Silvestri Maternity Practice NCLEX questions

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A pregnant woman tests positive for the hepatitis B virus (HBV). The woman asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which response by the nurse is most appropriate?

"Breast-feeding is allowed after the baby has been vaccinated with immune globulin."

Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn?

"Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method.

A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client?

"Do you have a history of rheumatic fever?" Clients with a history of rheumatic fever may develop mitral valve prolapse, which increases the risk of cardiac decompensation due to the increased blood volume that occurs during pregnancy.

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

"Do you plan to have any other children?"

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

"Do you plan to have any other children?"

The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instruction?

"During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection."

The nurse is providing instructions about treatment for hemorrhoids to a client in the second trimester of pregnancy. Which statement made by the client indicates a need for further teaching?

"I should apply heat packs to the hemorrhoids to help them shrink."

The clinic nurse is providing instructions to a pregnant client regarding measures that assist in alleviating heartburn. Which statement by the client indicates an understanding of the instructions?

"I should avoid eating foods that produce gas and fatty foods."

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?

"I should avoid exercise because of the negative effects on insulin production."

A pregnant client tells the nurse that she frequently has a backache, and the nurse provides instructions regarding measures that will assist in relieving the backache. Which statement by the client indicates a need for further instruction?

"I should do more exercises to strengthen my back muscles."

The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?

"I should drink adequate fluids and increase my intake of high-fiber foods."

A clinic nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse tells the client about the importance of an adequate daily fluid intake. Which client statement best indicates an understanding of the daily fluid requirement?

"I should drink at least 8 to 10 glasses of fluid each day, of which at least 6 glasses should be water."

The nurse in a health care clinic is instructing a client on how to perform kick counts. Which statement made by the client indicates a need for further teaching?

"I should lie on my back to perform the procedure."

The nurse is teaching a woman in her first trimester measures to alleviate nausea and vomiting. Which statement by the woman indicates that further teaching is required?

"I will eat dry crackers for breakfast after I get up."

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and then teaches the client about proper nutrition to minimize this problem. Which statement, if made by the client, indicates an understanding of the proper nutritional measures to minimize this problem?

"I will eat fresh fruits and vegetables for snacks and for dessert each day."

"I will maintain strict bed rest throughout the remainder of the pregnancy."

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 RhoGAM during pregnancy."

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus?

"It connects the umbilical vein to the inferior vena cava."

The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation?

"It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus.

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 nursing instructor asks a nursing student who is preparing to assist with the assessment of an 18 weeks' gestation gravida 2, para 1 (G2P1) pregnant woman to describe expectations related to the process of quickening. Which statements, if made by the student, indicate an understanding of this process? Select all that apply.

"It is the fetal movement that is felt by the mother." "It is typically experienced by the multigravida client between 16 and 18 weeks' gestation."

A female client with insulin-dependent diabetes arrives at the clinic seeking a plan to get pregnant in approximately 6 months. She tells the nurse that she want to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client?

"Maintain blood sugar levels in a constant rage within normal limits during pregnancy."

The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response, if made by the student, indicates an understanding of this physiological process? Select all that apply.

"Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high." "The release of the follicle-stimulating hormone and luteinizing hormone is inhibited by adaptations related to pregnancy."

The nurse is assisting in conducting a prenatal session with a group of expectant parents. One of the expectant parents asks, "How does the milk get secreted from the breast?" What should be the nurse's response?

"Prolactin stimulates the secretion of milk, which is called lactogenesis."

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny-looking head." Which response by the nurse is best?

"That is normal. The head will return to a round shape within 7 to 10 days."

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? Select all that apply.

"The ductus arteriosus allows blood to bypass the fetal lungs." "One vein carries oxygenated blood from the placenta to the fetus." "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta."

A nursing student is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of Kegel exercises. Which response made by the student indicates an understanding of the purpose? Select all that apply.

"The exercises will help strengthen the pelvic floor in preparation for delivery." "The exercises will help strengthen the muscles that support the bladder and urethra."

The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement, if made by the client, indicates an understanding of the instructions?

"The iron is best absorbed if taken on an empty stomach."

A couple is seen in the fertility clinic. After several tests it has been determined that the husband is not sterile and that the wife has nonpatent fallopian tubes. The nurse is preparing the woman and her husband for an in vitro fertilization. Which statement by the woman or her spouse indicates a need for further information about the procedure?

"The procedure is performed using artificial insemination of sperm instilled through the vagina."

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?

"The vaginal discharge may be bothersome, but is a normal occurrence."

The nurse encourages a pregnant client who is human immunodeficiency virus (HIV) positive to immediately report any early signs of vaginal discharge or perineal tenderness to the health care provider. The client asks the nurse about the importance of this action, and the nurse responds by making which statement to the client?

"This is necessary to assist in identifying potential infections that may need to be treated."

A pregnant client at 16 weeks' gestation reports to the health care clinic for a triple screen test. The nurse determines that the client understands the purpose of this test when the client makes which statements? Select all that apply.

"This test can be used as a screening for spina bifida." "This test is a screening test, and I will need other testing if I have abnormal results." "This test can indicate if I may be at an increased risk for having a child with Down syndrome."

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 most appropriate and supportive to the woman?

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

A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to the chart.

"You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk."

A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse plan to tell the client?

"You will be evaluated at the time of delivery for genital lesions, and if any are present, a cesarean delivery will be needed."

A client who has just been told that she is pregnant wants to know when the baby's heart will be completely developed and beating. The nurse reads in the client's chart that the health care provider has determined the client to be at 6 weeks' gestation. What is the nurse's best response?

"Your baby's heart right now has double heart chambers and has begun to beat, so we should be able to see it beat using an ultrasound machine."

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

"Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative of adequate nutrition, most home scales do not measure this accurately, and the suggestion will likely make the mother anxious.

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis?

"Your type of pelvis is the most favorable for labor and birth."

The nurse is creating a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply.

- Keep the room semi-dark. - Initiate seizure precautions. - Pad the side rails of the bed. - Avoid environmental stimulation.

The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply

-Tachycardia -Fetal hypoxia -Metabolic acidemia -Congenital anomalies

Steps to take if umbilical cord prolapse is suspected

1. Elevate fetal presenting part that is lying on cord by applying finger pressure 2. Place client into extreme Trendelenburg's or modified SIm's position or knee chest position. 3. Admin oxygen face mask 8-10L/min 4. Monitor FHR and assess for hypoxia 5. IV fluids 6. Prepare for immediate birth

An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse would identify which findings as normal? 1. Light green, with no odor 2. Clear and dark amber-colored 3. Thick and white, with no odor 4. Pale straw-colored, with flecks of vernix

4 Amniotic fluid normally is pale straw-colored and may contain flecks of vernix caseosa. Greenish fluid may indicate the presence of meconium and suggests fetal distress. Amber-colored fluid suggests the presence of bilirubin. The fluid should not be thick and white.

A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for throughout the client's labor? 1. Anxiety 2. Hemorrhage 3. Low self-esteem 4. Postpartum infection

4 Anemic women have a greater likelihood of cardiac decompensation during labor, postpartum infection, and poor wound healing. Anemia does not specifically present a risk for hemorrhage. Anxiety and low self-esteem are unrelated to physiological integrity.

The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of which condition? 1. Hematoma 2. Uterine atony 3. Placenta previa 4. Placental separation

4 As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. Options 1, 2, and 3 are incorrect interpretations.

A nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse should document these observations as signs of which condition? 1. Hematoma 2. Uterine atony 3. Placenta previa 4. Placental separation

4 As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. The other options are not characterized by these findings.

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

Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?" A. Lying prone with a pillow on the abdomen. B. Using a breast pump. C. Massaging the abdomen. D. Giving oxytocic medications.

A. Lying prone with a pillow on the abdomen.

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

A. Raise the foot of the bed.

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

A. complete sterile vag exam

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

A. gestational diabetes

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

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

The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Bassed on this assessment the nurse determines that the neonate has a maturity rating 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (select all that apply)

Admission weight of 4 pounds, 15oz Head to heel length of 17in Frontal occipital circumference of 12.5in

Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home?

Allow the cord to air-dry as much as possible Recent studies have indicated that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process.

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply.

Allows for fetal movement Surrounds, cushions, and protects the fetus Maintains the body temperature of the fetus Can be used to measure fetal kidney function

A contraction stress test is scheduled for a pregnant woman, and she asks the nurse to describe the test. What should the nurse include in the teaching? Select all that apply.

An external monitor is attached in order to view fetal heart rate response to an established contraction pattern. The uterus is stimulated to contract by the administration of small amounts of oxytocin or by nipple stimulation.

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?

An informed consent needs to be signed before the procedure.

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

A woman who gave birth 48 hours ago is bottle feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take?

Apply cold compress to both breast for comfort

Multigravida at term with back labor, cervix is 3 cm dilated, 50% effaced, -1 station.

Apply counter pressure to sacral area. RATIONALE: Caused by malposition of the fetus.

A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement?

Apply firm pressure to sacral area

A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps?

Apply heat to the affected area.

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?

Are where fertilization occurs

The nurse is assessing a client who is having a non-stress test at 41 weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take?

Ask the client if she has felt any fetal movement

The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. the nurse determines that the client is not having contractions, the fetal heart rate baseline is 144bpm, and no FHR accelerations are occurring. What action should the nurse take?

Ask the client if she has felt any movement.

A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. Which of the following should be the focus of the nurse's response?

Asking the client and her partner if they would like the nurse to stay in the room Offering to remain with the client and her partner offers support without providing false reassurance.

The nurse is reviewing the medical record of a woman scheduled for her weekly prenatal appointment. The nurse notes that the woman has been diagnosed with mild preeclampsia. Which interventions should the nurse include in planning nursing care for this client? Select all that apply.

Assess blood pressure. Check the urine for protein. Assess deep tendon reflexes. Teach the importance of keeping track of a daily weight.

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks' gestation. What is the priority nursing action for this client?

Assess for signs and symptoms of labor

. Patient had twins born to multigravida, 12 hours ago. Nursing Dx?

Assess fundal tone and lochia flow.

Sore nipples on day 2 of breastfeeding.

Assess infants position while feeding. RATIONALE: To make sure baby is latching properly.

Assess the baseline fetal heart rate.

The nurse assist the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure?

Assess the fetal heart rate

After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action?

Assess the vagina and cervix with a gloved hand.

A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year old child that was delivered at 37 weeks and tells the nurse that she doesn't have any history of abortion or fetal demise. The nurse would document the GTPAL for this client as: A) G = 3, T = 2, P = 0, A = 0, L =1 B) G = 2, T = 0, P = 1, A = 0, L =1 C) G = 1, T = 1. P = 1, A = 0, L = 1 D) G = 2, T = 0, P = 0, A = 0, L = 1

B) G = 2, T = 0, P = 1, A = 0, L =1 Rationale: Pregnancy outcomes can be described with the acronym GTPAL. "G" is Gravidity, the number of pregnancies. "T" is term births, the number of born at term (38 to 41 weeks). "P" is preterm births, the number born before 38 weeks gestation. "A" is abortions or miscarriages, included in "G" if before 20 weeks gestation, included in parity if past 20 weeks AOE. "L" is live births, the number of births of living children. Therefore, a woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 37 weeks, the number of preterm births is 1, and the number of term births is 0. The number of abortions is 0, and the number of live births is 1.

Gravida refers to which of the following descriptions? A) A serious pregnancy B) Number of times a female has been pregnant C) Number of children a female has delivered D) Number of term pregnancies a female has had

B) Number of times a female has been pregnant Rationale: Gravida refers to the number of times a female has been pregnant, regardless of pregnancy outcome or the number of neonates delivered.

A 21-year old client, 6 weeks' pregnant is diagnosed with hyperemesis gravidarum. This excessive vomiting during pregnancy will often result in which of the following conditions? A) Bowel perforation B) Electrolyte imbalance C) Miscarriage D) Pregnancy induced hypertension (PIH)

B) Electrolyte imbalance Rationale: Excessive vomiting in clients with hyperemesis gravidarum often causes weight loss and fluid, electrolyte, and acid-base imbalances.

A nurse is performing an assessment of a primipara who is being evaluated in a clinic during her second trimester of pregnancy. Which of the following indicates an abnormal physical finding necessitating further testing? A) Consistent increase in fundal height B) Fetal heart rate of 180 BPM C) Braxton hicks contractions D) Quickening

B) Fetal heart rate of 180 BPM Rationale: The normal range of the fetal heart rate depends on gestational age. The heart rate is usually 160-170 BPM in the first trimester and slows with fetal growth, near and at term, the fetal heart rate ranges from 120-160 BPM. The other options are expected.

An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention should the nurse prepare the client for?

Delivery of the fetus

A woman with type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement?

Describe diet changes that can improve the management of her diabetes

Dystocia

Difficult labor that is prolonged or more painful Occurs because of problems caused by uterine contractions, fetus or bones and tissues of maternal pelvis. Fetus large, malpositioned or abnormal presentation. Hypertonic contractions- painful, frequently, uncoordinated Hypotonic contractions- short, irregular, weak, amniotomy and oxytocin tx. Can result in maternal dehydration, infection, fetal injury or death.

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

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

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

B.screen for neural tube defects

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply.

Ballottement Chadwick's sign Uterine enlargement Positive pregnancy test

A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first?

Bathe the infant with an antimicrobial soap

A pregnant client asks the nurse in the clinic, "When will I begin to feel fetal movement?" Which response should the nurse make?

Between 16 and 20 weeks

Between the time the temperature falls and rises

Terbutaline (Brethine) injections for preterm labor. When do you hold and call the MD?

Bilateral crackles in lungs on auscultation (critical complication). RATIONALE: Could indicate pulmonary edema.

A multigravida client at 41-weeks gestation presents in the labor and delivery unit afer a non-stress test indicatied that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status?

Biophysical profile (BPP)

Subarachnoid (spinal) block

Block administered just before birth -Anesthetic relieves uterine and perineal pain and numbs vagina, perineum, and lower ext. -May cause maternal hypotention, *Post pardum H/A* Mother must lie flat for 8-12 hours after spinal injection.

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

Bluish discoloration of cervix and vagina

A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide?

Breastfeed the infant every 2 hours. The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. If the infant does not feed adequately and empty the breast, using a breast pump helps extract the milk and relieve some of the discomfort. Dehydration irritates swollen breast tissue. Skipping feedings may cause further engorgement and discomfort.

A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client?

Breastfeed the infant, ensuring that both breasts are completely emptied. Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue.

Accelerations

Brief temp increases in FHR atleast 15bpm more than baseline lasting 15 sec Usually reasssuring= reflecting a responsive, nonacidotic fetus Occurs with fetal movement May occur with uterine contractions, vaginal exams, mild cord compression or fetus in breech presentation

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first? A.Provide oral hydration. B.Have a complete blood count (CBC) drawn. C.Obtain a specimen for urine analysis. D.Place the client on strict bedrest.

C.Obtain a specimen for urine analysis.

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

C.Place the woman in a lateral position.

A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complaint indicates that the fallopian tubes are patent? A.Back pain B.Abdominal pain. C.Shoulder pain. D. Leg cramps.

C.Shoulder pain.

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

C.Three vessels: two arteries and one vein.

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

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

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

C.the cervix is completely dilated.

A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action?

Continue to monitor the client.

A client with no prenatal care arrives at the labor unit scraming, "The baby is coming!" The nurse preforms a vaginal examination that reveals the cervix is 3 centimeters dialated and 75% effaced. What additional information is most important for the nurse to obtain?

Date of last menstrual period.

Early decelerations

Decreases in FHR below baseline; rare at lowest point and remains greater than 100bpm Occur during contractions as fetal head is pressed against the mothers pelvis or soft tissues and return to baseline FHR by end of contraction -*Tracing shows a uniform shape and mirror image of uterine contractions.* *Not associated with fetal compromise and require no interventions*

A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue and a moist cough. Which question is most important for the nurse to ask this client?

Do you have a history of rheumatic fever?

A 24-hour old newborn has a pink popular rash with vesicles superimposed on the thorax, back and abdomen. What action should the nurse implement

Document the finding in the infants record.

Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

Explain to the client why a cesarean delivery is necessary.

Stage 2

Expulsion of fetus *Pushing stage* Mother has intense concentration on pushing with contractions; may fall asleep b/w contractions Interventions: cervical dilation complete, descent of fetal head, bloody show, mother feels urge to bear down. *Perineal bulging or visual of fetal head* Assess q5min, Monitor VS, FHR, uterine contractions

A client is active labor complains of cramps in her leg. What intervention should the nurse implement?

Extend the leg and dorsiflex the foot

The nurse is teaching breastfeeding to prospective parents in a childbirth education calss.. Which instruction should the nurse include as content in the class?

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

The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information?

Fetal heart rate (FHR) The FHR should be assessed before and after the procedure to detect changes that may indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix is favorable. The fluid should be assessed for color, odor, and consistency.

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

Fetal heart rate of 180 beats per minute

The nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of pregnancy. Which findings concern the nurse and indicate the need for follow-up? Select all that apply.

Fetal heart rate of 180 beats/minute Elevated level of maternal serum alpha-fetoprotein (MSAFP)

Which assessment following an amniotomy should be conducted first?

Fetal heart rate pattern

. Newborn assessment for respiratory distress.

Flaring of the nares. RATIONALE: Forced inspiration, grunting, tachy (respirations >60), cyanosis, and retractions over chest wall).

. Full term infant, vaginal birth, placed in radiant warmer, is apneic. What to do FIRST?

Flick soles of feet. RATIONALE: Infant needs additional stimulation to initiate breathing.

Rheumatic fever hx as a child, resulted in heart damage, risk for CHF post delivery. Nursing Dx?

Fluid volume excess. RATIONALE: 3rd spacing.

Preterm labor interventions

Focus on stopping labor Identify and treat infection Restrict activity Ensure hydration; admin fluids Bed rest; Lateral position Monitor fetal status Admin meds *(Tocolytics)*

The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred?

Forceps delivery

To measure contractions...

From beginning of a contraction, to the beginning of the next contractions.

