Student

A newborn in the nursery is exhibiting signs of neonatal abstinence syndrome. Which of the following signs/symptoms is the nurse observing? Select all that apply. 1. Hyperphagia 2. Lethargy 3. Prolonged period of sleep 4. Hyporeflexia 5. Persistent shrill cry

1 and 5 babies with neonatal abstinence syndrome repeatedly show signs of hunger and often have shrill cry that may continue for prolonged periods of time

An antenatal client is informing the nurse of her prenatal signs and symptoms. Which of the following findings would the nurse determine are presumptive signs of pregnancy? Select all that apply. 1. Amenorrhea. 2. Breast tenderness. 3. Quickening. 4. Frequent urination. 5. Uterine growth.

1,2,3,4 are correct they are presumptive signs

A nurse is advising a pregnant woman about the danger signs of pregnancy. The nurse should teach the mother that she should notify the physician immediately if she experiences which of the following signs/symptoms? Select all that apply 1. Convulsions 2. Double vision 3. Epigastric pain 4. Persistent Vommiting 5. polyuria

1,2,3,4 are correct all are danger signs

A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? 1. Type O negative 2. Type A negative 3. Type B positive 4. Type AB positive

1. ABO incompatibility can arise when the mother is type O and the baby is either type A or B

A full-term infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. Which of the following actions should the nurse perform at this time? 1. Feed the baby formula or breast milk 2. assess the baby's blood pressure 3. tightly swaddle the baby 4. Monitor the baby's urinary output

1. A baby's blood glucose of 35 mg/dL is hypoglycemic.

A 36-week gestation gravid client is complaining if dyspnea when lying flat. Which of the following is the likely clinical reason for this complaint? 1. Maternal hypertension 2. Fundal height 3. Hydramnios 4. Congestive heart failure

2. The fundal height is the likely cause of the woman's dyspnea

During a preconception counseling, the nurse encourages a couple to prepare a birth plan. Which of the following is the most important goal for this action? 1. Promote communication between the couple and HCP 2. Enable the couple to learn about the types of medicine used in labor 3. Provide the couple with a list of items that they should put in a bag for labor 4. Give the high-risk couple a sense of control over having to have a cesarean

1. Birth plans help to facilitate communication between couples and their HCPs

The nurse assessed four newborns admitted to the neonatal nursery and called the neonatalogist for a consult on the baby who exhibited which of the following? 1. Excessive amounts of frothy saliva from the mouth 2. blood-tinged discharge from the vaginal canal 3. secretions of a milk-like substances from both breasts 4 HR that sped during inhalation and slowed with exhalation

1. Excessive amounts of frothy saliva may indicate that the child has esophageal atrsia

A 38 week gestation woman is in labor and delivery with painful- board like abdomen and progressively larger serial girth measurements. Which of the following assessments is appropriate at this time? 1. FHR 2. Cervical dilation 3. WBC count 4. maternal lung sounds

1. FHR check is the appropriate assessment

Because nausea and vomiting are such common complaints of pregnant women, the nurse provides anticipatory guidance to a 6-week gestation client by telling her to do which of the following? 1. Avoid eating greasy foods. 2. Drink orange juice before rising. 3. Consume 1 teaspoon of nutmeg each morning. 4. Eat 3 large meals plus a bedtime snack.

1. Greasy foods should be avoided

Four full-term babies were admitted to the neonatal nursery. The mothers of each of the babies had labors of 4 hours or less. The nursery nurse should carefully monitor which of the babies for hypothermia? 1. The baby whose mother cultured positive for group B strep during her third trimester. 2. The baby whose mother had gestational diabetes. 3. The baby whose mother was hospitalized for 3 months with complete placenta previa. 4. The baby whose mother previously had a stillbirth.

1. Group B streptococus causes severe infection in the newborn. A sign of neonatal sepsis is hypothermia.

The physician has ordered oxytocin for induction for 4 gravida. In which of the following situations should the nurse refuse to comply with order? 1. Primigravida with a transverse lie 2. Multigravida with cerebral palsy 3. Primigravida who is 14 years old 4. Multigravida who has type 1 diabetes

1. Induction is contraindicated in transverse lie

A gravida, G1 P000 is having her first prenatal physical examination. Which of the following assessments should the nurse inform the client that she will have that day> 1. pap smear 2. mammogram 3. Glucose challenge test 4. biophysical profile

1. The client will have a pap smear

A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital sugns and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? 1. assess deep tendon reflexes 2. obtain complete blood count 3. assess baseline weight 4. obtain routine urinalysis

