning interventions for counseling a maternity client newly diagnosed with sickle cell anemia. The nurse understands that the important psychosocial intervention at this time is which action?

Provide emotional support.

The nurse assisting in the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which nursing intervention is the priority in caring for the client?

Provide pain relief measures.

The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta?

Provides an exchange of nutrients and waste products between the mother and the fetus.

The nurse is preparing a client for a cesarean delivery. A urinary catheter is to be inserted into the client's bladder, and the client asks the nurse why this is necessary. The nurse appropriately replies by telling the client that which is the catheter's primary purpose?

Reduce the risk of injuring the bladder during the surgery.

A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. The nurse determines which physiological need is primary to the client at this time?

Rest between contractions

A client is admitted for an emergency cesarean section delivery. Contractions are occurring every 15 minutes. The client has a temperature of 100° F and ate 2 hours ago. Which intervention has priority?

Report the time of last food intake to the primary health care provider.

A client is admitted to the labor and delivery suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents make which response?

Request to hold the infant following delivery

The nurse reviews the arterial blood gas report on a newborn with respiratory distress syndrome (RDS) who was recently weaned from the ventilator and placed in an oxygen hood at 50% oxygen. The results indicate a pH of 7.25, Pao2 of 80 mm Hg, Paco2 of 50 mm Hg, and HCO3- of 24 mEq. Which interpretation should the nurse make of these results?

Respiratory acidosis

A postpartum client suspected of having an infection is informed that she will be unable to have the newborn present in the room with her. The nurse plans care, knowing that which problem is the highest priority at this time?

Risk of ineffective bonding between the mother and newborn

The nurse assists in developing a plan of care for a multigravida client who has a history of cesarean birth. It is determined that the client is at high risk of uterine rupture. The nurse plans to monitor the client closely for which sign or symptom?

Signs of shock

A breastfeeding mother of an infant with lactose intolerance asks the nurse about dietary measures. Which food should the nurse instruct the mother to avoid?

Soft cheeses

The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn?

Tachypnea and retractions

The nurse is preparing a 36-year-old gravida II, para I pregnant client for an amniocentesis. She is at 16 weeks of gestation. Which action should the nurse take before the procedure to ensure fetal safety?

Test the ultrasound equipment to ensure proper functioning.

The nurse is collecting data on a newborn admitted to the nursery with a diagnosis of subdural hematoma after a difficult vaginal delivery. Which intervention implemented by the nurse indicates an understanding of a subdural hematoma?

Testing for equality of extremities when stimulating reflexes

A client has just had surgery to deliver a nonviable fetus because of abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams, "God, just let me die now!" Which problem would direct care for this client?

The client feels hopeless about the situation.

A client beginning week 30 of gestation comes to the clinic for a routine visit. Which observation by the nurse indicates a need for further teaching?

The client is wearing knee-high hose.

The nurse is preparing to administer an injection of vitamin K to a newborn. When administering the injection, the nurse should select which injection site?

The lateral aspect of the middle third of the vastus lateralis muscle

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers?

The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.

The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make which observation while caring for the neonate?

The neonate cries incessantly.

The nurse is preparing to reinforce instructions to a pregnant client about nutrition. The nurse plans to include which instruction in this client's teaching plan?

The nutritional status of the mother significantly influences fetal growth and development.

After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother is discharged. The nurse determines that the mother needs further teaching if the new mother makes which statement?

The only medications that I will take are prenatal vitamins and stool softeners."

An elective cesarean delivery is being planned for a pregnant client. The nurse is reviewing the plans for the surgery with the client. A low transverse uterine incision will be used. The client asks the nurse to explain why this approach is being used. The nurse's response is based on which premise?

This incision allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy.

The nurse in the postpartum unit is assigned to care for a client who delivered a full-term, healthy baby. The nurse receives the report and is told that the mother had lost 500 mL of blood during the delivery. When checking the vital signs, the nurse notes that the woman's pulse is 90 beats per minute and is weak and thready. This finding should indicate which accurate interpretation to the nurse?

This may be a sign of hemorrhage or shock.

The nurse prepares to administer erythromycin ophthalmic ointment to a newborn infant immediately after delivery. Which statement made by the mother indicates that the mother understands the purpose of her newborn receiving this medication?

This medication will provide protection from Neisseria gonorrhoeae and Chlamydia."

The mother of a newborn calls the clinic and reports to the nurse that when she was cleansing the newborn's umbilical cord, the cord was moist and discharge was noted. Which nursing instruction to the mother is appropriate?

To bring the infant to the clinic

The nurse is caring for a client who is being treated with antibiotics for mastitis. To reinforce instructions, what does the nurse tell the client?

To complete the entire antibiotic regimen

The nurse has reinforced instructions to a postpartum client who is hepatitis B positive on how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure?

Washes and dries her hands before feeding

The nurse is collecting data from a pregnant client with a history of cardiac disease. The nurse is checking for venous congestion. The nurse inspects which area, knowing that venous congestion is most commonly noted where

Vulva

The nurse is assessing a 2-day postpartum mother. The mother complains of severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing these complaints, the nurse should check which as a priority?

Vulva for a hematoma

A client is a gravida IV, para III in her final trimester of pregnancy. She does not attend usual social functions because of the fear of stress incontinence. Her oldest child is in a school play, which she wants to attend. Which measure is appropriate to suggest to the client?

Wear a perineal pad to the play.

A postpartum nurse is monitoring the amount of lochial flow in a client following delivery. Which activity should the nurse implement as part of the method to accurately determine the amount of flow for documentation purposes?

Weigh the perineal pad before and after use.

The nurse is gathering data from a pregnant client about physiological risk factors. The nurse should be sure to obtain which priority data?

Weight and height

During the first trimester of pregnancy, a client complains of frequent nausea followed by vomiting. On data collection, which finding indicates a serious nutritional disorder of pregnancy?

Weight compared to last visit is a loss of 2.3 pounds

The nurse is preparing a client for an emergency cesarean delivery. Which information regarding the client has priority?

When was the last time the client ate or drank?

The nurse educates a mother about her newborn's diagnosis of fetal alcohol syndrome (FAS). Which statement by the mother provides the nurse with assurance that the mother understands this syndrome?

Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying."

The nurse is talking to a pregnant client with human immunodeficiency virus (HIV) infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

You will need to bottle-feed your newborn."