The client is being seen at 24 weeks' gestation at the prenatal clinic. At her last routine visit, the fundus was located at the umbilicus. Today, the fundus is measured and found to be 23 cm. How should the nurse interpret this finding?

Fundus is at the appropriate level.

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 the GTPAL for this client as which?

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

The healthcare provider prescribes terbutaline (Brethine) for a clint in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition.

Gestational diabetes

Abacavir (ziagen) 450 mg po tid ordered for HIV positive. Stock is 300 mg tabs. Give?

Give 1.5 tabs.

FHR decreases after each contraction. What should the nurse do?

Give 10 lpm 02 via mask.

Not Rubella immune (negative titer) and 6 weeks pregnant. When should the vaccine be given?

Give early postpartum within 72 hours. HESI HINT: "Rubella is teratogenic to the fetus during the first trimester, causing congenital heart disease, congenital cataracts, or both. All women should have their titers checked during pregnancy. If a woman's titers are low, she should receive the vaccine after delivery and be instructed not to get pregnant within 3 months. Breast-feeding mothers may take the vaccine" (p. 288).

Nonreassuring FHR pattern interventions

Identify cause (bradycardia, tachycardia, late decelerations, prolonged decelerations, hypertonic uterine activity, decreased/absent variability, variable desceleration <70 longer than 1 min) D/C oxytocin (Pitocin) infusion Change mothers position Admin oxygen 8-10Lm via mask IV fluids Initiate cont electronic fetal monitoring with internal devices Prepare for c-section

Immediately after birth a newborn infant is suctioned, dried and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse preform next?

Initiate positive pressure ventilation

Lumbar epidural block

Injection site is in epidural space. -Block administered after labor is established or before scheduled c-section. -Anesthetic relives pain from contractions and numbs vagina and perineum. -*Block may cause hypotension, bladder distention and prolonged 2nd stage but observe for S/E: N/V, pruritus, respiratory dispression* -*Does not cause H/A*- dura mater not penetrated. Assess maternal BP in side lying position or place rolled blanket beneath (R) hip to displace the uterus from vena cava.

. 12 hours after birth, mother c/o vaginal pressure, fundus firm @ midline, with moderate

Inspect perineal and rectal area.

Amniotic fluid embolism interventions

Institute emergency measures to maintain life Admin oxygen 8-10 l Prepare for intubation and mechanical ventilation Position client on side Admin IV fluids, blood products and meds Monitor fetal status *Prepare for emergency delivery when client stabilized.*

The nurse reviews the plan of care for a woman at 37 weeks' gestation who has sickle cell anemia. The nurse determines that which problem listed on the nursing care plan will receive the highest priority?

Insufficient fluid volume

Four major factors (four Ps)

Interact during normal childbirth Interrelated and depend on each other for a safe delivery Include: Powers, Passageway, Passenger, Psyche

Nutrition teaching for pregnant teens.

Iron-deficient anemia.

A pregnant client reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. A sputum culture is obtained, and Mycobacterium tuberculosis is identified in the sputum. Which instruction should the nurse provide to the client regarding therapeutic management of tuberculosis?

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

The nurse is teaching a pregnant client about the physiological effects and hormonal changes that occur during pregnancy. The client asks the nurse about the role of estrogen in pregnancy. Which responses should the nurse give the client about the role of estrogen? Select all that apply.

It increases the blood flow to mucous membranes and causes them to swell and soften. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response based on what knowledge?

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

A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide?

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

The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormone 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 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 characterizes the 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 counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur?

January 29 to 30 This client can expect her next period to begin 36 days from the first day of her last menstrual period. Her next period would begin on February 12. Ovulation occurs 14 days before the first day of the menstrual period. The client can expect ovulation to occur January 29 to 30.

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

January 30-31

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 was October 20, 2016. Using Nägele's rule, the nurse determines the estimated date of birth is which?

July 27, 2017

Leopold's Maneuvers

Methods of palpation to determine presentation and position of the fetus and aid in location of fetal heart sounds. -If head in fundus-> hard, round, movable object is felt. -Buttocks feel soft and have irregular shape and more difficult to move. -Fetus back; smooth hard surface should be felt on one side of abdomen. -Irregular knobs and lumps (hands, feet, elbows and knees felt on opposite side of abdomen.

The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia?

Monitoring the mother's blood pressure

When explaining "postpartum blues" to a client who is 1 day postpartum, which symtoms should the nurse include in the teaching plan?(Select all that apply)

Mood swings Tearfulness

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities?

Move about every hour Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous return.

The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct?

Two weeks before menstruation Ovulation occurs 14 days before the first day of the menstrual period. Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of the menstrual cycle varies. Options B, C, and D are incorrect.

The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor? (Select all that apply.)

Pain in the lower back that radiates to abdomen Progressive cervical dilation and effacement Regular and rhythmic painful contractions

Gravida 1, para 0, cervix dilated 8 cm, contractions Q2 min, bloody show, and nausea. Nurse Dx?

Pain r/t transitional phase of labor.

A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and should suspect a diagnosis of placenta previa if which finding is noted?

Painless vaginal bleeding

The nurse is caring for a client with a diagnosis of placenta previa. The nurse collects data knowing that which are characteristic of placenta previa? Select all that apply.

Painless, bright red vaginal bleeding Location in the lower uterine segment

Most accurate way to determine fetal position at 29 weeks gestation.

Ultrasound. RATIONALE: Provides direct view of the fetus.

An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse should identify which findings as normal?

Pale straw in color, with flecks of vernix

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise?

Persistent nonreassuring fetal heart rate

Stage 4

Physical recovery 1-4 hours after expulsion of placenta Mother is tired, but is eager to become acquainted with her newborn. *Monitor lochia discharge* Moderate amount and red in color. Assessment: BP & pulse returns to prelabor level, Fundus remains contracted, in midline 1-2 fingerbreadths below umbilicus Interventions- Assess every q15min, ice packs to perineum, massage uterus, breast feeding support

Presentation

Portion of the fetus that enters the pelvic inlet first a. Cephalic (Head) - most common - vertex, military, brow & face b. Breech (buttocks present) - frank, full (complete), and footling - c-section may be required c. Shoulder - fetus in transverse lie; arm, back, abdomen, side could be preent -If fetus does not spontaneously rotate or can be manually turned, need c-section

Postpartum temporary bed-rest should be placed if?

Positive Homan's sign.

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

Urine output 90mL / 4 hours

Patient asks if she can use the same diaphragm for birth control after her pregnancy, the nurse answers ...

Use alternative form of birth control until new diaphragm can be obtained.

. Post partum teaching to prevent pregnancy.

Use condom and spermicidal gel.

The nurse reviews the assessment history for a client with a suspected ectopic pregnancy. Which assessment findings predispose the client to an ectopic pregnancy? Select all that apply.

Use of fertility medications History of Chlamydia Use of an intrauterine device History of pelvic inflammatory disease (PID)

Ativan 0.5 mg IM every 1 hour as needed is prescribed for a client experiencing delirium tremens. The medication vial reads 2mg/mL of solution. How many mL should the LPN draw into the syringe for single dose administration?

Possible correct answers: 0.25 mL0.25mL0.25ml0.25 ml Explanation 2mg/mL= 0.5mg/xmL 2x=0.5 x=0.5/2 x=0.25 mL

Local anesthesia

Used for blocking pain during episiotomy. Administered just before birth of infant No effect on fetus

General anesthesia

Used for surgical interventions. Mother not awake - Maternal danger of respiratory depression, vomiting and aspiration.

In PACU, the most important assessment for first 8 hours after cesarean:

Uterine atony. RATIONALE: Uterine atony can lead to hemorrhage.

After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac Soy Isomil Formula, a soy protein isolate based infant formula. What information should the nurse provide to the mother about newly prescribed formula?

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

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply.

The cervix is dilated completely. The spontaneous urge to push is initiated from perineal pressure.

Powers

Uterine contractions 1. Forces acting to expel the fetus 2. *Effacement* shortening and thinning of cervix during the 1st stage of labor 3. *Dilation*- enlargement of cervical os and cervical canal during the 1st sage of labor 4. Pushing efforts of mother during 2nd stage

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

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

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately? a.Heart rate of 100 beats/minute. b.Variable fetal heart rate. c.Onset of uterine contractions. d.Burning on urination.

c.Onset of uterine contractions.

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next? a.Cleanse the perineum. b.Obtain a blood pressure. c.Palpate the firmness of the fundus d. Inspect the perineum for lacerations.

c.Palpate the firmness of the fundus

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

c.Places the infant prone in the bassinet.

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the health care provider (HCP)?

The client complains of a headache and blurred vision.

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor?

The client has a history of cardiac disease.

The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment?

The client has a history of hypertension.

Forceps delivery

Two double crossed, spoon like articulated blades used to assist in delivery of fetal head. -Check neonate and mother after delivery for possible injury. -Repair any lacerations

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?

Two umbilical arteries and one umbilical vein

A 23-year-old client who is receiving Medicaid benefits is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client? a.Refer the client to a social worker to arrange for home care. b.Recommend perinatal care from an obstetrician, not a nurse-midwife. c.Teach the client why keeping prenatal care appointments is important. d.Advise the client that neonatal intensive care may be needed.

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

Variability

*Fluctuations in baseline FHR* -Absent or undetected is nonreassuring -Decreased can result from fetal hypoxemia, acidosis or meds -Temporary decrease can occur when fetus is in a sleep state (not longer than 30 min)

Late decelerations

*Nonreassuring patterns that reflect impaired placental exchange or uteroplacental insufficiency* Patterns look similar to early decelerations but begin well after the contraction begins and return to baseline after contraction ends. Interventions: immediately improving placental blood flow and fetal oxygenation

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

18 and 20

The nurse is collecting data from a client who suspects she is pregnant. The nurse is checking the client for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.

-Ballottement -Chadwick's sign -Uterine enlargement -Braxton Hicks contractions

Mechanisms of Labor

-Lightening or dropping -Braxton Hicks increase -Vaginal mucosa is congestion; vaginal discharge increases -Brownish or blood-tinged cervical mucus is passed -Cervix ripens, becomes soft and partly effaces, dilate -Mother has sudden burst of energy "Nesting"- 24-48 hrs before onset of labor Wt loss of 1-3 lbs r/t fluid shifts d/t progesterone and estrogen levels -Spontaneous rupture of membranes

A 30-year-old multiparous woman who has a 3-year-old boy and an newborn girl tells the nurse, "My son is so jealous of my daughter, I don't know how I'll ever manage both children when I get home." How should the nurse respond? a.Tell the older child that he is a big boy now and should love his new sister. b.Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him. c.Let the older child stay with his grandparents for the first six weeks to allow him to adjust to the newborn. d.Regression in behaviors in the older child is a typical reaction so he needs attention at this time.

...

. Primigravida, 36 week, admitted, water broke, 2cm dilated, 50% effaced, -2 station, vertex presentation, greenish colored amniotic fluid, contractions Q3-5 min with deceased in FHR after the last 4 contraction peaks. What to do FIRST?

02 via facemask.

The nurse is assessing the deep tendon reflexes of a client with severe preeclampsia who is receiving intravenous magnesium sulfate. The nurse should perform which procedure to assess the brachioradialis reflex? Click on the image to indicate your answer.

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/minute. Which nursing action is most appropriate? 1. Notify the health care provider (HCP). 2. Continue monitoring the fetal heart rate. 3. Encourage the client to continue pushing with each contraction. 4. Instruct the client's coach to continue to encourage breathing techniques.

1 A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate should be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the HCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.

On March 10, 2015, the nurse performed an initial assessment on a client admitted to the labor and delivery unit for "rule out labor." The client has not received prenatal care but is certain that the first day of her last menstrual period (LMP) was July 7, 2014. The nurse plans care based on which interpretation? 1. The client is possibly in preterm labor. 2. The fetus may not be viable at delivery. 3. The client may require labor augmentation. 4. The fetus is at high risk for shoulder dystocia.

1 According to Nägele's rule, subtracting 3 months and adding 7 days and 1 year to this client's LMP, her estimated date of delivery (EDD) would be April 14, 2015. This client is in the labor and delivery unit to be evaluated for the presence of labor more than 1 month before her EDD, therefore possibly being in preterm labor. Viability is said to occur between the 22nd and 25th weeks of gestation, so this would eliminate option 2. This fetus is approximately 4 weeks before term. Because of the typical 36-week gestational size of a fetus, 2200 to 2900 g, there would be no risk for a difficult shoulder delivery, so option 4 can be eliminated. If this client truly is in labor, the health care provider's plan would be to try to stop the labor in order to prevent delivery at this early stage in the pregnancy. This would eliminate option 3, labor augmentation.

A nurse assists the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure? 1. Assess the fetal heart rate. 2. Check the client's temperature. 3. Change the pads under the client. 4. Check the client's respiratory rate.

1 After amniotomy or rupture of the membranes in the birth setting, the nurse immediately assesses the fetal heart rate for at least 1 minute to detect changes associated with prolapse or compression of the umbilical cord. The quantity, color, and odor of the amniotic fluid also are noted. The client's temperature should be assessed every 2 to 4 hours, and the nurse also would check the client's vital signs. The pads under the client should be changed regularly to promote comfort and reduce the moist environment that favors bacterial growth, but this is not the priority.

The nurse is administering magnesium sulfate to a client for preeclampsia at 34 weeks gestation. What is the priority nursing action for this client? 1. Assess for signs and symptoms of labor. 2. Assess the client's temperature every 2 hours. 3. Schedule a daily ultrasound to assess fetal movement. 4. Schedule a non-stress test every 4 hours to assess fetal well-being.

1 As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor. This client is not at high risk for infection. Daily ultrasound exams are not necessary for this client. A non-stress test may be done, but not every 4 hours.

The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred? 1. Forceps delivery 2. Schultz presentation 3. Hypotonic contractions 4. Weak bearing-down efforts

1 Excessive fundal pressure, forceps delivery, violent bearing-down efforts, tumultuous labor, and shoulder dystocia can place a client at risk for traumatic uterine rupture. Schultz presentation is the expulsion of the placenta with the fetal side presenting first and is not associated with uterine rupture. Hypotonic contractions and weak bearing-down efforts do not add to the risk of rupture because they do not add to the stress on the uterine wall.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1. Provide pain relief measures. 2. Prepare the client for an amniotomy. 3. Promote ambulation every 30 minutes. 4. Monitor the oxytocin (Pitocin) infusion closely.

1 Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes, but would be encouraged to rest.

The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia? 1. Hypotonic 2. Precipitous 3. Hypertonic 4. Preterm labor

1 Hypotonic labor contractions are short, irregular, and weak and usually occur during the active phase of labor. Hypertonic dystocia usually occurs during the latent phase of labor, and contractions are painful, frequent, and usually uncoordinated. Precipitous labor is labor that lasts in its entirety for 3 hours or less. Preterm labor is the onset of labor after 20 weeks of gestation and before the thirty-seventh week of gestation.

A nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing? 1. Hypotonic 2. Precipitate 3. Hypertonic 4. Preterm labor

1 Hypotonic labor contractions are short, irregular, weak, and usually occur during the active phase of labor. Precipitate labor is that which lasts in its entirety for 3 hours or less. Hypertonic dysfunction usually occurs during the latent phase of labor. Preterm labor is the onset of labor after 20 weeks of gestation and before the beginning of the 38th week of gestation.

A nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. What is the initial nursing action? 1. Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min. 2. Turn the client on her back and administer oxygen by face mask at 8 to 10 L/min. 3. Turn the client on her side and administer oxygen by nasal cannula at 2 to 4 L/min. 4. Turn the client on her back and administer oxygen by nasal cannula at 2 to 4 L/min.

1 If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To facilitate oxygen to the mother and her fetus, the client is turned to her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen at 8 to 10 L/min is applied to the mother by face mask.

A nurse is caring for a client in the active stage of labor. The nurse notes that the fetal pattern shows a late deceleration on the monitor strip. Based on this finding the nurse should prepare for which appropriate nursing action? 1. Administering oxygen via face mask 2. Placing the mother in a supine position 3. Increasing the rate of the intravenous (IV) oxytocin (Pitocin) infusion 4. Documenting the findings and continuing to monitor the fetal patterns

1 Late decelerations are caused by uteroplacental insufficiency as a result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is discontinued when a late deceleration is noted; otherwise the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency caused by stimulation of contractions caused by the oxytocin. Option 4 would delay necessary treatment.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen via face mask. 2. Place the mother in a supine position. 3. Increase the rate of the oxytocin (Pitocin) intravenous infusion. 4. Document the findings and continue to monitor the fetal patterns.

1 Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment.

A nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which is the priority nursing intervention? 1. Provide pain relief measures. 2. Prepare the client for an amniotomy. 3. Promote ambulation every 30 minutes. 4. Monitor the oxytocin (Pitocin) infusion closely.

1 Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. The client with hypertonic uterine dysfunction would not be encouraged to ambulate every 30 minutes but would be encouraged to rest.

The nurse is caring for a client who is receiving oxytocin (Pitocin) for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first? 1. Stop the oxytocin infusion. 2. Check the client's blood pressure. 3. Check the client for bladder distention. 4. Place the client in a side-lying position.

1 Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse needs to intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The health care provider is notified. The nurse would monitor the client's blood pressure and intake and output; however, the nurse would first stop the infusion.

A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client? 1. Measure fundal height. 2. Attach electronic fetal monitoring. 3. Prepare the client for a possible cesarean section. 4. Visually examine the perineum and vaginal opening.

1 The correct option is least appropriate because fundal height should be measured at each antepartum clinic visit, not in the intrapartum period. All other options are priorities. Intrapartum management and assessment require careful attention to maternal and fetal status. The fetuses should be monitored by dual electronic fetal monitoring, and any signs of distress must be reported to the health care provider. A cesarean section may be necessary if a fetus is breech. The nurse should examine the perineum and vaginal opening visually for signs of the cord, which sometimes prolapses through the cervix.