1. The nurse should check the client's patellar reflexes. The most common way of assess the deep tendon reflexes is to assess the patellar reflexes

A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9lbs 2oz, 21 inches long. TPR: 96.6 F, 158, 62, Jitter, pink body with bluish hands and feet, crying. Which of the following actions should the nurse perform first? 1. swaddle the baby to provide warmth 2. assess the glucose level of the baby 3. take the baby to the mother for feeding 4. administer the neonatal medications

2. The glucose level should be assessed to determine whether or not this baby is hypoglycemic

A baby was born 24 hours ago to a mother who received no prenatal care. The infant has tremors, sneezes excessively, constantly mouths for food, and has a shrill, high-pitched cry. The baby's serum glucose levels are normal. For which of the following should the nurse request an order from the pediatrician? 1. urine drug toxicology test 2. biophysical profile test 3. chest and abdominal ultrasound evaluations 4. oxygen saturation and blood gas assessments

1. The symptoms are characteristics of neonatal abstinence syndrome. A urine toxicology would provide evidence of drug exposure

A woman ask the nurse about the function of amniotic fluid. Which of the following statements by the woman indicated that additional teaching is needed? 1. the fluid provides fetal nutrition 2. the fluid cushions the fetus from injury 3. the fluid enables fetus to grow 4. the fluid provides a stable thermal environment

1. The umbilical cord, not the amniotic fluid, delivers nutrutoin to the developing fetus

A gravid woman who recently emigrated from mainland China is being seen at her first prenatal visit. She was never vaccinated in her home country. An injection to prevent which of the following communicable diseases should be administered to the woman during her pregnancy. 1. Influenza 2. Mumps 3. Rubella 4. Varicella

1. The woman should receive the influenza injection. The nasal spray however should not be administered to a pregnant woman.

the nurse is evaluating the effectiveness of bed rest for a client with mild preeclampsia. Which of the following signs/symptoms would the nurse determine is a positive findings? 1. weight loss 2. 2+ proteinuria 3. decrease in plasma protein 4. 3+ patellar reflexes

1. Weight loss is a positive sign

A client, 38 weeks' gestation, is being induced with IV oxytocin for hypertension and oligohydramnios. She is contracting q 3 min X60 to 90 seconds. She suddenly complains of abdominal pain accompanied by significant fetal heart bradycardia. Which of the following interventions should the nurse perform first? 1. turn off the oxytocin infusion 2. administer oxygen via face mask 3. reposition the patient 4. call the OB

1. Whenever there is marked fetal bradycardia and oxytocin is running, the nurse should immediately turn off the oxytocin drip.

A 32-week gestation client was last seen in the prenatal client at 28 weeks gestation. Which of the following changes should the nurse bring to the attention of the certified midwife? 1. weight change from 128 pounds to 138 pounds 2. pulse rate changes from 88 bpm to 92 bpm 3. blood pressure changes from 120/80 to 118/78 4. respiratory rate change from 16 rpm to 20 rpm

1. a weight change of 10 pounds in a 4- week period is worrisome. the recommended weight gain during the second and third trimesters is approximately 1 pound per week

A labor nurse is caring for a client, 38 weeks' gestation, who has diagnosed with symptomatic placenta previa. Which of the following physician orders should the nurse question? 1. Begins oxytoxin drip rate at 0.5 millunits/min 2. assess FHR every 10 min 3. weigh all vaginal pads 4. assess hematocrit and hemoglobin

1. an order for oxytocin administration should be questioned

The neonatalogist assess a newborn for Hirschsprung's disease after the baby exhibited which of the following signs and symptoms? 1. passed meconium at 50 hrs of age 2. apical heart rate of 200 bpm 3. maculopapular rash 4. asymmetrical leg folds

1. babies who have delayed meconium excertion may have Hirschsprung's disease

A client with 4+ protein and 4+ reflexes is admitted to the hospital with severe preeclampsia. The nurse must closely monitor the woman for which of the following? 1. Grand mal seizure. 2. High platelet count. 3. Explosive diarrhea. 4. Fractured pelvis.