A woman in active labor has requested a regional anesthetic. She is currently 5 cm dilated. The health care provider (HCP) has prescribed an epidural block. Which nursing intervention would be implemented after the epidural block has been placed? 1. Palpate the bladder at frequent intervals. 2. Encourage the woman to walk to progress the labor. 3. Assess the blood pressure frequently for hypertension. 4. Encourage the woman to assume a supine position after the epidural has been placed.

1 The effect of the epidural is that anesthesia is felt from the fifth lumbar space to the sacral region of the vertebral column. The woman loses sensation that she needs to urinate. The nurse must palpate the bladder frequently because a full bladder will impede progression of the fetus during the laboring process. Hypotension, not hypertension, is a concern. Ambulation is not allowed because of the anesthesia. The woman is encouraged to lie on her side to increase placental perfusion to the fetus.

The nurse caring for a client in labor notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which best describes minimal variability? 1. FHR fluctuations are lasting more than 15 seconds. 2. FHR fluctuations last at least 15 seconds and go at least 15 beats/min below the baseline rate. 3. FHR fluctuations are lasting more than 15 seconds. 4. FHR fluctuations last at least 15 seconds and go at least 15 beats/min below the baseline rate.

1 The fluctuations in the baseline FHR are the definition of variability. Variability can be classified into four different categories: absent, minimal, moderate, and marked. Minimal variability is defined as fluctuations that are fewer than 6 beats/min. If the depth of the fluctuations is between 6 and 25 beats/min, moderate variability is present. Accelerations are defined as lasting more than 15 seconds and reaching at least 15 beats/min above the baseline. Decelerations, like accelerations, must last at least 15 seconds and go at least 15 beats/min below the baseline rate.

An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention should the nurse prepare the client for? 1. Delivery of the fetus 2. Strict monitoring of intake and output 3. Complete bed rest for the remainder of the pregnancy 4. The need for weekly monitoring of coagulation studies until the time of delivery

1 The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Because delivery of the fetus is necessary, the remaining options are incorrect regarding management of the client with abruptio placentae.

A nurse is providing emergency measures to a client in labor who has been diagnosed 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 client problem is most appropriate to address at this time? 1. The client's fear 2. The client's fatigue 3. The client's inability to control the situation 4. The client's inability to cope with the situation

1 The mother is anxious and frightened, and the most appropriate problem to address for the client at this time is fear. No data in the question support a client problem with fatigue, inability to control the situation, or inability to cope with the situation. These problems may be considered for this client at some point during the hospitalization experience.

A nurse is developing a plan of care for a client experiencing dystocia, and includes several nursing interventions in the plan. The nurse prioritizes the plan and selects which nursing intervention as the highest priority? 1. Monitoring fetal status 2. Providing comfort measures 3. Changing the client's position frequently 4. Keeping the significant other informed of the progress of the labor

1 The priority in the plan of care would include the intervention that addresses the physiological integrity of the fetus. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, fetal status is the priority.

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with the legs in stirrups 3. Prone position with the legs separated and elevated 4. Semi-Fowler's position with a pillow under the knees

1 Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying, with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position, however; a wedge placed under the right hip provides displacement of the uterus. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler's position or prone position is not practical for this type of abdominal surgery.

A nurse is monitoring a client in labor whose membranes ruptured spontaneously. What is the initial nursing action? 1. Determine the fetal heart rate. 2. Provide peripads for the client. 3. Take the client's blood pressure. 4. Note the amount, color, and odor of the amniotic fluid.

1 When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Options 3 and 4 are also appropriate actions, but are not the initial actions in this situation. The nurse may assist the client in cleaning, changing clothing, and providing peripads but determining the fetal heart rate is the initial action.

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action? 1. Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min. 2. Turn the client onto her back and give oxygen by face mask at 8 to 10 L/min. 3. Turn the client onto her side and give oxygen by nasal cannula at 2 to 4 L/min. 4. Turn the client onto her back and give oxygen by nasal cannula at 2 to 4 L/min.

1 f a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To promote adequate oxygenation for the mother and her fetus, the mother is turned to her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen by face mask at 8 to 10 L/min is applied to the mother.

The purpose of a vaginal examination is to specifically assess the status of which findings? Select all that apply. 1. Station 2. Dilation 3. Effacement 4. Bloody show 5. Contraction effort

1, 2, 3 The vaginal examination for a client in labor specifically determines effacement 0 to 100%, dilation 0 to 10 cm, and station -5 cm (above the maternal ischial spine) to +5 cm (below the maternal ischial spine). Bloody show is the brownish or blood-tinged cervical mucus that may be passed preceding labor and is not a specific part of the assessment when performing a vaginal examination. Contraction effort is not determined by vaginal examination.

The nurse is developing a plan of care for a pregnant client with a diagnosis of severe preeclampsia. Which nursing actions should be included in the care plan for this client? Select all that apply. 1. Keep the room semi-dark. 2. Initiate seizure precautions. 3. Pad the side rails of the bed. 4. Avoid environmental stimulation. 5. Allow out-of-bed activity as tolerated.

1, 2, 3, 4 Clients with severe preeclampsia are maintained on bed rest in the lateral position. Only bathroom privileges may be allowed. Keeping the room semi-dark, initiating seizure precautions, and padding the side rails of the bed are accurate interventions. Additionally, environmental stimuli such as interactions with visitors are kept at a minimum to avoid stimulating the central nervous system and causing a seizure.

A nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply. 1. Uterine tenderness 2. Acute abdominal pain 3. A hard, "board-like" abdomen 4. Painless, bright red vaginal bleeding 5. Increased uterine resting tone on fetal monitoring

1, 2, 3, 5 In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by placental abruption. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa.

The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation. Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply. 1. Hematuria 2. Prolonged clotting times 3. Increased platelet count 4. Swelling of the calf of one leg 5. Petechiae, oozing from injection sites, and hematuria

1, 2, 5 Disseminated intravascular coagulation (DIC) is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process. Coagulation studies show no clot formation (and are thus normal to prolonged), and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrombophlebitis.

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply.

1. Age 54 2. Body mass index of 28 3. Previous difficulty with fertility

A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply.

1. Increased efficiency of contractions 2. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

A client in the prenatal clinic asks the nurse about the delivery date. The nurse notes that the client's record indicates that the client began her last menses on March 7, 2018, and ended the menses on March 14, 2018. Using Nägele's rule, the nurse should tell the client that the estimated date of delivery is what date? Fill in the blank. Record your answer using 6 digits (mmddyy).

121418

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

Patient with preeclampsia is receiving IV Mag 6 grams administered over 20 min. The nurse attaches a volume control device between the infusion pump and the bag of solution labeled "Magnesium Sulfate 20 grams/500 mL of D5W". How many mL should nurse place in volume controlled device?

150 mL

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

IV LR 1000 mL with oxytocin (Pitocin) 40 units to deliver 15mL/hr. How many milli-units/minute is the client receiving?

10 mu/min.

The nurse is performing an assessment on a client seen in the health care clinic for a first prenatal visit. The client reports February 9 as the first day of the last menstrual period (LMP). Using Nägele's rule, what date later that same year will the nurse relay as the client's due date? Fill in the blank. Record your answer using 4 digits (mmdd).

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The nurse is collecting data from a client seen in the health care clinic for a first prenatal visit. The nurse asks the client when the first day of her last menstrual period was and the client reports February 9, 2018. Using Nägele's rule, the nurse determines that what is the estimated date of delivery? Fill in the blank. Record your answer using 6 digits (mmddyy).

111618

The nurse is caring for a client in labor who is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued? 1. Increased urinary output 2. A fetal heart rate of 90 beats/min 3. Three contractions occurring within a 10-minute period 4. Adequate resting tone of the uterus palpated between contractions

2 A normal fetal heart rate is 110 to 160 beats/min. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue the oxytocin. Increased urinary output is unrelated to the use of oxytocin. The goal of labor augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider? 1. Hemoglobin of 11 g/dL 2. Fetal heart rate of 180 beats/minute 3. Maternal pulse rate of 85 beats/minute 4. White blood cell count of 12,000 cells/mm3

2 A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute could indicate fetal distress and would warrant immediate notification of the HCP. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000 cells/mm3 (up to 18,000 cells/mm3). During the immediate postpartum period, the white blood cell count may be 25,000 to 30,000 cells/mm3 because of increased leukocytosis that occurs during delivery.

A client in labor is receiving oxytocin (Pitocin) by intravenous infusion to stimulate uterine contractions. Which finding indicates that the rate of the infusion needs to be decreased? 1. Increased urinary output 2. A fetal heart rate of 180 beats/min 3. Three contractions occurring in a 10-minute period 4. Adequate resting tone of the uterus palpated between contractions

2 A normal fetal heart rate is 120 to 160 beats/min. Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia, which can occur from excessive uterine activity. The goal of labor augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions, and there should be no evidence of fetal distress. Increased urinary output is unrelated to the use of oxytocin.

During the intrapartum period, a nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? 1. Stimulate the labor process. 2. Prevent dehydration and hypoxemia. 3. Avoid the necessity of a cesarean delivery. 4. Eliminate the need for analgesic administration.

2 A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during the intrapartum period. Maintaining adequate intravenous fluid intake and the administration of oxygen via face mask will help to ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the need for a cesarean delivery, or eliminate the need for analgesic administration.

On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies is which category of decelerations? 1. Episodic, late decelerations that indicate uteroplacental insufficiency 2. Periodic, early decelerations and indicative of fetal head compression 3. Periodic, variable decelerations and an indication of cord compression 4. Episodic, early decelerations that may be a result of maternal hypotension

2 An early deceleration is described as a visually apparent gradual decrease of the fetal heart rate with a gradual return to the FHR baseline. Early decelerations are caused by fetal head compression, resulting from uterine contractions, vaginal examination, or fundal pressure, which would eliminate option 4. Late decelerations do not return to the FHR baseline until after the uterine contraction is over, thus eliminating option 1. Variable decelerations are defined as having a rapid onset of less than 30 seconds with a rapid return to FHR baseline, which does not match the description of the FHR described, so therefore eliminate option 3.

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? 1. Identify the types of accelerations. 2. Assess the baseline fetal heart rate. 3. Determine the intensity of the contractions. 4. Determine the frequency of the contractions.

2 Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options 1 and 4 are important to assess, but not as the first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the fetal heart rate.

The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1. Providing comfort measures 2. Monitoring the fetal heart rate 3. Changing the client's position frequently 4. Keeping the significant other informed of the progress of the labor

2 Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority.

After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action? 1. Reposition the laboring woman to knee-chest. 2. Assess the vagina and cervix with a gloved hand. 3. Notify the health care provider of the need for an amnioinfusion. 4. Document the description of the fetal bradycardia in the nursing notes.

2 It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action would be to glove the examining hand and insert two fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the woman to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression is the first intervention that should be implemented so therefore option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.

The goal for a woman with partial premature separation of the placenta is, "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, would indicate that this goal has been achieved? 1. No accelerations of FHR 2. Short-term variability present 3. Variable decelerations present 4. Fetal heart rate (FHR) of 170 to 180 beats/min

2 Reassuring signs in the fetal heart tracing include an FHR of 120 to 160 beats/min, accelerations of the FHR, no variable decelerations, and the presence of short-term variability. The short-term variability indicates that the fetus is able to make the necessary adjustments to the stresses of the labor. Variable decelerations would indicate cord compression.

A nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise? 1. Maternal fatigue 2. The passage of meconium 3. Coordinated uterine contractions 4. Progressive changes in the cervix

2 Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but does not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.

A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/min and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action? 1. Contact the obstetrician. 2. Continue to monitor the client. 3. Report the FHR to the anesthesiologist. 4. Prepare for imminent delivery of the fetus.

2 The FHR normally is 110 to 160 beats/min. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer, or consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR. The assessment findings identified in the question are not signs of potential complications.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1. Ambulation 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids

2 The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Changing positions frequently is not the primary physiological need. Ambulation is encouraged during early labor. Ice chips should be provided. Food and fluids are likely to be withheld at this time.

A nurse has collected the following data on a client in labor. The fetal heart rate (FHR) is 154 beats/min and is regular; and contractions have moderate intensity, occur every 5 minutes and have a duration of 35 seconds. Using this information, what is the most appropriate action for the nurse to take? 1. Prepare for imminent delivery. 2. Continue to monitor the client. 3. Report the findings to the obstetrician. 4. Report the FHR to the anesthesiologist on call.

2 The data collected by the nurse are within normal limits and require no further action on the part of the nurse other than continued monitoring. The FHR is normally 120 to 160 beats/min. Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer; contractions consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR.

The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action? 1. Administer oxygen by face mask. 2. Clear and maintain an open airway. 3. Administer magnesium sulfate intravenously. 4. Assess the blood pressure and fetal heart rate.

2 The first action during a seizure (eclampsia) is to ensure a patent airway. All other options are actions that follow.

The nurse is assisting a client undergoing induction of labor at 41 weeks' gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? 1. Notify the health care provider. 2. Discontinue the infusion of oxytocin (Pitocin). 3. Place oxygen on at 8 to 10 L/minute via face mask. 4. Contact the client's primary support person(s) if not currently present.

2 The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse should reposition the laboring mother. Applying oxygen, increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin), and notifying the health care provider are also actions that are indicated in this situation. Contacting the client's primary support person(s) is not the priority action at this time.

The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the health care provider's prescriptions and would expect to note which prescribed treatment for this condition? 1. Increased hydration 2. Oxytocin (Pitocin) infusion 3. Administration of a tocolytic medication 4. Administration of a medication that will provide sedation

2 Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. A cesarean birth will be performed if no progress in labor occurs. Options 1, 3, and 4 identify therapeutic measures for a client with hypertonic dysfunction.

A nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action? 1. Gently push the cord into the vagina. 2. Place the client in Trendelenburg's position. 3. Find the closest telephone and page the health care provider stat. 4. Call the delivery room to notify the staff that the client will be transported immediately.

2 When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with her hips higher than her head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is administered to the mother to increase fetal oxygenation.

A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse plan to assess and document the fetal heart rate? 1. Hourly 2. Every 15 minutes 3. Every 30 minutes 4. Before each contraction

2 he second stage of labor begins when the cervix is dilated completely (10 cm). Maternal pulse, blood pressure, and fetal heart rate are assessed every 5 to 15 minutes, depending on agency protocol; some agency protocols recommend assessment after each contraction. Hourly and every 30 minutes represent lengthy time intervals for assessment in this stage of labor.

The nurse is collecting data from a pregnant client who is at 28 weeks' gestation. The nurse measures the fundal height in centimeters and should expect which finding?

28 cm

The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area? Click on the image to indicate your answer.

A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcome of the amniotomy? 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring

3 Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary following this procedure. The fetal heart rate needs to be monitored frequently, however.

A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action? 1. Perform an abdominal prep on the client. 2. Prepare the delivery room for a vaginal delivery. 3. Explain to the client why a cesarean delivery is necessary. 4. Call the health care provider to obtain a prescription for an antiviral medication.

3 Because neonatal infection of HSV is life threatening, prevention of neonatal infection is critical. Current recommendations state that a cesarean delivery within 4 hours after labor begins or membranes rupture is necessary if visible lesions are present on the woman's perineum. An abdominal prep will be necessary eventually for the cesarean delivery but should not be the nurse's initial action. Antiviral medications are used to control symptoms not eradicate the infection. At this phase in the client's pregnancy, the focus is on preventing transmission to the fetus rather than controlling the symptoms of HSV.

The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency? 1. Fentanyl 2. Morphine sulfate 3. Butorphanol tartrate 4. Meperidine hydrochloride (Demerol)

3 Butorphanol tartrate is an opioid analgesic that can precipitate withdrawal symptoms in an opioid-dependent client. Therefore, it is contraindicated if the client has a history of opioid dependency. Fentanyl, morphine sulfate, and meperidine are opioid analgesics but do not tend to precipitate withdrawal symptoms in opioid-dependent clients.

A nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin (Pitocin). The nurse should ensure that which is implemented before the beginning of the infusion? 1. An IV infusion of antibiotics 2. Placing the client on complete bed rest 3. Continuous electronic fetal monitoring 4. Placing a code cart at the client's bedside

3 Continuous electronic fetal monitoring should be implemented during an IV infusion of oxytocin (Pitocin). There are no data in the question that indicate the need for complete bed rest or the need for antibiotics. It is not necessary to place a code cart at the bedside of a client receiving an oxytocin infusion.

The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the health care provider to arrive. When the infant's head crowns, what instruction should the nurse give the client? 1. Bear down. 2. Hold her breath. 3. Breathe rapidly. 4. Push with each contraction.

3 During a precipitous labor, when the infant's head crowns, the nurse instructs the client to breathe rapidly to decrease the urge to push. The client is not instructed to push or bear down. Holding the breath decreases the amount of oxygen to the mother and the fetus.

The nurse explains the purpose of effleurage to a client in early labor. Which statement should the nurse include in the explanation? 1. "It is the application of pressure to the sacrum to relieve a backache." 2. "It is a form of biofeedback to enhance bearing-down efforts during delivery." 3. "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." 4. "It is performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest."

3 Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage also provides tactile stimulation to the fetus. Options 1, 2, and 4 are inaccurate descriptions of effleurage.

Which assessment finding following an amniotomy should be conducted first? 1. Cervical dilation 2. Bladder distention 3. Fetal heart rate pattern 4. Maternal blood pressure

3 Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Bladder distention or maternal blood pressure would not be the first things to check after an amniotomy. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection.

The nurse in a maternity unit is reviewing the clients' records. Which client would the nurse identify as being at the most risk for developing disseminated intravascular coagulation? 1. A primigravida with mild preeclampsia 2. A primigravida who delivered a 10-lb infant 3 hours ago 3. A gravida II who has just been diagnosed with dead fetus syndrome 4. A gravida IV who delivered 8 hours ago and has lost 500 mL of blood

3 In a pregnant client, disseminated intravascular coagulation (DIC) is a condition in which the clotting cascade is activated, resulting in the formation of clots in the microcirculation. Dead fetus syndrome is considered a risk factor for DIC. Severe preeclampsia is considered a risk factor for DIC; a mild case is not. Delivering a large newborn is not considered a risk factor for DIC. Hemorrhage is a risk factor for DIC; however, a loss of 500 mL is not considered hemorrhage.