1. clients with severe preeclampsia are high risk for seizures

The nurse is caring for a pregnant client who is a vegan. Which of the following foods should the nurse suggest the client consume as substitutes for restricted foods? 1. Tofu, legumes, broccoli 2. corn, yams, green beans 3. potatoes, parsnips, turnips 4. cheese, yogurt, fish

1. excellent substitutes for the restricted foods

Which of the following clients is at highest risk for developing hypertensive illness of pregnancy? 1. G1P0000, age 44 with history of diabetes mellitus 2. G2P0101, age 27 with history of rheumatic fever 3. G3P1102, age 25 with history of scoliosis 4. G3P1011, age 20 with history of celiac disease

1. is very high risk for preclampsia

A nurse is discussing diet with a pregnant woman. Which of the following should the nurse advise the client to avoid consuming during her pregnancy? 1. bologna 2. cantaloupe 3. asparagus 4. popcorn

1. should not be consumed unless cooked throughly

A baby is born with a suspected coarctation of the aorta. Which of the following assessments should be done by the nurse? 1. check the BP in all four limbs 2. palpate the anterior fontanel for bulging 3. assess hematocrit and hemogloblin values 4. monitor for harlequin color changes

1. the BP in all four quadrants should be assessed

A baby is in the NICU whose mother was addicted to herion during the pregnancy. Which of the following nursing actions would be appropriate? 1. tightly swaddle the baby 2. place the baby prone in the crib 3. provide needed stimulation to the baby 4. feed the baby half- strength formula

1. tightly swaddling drug addicted babies often helps control the hyperrerflexia that they may exhibit

The nurse working in an outpatient obstetric office assess four primigravid clients. Which of the following findings would the nurse highlight for the physician? 1. 17-weeks' gestation; denies feeling fetal movements 2. 24- weeks gestation; fundal height at the umbilicus 3. 27- weeks gestation; complains of excess salivation 4. 34- weeks gestation; complains of hemorrhoid pain

2. The fundal height at 24 weeks should be 4 cm above the umbilicus. The fundal height at that level of the umbilicus is expected at 20 weeks.

A third-trimester client is being seen for routine prenatal care. Which of the following assessments will the nurse perform during the visit? Select all that apply. 1. Blood glucose. 2. Blood pressure. 3. Fetal heart rate. 4. Urine protein. 5. Pelvic ultrasound.

2,3,4 are correct the blood pressure is assessed at each prenatal appointment the FHR is assessed at each prenatal appointment urine protein is assessed at each prenatal appointment

The nurse is assessing the laboratory report of a 40-week gestation client. Which of the following values would the nurse expect to find elevated above pregnancy levels? 1. Glucose 2. Fibrinogen 3. Hematocrit 4. Bilirubin

2. fibrinogen levels will be elevated slightly in a 40 week pregnant women because coagulation factors like fibrinogen increase to help prevent excessive blood loss during delivery

a newborn nursery nurse notes that a baby's body is jaundiced at 36 hours of life. Which of the following nursing interventions will be most therapeutic? 1. Maintain a warm ambient environment 2. Have the mother feed the baby frequently 3. Have the mother hold the baby skin to skin 4. Place the baby naked by a closed sunlit window

2. Billirubin is excreted through the bowel. The more the baby consumes, the more stools, and therefor the more billiruibin the baby will expel

During vaginal delivery, the OB declares that a shoulder dystocia has occured. Which of the following actions by the nurse is appropriate at this time? 1. administer oxytocin IV per Dr orders 2. Flex the woman's thigh sharply toward her hips 3. apply oxygen tight- fitting face mask 4. apply downward pressure of the woman's fundus

2. Flexing the woman's hips sharply toward her shoulders, called mcRoberts' maneuver

In the delivery room, which of the following infant care interventions must a nurse perform when a neonate with menigomyeloccle is born? 1. Perform nasogastric suctioning 2. place baby in the prone position 3. administer oxygen via face mask 4. swaddle the baby in warm blankets

2. The baby should be pain prone to prevent injury to the sac

A diabetic client is to receive 5 units regular and 15 units NPH insulin at 0800. In order to administer the medication appropriately, what should the nurse do? 1. draw 5 units regular in one syringe and 15 units NPH in a second syringe and inject in different locations 2. draw 5 units regular first and 15 units NPH second into the same syringe and inject 3. draw 15 units NPH first and 5 units regular second into the same syringe and inject 4. Mix 5 units regular and 15 units NPH in a vial before drawing the full 20 units into a syringe and inject

2. this is the appropriate method. The regular insulin should be drawn up first then the NPH insulin in the same syringe "cloudy over regular"

A gravid client, 27 weeks' gestation, has been diagnosed with gestational diabetes. Which of the following therapies will most likely be ordered for this client? 1. oral hypoglycemia agents 2. diet control with excerise 3. regular insulin injections 4. inhaled insulin