The nurse is administering an intravenous analgesic to a laboring woman. The woman inquires as to why the nurse is waiting for a contraction to begin before she infuses the medication into the intravenous line. Which is the nurse's most appropriate response? 1. "The medication will only affect you and your pain level when given during a contraction." 2. "The medication will provide the most optimal relief when it is given while your pain level is highest." 3. "Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." 4. "You will experience a lower incidence of adverse effects from the medication when administered during a contraction."

3 Intravenous medication should be administered slowly in small doses starting at the beginning of a contraction and carrying over for three to five contractions. This intervention minimizes the amount of the medication that crosses the placenta and enters the fetal circulation, thus minimizing its effects on the fetus. Although this method of administration may decrease the amount of the medication reaching the fetus, it does not totally eliminate effects of the medication on the fetus. Options 1, 2, and 4 are incorrect information about the medication effects.

The nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin (Pitocin). The nurse ensures that which intervention is implemented before initiating the infusion? 1. An IV infusion of antibiotics 2. Placing the client on complete bed rest 3. Continuous electronic fetal monitoring 4. Placing a code cart at the client's bedside

3 Oxytocin is a uterine stimulant used to induce labor. Continuous electronic fetal monitoring should be implemented during an IV infusion of oxytocin. No data in the question indicate the need for complete bed rest or the need for antibiotics. Placing a code cart at the bedside of a client receiving an oxytocin infusion is not necessary.

The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate decelerations? 1. Prepare the client for a cesarean delivery. 2. Monitor the fetal heart rate every 30 minutes. 3. Encourage an upright or side-lying maternal position. 4. Increase the rate of the oxytocin (Pitocin) infusion every 10 minutes.

3 Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. Many nursing actions are available to prevent fetal heart rate decelerations, without necessitating surgical intervention. Monitoring the fetal heart rate every 30 minutes will not prevent fetal heart rate decelerations. The nurse should discontinue an oxytocin infusion in the presence of fetal heart rate decelerations, thereby reducing uterine activity and increasing uteroplacental perfusion.

3 Station is the measurement of the progress of descent in centimeters above or below the midplane from the presenting part to the ischial spine. It is measured in centimeters, and noted as a negative number above the line and as a positive number below the line. At the negative 1 (-1) station, the fetal presenting part is 1 cm above the ischial spine.

A pregnant 39-week-gestation gravida 1 para 0 client arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that she has had a positive group B Streptococcus (GBS) laboratory report during her prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which should be the nurse's first action? 1. Provide the client with instructions on how to push. 2. Prepare the labor room and the client for an imminent delivery. 3. Call the HCP to obtain a prescription for intravenous antibiotic prophylaxis (IAP). 4. Call the health care provider (HCP) to the labor and delivery unit to perform a delivery.

3 The client evidences progression toward delivery because the cervix is 6 cm dilated and the signs and symptoms of active labor are present. Because the client has had a positive GBS result during pregnancy, her neonate is at risk for becoming infected with GBS via vertical transmission during birth. GBS poses a significant risk for infant morbidity and mortality. To decrease this risk, it is recommended that intravenous antibiotic prophylaxis (IAP) be administered during labor. Providing the client with instructions in regard to pushing is not appropriate at a time when she does not need to use this information; thus, this is not a priority. The client is not close to complete dilation; therefore the HCP is not required for delivery at this time.

The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately? 1. Noting whether the heart rate is greater than 140 beats/min 2. Placing the diaphragm of the Doppler on the mother's abdomen 3. Palpating the maternal radial pulse while listening to the fetal heart rate 4. Performing Leopold's maneuver first to determine the location of the fetal heart

3 The nurse should simultaneously palpate the maternal radial or carotid pulse and auscultate the fetal heart rate (FHR) to differentiate between the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the FHR. Noting whether the heart rate is more than 140 beats/min or placing the diaphragm of the Doppler on the mother's abdomen will not ensure accuracy in obtaining the FHR. Leopold's maneuver may help the examiner locate the position of the fetus but will not ensure a distinction between the two heart rates.

A nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which is documented in the client's record? 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is completely dilated. 4. The client begins to expel clear vaginal fluid.

3 The second stage of labor begins when the cervix is completely dilated and ends with birth of the infant. The other options are not specific assessment findings of the second stage of labor.

A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment finding would indicate the presence of concealed bleeding? 1. Back pain 2. Heavy vaginal bleeding 3. Increase in fundal height 4. Early deceleration on the fetal heart monitor

3 The signs of concealed abdominal bleeding in a pregnant client include an increase in fundal height, hard board-like abdomen, persistent abdominal pain, late decelerations in fetal heart rate, or decreasing baseline variability. Heavy vaginal bleeding, early deceleration on the fetal heart monitor, and back pain are not specific signs of concealed bleeding.

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. Monitor fetal heart rate continuously. 2. Monitor maternal vital signs frequently. 3. Perform a vaginal examination every shift. 4. Administer ampicillin 1 g as an intravenous piggyback every 6 hours.

3 Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.

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

3+ deep tendon reflexes and hyperclonus.

he nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor? 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid.

3. The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.

The nurse is collecting data from a client who is at 32 weeks' gestation. The nurse measures the fundal height in centimeters and expects the findings to be how many centimeters (cm)?

32 cm

The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia? 1. Assessing the mother's reflexes 2. Taking the mother's temperature 3. Taking the mother's apical pulse 4. Monitoring the mother's blood pressure

4 A major side effect of regional anesthesia is hypotension, which results from vasodilation in the lower body and a reduction in venous return. After regional anesthesia, the blood pressure is taken every 1 to 2 minutes for 15 minutes and then every 10 to 15 minutes. Reflexes, temperature, and apical pulse are not specifically related to this type of anesthesia.

A nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse should assess that the amniotic fluid is normal if it has which characteristics? 1. Clear and dark amber color 2. Light green color with no odor 3. Thick white color with no odor 4. Straw-colored, with flecks of vernix

4 Amniotic fluid is normally a pale straw color and may contain flecks of vernix caseosa. It should have a thin watery consistency and may have a mild odor. The other options are not descriptions of normal amniotic fluid.

Cesarean - hemorrhage risk assessment?

Check for fundal firmness Q15 min. RATIONALE: Risk for postpartum hemorrhage is decreased when uterus is firm after delivery. Q15 min checks stimulate fundus to contract and prevents bleeding.

A nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action? 1. Contact the health care provider. 2. Place the mother in a Trendelenburg position. 3. Administer oxygen to the client by face mask. 4. Document the findings and continue to monitor fetal patterns.

4 Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by a return to baseline, in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. Therefore, options 1, 2, and 3 are unnecessary.

Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement? 1. Slow the intravenous (IV) rate. 2. Continue the oxytocin (Pitocin) drip. 3. Place the client in a high Fowler's position. 4. Administer oxygen at 8 to 10 L/min via face mask.

4 Oxygen is administered at 8 to 10 L/min via face mask to optimize oxygenation of the circulating blood volume. The IV infusion should be increased not decreased so as to increase the maternal blood volume. Oxytocin stimulates the uterus and is discontinued if fetal heart rate patterns change for any reason. The woman's position should be lateral with legs raised to increase maternal blood volume and improve the maternal vascular system.

The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes and she cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior? 1. Exhaustion 2. Valsalva maneuver 3. Involuntary grunting 4. Fear of losing control

4 Pain, helplessness, panicking, and fear of losing control are possible behaviors in the transition phase of the first stage of labor. Options 1, 2, and 3 are not indicative of the description provided in the question

The nurse in a labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise? 1. Maternal fatigue 2. Coordinated uterine contractions 3. Progressive changes in the cervix 4. Persistent nonreassuring fetal heart rate

4 Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged, but do not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.

The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention? 1. Chest pain 2. A rigid abdomen 3. A soft and boggy uterus 4. Complaints of severe abdominal pain

4 Signs of uterine inversion include a depression in the fundal area, visualization of the interior of the uterus through the cervix or vagina, severe abdominal pain, hemorrhage, and shock. Chest pain and a rigid abdomen are signs of a ruptured uterus. A soft and boggy uterus would indicate that the muscle is not contracting.

A prenatal client with vaginal bleeding is being admitted to the labor unit. The labor room nurse is performing the admission assessment and would suspect a diagnosis of placenta previa if which finding is noted? 1. Back pain 2. Abdominal pain 3. Painful vaginal bleeding 4. Painless vaginal bleeding

4 The classic sign of placenta previa is the sudden onset of painless vaginal bleeding. Painful vaginal bleeding, abdominal pain, and back pain identify signs and symptoms of abruptio placentae.

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1. Notify the health care provider of the findings. 2. Reposition the mother and check the monitor for changes in the fetal tracing. 3. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen. 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

4 The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? 1. "I won't be in labor until my baby drops." 2. "My contractions will be felt in my abdominal area." 3. "My contractions will not be as painful if I walk around." 4. "My contractions will increase in duration and intensity."

4 True labor is present when contractions increase in duration and intensity. Lightening or dropping is also known as engagement and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Accelerations 3. Early decelerations 4. Variable decelerations

4 Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction.

A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/min and the umbilical cord protruding from the vagina. The client tells the nurse that her "water broke" before coming to the hospital. What is the most appropriate nursing action? 1. Sit the client in a high Fowler's position. 2. Call the pharmacy for a tocolytic medication. 3. Get intravenous (IV) therapy equipment and solution from the storage area. 4. Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.

4 When an umbilical cord is protruding, the cord must be protected from drying out and becoming compressed. Wrapping the cord with a sterile, saline-soaked towel will help accomplish this. The nurse must also help reduce compression of the cord by placing the client in an extreme Trendelenburg's or modified Sims position. A tocolytic would be used if the client had inadequate uterine relaxation. IV solutions may be administered but are not the priority item with the information given.

A newborn infant iss brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactory but appears dusky. What action should the nurse take first?

Check the infant's oxygen saturation rate

Shortly after receiving epidural anesthesia, a laboring woman's blood pressure drops to 95/43 mm Hg. Which immediate actions should the nurse take? Select all that apply. 1. Prepare for delivery. 2. Administer a tocolytic. 3. Administer an opioid antagonist. 4. Turn the woman to a lateral position. 5. Increase the rate of the intravenous infusion. 6. Administer oxygen by face mask at 10 L/minute.

4, 5, 6 Maternal hypotension results in decreased placental perfusion, so the focus of nursing care would be to initiate interventions that increase oxygen perfusion to the fetus. Turning the woman to left lateral position assists in deflecting the uterus off of the vena cava, thus improving maternal circulation. Increasing the rate of the intravenous infusion will increase blood volume, which will increase the maternal blood pressure. An increase in blood pressure would increase placental perfusion. Administering a high flow rate of oxygen will increase the oxygen levels in the maternal circulation and increase oxygen delivery to the fetus. The woman is not revealing any signs or symptoms of imminent delivery, so option 1 can be eliminated. Option 2 can be eliminated because the decrease in placental perfusion is the result of maternal hypotension, not uterine hyperstimulation. Option 3 can be eliminated because the client is not experiencing an ineffective breathing pattern caused by opioid administration.

The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply. 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age.

4, 5, 6 Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability.

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best? A. home pregnancy test can be used right after your first missed period. B.These tests are most accurate after you have missed your second period. C. Home pregnancy tests often give false positives and should not be trusted. D . The test can provide accurate information when used right after ovulation.

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

1st trimester, Hgb 8.6, Hct 25.1, what food should the nurse encourage?

Chicken.

The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign?

5 The Silverman-Anderson index is an assessment scale that scores a newborn's respiratory status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded 0, and a total of 10 indicates maximum respiratory distress. This infant is demonstrating respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory grunting, plus grade 1 for just visible retractions, which is a total score of 5.

According to Diane, her LMP is November 15, 2002, using the Naegle's rule what is her EDC? A. August 23, 2003 B. August 18, 2003 C. July 22, 2003 D. February 22, 2003

Family centered nursing care for women and newborn focuses on which of the following? A. Assisting individuals and families achieve their optimal health B. Diagnosing and treating problems promptly C. Preventing further complications from developing D. Conducting nursing research to evaluate clinical skills

Which of the following would cause a false-positive result on a pregnancy test? A. The test was performed less than 10 days after an abortion B. The test was performed too early or too late in the pregnancy C. The urine sample was stored too long at room temperature D. A spontaneous abortion or a missed abortion is impending

A - Explanation A false-positive reaction can occur if the pregnancy test is performed less than 10 days after an abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too long at room temperature, or having a spontaneous or missed abortion impending can all produce false- negative results.

The nurse is collecting data on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client is least likely to be at risk for the development of thrombophlebitis in the postpartum period?

A 26-year-old client with a family history of thrombophlebitis

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

A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged.

A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symtoms are this newborn likely to exhibit?

Chocking, coughing, and cyanosis

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

A decrease in respiratory rate from 24 to 16

The nurse is caring for a client in labor who is receiving oxytocin by intravenous infusion to stimulate uterine contractions. Which assessment finding should indicate to the nurse that the infusion needs to be discontinued?

A fetal heart rate of 90 beats/minute

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is appropriate?

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

A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is

A persistent cold

A primigravida client who is 5cm dilated, 90% effaced and 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider?

A platelet count of 67.000/mm3

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? A. Between the time the temperature falls and rises. B. Between 36 and 48 hours after the temperature rises. C. When the temperature falls and remains low for 36 hours. D. Within 72 hours before the temperature falls.

A. Between the time the temperature falls and rises.

A client with severe preeclampsia is admitted to the maternity department. Which room assignment is most appropriate for this client?

A private room 2 doors away from the nurses' station

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?

A softening of the cervix

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. Based on her last normal menstrual period, she is 8 weeks' gestation. Appropriate physical assessments are completed. Which findings are anticipated to be present at this time? Select all that apply.

A softening of the cervix Bluish discoloration of the vaginal tissue The presence of human chorionic gonadotropin in the urine

Psyche

A woman's emotional structure that can determine her entire response to labor and influence physiological and psychological functioning; Mother may experience anxiety or fear

A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement, if made by the client, indicates a need for further education? A) "I will maintain strict bedrest throughout the remainder of pregnancy." B) "I will avoid sexual intercourse until the bleeding has stopped, and for 2 weeks following the last evidence of bleeding." C) "I will count the number of perineal pads used on a daily basis and note the amount and color of blood on the pad." D) "I will watch for the evidence of the passage of tissue."

A) "I will maintain strict bedrest throughout the remainder of pregnancy." Rationale: Strict bed rest throughout the remainder of pregnancy is not required. The woman is advised to curtail sexual activities until the bleeding has ceased, and for 2 weeks following the last evidence of bleeding or as recommended by the physician. The woman is instructed to count the number of perineal pads used daily and to note the quantity and color of blood on the pad. The woman also should watch for the evidence of the passage of tissue.

A nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The physician has documented the presence of a Goodell's sign. The nurse determines this sign indicates: A) A softening of the cervix B) A soft blowing sound that corresponds to the maternal pulse during auscultation of the uterus. C) The presence of hCG in the urine D) The presence of fetal movement

A) A softening of the cervix Rationale: In the early weeks of pregnancy the cervix becomes softer as a result of increased vascularity and hyperplasia, which causes the Goodell's sign.

During a prenatal examination, the nurse draws blood from a young Rh negative client and explain that an indirect Coombs test will be performed to predict whether the fetus is at risk for: A) Acute hemolytic disease B) Respiratory distress syndrome C) Protein metabolic deficiency D) Physiologic hyperbilirubinemia

A) Acute hemolytic disease Rationale: When an Rh negative mother carries an Rh positive fetus there is a risk for maternal antibodies against Rh positive blood; antibodies cross the placenta and destroy the fetal RBC's.

In the 12th week of gestation, a client completely expels the products of conception. Because the client is Rh negative, the nurse must: A) Administer RhoGAM within 72 hours B) Make certain she receives RhoGAM on her first clinic visit C) Not give RhoGAM, since it is not used with the birth of a stillborn D) Make certain the client does not receive RhoGAM, since the gestation only lasted 12 weeks.

A) Administer RhoGAM within 72 hours Rationale: RhoGAM is given within 72 hours postpartum if the client has not been sensitized already.

A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of severe preeclampsia. A nurse monitors for complications associated with the diagnosis and assesses the client for: A) Any bleeding, such as in the gums, petechiae, and purpura. B) Enlargement of the breasts C) Periods of fetal movement followed by quiet periods D) Complaints of feeling hot when the room is cool

A) Any bleeding, such as in the gums, petechiae, and purpura. Rationale: Severe Preeclampsia can trigger disseminated intravascular coagulation because of the widespread damage to vascular integrity. Bleeding is an early sign of DIC and should be reported to the M.D.

A primigravida patient who is 12 weeks pregnant visits a helath promotion program in the community pertaining to the pregnancy care. A group of nursing student is educating the public about measures to prevent discomfort of pregnancy. The primigravida patient asks one of the student about measures on how to prevent heartburn she is experiencing throughout the day. Select all the necessary measures to prevent the primigravia patient's complaint. A. Eating small, frequent meals and avoiding fatty and spicy food B. Eating high fiber foods and increase drinking fluids C. Drinking milk between milk D. Arranging frequent rest periods throughout the day E. Sitting upright for 30 minutes after a meal F. Engaging in regular exercise

A, C, E

Rho (D) immune globulin (RhoGAM) is prescribed for a woman following delivery of a newborn infant and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following? A) Being affected by Rh incompatibility B) Having Rh positive blood C) Developing a rubella infection D) Developing physiological jaundice

A) Being affected by Rh incompatibility Rationale: Rh incompatibility can occur when an Rh-negative mom becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the baby's Rh positive blood can enter the maternal circulation, causing the woman's immune system to form antibodies against Rh positive blood. Administration of Rho(D) immune globulin prevents the woman from developing antibodies against Rh positive blood by providing passive antibody protection against the Rh antigen.

The antagonist for magnesium sulfate should be readily available to any client receiving IV magnesium. Which of the following drugs is the antidote for magnesium toxicity? A) Calcium gluconate B) Hydralazine (Apresoline) C) Narcan D) RhoGAM

A) Calcium gluconate Rationale: Calcium gluconate is the antidote for magnesium toxicity. Ten ml of 10% calcium gluconate is given IV push over 3-5 minutes. Hydralazine is given for sustained elevated blood pressures in preeclamptic clients.

Clients with gestational diabetes are usually managed by which of the following therapies? A) Diet B) NPH insulin (long-acting) C) Oral hypoglycemic drugs D) Oral hypoglycemic drugs and insulin

A) Diet Rationale: Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Oral hypoglycemic agents are contraindicated in pregnancy. NPH isn't usually needed for blood glucose control for GDM.

A pregnant client calls the clinic and tells a nurse that she is experiencing leg cramps and is awakened by the cramps at night. To provide relief from the leg cramps, the nurse tells the client to: A) Dorsiflex the foot while extending the knee when the cramps occur B) Dorsiflex the foot while flexing the knee when the cramps occur C) Plantar flex the foot while flexing the knee when the cramps occur D) Plantar flex the foot while extending the knee when the cramps occur.

A) Dorsiflex the foot while extending the knee when the cramps occur Rationale: Legs cramps occur when the pregnant woman stretches the leg and plantar flexes the foot. Dorsiflexion of the foot while extending the knee stretches the affected muscle, prevents the muscle from contracting, and stops the cramping.

A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk for Preeclampsia. The nurse checks the client for which specific signs of Preeclampsia ? (Select all that apply) A) Elevated blood pressure B) Negative urinary protein C) Facial edema D) Increased respirations

A) Elevated blood pressure C) Facial edema Rationale: The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. Increased respirations are not a sign of preeclampsia.

A pregnant woman's last menstrual period began on April 8, 2005, and ended on April 13. Using Naegele's rule her estimated date of birth would be: A) January 15, 2006 B) January 20, 2006 C) July 1, 2006 D) November 5, 2005

A) January 15, 2006 Rationale: Naegele's rule requires subtracting 3 months and adding 7 days and 1 year if appropriate to the first day of a pregnant woman's last menstrual period. When this rule, is used with April 8, 2005, the estimated date of birth is January 15, 2006.

The pituitary hormone that stimulates the secretion of milk from the mammary glands is: A) Prolactin B) Oxytocin C) Estrogen D) Progesterone

A) Prolactin Rationale: Prolactin is the hormone from the anterior pituitary gland that stimulates mammary gland secretion. Oxytocin, a posterior pituitary hormone, stimulates the uterine musculature to contract and causes the "let down" reflex.

A nurse is assisting in performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. (Select all that apply) A) Uterine enlargement B) Fetal heart rate detected by nonelectric device C) Outline of the fetus via radiography or ultrasound D) Chadwick's sign E) Braxton Hicks contractions F) Ballottement

A) Uterine enlargement D) Chadwick's sign E) Braxton Hicks contractions F) Ballottement Rationale: The probable signs of pregnancy include: >Uterine Enlargement >Hegar's sign or softening and thinning of the uterine segment that occurs at week 6. >Goodell's sign or softening of the cervix that occurs at the beginning of the 2nd month >Chadwick's sign or bluish coloration of the mucous membranes of the cervix, vagina and vulva. Occurs at week 6. >Ballottement or rebounding of the fetus against the examiner's fingers of palpation >Braxton-Hicks contractions Positive pregnancy test measuring for hCG. >Positive signs of pregnancy include: >Fetal Heart Rate detected by electronic device (doppler) at 10-12 weeks >Fetal Heart rate detected by nonelectronic device (fetoscope) at 20 weeks AOG >Active fetal movement palpable by the examiners >Outline of the fetus via radiography or ultrasound

A nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? Select all that apply. A. Allows for fetal movement B. Is a measure of kidney function C. Surrounds, cushions, and protects the fetus D. Maintains the body temperature of the fetus E. Prevents large particles such as bacteria from passing to the fetus F. Provides an exchange of nutrients and waste products between the mother and the fetus

A, B, C, D

The nurse knows that there are psychological maternal changes that occurs during pregnancy in a primigravida patient. Select all the normal psychological maternal changes that happens throughout pregnancy. A. Ambivalence B. Breast tenderness C. Emotional lability D. Body image changes E. Bonding or relationship with the fetus F. Nausea and vomiting G. Syncope H. Urinary frequency

A, C, D, E

A 36 weeks gestation pregnant woman is complaining of urinary urgency and frequency. The nurse explained that the enlarging fetus is pressing the bladder which causes frequent urination. This is normally occuring during the first and third trimesters of pregnancy. The nurse advices the patient to do the following measures to prevent urinary frequency. Select all the necessary measures that the nurse can provide to the patient. A. Drink 2 quarts of fluid during the day B. Engaging in a regular exercise C. Performing Kegel exercises D. Soaking in a warm sitz bath E. Limiting fluid intake during the evening

A, C, E

The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.) A.Admission weight of 4 pounds, 15 ounces (2244 grams) B.Head to heel length of 17 inches (42.5 cm). C.Frontal occipital circumference of 12.5 inches (31.25 cm). D.Skin smooth with visible veins and abundant vernix. E.Anterior plantar crease and smooth heel surfaces. F. Full flexion of all extremities in resting supine position.

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

A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first?

A.Bathe the infant with an antimicrobial soap. B.Measure the head and chest circumference. C. Obtain the infant's footprints. D. Administer vitamin K (AquaMEPHYTON).

A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? A.Come to the clinic today for an ultrasound. B.Go immediately to the emergency room. C.Lie on your left side for about one hour and see if the bleeding stops. D.Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection.

A.Come to the clinic today for an ultrasound.

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client? A.Complete bedrest decreases oxygen needs and demands on the heart muscle tissue. B.We want your baby to be healthy, and this is the only way we can make sure that will happen. C.I know you're upset. Would you like to talk about some things you could do while in bed? D.Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties.

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

The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? A.Edema, basilar rales, and an irregular pulse. B. Increased urinary output and tachycardia. C.Shortness of breath, bradycardia, and hypertension. D.Regular heart rate and hypertension.

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

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate? A.Grief related to her perceptions about the loss of this child. B.Relief of ambivalent feelings experienced with this pregnancy. C.Shock because she may not have realized that she was pregnant. D. Guilt because she had not followed her healthcare provider's instructions.

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

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

A.Using relaxation breathing techniques.

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

A.two weeks before menstruation.

Lightening or dropping

AKA Engagement and occurs when the fetus descends into the pelvis about 2 weeks before delivery; most noticeable in first pregnancies

A 35-week-gestation pregnant woman is transferred to the maternity unit from the emergency department, where she was treated for minor injuries sustained in a motor vehicle crash. The maternity nurse's priority will be to assess for which complication?

Abruptio placentae

38 weeks, laboring, which finding (condition) warrants a cesarean?

Active herpes lesions on perineum.

. Neonate under radiant warmer, naso-oral suctioned. Which indicates infant is "vigorous"?

Active movement and lusty cry.

Delivery

Actual event of birth

When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?

At 30 weeks of gestation Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy, when they are beginning to anticipate the onset of labor and the birth of their child.

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan?

Avoid alcohol because it is excreted in breast milk. Alcohol should be avoided while breastfeeding because it is excreted in breast milk and may cause a variety of problems, including slower growth and cognitive impairment for the infant.

Q.12) A nurse is collecting data during the admission asessment of a client who is pregnant with twins. The client also has 5 year old child. The nurse would document which gravida and para status on this client? A. G1P1 B. G2P1 C. G2P2 D. G3P2

Which of the following prenatal laboratory test values would the nurse consider as significant? A. Hematocrit 33.5% B. Rubella titer less than 1:8 C. White blood cells 8,000/mm3 D. One hour glucose challenge test 110 g/dL

B Explanation A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal parameters.

A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How should the nurse respond? A. "Yes, it produces no adverse effect." B. "No, it can initiate premature uterine contractions." C. "No, it can promote sodium retention." D. "No, it can lead to increased absorption of fat-soluble vitamins."

B Explanation Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Castor oils is not known to increase absorption of fat-soluble vitamins, although laxatives in general may decrease absorption if intestinal motility is increased.

During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition? A. post partum phase B. first trimester C. second trimester D. third trimester

B Explanation First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples. Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.

The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The LPN should tell the patient that she can expect to feel the fetus move at which time? A. Between 10 and 12 weeks' gestation B. Between 16 and 20 weeks' gestation C. Between 21 and 23 weeks' gestation D. Between 24 and 26 weeks' gestation

B Explanation A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks' gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins.

Which of the following would the nurse identify as a presumptive sign of pregnancy? A. Hegar sign B. Nausea and vomiting C. skin pigmentation changes D. positive serum pregnancy test

B Explanation resumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are presumptive signs. Hegar sign, skin pigmentation changes, and a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnancy.

Nutritional planning for a newly pregnant woman of average height and weighing 145 pounds should include: A) A decrease of 200 calories a day B) An increase of 300 calories a day C) An increase of 500 calories a day D) A maintenance of her present caloric intake per day

B) An increase of 300 calories a day Rationale: This is the recommended caloric increase for adult women to meet the increased metabolic demands of pregnancy.

The nurse teaches a pregnant woman to avoid lying on her back. The nurse has based this statement on the knowledge that the supine position can: A) Unduly prolong labor B) Cause decreased placental perfusion C) Lead to transient episodes of hypotension D) Interfere with free movement of the coccyx

B) Cause decreased placental perfusion Rationale: This is because impedance of venous return by the gravid uterus, which causes hypotension and decreased systemic perfusion.

A nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse accurately tells the client that fetal circulation consists of: A) Two umbilical veins and one umbilical artery B) Two umbilical arteries and one umbilical vein C) Arteries carrying oxygenated blood to the fetus D) Veins carrying deoxygenated blood to the fetus

B) Two umbilical arteries and one umbilical vein Rationale: Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries. Once oxygenated, the blood then is returned by one umbilical vein. Arteries carry deoxygenated blood and waste products from the fetus, and veins carry oxygenated blood and provide oxygen and nutrients to the fetus.

At a prenatal visit at 36 weeks' gestation, a client complains of discomfort with irregularly occurring contractions. The nurse instructs the client to: A) Lie down until they stop B) Walk around until they subside C) Time contraction for 30 minutes D) Take 10 grains of aspirin for the discomfort

B) Walk around until they subside Rationale: Ambulation relieves Braxton Hicks.

A client at 36 weeks' gestation is schedule for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? A. The ultrasound will help to locate the placenta B. The ultrasound identifies blood flow through the umbilical cord C. The test will determine where to insert the needle D. The ultrasound locates a pool of amniotic fluid

B. Explanation Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.

A 25-year-old client with diabetes type I visits the clinic to discuss her and her husband's desire to start a family. This diabetic client A. should be discouraged from becoming pregnant B. has a greater risk of complications during pregnancy C. should be informed about treatment for infertility D. will be able to carry out a completely normal pregnancy

B. Explanation Clients with DM are at greater risk for developing maternal and fetal complications during pregnancy.

The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention? A. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part. B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor. C.Urine specimens for glucose and protein must be obtained at certain intervals throughout labor. D. Frequent voiding minimizes the need for catheterization which increases the chance of bladder infection.

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

During a lecture on reproduction, a student nurse asks the instructor what determines the sex of a fetus. Accurate information in response to this question would be: A. "The sex of the fetus is not determined until the eighth week of gestation." B. "The fertilization of the zygote is the point at which sex is determined." C. "Males have one less pair of chromosomes than females." D. "Sex is determined by the chromosomes contributed by the ovum."

B. Explanation The sex of the fetus is determined at the point that the sperm fertilizes the ovum to form the zygote. Sex is ultimately determined by the chromosome contributed by the sperm.

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

B. Extend the leg and dorsiflex the foot

client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? A. Supplementary iron is more efficiently utilized during pregnancy. B. It is difficult to consume 18 mg of additional iron by diet alone. C. Iron absorption is decreased in the GI tract during pregnancy. D. Iron is needed to prevent megaloblastic anemia in the last trimester.

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

30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks' gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous. Which assessment is the highest priority for the nurse to monitor during the administration of this drug? A. Maternal blood pressure and respirations. B.Maternal and fetal heart rates. C.Hourly urinary output. D.Deep tendon reflexes.

B.Maternal and fetal heart rates.

The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency?

Butorphanol tartrate

The LPN is preparing to administer Solu-medrol 40 mg mixed in 150 mL of sodium chloride via intravenous piggyback. The medication is to be administered over 30 minutes. Using the tubing with a drop factor of 15 ggts/mL, what would the LPN calculate the rate to be in drops per minute? A. 40 B. 50 C. 75 D. 150

The hormone responsible for the development of the ovum during the menstrual cycle is? A. estrogen B. progesterone C. follicle stimulating hormone (Correct Answer) D. leutenizing hormone (Your Answer)

A client LMP began July 5. Her EDD should be which of the following? A. January 2 B. March 28 C. April 12 D. October 12

C Explanation To determine the EDD when the date of the client's LMP is known use Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). Therefore, the client's EDD is April 12.

Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following? A. increased plasma HCG levels B. decreased intestinal motility C. decrease gastric acidity D. elevated estrogen levels

C Explanation During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation, can cause heartburn and flatulence. HCG levels increase in the first, not the second, trimester. Decrease intestinal motility would most likely be the cause of constipation and bloating. Estrogen levels decrease in the second trimester.

Which of the following represents the average amount of weight gained during pregnancy? A. 12 to 2 lbs B. 15 to 25 lbs C. 25 to 35 lbs D. 25 to 40 lbs

C Explanation The average amount of weight gained during pregnancy is 25 to 35 lb. This weight gain consists of the following: fetus - 7.5 lb; placenta and membrane - 1.5 lb; amniotic fluid - 2 lb; uterus - 2.5 lb; breasts - 3 lb; and increased blood volume - 2 to 4 lb; extravascular fluid and fat - 4 to 9 lb. A gain of 12 to 22 lb is insufficient, whereas a weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 40 lb is considered excessive.

When talking with a pregnant client who is experiencing aching swollen, leg veins, the nurse would explain that this is most probably the result of which of the following? A. thrombophlebitis B. pregnancy induced hypertension C. pressure on blood vessels from the enlarging uterus D. the force of gravity pulling down on the uterus

C - Explanation Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur. Thrombophlebitis is an inflammation of the veins due to thrombus formation. Pregnancy-induced hypertension is not associated with these symptoms. Gravity plays only a minor role with these symptoms.

A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes. Which statement if made by the client indicates a need for further education? A) "I need to stay on the diabetic diet." B) "I will perform glucose monitoring at home." C) "I need to avoid exercise because of the negative effects of insulin production." D) "I need to be aware of any infections and report signs of infection immediately to my health care provider."

C) "I need to avoid exercise because of the negative effects of insulin production." Rationale: Exercise is safe for the client with gestational diabetes and is helpful in lowering the blood glucose level.

A prenatal nurse is providing instructions to a group of pregnant client regarding measures to prevent toxoplasmosis. Which statement if made by one of the clients indicates a need for further instructions? A) "I need to cook meat thoroughly." B) "I need to avoid touching mucous membranes of the mouth or eyes while handling raw meat." C) "I need to drink unpasteurized milk only." D) "I need to avoid contact with materials that are possibly contaminated with cat feces."

C) "I need to drink unpasteurized milk only." Rationale: All pregnant women should be advised to do the following to prevent the development of toxoplasmosis. Women should be instructed to cook meats thoroughly, avoid touching mucous membranes and eyes while handling raw meat; thoroughly wash all kitchen surfaces that come into contact with uncooked meat, wash the hands thoroughly after handling raw meat; avoid uncooked eggs and unpasteurized milk; wash fruits and vegetables before consumption, and avoid contact with materials that possibly are contaminated with cat feces, such as cat litter boxes, sandboxes, and garden soil.

A nursing instructor asks a nursing student who is preparing to assist with the assessment of a pregnant client to describe the process of quickening. Which of the following statements if made by the student indicates an understanding of this term? A) "It is the irregular, painless contractions that occur throughout pregnancy." B) "It is the soft blowing sound that can be heard when the uterus is auscultated." C) "It is the fetal movement that is felt by the mother." D) "It is the thinning of the lower uterine segment."

C) "It is the fetal movement that is felt by the mother." Rationale: Quickening is fetal movement and may occur as early as the 16th and 18th week of gestation, and the mother first notices subtle fetal movements that gradually increase in intensity.

During a prenatal visit at 38 weeks, a nurse assesses the fetal heart rate. The nurse determines that the fetal heart rate is normal if which of the following is noted? A) 80 BPM B) 100 BPM C) 150 BPM D) 180 BPM

C) 150 BPM Rationale: The fetal heart rate depends in gestational age and ranges from 160-170 BPM in the first trimester but slows with fetal growth to 120-160 BPM near or at term. At or near term, if the fetal heart rate is less than 120 or more than 160 BPM with the uterus at rest, the fetus may be in distress.

The nurse recognizes that an expected change in the hematologic system that occurs during the 2nd trimester of pregnancy is: A) A decrease in WBC's B) In increase in hematocrit C) An increase in blood volume D) A decrease in sedimentation rate

C) An increase in blood volume Rationale: The blood volume increases by approximately 40-50% during pregnancy. The peak blood volume occurs between 30 and 34 weeks of gestation. The hematocrit decreases as a result of the increased blood volume.

A nurse is caring for a pregnant client with Preeclampsia. The nurse prepares a plan of care for the client and documents in the plan that if the client progresses from Preeclampsia to eclampsia, the nurse's first action is to: A) Administer magnesium sulfate intravenously B) Assess the blood pressure and fetal heart rate C) Clean and maintain an open airway D) Administer oxygen by face mask

C) Clean and maintain an open airway Rationale: The immediate care during a seizure (eclampsia) is to ensure a patent airway. The other options are actions that follow or will be implemented after the seizure has ceased.