2. about 95% of gestation diabetic clients are managed with diet and exercise

A 24 week gravid client is being seen in the prenatal clinic. She states, "I have a terrible headache for the past 2 days." Which of the following is most appropriate action for the nurse to perform next? 1. inquire whether or not the client has allergies 2. take the women blood pressure 3. assess the woman's fundal height 4. ask the woman about stressors at work

2. assess the blood pressure

The nurse is caring for an eclamptic client. Which of the following is an important action for the nurse to perform? 1. check each urine for the presence of ketones 2. Pad the client's bed rails and headboard 3. provide visual and auditory stimulation 4. Place the bed in the high fowler's position

2. for safety in case of seizure

The nurse is caring for a 30 wee gestation client whose fetal fibronection levels are positive. It is essential that she be taught about which of the following? 1. How to use a blood glucose monitor 2. signs of preterm labor 3. signs of preeclampsia 4. how to do fetal kick counts

2. positive fetal fibronectin levels are seen on clients who delivers preterm

A baby has just been admitted into the neonatal intensive unit with a diagnosis of intrauterine growth restriction. Which of the following maternal factors would predispose the baby to this diagnosis? Select all that apply. 1. hyperopia 2. gestational diabetes 3. substance abuse 4. chronic hypertension 5. Advanced maternal age

3, 4, and 5 are correct

Three 30-week-gestation clients are on the labor and delivery unit in preterm labor. For which of the clients should the nurse question a doctor's order for beta agonist tocolytics? 1. A client with hypothyroidism. 2. A client with breast cancer. 3. A client with cardiac disease. 4. A client with asthma.

3. A history of cardiac disease would place a client who is to receive a beta agonist medication at risk. The nurse should question this order.

There are four clients in active labor in the labor suite. Which of the women should the nurse monitor carefully for the potential of uterine rupture? 1. Age 15, G3P0020, in active labor 2. Age 22, G1P0000, eclampsia 3. age 25, G4P3003, last delivery by cesarean section 4. age 32, G2P0100, first baby dies during labor

3. A woman, no matter what age, who has had a previous cesarean section is at risk for uterine rupture

A woman is to receive RhoGAM at 28 weeks' gestation. What action must the nurse take before giving the injection? 1. Validate that the baby is Rh negative. 2. Assess that the direct Coombs' test is positive. 3. Verify the identity of the woman. 4. Reconstitute the globulin with sterile water.

3. Although this is an important action that must be taken before administration of any medication, especially in this situation

Which of the following findings should the nurse expect when assessing a client, 8 weeks' gestation, with gestational trophoblastic disease? 1. protracted pain 2. variable FHR decelerations 3. Dark brown vaginal bleeding 4. suicidal ideas

3. this condition is usually diagnosed after a client complains of brown vaginal discharge early in the pregnancy

A 20-year-old client states that the at home pregnancy test that she took this morning was positive. Which of the following comments by the nurse is appropriate at this time? 1. Congratulations, you and your family must be so happy. 2. Have you told the baby's father yet? 3. How do you feel about the results? 4. Please tell me when your last menstrual period was?

3. It is important for the nurse to ask the young lady how she feels about being pregnant. She may decide not to continue the pregnancy.

A pregnant woman informs the nurse that her last menstrual period was on September 20,2006, Using Nagele's rule, the nurse calculates the clients estimated date of delivery as: 1. May 30, 2007 2. June 20, 2007 3. June 27, 2007 4. July 3, 2007

3. June 27,2007

Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? 1. Hematocrit 48% 2. Potassium 5.5 mEq/L 3. Platelets 75,000 4. Sodium 130 mEq/L

3. Low platelets are consistent with the HELLP syndrome

There is a baby in the neonatal intensive care unit (NICU) who is exhibiting signs of neonatal abstinence syndrome. Which of the following medications is contraindicated for this neonate? 1. Morphine 2. Opium 3. Narcan 4. PHenobarbital

3. Narcan is an opiate. If it were to be given to the neonate with neonatal abstinence syndrome, the baby would go into traumatic withdrawal

A one day old neonate, 32 weeks' gestation is in an overhead warmer. The nurse assess the morning axillary temperature as 96.9. Which of the following could explain this assessment finding? 1. This is a normal temperature for a preterm neonate 2. Axillary temperatures are not valid for preterm babies 3. The suppl of brown adipose tissue is incomplete 4. Conduction heat loss is pronounced in the baby

3. Preterm babies are born with an insuffcient supply of brown adipose tissue that is needed for thermogenesis at heat generations

When analyzing the need for health teaching a prenatal multigravida, the nurse should ask which of the following questions? 1. What are the ages of your children? 2. what is your marital status? 3. Do you ever drink alcohol? 4. Do you have allergies?