A pregnant client is making her first Antepartum visit. She has a two year old son born at 40 weeks, a 5 year old daughter born at 38 weeks, and 7 year old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. Using the GTPAL format, the nurse should identify that the client is: A) G4 T3 P2 A1 L4 B) G5 T2 P2 A1 L4 C) G5 T2 P1 A1 L4 D) G4 T3 P1 A1 L4

C) G5 T2 P1 A1 L4 Rationale: 5 pregnancies; 2 term births; twins count as 1; one abortion; 4 living children.

A client arrives at a prenatal clinic for the first prenatal assessment. The client tells a nurse that the first day of her last menstrual period was September 19th, 2013. Using Naegele's rule, the nurse determines the estimated date of confinement as: A) July 26, 2013 B) June 12, 2014 C) June 26, 2014 D) July 12, 2014

C) June 26, 2014

A nurse is caring for a pregnant client with severe preeclampsia who is receiving IV magnesium sulfate. Select all nursing interventions that apply in the care for the client. A) Monitor maternal vital signs every 2 hours B) Notify the physician if respirations are less than 18 per minute. C) Monitor renal function and cardiac function closely D) Keep calcium gluconate on hand in case of a magnesium sulfate overdose E) Monitor deep tendon reflexes hourly F) Monitor I and O's hourly G) Notify the physician if urinary output is less than 30 ml per hour.

C) Monitor renal function and cardiac function closely D) Keep calcium gluconate on hand in case of a magnesium sulfate overdose E) Monitor deep tendon reflexes hourly F) Monitor I and O's hourly G) Notify the physician if urinary output is less than 30 ml per hour. Rationale: When caring for a client receiving magnesium sulfate therapy, the nurse would monitor maternal vital signs, especially respirations, every 30-60 minutes and notify the physician if respirations are less than 12, because this would indicate respiratory depression. Calcium gluconate is kept on hand in case of magnesium sulfate overdose, because calcium gluconate is the antidote for magnesium sulfate toxicity. Deep tendon reflexes are assessed hourly. Cardiac and renal function is monitored closely. The urine output should be maintained at 30 ml per hour because the medication is eliminated through the kidneys.

A 26-year old multigravida is 14 weeks' pregnant and is scheduled for an alpha-fetoprotein test. She asks the nurse, "What does the alpha-fetoprotein test indicate?" The nurse bases a response on the knowledge that this test can detect: A) Kidney defects B) Cardiac defects C) Neural tube defects D) Urinary tract defects

C) Neural tube defects Rationale: The alpha-fetoprotein test detects neural tube defects and Down syndrome.

Which of the following conditions is common in pregnant women in the 2nd trimester of pregnancy? A) Mastitis B) Metabolic alkalosis C) Physiologic anemia D) Respiratory acidosis

C) Physiologic anemia Rationale: Hemoglobin and hematocrit levels decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production.

The chief function of progesterone is the: A) Development of the female reproductive system B) Stimulation of the follicles for ovulation to occur C) Preparation of the uterus to receive a fertilized egg D) Establishment of secondary male sex characteristics

C) Preparation of the uterus to receive a fertilized egg Rationale: Progesterone stimulates differentiation of the endometrium into a secretory type of tissue.

A primigravida is receiving magnesium sulfate for the treatment of pregnancy induced hypertension (PIH). The nurse who is caring for the client is performing assessments every 30 minutes. Which assessment finding would be of most concern to the nurse? A) Urinary output of 20 ml since the previous assessment B) Deep tendon reflexes of 2+ C) Respiratory rate of 10 BPM D) Fetal heart rate of 120 BPM

C) Respiratory rate of 10 BPM Rationale: Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the physician or other health care provider needs to be notified, and continuation of the medication needs to be reassessed. A urinary output of 20 ml in a 30 minute period is adequate; less than 30 ml in one hour needs to be reported. Deep tendon reflexes of 2+ are normal. The fetal heart rate is WNL for a resting fetus.

A woman with preeclampsia is receiving magnesium sulfate. The nurse assigned to care for the client determines that the magnesium therapy is effective if: A) Ankle clonus in noted B) The blood pressure decreases C) Seizures do not occur D) Scotomas are present

C) Seizures do not occur Rationale: For a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). Magnesium sulfate is an anticonvulsant, not an antihypertensive agent. Although a decrease in blood pressure may be noted initially, this effect is usually transient. Ankle clonus indicated hyperreflexia and may precede the onset of eclampsia. Scotomas are areas of complete or partial blindness. Visual disturbances, such as scotomas, often precede an eclamptic seizure.

A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and who is being monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a worsening of the Preeclampsia and the need to notify the physician? A) Blood pressure reading is at the prenatal baseline B) Urinary output has increased C) The client complains of a headache and blurred vision D) Dependent edema has resolved

C) The client complains of a headache and blurred vision Rationale: If the client complains of a headache and blurred vision, the physician should be notified because these are signs of worsening Preeclampsia.

The nurse identifies substance abuse behaviors exhibited by a pregnant client during an initial prenatal screening. While promoting a therapeutic and accepting environment, the care managment by the nurse would be MOST appropriate if focused on which of the following? A. Discouraging substance use during pregnancy B. Termination of the pregnancy at an early stage C. Eliminating substance use during pregnancy D. Setting boundaries with the client in regards to substance use

C. Explanation Use of substances during pregnancy can lead to severe fetal or neonatal abnormalities, complications, and death. The primary goal of nursing care should be prevention or elimination of substance use during pregnancy.

Cervical softening and uterine souffle are classified as which of the following? A. diagnostic signs B. presumptive signs C. probable signs D. positive signs

C. Explanation Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy.Probable signs are objective findings that strongly suggest pregnancy. Other probable signs include Hegar sign, which is softening of the lower uterine segment; Piskacek sign, which is enlargement and softening of the uterus; serum laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac. Presumptive signs are subjective signs and include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and quickening.

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best? A.This is not an unusual shaped head, especially for a first baby. B.It may look funny to you, but newborn babies are often born with heads like your baby's. C. That is normal; the head will return to a round shape within 7 to 10 days. D.Your pelvis was too small, so the baby's head had to adjust to the birth canal.

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

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

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

A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first? A.Notify the pediatrician immediately. B.Suction the infant's nares, then the oral cavity. C.Check the infant's oxygen saturation rate. D.Position the infant on the right side.

C.Check the infant's oxygen saturation rate.

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

C.Encourage the mother to breastfeed frequently.

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

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

The nurse is caring for a client with preeclampsia who is receiving an intravenous (IV) infusion of magnesium sulfate. When gathering items to be available for the client, which highest priority item should the nurse obtain?

Calcium gluconate injection

A pregnant 39-week-gestation gravida 1, para 0 client arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that she has had a positive group B streptococcus (GBS) laboratory report during her prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which should be the nurse's first action?

Call the health care provider (HCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP).

One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM X 1. What action should the nurse take immediately?

Call the heathcare provider to question the prescription

Vacuum extraction

Cap like suction device applied to fetal head to facilitate extraction. -Suction used to assist in delivery of fetal head -Traction applied during uterine contractions until descent of fetal head -Suction device should NOT be kept in place longer then 25 mins *Monitor for developing cephalhematoma. Caput succedaneum is normal and resolves in 24 hours.*

Variable decelerations

Caused by conditions that restrict flow thru the umbilical cord. Do not have the uniform appearance of early and late decelerations. -Shape, duration, and degree of decline below baseline FHR are variable. These fall and rise abruptly with the onset and relief of cord compression. Nonperiodic-Occur at times unrelated to contractions. Interventions- <70 bpm for 1 min; change position of mother, admin Oxygen, *D/C Oxytocin (Pitocin)*, assess mother's vital signs. Notify MD, Assist with amnioinfusion- intrauterine instillation of warmed saline to decrease compression on umbilical cord.

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line?

Cephalhematoma, which is caused by forceps trauma Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and skull.

Stage 1 (2. Active Phase)

Cervical dilation 4-7cm Contractions occur every 3-5 mins; 30-60 sec; mod intensity Interventions: encourage effective breathing, quiet environment, comfort, *Effleurage (light stroking of abdomen)*, void 1-2 hours

Stage 1 (3. Transition phase)

Cervical dilation 8-10cm Contractions every 2-3 mins; 45-90 sec duration, strong intensity Interventions: rest b/w contractions, wake mother at beginning of contractions for breathing patterns, provide privacy, offer ice chips, void 1-2 hours.

A 4-week old premature infant has been receiving epoetin alfa (Epogen) for the last tree weeks. Which assessment finding indicates to the nurs that the drug is effective?

Change in indirect bilirubin from 12mg/dl to 8mg/dl

Fetal bradycardia or tachycardia occurs

Change the position of the mother, admin oxygen and assess the mothers vital signs. Notify MD

Come into the clinic today for an ultrasound

A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?

Come to the clinic today for an ultrasound. Third-trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound. Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which is life threatening to the mother and fetus.

The nurse is collecting data on a pregnant client in the first trimester of pregnancy diagnosed with iron deficiency anemia. The nurse should monitor the client to detect which manifestation indicating that this problem has not yet resolved?

Complaints of daily headaches and fatigue

The nurse in a delivery room is assessing a client immediately after delivery of the placenta. Which maternal observation could indicate uterine inversion and require immediate intervention?

Complaints of sever abdominal pain

A multigravida client arrives at the labor and delivery unit and tell the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140-150 beats/minute. What action should the nurse implement next?

Complete a sterile vaginal exam

A multigravida client arrives at the labor and delivery unit and tell the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 bpm. What action should the nurse implement next?

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

A pregnant client with Mitral stenosis class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client?

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

The nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During the measurement the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy, the nurse understands that which is the cause of the lightheadedness?

Compression of the vena cava

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

DM I, HbgA1c level 7.8 at 10 weeks pregnant. What should the nurse do?

Contact MD for BPP (BioPhysical Profile).

APGAR 3. Intervention?

Continue resuscitation efforts.

Newborn respiratory rate of 40 breaths per minute and cyanotic hands and feet:

Continue to monitor (normal).

The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take?

Continue to monitor labor progress. The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should continue to monitor the labor progress and document the findings in the client's record. There is no reason to reapply the external transducer if the FHR tracings are being captured

The nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion?

Continuous electronic fetal monitoring

True labor

Contractions increase in duration and intensity Cervical dilation and effacement are progressive Fetus becomes engaged in pelvis and begins to descend

Labor

Coordinate sequence of involuntary, intermittent uterine contractions

Prolapsed Umbilical cord

Cord is displaced b/w the presenting part and amnion or protruding thru the cervix, causing compression of the cord and compromising fetal circulation. S/S client has feeling something is coming thru vagina opening, cord visible or palpable, FHR irregular and slow., FHR monitor shows variable decelerations or bradycardia, If FHR severe, violent fetal activity may occur then cease.

Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.)

Cramping with bright red spotting Lack of tenderness of the breast Increased right-side flank pain

During which of the following phase of the menstrual cycle is it ideal for implantation of a fertilized egg to occur? A. ischemic phase B. mentrual phase C. proliferative phase D. secretory phase

A client is pregnant with her third child. Medical history of the client indicates a previous precipitate labor and birth. Which of the following interventions would NOT be expected during labor of the present pregnancy? A. Use of magnesium sulfate B. Close monitoring of the fetus for hypoxia C. The nurse stays at the bedside constantly or as much as possible D. amnioinfusion will be performed

D Explanation Amnioinfusion is instillation of fluid into the amniotic sac within the uterus to treat oligohydraminios. This is not done to prevent precipitate labor and birth.

The LPN has initiated the administration of vancomycin via IV piggyback . In which of the following situations should the nurse recognize that the client may be experiencing a fatal reaction to this medication? A. The client start coughing B. The client complains of pain at the intravenous catheter insertion site C. The nurse hears the client snoring from the hall D. The nurse notices the client's neck and chest is bright red

D Explanation While administering vancomycin the LPN should know to monitor the client carefully for the development of Red Man Syndrome or anaphylactic shock. The common side effects of this medicine are pruritus, flushing and erythema to the head, neck, and upper body.

31) During the prenatal visit, the client states that she has been experiencing heartburn frequently. The LPN provides instruction on the cause and prevention of heartburn. When she ask to verbalize understanding of the information, which of the following statements by the client indicates further instruction may be necessary? A. "The sphincter that normally prevents stomach contents from going back up into the esophagus is relaxed." B. "I should try to avoid drinking fluids while I'm eating." C. "Eating six or seven small meals a day may help my symptoms." D. "I'll eat enough to ensure that I am full at every meal."

D Explanation It suggests that the instruction might need to be reinforced on preventing stomach distention.

The nurse is aware than an adaptation of pregnancy is an increased blood supply to the pelvic region that results in a purplish discoloration of the vaginal mucosa, which is known as: A) Ladin's sign B) Hegar's sign C) Goodell's sign D) Chadwick's sign

D) Chadwick's sign Rationale: A purplish color results from the increased vascularity and blood vessel engorgement of the vagina.

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

D.Urine output 90 ml/4 hours.

A nurse midwife is performing an assessment of a pregnant client and is assessing the client for the presence of ballottement. Which of the following would the nurse implement to test for the presence of ballottement? A) Auscultating for fetal heart sounds B) Palpating the abdomen for fetal movement C) Assessing the cervix for thinning D) Initiating a gentle upward tap on the cervix

D) Initiating a gentle upward tap on the cervix Rationale: Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. In the technique used to palpate the fetus, the examiner places a finger in the vagina and taps gently upward, causing the fetus to rise. The fetus then sinks, and the examiner feels a gentle tap on the finger.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines the client is experiencing toxicity from the medication if which of the following is noted on assessment? A) Presence of deep tendon reflexes B) Serum magnesium level of 6 mEq/L C) Proteinuria of +3 D) Respirations of 10 per minute

D) Respirations of 10 per minute Rationale: Magnesium toxicity can occur from magnesium sulfate therapy. Signs of toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden drop in the fetal heart rate and maternal heart rate and blood pressure. Therapeutic levels of magnesium are 4-7 mEq/L. Proteinuria of +3 would be noted in a client with preeclampsia.

An expected cardiopulmonary adaptation experienced by most pregnant women is: A) Tachycardia B) Dyspnea at rest C) Progression of dependent edema D) Shortness of breath on exertion

D) Shortness of breath on exertion Rationale: This is an expected cardiopulmonary adaptation during pregnancy; it is caused by an increased ventricular rate and elevated diaphragm.

A pregnant woman at 32 weeks' gestation complains of feeling dizzy and lightheaded while her fundal height is being measured. Her skin is pale and moist. The nurse's initial response would be to: A) Assess the woman's blood pressure and pulse B) Have the woman breathe into a paper bag C) Raise the woman's legs D) Turn the woman on her left side

D) Turn the woman on her left side Rationale: During a fundal height measurement the woman is placed in a supine position. This woman is experiencing supine hypotension as a result of uterine compression of the vena cava and abdominal aorta. Turning her on her side (specifically left side) will remove the compression and restore cardiac output and blood pressure. Then vital signs can be assessed. Raising her legs will not solve the problem since pressure will still remain on the major abdominal blood vessels, thereby continuing to impede cardiac output. Breathing into a paper bag is the solution for dizziness related to respiratory alkalosis associated with hyperventilation.

A nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast tenderness. The nurse tells the client to: A) Avoid wearing a bra B) Wash the nipples and areola area daily with soap, and massage the breasts with lotion. C) Wear tight-fitting blouses or dresses to provide support D) Wash the breasts with warm water and keep them dry

D) Wash the breasts with warm water and keep them dry Rationale: The pregnant woman should be instructed to wash the breasts with warm water and keep them dry. The woman should be instructed to avoid using soap on the nipples and areola area to prevent the drying of tissues. Wearing a supportive bra with wide adjustable straps can decrease breast tenderness. Tight-fitting blouses or dresses will cause discomfort.

Which of the following answers best describes the stage of pregnancy in which maternal and fetal blood are exchanged? A) Conception B) 9 weeks' gestation, when the fetal heart is well developed C) 32-34 weeks gestation D) maternal and fetal blood are never exchanged

D) maternal and fetal blood are never exchanged Rationale: Only nutrients and waste products are transferred across the placenta. Blood exchange only occurs in complications and some medical procedures accidentally.

Pediazole is a suspension medication that contains 200 mg erythromycin and 600 mg sulfisoxazole per 5 mL. The physician orders Pediazole 4 mL PO every 12 hours. How many mg of sulfisoxazole is this client receiving in a 24-hour period? A. 160 mg B. 320 mg C. 480 mg D. 960 mg

D. Explanation 600 mg/ 5 mL = x mg/ 4 mL 2400 = 5x x= 2400/5 x= 480 mg per dose x 2 = 960 mg in 24 hours.

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

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

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

D. Take prescribed multivitamin and mineral supplements.

An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse. B.Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed. C. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit. D.Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

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

A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? A. Encourage the mother to provide total care for her infant. B. Provide privacy so the mother can develop a relationship with the infant. C. Encourage the father to provide most of the infant's care during hospitalization. D.Meet the mother's physical needs and demonstrate warmth toward the infant.

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

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first? A.Assess the husband's feelings about his wife's decision to breastfeed their baby. B.Ask the client to describe why she was unsuccessful with breastfeeding her last child. C.Encourage the client to develop a positive attitude about breastfeeding to help ensure success. D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A.Use a thread to tie off the umbilical cord. B.Provide as much privacy as possible for the woman. C.Reassure the husband and try to keep him calm. D.Put the newborn to breast

D.Put the newborn to breast

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

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

A HCP informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruption placentae. What findings should the nurse expect the client to demonstrate?

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

False Labor

Does not produce dilation, effacement or descent Contractions are irregular w/o progression *Activity such as walking, drinking fluids relieves false labor*

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

Patient is 5 weeks pregnant, educate on nutrition...

Eat a well balanced diet, adjust PRN for proper weight gain.

A client who is 8 weeks' pregnant calls the prenatal clinic and tells the nurse that she is experiencing nausea and vomiting every morning. The nurse should suggest which measure that will best promote relief of the signs and symptoms?

Eating dry crackers before arising

The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern?