3. this is an important question to ask in order to determine client's health teaching needs

A woman provide the nurse with the following obstetrical history; Delivered a son now 7 years old, at 28 weeks; gestation; delivered a daughter now 5 years old at 39 weeks gestation; has a miscarriage 3 years ago, and had a first trimester abortion 2 years ago. She is currently pregnant. Which of the following portrays an accurate picture of this woman's gravidity and parity? 1. G4 P2121 2. G4 P1212 3. G5 P1122 4. G5 P2211

3. This accurately reflects the woman;s gravidity and parity

A client makes the following statement after finding out that her pregnancy test is positive. "This is not a good time. I am in college and the baby will be due during final exams!" Which of the following responses by the nurse would be most appropriate at this time? 1. I am absolutely positive that everything will turn out all right 2. I suggest that you email your professors to set-up an alternate plan 3. It sounds like you're feeling overwhelmed right now 4. You ad the baby's father will find a way to get through the pregnancy

3. This is the best comment. It acknowledges the clients concerns that she is having.

a women is 36-weeks' gestation. Which of the following tests will be done during her prenatal visit? 1. Glucose challenge test amniotic fluid volume assessment 3. Vagina and rectal cultures 4. Karyotype analysis

3. Vaginal and rectal cultures are done at approximately 36 weeks' gestation

A baby has been admitted to the neonatal nursery whose mother is hepatitis B- surface antigen positive. Which of the following actions by the nurse should be taken at this time? 1. Monitor the baby for signs of hepatitis B 2. Pace the baby on contact isolation 3. Obtain an order for the hepatitis B vaccine and the immune globulin 4, advise the mother that breastfeeding is absolutely contraindicated

3. babies exposed to hepatitis B in utero should receive the first dose of hepatitis B vaccine as well as hepatitis B immune globulin within 12 hours of delivery to reduce transmission of the virus

which of the following would lead the nurse to suspect cold stress syndrome in a newborn with a temperature of 96.5 F? 1. Blood Glucose of 50 mg/ dL 2. Acrocyanosis 3. Tachypnea 4. Oxygen saturation of 96%

3. babies who have cold stress syndrome will develop respiratory distress is tachypnea

A nurse is caring for four laboring women. Which of the women will the nurse carefully monitor for signs of abruptio placentae? 1. G3P0020, 17 yrs 2. G4P2101, cancer survior 3. G5P1211, cocaine abuser 4. G6P0323, 27 weeks

3. cocaine is powerful vasoconstrictive agent, it places pregnant clients at higher risk for placental abruption

A client, 37 weeks' gestation, has been advised that she is positive for group B streptococci. Which of the following by the nurse is appropriate at this time? 1. The doctor will prescribe IV antibiotics for you. A visiting nurse will administer them to you in your home 2. You are very high risk for intrauterine infection. It is very important for you to check your temperature daily 3. The bacteria living in your vagina. They will not hurt you but we will give you medicine in labor to protect baby from getting sick 4. This bacteria causes scarlet fever. If you notice your tongue becomes very red and that you feel feverish you should call the doctor immediately

3. exposure to Group B is dangerous for neonates, for mom may be her normal flourish

A 28 week gestation client with intact membranes is admitted with the following findings. Contraction every 5 min X 60 sec, 3 cm dilated, 80% effeced. Which of the following medications will the OB likely order? 1. Oxytocin 2. Ergonovine 3. magnesium sulfate 4. morphine sulfate

3. magnesium sulfate is a tocolytic agent.