Edema, basilar rales, and irregular pulse

Stage 1

Effacement and dilation of cervix *3 stages: Latent, Active, Transition* Mother is talkative and eager in Latent phase, becoming tired, restless, and anxious as labor intensifies and contractions become stronger. Interventions: Monitor VS, FHR, before and after contraction, assess status of cervical dilation and position by Leopold's maneuvers. Pelvix exam and fern test. *Ruptured membranes*- assess FHR, color of amniotic fluid

The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations?

Encourage an upright or side-lying maternal position

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

Encourage healthy lifestyles for families desiring pregnancy

The total bilirubin level of a 36-hour, breastfeeding newborn is 14mg/dl. Based on this finding, which intervention should the nurse implement?

Encourage the mother to breast feed frequently

The Total bilirubin of a 36-hour, breastfeeding newborn is 14mg/dL. Based on this finding, Which intervention should the nurse implement?

Encourage the mother to breastfeed frequently.

A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement?

Encourage the mother to stop feeding for a few minutes and comfort the infant. The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often more successful.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness?

Ensure that the baby is positioned correctly for latching on. The most common cause of nipple soreness is incorrect positioning of the infant on the breast for latching on. The baby's body is in alignment with the ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast. Option A helps prevent chafing, and nonbinding support aids in prevention of discomfort from the stretching of the Cooper ligament. Option B is important but is not necessary for all women. Option D helps soften an engorged breast and encourages correct infant latching on but is not the best answer

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

Epigastric pain

Assessing a 3 day old with cephalohematoma. What intervention is highest priority?

Examine Q8 hrs for jaundice (look for hyperbilirubinemia). RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.

24 hours after birth, cephalohematoma, what intervention?

Examine jaundice Q8 hours. RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.

Dystocia S/S and Interventions

Excessive abdominal pain, abnormal contraction pattern, fetal distress, maternal or fetal tachycardia, lack of progress in labor 1. Assess FHR, monitor fetal distress 2. Monitor uterine contractions 3.Monitor maternal temp and HR 4. Assist w/ pelvic exam, us, measurements 5. Admin prophylactic antibiotic 6. Admin IV fluids 7. Monitor I&Os, Keep hydrated

A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color. Which action should the nurse take?

Explain this is a normal finding. The client is describing lochia serosa, a normal change in the lochial flow

The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn which infectious organism will this treatment prevent from harming the infant?

Gonorrhea

The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate?

Gonorrhea Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal.

A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. Which is the correct description of this client that should be documented in the medical record?

Gravida 2, para 0 The spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0. Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond.

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 providing instructions to a pregnant client visiting the antenatal clinic about foods that are rich in folic acid. Which food should the nurse encourage the client to consume because it is highest in folic acid?

Green leafy vegetables

The nurse attempts to help and unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate?

Grief related to her perceptions about loss of this child.

A pregnant woman seen in the health care clinic has tested positive for human immunodeficiency virus (HIV). What can the nurse determine based on this information?

HIV antibodies are detected by the enzyme-linked immunosorbent assay (ELISA) test.

A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV-infected. Which explanation should the nurse provide?

HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present. All newborns of HIV-positive mothers receive passive HIV antibodies from the mother, so the evaluation of an infant for the HIV virus is determined at 18 months of age, when all the maternal antibodies are no longer in the infant's blood. Passive HIV antibodies disappear in the infant within 18 months of age. Option B is inaccurate. Although administration of HIV medication during pregnancy can significantly reduce the risk of vertical transmission, treatment does not ensure that the virus will not become manifest in the infant.

During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take?

Have her cup both hands over her nose and mouth while breathing. Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes transient respiratory alkalosis, so the client should cup both her hands over her mouth and nose so that she can rebreathe carbon dioxide.

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take?

Have the client breathe into her cupped hands. Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands.

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client?

Have the client empty her bladder.

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The health care provider has documented the presence of first trimester pregnancy signs. Which signs should the nurse anticipate as being present during this time frame? Select all that apply.

Hegar's sign Goodell's sign Chadwick's sign

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

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

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for a spontaneous abortion?

History of syphilis

A primigracida at 40-weeks gestation is receiving oxytocin to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin?

Hyperstimulation

38 week (IDM) infant of diabetic mother admitted to NICU @ 8.2 lbs. What is the priority Nursing Dx?

Hypoglycemia.

A primigravida, when returning for the results of her multiple marker screening (triple screen), asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to describe best how the test is interpreted?

If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect. Low levels of MSAFP and estriol and elevated levels of hCG found in the maternal blood sample are indications of possible chromosomal defects. High levels of MSAFP and estriol in the blood sample after 15 weeks of gestation can indicate a neural tube defect, such as spina bifida and anencephaly, not chromosomal defects. One of the limitations of the multiple marker screening is that any defects covered by skin will not be evident in the blood sampling. After 15 weeks of gestation, there will be traces of MSAFP, estriol, and hCG in the blood sample.

24 hour old baby, mom is scared she is not breastfeeding right, the nurse should say...

If your baby's urine is straw colored , then she is feeding well.

A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating and states that because she has had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority?

Impaired bowel motility related to pain medication and immobility Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. Options A and B are both caused by impaired bowel motility. Option D is not as important as impaired motility.

Placenta Previa

Improperly implanted placenta in lower uterine segment over internal cervical. S/S Sudden onset of *PAINLESS, Bright Red* vaginal bleeding, Uterus soft, relaxed, NONtender. Interventions- monitor vs, FHR, prepare for US, avoid vaginal exam, bed rest in side lying position, admin IV fluids, possible RhoGAM, tocolytic meds

Episiotomy

Incision made into perineum to enlarge the vaginal outlet and facilitate delivery. Interventions: check site, relieve pain, ice packs first 24 hours then sitz bath, apply analgesic spray, perineal care, report bleeding or discharge from site

A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement?

Increase the rate of the oxytocin (Pitocin) infusion. The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate the frequency and intensity of contractions.

40 wks, cesarean, receives anticholinergic, atropine 0.4 mg IM as adjunct to inhaled anesthesia. What would be a therapeutic response to the injection?

Increased HR and decrease in oral secretions.

Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.)

Increased heartburn that is not relieved with doses of antacids Chronic headache that has been lingering for a week behind the client's eyes

The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that which may be required during the second half of pregnancy?

Increased insulin

Cytotec (Misoprostol) for peptic ulcer (Synthetic Prostaglandin E Drug). Nurse response?

Increased risk for spontaneous miscarriage. RATIONALE: Cytotec (Misoprostol) can induce uterine contractions resulting in miscarriage.

A full term infant is transferred to the nursery from the labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn?

Infant's condition at birth and treatment received

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate?

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

This is a dark streak down the midline of the abdomen that may appear as the uterus is enlarging. The LPN correctly describes this to the pregnant woman as?

LINEA NIGRA

Symptoms of hemorrhage/bleeding out:

LR 200 mL/hr using 18 gauge needle.

Precipitous Labor and Delivery

Labor lasting less than 3 hours -Interventions Delivery tray (hemostats, scissors, cord clamp) Stay with client Support; keep client calm Pant b/w contractions Prepare for ruptured membranes / head crowns -Before arrival of MD or none: 1. Apply gentle pressure to fetal head upward toward vagina to prevent damage 2. Support infants body during delivery 3. Deliver infant b/w contractions; check for cord around neck 4. Use restitution to deliver posterior shoulder 5. Use gentle downward pressure to move anterior shoulder under public symphysis 6. *Bulb suction infant's mouth first then suction nares. 7. Dry and cover infant to keep warm 8. Allow the placenta to separate naturally 9. Place infant on mothers abdomen or breast to induce uterine contractions.

. Second stage of labor, what does nurse do first?

Let pt know that birth is imminent. RATIONALE: Second stage pt is fully dilated and fetus is crowning.

Stage 1 (1. Latent phase)

Longest stage A labor curve (Friedman) used to identify whether a woman's cervical dilation is progression at expected rate. S/S Cervical dilation 1-4cm* Uterine contractions occur every 15-30 mins; 15-30 sec in duration; mild intensity Interventions: comfort measures, change positions, keep family informed of progress, offer fluids, encourage voiding 1-2 hours

During a prenatal visit, the nurse discusses the effects of smoking on the fetus with a client. Which statement is most characteristic of an infant whose mother smoked during pregnancy compared with the infant of a nonsmoking mother?

Lower initial weight documented at birth Smoking is associated with low-birth-weight infants. Therefore, mothers are encouraged not to smoke during pregnancy.

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

Lying prone with a pillow on the abdomen

A female client with insulin-dependent diabetes arrives at the clinic seeking a plan to get pregnant in approximately 6 months. She tells the nurse that she wants to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client?

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

The nurse is 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 doing which action?

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

A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is started on an IV solution of tervutaline (Berthine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug?

Maternal and fetal heart rates.

During a woman's 38-week prenatal visit, the nurse assesses the fetal heart rate to be 180 beats/minute. What might the nurse suspect as the most likely cause of this tachycardia?

Maternal infection

A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Ngele's rule, what is the estimated date of delivery?

May 9, 2006

A pregnant client tells the nurse that the first day of her last menstrual period was Aug. 2, 2006. Based on Ngele's rule, what is the estimated date of delivery?

May 9, 2007

Station

Measurement of the progress of descent in cm above or below the midplane from the presenting part to ischial spine Station 0= at ischial spine Minus station= above ischial spine Plus station= below ischial spine Engagement= widest diameter of presenting part has passed the inlet, corresponds to a 0 station.

Intrathecal opioid analgesics

Medication is injected into subarachnoid space and has a rapid onset of action. Used in combination with a lumbar epidural block

The goal for a woman with partial premature separation of the placenta is: "The woman will not exhibit signs of fetal distress." Which outcome, documented by the nurse, indicates that this goal has been achieved?

Moderate variability present

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tese between contractions, BP 110/68 FHR 110 beats/min, cervix 1 cm dialated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?

Monitor bleed from IV sites

Rupture uterus interventions

Monitor for and treat signs of shock *( admin oxygen, IV fluids, Blood products)* Prepare client for c-section & possible hysterectomy Emotional support

The nurse is conducting a session about nutrition with a group of adolescents who are pregnant. Which measure is most appropriate to teach these adolescents?

Monitor for appropriate weight gain patterns.

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

Monitoring fetal status

The nurse is preparing to care for a client who is being admitted to the hospital with a possible diagnosis of ectopic pregnancy. The nurse develops a plan of care for the client and determines that which nursing action is the priority?

Monitoring the apical pulse

The nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the documentation related to the results of the test. The nurse notes that the health care provider has documented the test results as reactive. How should the nurse interpret this result?

Normal findings

The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse?

Notify the health care provider The health care provider should be notified when a client practices pica (craving for and consumption of nonfood substances). The practice of pica may displace more nutritious foods from the diet, and the client should be evaluated for anemia.

A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 90 beats/minute. Which nursing action is appropriate?

Notify the health care provider (HCP).

On admission to the prenatal clinic, a 23 year old woman tells the nurse that her last menstrual period began on Feb 15, and that her previous periods were regular. Her pregnancy test is positive. The client's expected date of delivery (EDD) would be

November 22

On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on February 15 and that previously her periods were regular (28-day cycle). Her pregnancy test is positive. What is this client's expected date of birth (EDB)?

November 22 correctly applies the Nägele rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15 + 7 = 22).

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

Observe for an asymmetrical Moro reflex

A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for discharge. Which nursing intervention should be included in this infant's discharge teaching plan?

Observe the parents applying a Pavlik harness. It is important that the hips of infants with hip dysplasia are maintained in an abducted position, which can be accomplished by using the Pavlik harness; this keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum.

One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first?

Obtain a serum glucose level. This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level. Option A is an intervention for a lethargic infant. Option B should be done based on the temperature, but first the glucose level should be obtained. Option C helps raise the blood sugar, but first the nurse should determine the glucose level.

Obtain a specimen for urine

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?

Obtain equipment for a manual pelvic examination.

Preterm labor

Occurs after the 20th week but before 37 week. -Risk factors: H/O medical conditions, present & past obstetric problems, infection, and social/environmental factors, substance abuse. Multiple pregnancy, anemia, age 18, or 40 years old S/S Uterine contractions, abdominal cramping, low back pain, pelvic pressure or heaviness, change in character and amount of usual discharge, rupture of amniotic membranes

Supine Hypotension (Vena Cava Syndrome)

Occurs when venous return to heart is impaired by wt of uterus on vena cava. -Results in partial occlusion of vena cava and aorta and reduced cardiac return, cardiac output and BP S/S Pallor, faintness, dizziness, breathlessness, tachycardia, hypotension, sweating, cool and damp skin, fetal distress. Interventions- position client on her side to shift wt of fetus off vena cava. Monitor vs and FHR

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately?

Onset of uterine contractions

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the HCP?

Onset of uterine contractions. The onset of uterine contractions places the client at risk for dilation and placental separation, which causes painless hemorrhaging

The nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if she states that she will take the supplements with which item?

Orange juice

Baby born breech, in the NICU they assess?

Ortolani's test. RATIONALE: (from Saunders, couldn't find it in HESI). It is a test of hip laxity, used to diagnose hip dysplasia.

The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately?

Palpating the maternal radial pulse while listening to the FHR

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

Patellar reflex 4+

Perform a vaginal examination every shift.

A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan?

Place petroleum ointment around the glans with each diaper change and cleansing With each diaper change, the glans penis should be washed with warm water to remove any urine or feces, and petroleum ointment should be applied to prevent the diaper from sticking to the healing surface. Prepackaged wipes often contain other products that may irritate the site. The yellow exudate, which covers the glans penis as the area heals and epithelializes, is not an infective process and should not be removed. If bleeding occurs at home, the client should be instructed to apply gentle pressure to the site of the bleeding with sterile gauze squares and call the health care provider.

40 weeks pregnant, laboring, patient states supine is position of comfort, the nurse should?

Place pillow wedge under right hip. RATIONALE: Hypotension from pressure on vena cava is risk, the wedge relieves the pressure on the vena cava.

Water broke, umbilical cord is on perineum, what does nurse do?

Place pt in trendelenburg. RATIONALE: Take the pressure off the presenting part of cord by vaginal exam and holding up the presenting part as much as possible.

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action?

Place the client in Trendelenburg's position.

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

Place the client in a lateral position. The nurse should immediately turn the client to a lateral position or place a pillow or wedge under one hip to deflect the uterus. Other immediate interventions include increasing the rate of the main line IV infusion and administering oxygen by facemask. If the blood pressure remains low after these interventions or decreases further, the anesthesiologist or health care provider should be notified immediately. To continue to monitor blood pressure without taking further action could constitute malpractice.

Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement?

Place the client in a slight Trendelenburg position. The goal is to relieve pressure on the umbilical cord, and placing the client in a slight Trendelenburg position is most likely to relieve that pressure. The FHR pattern is indicative of a variable fetal heart rate deceleration, which is typically caused by cord compression and can occur with or without contractions.

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

Place the woman in lateral position

Placental separation

The nurse observes a new mother is rooming in and caring for her newborn infant. Which observation indicated the need for further teaching?

Places the infant prone in the bassinet

The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn son at home. The woman tells the nurse, "I don't know what is wrong. I love my son, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should the nurse determine the client is experiencing?

Postpartum blues During the postpartum period, when serum hormone levels fall, women are emotionally labile, often crying easily for no apparent reason. This phase is commonly called postpartum blues, which peaks around the fifth postpartum day. The taking-in phase is the period following birth when the mother focuses on her own psychological needs; typically, this period lasts for 24 hours. Crying is not a maladaptive attachment response. It indicates a normal physical and emotional response. The letting-go phase is when the mother sees the child as a separate individual.

The clinic nurse is instructing a pregnant client in her first trimester about nutrition. The nurse should determine that the client needs further teaching if the client believes that which is true about nutrition during pregnancy?

Pregnancy greatly increases the risk of malnourishment for the mother.

Abruptio placentae

Premature separation of placenta from uterine wall S/S *Dark Red, Uterine PAIN, tenderness*, uterine rigidity, severe ABDOMINAL pain, S/S fetal distress, Maternal shock Interventions- Monitor vs, FHRA, assess bleeding, increase in fundal ht, bed rest, admin oxygen, IV fluids, blood, place client in Trendelenburg position to decrease pressure from fetus or hypovolemic shock occurs, Prepare for delivery of fetus

During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome?

Prevent dehydration and hypoxemia.

Eye ointment QS is for?

Prevent eye infection.

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention should the nurse implement first?

Provide assistance to the mother to begin breastfeeding as soon as possible after delivery Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery.

Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.

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

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?

Put the newborn to the breast immediately Putting the newborn to the breast will help contract the uterus and prevent a postpartum hemorrhage. This intervention has the highest priority. Option A is not necessary; the infant can be transported attached to the placenta. Option B is an important psychosocial need but does not have the priority of option D. Although the husband is an important part of family-centered care, he is not the most important concern at this time.

Newborn assessment that indicates a cardiac problem?

RR 78/min. RATIONALE: Normal respiratory rate for a newborn is 40 - 60.

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

Raise the foot of the bed

An expectant father tells the nurse he fears that his wife "is losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father?

Reassure him that normal maternal-fetal bonding is occurring These behaviors are positive signs of maternal-fetal bonding and do not reflect ambivalence. No intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal bonding during the second trimester.

The nurse is providing discharge teaching for a client who is 24 hours post partum. The nurse explains to the client that her vaginal discharge will change from red to pink then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do?

Reduce activity level and notify the healthcare provider.

The nurse assists a pregnant client with cardiac disease to identify 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 for which reason?

Reduce excessive maternal stress and fatigue.

A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan?

Reduce external stimuli.

A 30-year-old multiparous woman who has a 3-year old boy and a newborn girl tells the nurse, "my son is so jealous of my daughter, I don't know how ill ever manage both children when I get home." How should the nurse respond?