A 29 week gravid client is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following? 1. Leopald's maneuver results 2. quantity of vaginal bleeding 3. presence of abdominal bleeding 4. maternal blood pressure

3. the most common difference between placenta previa and placenta abruption is the absence or prescence of abdominal pain

A nurse is caring for four clients on the labor and delivery unit. Which of the following actions should the nurse take first? 1. check the blood sugar of a gestational diabetic 2. asses the vaginal blood loss of a client who is post-spontaneous abortion 3. assess the patellar reflexes of a client with mild preeclampsia 4. Check the FHR of a client who just ruptured membranes

4, the priority action for this nurse is to assess the FHR of a client who has just ruptured membranes. The nurse is assessing for prolapsed cord, which is an emergency

A client is 15 weeks pregnant. She calls the obstetric office to request medication for a headache. The nurse answers the telephone. Which of the following is the nurse's best response? 1. Because the organ system in the baby are developing right now, it is risky to take medicine 2. You can take any of the over-the-counter medications because they are all safe in pregnancy 3. The physician will prescribe a category "X" medication for you 4. You can take acetaminophen because it is a category "B" medicine

4. Category "B" medications have been shown to be safe to take throughout pregnancy

A baby is grunting in the neonatal nursery. Which of the following actions by the nurse is appropriate? 1. Place pacifier in the baby's mouth 2. Check the babies diaper 3. Have the mother feed the baby 4. Assess the respiratory rate

4. Grunting is often accompanied by tachypnea, another sign of respiratory distress

A 37-week gravid client states that she noticed a "white liquid" leaking from her breasts during a recent shower. Which of the following nursing responses is appropriate at this time? 1. Advise the woman that she may have a galactocele 2. Encourage the woman to pump her breasts to stimulate an adequate milk supply 3. assess the liquid because a breast discharge is diagnostic of a mammary infection Reassure the mother that this is normal in the third trimester

4. It is normal for colostrum to be expressed late in prenancy

A client has been diagnosed with gestation diabetes. She cries, "Oh, no! I will never be able to give myself shots!" Which of the following responses by the nurse is appropriate at this time? 1. I am sure you can learn for your baby 2. I will work with you until you feel comfortable giving yourself the insulin 3. We will be giving you pills for the diabetes 4. If you follow your diet and exercise you will probably need no insulin

4. It is unlikely a client will need any medication. Diet and exercise will probably control diabetes

A 42-week gestation baby has been admitted to the neonatal intensive care unit. At delivery, thick green amniotic fluid was noted. Which of the following actions by the nurse is critical at this time? 1. Bath to remove meconium-contaminated fluids from the skin 2. Ophthalmic assessment to check for conjunctival irritation 3. rectal temperature to assess for septic hyperthermia 4. Respiratory evaluation to monitor for respiratory distress

4. Meconium aspiration syndrome is a serious complication seen in postterm neonates who are exposed to meconium- stained fluid. Respiratory distress would indicate that the baby has likely developed MAS.

A pregnant woman must have a glucose challenge test. Which of the following should be included in the pre-procedure teaching? 1. Fast for 12 hours before the test 2. bring a urine specimen to the laboratory the day of the test 3. Be prepared to have 4 blood specimens taken on the day of the test 4. the test should take one hour to complete

4. The test does take one hour to complete

A woman whose prenatal weight was 105 lbs weight 109 lbs at her 12-week visit. Which of the following comments by the nurse is appropriate at this time?

4. The weight gain is within normal for the first trimester

A newborn is admitted to the nursery has a positive direct Coombs' test. Which of the following is an appropriate action by the nurse? 1. Monitor the baby for jitters 2. Assess the blood glucose level 3. assess the rectal temperature 4. Monitor the baby for jaundice

4. When the neonatal bloodstream contains antibodies, hemolysis of the RBC's occurs and jaundice develops

A macrosomic infant of a non-insulin-dependent diabetic mother has been admitted to the neonatal nursery. The baby's glucose level on admission to the nursery is 25 mg/dL and after the feeding of the mother's expressed breast milk is 35 mg/dL. Which of the following actions should the nurse take at this time? 1. Nothing because the glucose level is normal for an infant of a diabetic mother 2. administer IV glucagon slowly over 5 minutes 3. Feed the baby a bottle of dextrose and water and reassess glucose levels 4. notify the neonatalogist of the abnormal glucose levels

4. if the glucose level has not risen to normal as a result of the feeding, the nurse should notify the physician and anticipate that the doctor will order IV of dextrose and water

Which of the following situations is considered an vaginal delivery emergency? 1. Third stage of labor lasting 20 minutes 2. FHR dropping during contractions 3 Three vessel Cord 4. Shoulder dystocia

4. is an OB emergency

a nurse administers magnesium sulfate via infusion pump to an eclamptic woman in labor. Which of the following outcomes indicates that the medication is effective? 1. Client has no patellar reflex resoinse 2. urinary output 30 cc/hr 3. respiratory rate 16 rpm 4. client has no grand mal seizures

4. the absence of seizures is an expected outcome related to these clients because it is an anticonvulsant