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

Position

Relationship of assigned area of the presenting part or landmark to the maternal pelvis

Lie

Relationship of the spine of the fetus to the spine of the mother -Longitudinal or vertical ( I ) a.Fetal spine is parallel to mothers pine b. Fetus is in cephalic or breech presentation -Transverse or horizontal ( ---- ) a.Fetal spine is at (R) angle or perpendicular, to mothers pine b.Presenting part is shoulder c.*Delivery by c-section is necessary*

During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement theses actions? (Place the first action on top and the last on the bottom) Provide oxygen via mask reposition client call HCP Increase IV Fluids

Reposition the client Increase IV Fluids provide oxygen via face mask Call HCP To stabilize the fetus, intrauterine reconstitution is first priority, and to enhance fetal blood supply, the laboring client should be repositioned to replace the gravid uterus and to improve fetal perfusion. Secondly, the IV fluids should be increased to expand the maternal circulating blood volume. Next, to optimize oxygenation of the circulatory blood volume, oxygen via face mask should be administered to mother. The HCP should provide other measures to relieve fetal stress.

Heelstick blood specimen on neonate for T4 and TSH prior to D/C home on 2 day old. Parents ask why, the nurse states?

Required by law to screen for metabolic def.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

Rest between contractions

The home care nurse is visiting a prenatal client who has a history of heart disease. The nurse provides instructions to the client regarding home care measures to promote a healthy pregnancy and includes which measure in that instruction?

Restrict visitors who may have an active infection.

A rubella titer is performed on a client who has just been told that she is pregnant. The results of the titer indicate that the client is not immune to rubella. Which should the nurse anticipate to be prescribed for this client?

Retesting rubella titer during pregnancy

Rh negative refuses Rhogam after delivery.

Rhogam prevents maternal antibody formation for future Rh positive babies.

Rupture of uterus

S/S Complete or incomplete separation of the uterine tissue as a result of a tear in wall from stress of labor Risk factors- labor after previous c-section, overdistened uterus, hydramnios, abdominal trauma. S/S abd pain or tenderness, chest pain, contractions stop or fail to progress, rigid abdomen, absent FHR, s/s shock, fetus palpated outside of uterus (Complete rupture)

Fetus distress

S/S FHR <110 or >160, meconium-stained amniotic fluid, fetal hyperactivity, progressive decrease in baseline variability, severe variable decelerations, late decelerations Interventions Place client in lateral position Admin oxygen D/C Oxytocin Monitor fetal and maternal status -If fetal in distress -> c-section

Intrauterine fetal demise

S/S Loss of fetal movement, absence of fetal heart tones, DIC- disseminated intravascular coagulation screen, low Hemoglobin & Hct, low platelett, prolonged bleeding Interventions- encourage client to verbalize feelings, etc

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

Screen for neural tube defects

Stage 3

Separation of placenta Expulsion of placenta Mother is relieved after birth of newborn; mother usually very tired. Interventions- *Schultze mechanism* center portion of placenta separates first, its shiny fetal surface emerges from vagina. *Duncan mechanism* margin of placenta separates and dull red, rough Maternal surface emerges from vagina first. *After expulsion of placenta*- uterine fundus remains firm and located 2 finger breadths below the umbilicus

A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding?

Skin color that is slightly jaundiced Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of the hands and feet) is a common finding in newborns; it occurs because the capillary system is immature. Milia are small white papules present on the nose and chin that are caused by sebaceous gland blockage and disappear in a few weeks. Small red patches on the cheeks and trunk are called erythema toxicum neonatorum, a common finding in newborns

Premature Rupture of the Membranes

Spontaneous rupture of amniotic membranes before the onset of labor. If ruptured is before term and delivery will be delay, Infections becomes a risk. S/S presence of fluid pooling in vaginal vault; nitrazine test is positive. Elevated temp= infection Interventions: assist with tests to assess gestational age, AVOID vaginal exams because of risk of infections. Monitor maternal and fetal for s/s complications or infection.

The purpose of a vaginal examination for a client in labor is to specifically assess the status of which findings? Select all that apply.

StationDilationEffacement

A clinic nurse is explaining to a client the changes in the integumentary system that occur during pregnancy and should tell the client that which change may persist after she gives birth?

Striae gravidarum

Supine position with a wedge under the right hip

A pregnant client asks the nurse about the types of exercises that are allowed during pregnancy. The nurse should tell that client that which exercise is safest?

Swimming

A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate?

Tachycardia and a feeling of nervousness Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of nervousness.

A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client?

Take prescribed multivitamin and mineral supplements

Receiving report on laboring pt from ER. Water broke and didn't know it. First thing the nurse does?

Take temperature. RATIONALE: Length of time membranes ruptured is important to monitor for infection.

A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide?

Take your blood pressure now, and if it is seriously elevated, go to the hospital. Checking the blood pressure for an elevation is the best instruction to give at this time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension.

A 23- year old client who is receiving Medicid benefits is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client?

Teach the client why keeping prenatal care appointments is important

Baby weighs 7.5 lbs today, tomorrow 7 lbs (5 lb weight loss). What does the nurse do?

Tell mother it is normal. RATIONALE: Newborns can lose 10% of their wt and regain it later.

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.

. Patient concerned about yellow nipple discharge.

Tell the patient it is normal.

One hand above pubic symphysis while massaging fundus of a patient who has a boggy uterine tone 15 min after delivery (7 lb baby). What does the nurse tell the patient?

Tell the patient that clots can form in a boggy uterus.

Assessing a 39 week pregnant patient admitted to L&D, which do you call MD for?

Temperature of 101.2

A client in week 35 of her pregnancy is placed on the fetal heart monitor for a nonstress test (NST) as a result of her complaints of decreased fetal movement. Twenty minutes after placing the client on the monitor, the nurse sees the following monitor strip and makes which conclusion regarding the NST?

The FHR is reactive, with a baseline of 130 beats/minute, moderate variability, and no decelerations.

In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan?

The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month. In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel closes by the end of the second month. These growth and development milestones are frequently included in questions on the licensure examination.

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor?

The appearance of the fetal external genitalia

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 exam.

A pregnant primigravida is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. The nurse plans to base the response on which facts? Select all that apply.

The breast changes occur because of the secretion of estrogen and progesterone. Blood vessels beneath the skin often appear as a blue, intertwining network, especially in a primigravida.

The nurse is providing emergency measures to a client in labor who has been diagnosed 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 client problem is most appropriate to address at this time?

The client's fear

Client teaching is an important part of the perinatal nurse's role. Which factor has the greatest influence on successful teaching of the pregnant client?

The client's investment in what is being taught When teaching any client, readiness to learn is related to how much the client has invested in what is being taught or how important the materials are to the client's particular life. For example, the client with severe morning sickness in the first trimester may not be ready to learn about labor and delivery but is probably very ready to learn about ways to relieve morning sickness.

Amniotic Fluid embolism

The escape of amniotic fluid into maternal circulation. -Debris-containing amniotic fluid deposits in pulmonary arterioles and fatal to mothers S/S Abrupt onset of respiratory distress and chest pain, Cyanosis, Fetal bradycardia and distress

The nurse is reviewing fetal development with a client who is at 36 weeks' gestation. Which statements describe the characteristics that are present in a fetus at this time? Select all that apply.

The fetus is approximately 42 to 48 cm long. The lecithin-sphingomyelin (L/S) ratio is greater than 2:1.

Passenger

The fetus, membranes, and placenta

A full-term infant is transferred to the nursery from labor and delicery. Which information is most important for the nurse to receive when planning immediate care for the newborn?

The infants condition at birth and treatment received.

The nurse working in a prenatal clinic reviews a client's chart and notes that the health care provider documents that the client has a gynecoid pelvis. The nurse understands that which is a characteristic of this type of pelvis?

The most favorable for labor and birth

Passageway

The mother's rigid bony pelvis and soft tissues of cervix, pelvic floor, vagina, and introitus (external opening to the vagina)

. Fundus hand placement: 1 massages the fundus the other is for...

The other hand anchors the lower uterine section.

The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise?

The passage of meconium

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. What is the initial nursing action?

Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min.

Attitude

The relationship of the fetal body parts to one another Normal intrauterine attitude is *flexion* (fetal back is rounded, head is forward on the chest, arms and legs are folded in against the body.) *Extension* tends to present larger fetal diameters

While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedneum. Which additional information should the nurse provide this new mother?

The scalp edema will subside in a few days after birth

Presenting part

The specific fetal structure lying nearest to the cervix

A 25-year-old woman arrives on the maternity unit on February 2. She states that her estimated date of delivery (EDD) is March 22. She is verbalizing complaints of dull lower back pain, pelvic heaviness, and diarrhea for the past few days. On admission for observation, the client's blood pressure is 128/80 mm Hg, pulse is 100 beats/minute, respirations are 16 breaths/minute, and temperature is 99°F. The nurse plans care based on which interpretation?

The woman requires further evaluation for preterm labor.

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client?

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

A couple has been trying to conceive for 9 months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child?

They use lubricants with each sexual encounter to decrease friction

A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couples ability to conceive a child?"

They use lubricants with each sexual encounter to decrease friction.

The nurse is assisting in the care of a client in labor who is having an amniotomy performed. The nurse should report which abnormal findings to the health care provider (HCP)? Select all that apply.

Thick white amniotic fluid with no odorLight green amniotic fluid with no odorClear, dark amber amniotic fluid

The nurse is assessing the umbilical cord of a newborn. Which finding constutes a normal finding?

Three vessels: two arteries and one vein

MVA, 36 weeks, BP 80/50, HR 130, what does the nurse do?

Tilt the backboard to displace uterus.

Primipara 20 week, schedule u/s, what's the reason for the u/s?

To evaluate fetal growth and to determine gestational age.

Oxytocin (Pitocin) 20 units in 1000 LR after delivery is for?

To stimulate uterine contractions to prevent hemorrhage. RATIONALE: Admin after placenta delivery. Prior to placental delivery would cause uterus to contract and retain placenta.

20 weeks gestation, gained 20 lbs, fundal height 20, clear liquid from breasts. What warrants further evaluation?

Too much weight gain, gestational weight gain should only be approx 10.3 lbs.

The nurse is collecting data from a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which findings are associated with abruptio placentae? Select all that apply.

Uterine tendernessAcute abdominal painA hard, "boardlike" abdomenIncreased uterine resting tone on fetal monitoring

The nurse is assessing a client with a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse understands that which findings are associated with this condition? Select all that apply.

Vaginal bleeding Excessive nausea and vomiting Larger-than-normal uterus for gestational age Elevated levels of human chorionic gonadotropin (hCG)

When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation?

Vernix is a white cheesy substance, predominantly located in the skin folds. Vernix, found in the folds of the skin, is a characteristic of term infants. Milia are not red marks made by forceps but are white pinpoint spots usually found over the nose and chin that represent blockage of the sebaceous glands. Meconium is the first stool, but it is tarry black, not yellow. Pseudostrabismus (crossed eyes) is normal at birth through the third or fourth month and does not require surgery.

The prenatal client asks the nurse about substances that can cross the placental barrier and potentially affect the fetus. The nurse most appropriately explains that which substances can cross this barrier? Select all that apply.

Viruses Nutrients Antibodies Medications

A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the health care provider (HCP). The nurse should tell the woman to call the HCP if which occurs?

Weight increases by more than 1 pound in a week.

The nurse is instructing a pregnant client on measures to increase iron in the diet. The nurse should tell the client to consume which food that contains the highest source of dietary iron?

Whole-grain cereal

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

a. Choking, coughing, and cyanosis.

A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? a. Describe diet changes that can improve the management of her diabetes. b.Inform the client that oral hypoglycemic agents are teratogenic during pregnancy. c. Demonstrate self-administration of insulin. d. Evaluate the client's ability to do glucose monitoring.

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

A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? a.Biophysical profile (BPP). t b.Ultrasound for fetal anomalies. c.Maternal serum alpha-fetoprotein (AF) screening d.Percutaneous umbilical blood sampling (PUBS).

a.Biophysical profile (BPP).

When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.) a.Mood swings. b.Panic attacks. c.Tearfulness d.Decreased need for sleep. e. Disinterest in the infant

a.Mood swings. c.Tearfulness

On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) is a.November 22. b.November 8. c.December 22. d.October 22.

a.November 22.

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

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

the nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider? a.Yellowish tinge to the skin. b. Babinski reflex present bilaterally. c.Pink papular rash on the face. d.Moro reflex noted after a loud noise.

a.Yellowish tinge to the skin.

A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurse's response should be based on what information? a.Males inherit the disorder with a greater frequency than females. b.Each pregnancy carries a 50% chance of inheriting the disorder. c.The disorder occurs in 25% of pregnancies. d.All children will be carriers of the disorder.

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

A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin? a.Dehydration. b.Hyperstimulation. c. Galactorrhea. d.Fetal tachycardia.

b.Hyperstimulation.

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

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

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

b.Observe the mother for other attachment behaviors.

c. January 30-31.

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

c. have the client breathe into her cupped hands.

A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement? a.Notify the healthcare provider. b.Move the newborn to an isolation nursery. c.Document the finding in the infant's record. d.Obtain a culture of the vesicles.

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

The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? a.Herpes. b.Staphylococcus c.Gonorrhea. d. Syphilis.

c.Gonorrhea.

A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? a.Cervical dilation of 5 cm with 90% effacement. b.White blood cell count of 12,000/mm3. c.Hemoglobin of 12 mg/dl and hematocrit of 38%. d.A platelet count of 67,000/mm3.

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

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

d.Central cyanosis when crying.

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

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

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

d.Encourage healthy lifestyles for families desiring pregnancy.

A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide? a.Herbs are a cornerstone of good health to include in your treatment. b.Touch is also therapeutic in relieving discomfort and anxiety. c.Your healthcare provider should direct treatment options for herbal therapy. d.It is important that you want to take part in your care.

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

The nurse is calculating the estimated date of confinement (EDC) using Nägele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? a.August 1. b.August 10. c.September 3. d.September 8.

d.September 8.

While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother? a.The infant should be positioned to reduce the swelling. b.The swelling is a subperiosteal collection of blood. c.The pediatrician will aspirate the blood if it gets larger. d.The scalp edema will subside in a few days after birth.

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

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

"My contractions will increase in duration and intensity."

A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply.

- Increase in fundal height - Hard, boardlike abdomen - Persistent abdominal pain

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? A.Wear support stockings. B. Reduce salt in her diet. C. Move about every hour. D. Avoid constrictive clothing.

...

The nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing?

Hypotonic

The maternity nurse is caring for a client with abruptio placentae and is monitoring her for disseminated intravascular coagulation (DIC). Which assessment findings are most likely associated with disseminated intravascular coagulation? Select all that apply.

1. Petechiae . 2.Hematuria 4. Prolonged clotting times 5. Oozing from injection sites

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

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

The nurse has collected the following data on a client in labor. The fetal heart rate (FHR) is 154 beats/min and is regular, and contractions have moderate intensity, occur every 5 minutes, and have a duration of 35 seconds. Using this information, what is the appropriate action for the nurse to take?

Continue to monitor the client.

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply.

A gravida II who has just been diagnosed with dead fetus syndrome A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia

Immediately after birth a newborn infant is suctioned, dried and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical HR of 80 beats/minute and respirations of 20 breaths/min. What action should be performed next? A. Initiate positive pressure ventilation B . Intervene after one min Apgar is assessed. C. Initiate CPR on the infant D. Assess the infant's blood glucose level

A. Initiate positive pressure ventilation

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? A. The client's readiness to learn. B. The client's educational background. C. The order in which the information is presented. .DThe extent to which the pregnancy was planned.

A. The client's readiness to learn.

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

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

The nurse is assessing a 3 day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider? A. yellowish tinge to the skin B. babinski reflex present bilaterally C. pink papular rash on the face D. moro reflex noted after a loud noise

A. yellowish tinge to the skin

Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement?

Administer oxygen at 8-10 L/min via face mask

Administer oxygen via face mask.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)?

Fetal heart rate of 180 beats/minute

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

B. Extend the leg and dorsiflex the foot.

A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? a. Length of labor and method of delivery b. Infant's condition at birth and treatment received. C. Feeding method chosen by the parents. D. History of drugs given to the mother during labor.

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

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

B. calcium gluconate

Breathe rapidly.

A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate? A. Drowsiness and bradycardia. B. Depressed reflexes and increased respirations. C. Tachycardia and a feeling of nervousness. D. A flushed, warm feeling and a dry mouth

C. Tachycardia and a feeling of nervousness.

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

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

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated a nd the client is lying in a 6inch diameter pool of blood. A. Cleanse the perineum B. obtain a BP C. palpate the firmness of the fundus D; inspect the perineum for lacerations

C. palpate the firmness of the fundus

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

C.Correctly place the infant on the breast.

At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?A. Check the hematocrit results. B. Administer pain medication. C.Increase the rate of IV fluids. D.Monitor client for contractions.

C.Increase the rate of IV fluids.

The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action?

Clear and maintain an open airway.

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

D. 3-1-1-0-3

When assessing a client who is at 12 week gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. at 16 weeks gestation B.at 20 weeks gestation C. at 24 weeks gestation D. at 30 weeks gestation

D. At 30 weeks gestation.

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

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

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

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

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

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

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

D. apply firm pressure to sacral area

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

D. central cyanosis when crying

When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A.At 16-weeks gestation. B.At 20-weeks gestation. C.At 24-weeks gestation. D.At 30-weeks gestation.

D.At 30-weeks gestation.

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?

Discontinue the infusion of oxytocin.

A client in labor is dilated 10 cm. At this point in the labor process, at least how often should the nurse assess and document the fetal heart rate?

Every 15 minutes

Fear of losing control

Measure fundal height.

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?

Monitoring the fetal heart rate

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

Move about every hour.

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately. A.heart rate of 100 beats min B. variable fetal HR C. Onset of uterine contractions D. Burning on urination

Onset of uterine contractions.

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

Provide pain relief measures

Provide pain relief measures.

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action?

Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min.

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

Uterine tenderness

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

Variable decelerations

A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/minute and the umbilical cord protruding from the vagina. The client tells the nurse that her "water broke" before coming to the hospital. What is the appropriate nursing action?

Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.

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