VN34: Maternal & Pediatric Nursing Theory

A nurse is reinforcing discharge teaching with a postpartum client regarding elimination. Which of the following statements should the nurse include in the teaching? A. "You should urinate at least twice daily." B. "Increase fluids to help prevent constipation." C. "Put your hand under running cold water if you experience hesitancy when trying to urinate." D. "You should use laxatives daily to keep your bowel movements regular."

B. "Increase fluids to help prevent constipation." *Rationale:* The nurse should encourage the client to increase fluids and fiber intake to help prevent constipation. Ambulation will also help with prevention of constipation.

A nurse is speaking with an expectant father who reports feeling resentful of the attention others are giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse provide? A. "Has your wife sensed your anger toward her and the baby?" B. "These feelings are common for expectant fathers in early pregnancy." C. "I'm sure that accepting this situation is hard when the baby's yours, too." D. "You should speak to a therapist about these feelings."

B. "These feelings are common for expectant fathers in early pregnancy." *Rationale:* The father needs reassurance that these feelings are expected. The nurse should reassure him that when the pregnancy becomes obvious, he will feel more involved. This therapeutic response addresses the client's feelings by providing information.

A nurse is assisting with performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks about the purpose of the test. Which of the following responses should the nurse provide? A. "This test will determine if you are likely to deliver within the next week." B. "This test will help determine if your baby is healthy." C. "This test can show how your baby responds when you have contractions." D. "This test will determine if your baby's lungs are mature."

B. "This test will help determine if your baby is healthy." *Rationale:* An NST is used for antenatal fetal assessment. It tracks fetal heart rate patterns expected with fetal movement and can help identify fetal distress

A nurse is reinforcing education with a client who is at 34 weeks of gestation about a non-stress test (NST). Which of the following pieces of information should the nurse include? A. "It will take about 10 minutes to complete the test." B. "You might have to drink orange juice during the test." C. "During the test, you will be asked to massage your nipples." D. "During the test, you will receive a medication to relax your uterus."

B. "You might have to drink orange juice during the test." *Rationale:* An NST monitors for accelerations of the fetal heart rate over a 20-minute period. During this time, the fetus can be asleep and experience hypoactivity. The parent might be asked to drink orange juice during testing to stimulate fetal movements.

The nurse is reinforcing teaching with a client who is postpartum about the rubella vaccine. Which of the following statements should the nurse include? A. "You must not take this immunization if you've had the chickenpox." B. "You must not become pregnant for 28 days after receiving this immunization." C. "You must not breastfeed because the virus is passed in breastmilk." D. "You must not receive other vaccines at the same time as the rubella vaccine."

B. "You must not become pregnant for 28 days after receiving this immunization." *Rationale:* Clients must not become pregnant for 28 days following rubella immunization. They should be educated about the possible side effects and risk of teratogenic effects on the developing fetus.

A nurse is assisting with the assessment of a 1-day-old newborn. Which of the following findings indicates that the newborn has acrocyanosis? A. Bluish-colored skin B. Pursed lips C. Clenched fists D. Rounded nose

A. Bluish-colored skin *Rationale:* Acrocyanosis is a bluish discoloration of the hands and feet. It is a normal finding in the first 24 hours after birth.

A nurse is caring for a client during her first prenatal visit and notes that she is lactose intolerant. Which of the following foods should the nurse recommend as a calcium source for this client? A. Collard greens B. Cottage cheese C. Orange juice D. Broccoli

A. Collard greens *Rationale:* Collard greens are a good source of lactose-free calcium. One cup of collard greens provides approximately the same amount of calcium as the equivalent volume of 240 mL (8 oz) of milk. They also contain folic acid, which is a nutrient that women should consume during pregnancy to prevent birth defects.

A nurse is reinforcing teaching about manifestations of postpartum depression with a client. Which of the following findings should the nurse include? A. Episodes of irritability without justification B. Sleeping more than 15 hours per day C. Desire to take care of the newborn without help D. Ability to verbalize negative feelings about the newborn

A. Episodes of irritability without justification *Rationale:* A client who has postpartum depression can experience episodes of irritability without justification that can escalate quickly and without warning.

A nurse is collecting data from a client who is postpartum. The nurse should identify which of the following findings as a manifestation of endometritis? A. Foul-smelling lochia B. Fundus 2 cm above the umbilicus C. Decreased heart rate D. Dysuria

A. Foul-smelling lochia *Rationale:* Endometritis is an infection of the lining of the uterus. Manifestations include a high fever, chills, anorexia, fatigue, pelvic pain, uterine tenderness, and foul-smelling lochia.

A nurse is reinforcing education with a client who is pregnant about symptoms that should immediately be reported to the provider. Which of the following client responses indicates an understanding of the teaching? A. "I should call my provider if I develop melasma." B. "If I notice that my eyes are puffy, I should call my provider." C. "I should call my provider if I notice that my feet and ankles are swollen." D. "If I notice periodic numbness and tingling in my fingers, I should call my provider."

B. "If I notice that my eyes are puffy, I should call my provider." *Rationale:* Puffy eyes are associated with facial edema, which is a sign of pregnancy-induced hypertension. This should be reported immediately.

A nurse is collecting data from a client who is 3 days postpartum. When examining the client's uterus, which of the following techniques should the nurse use? A. Press down and forward with the hand that is placed on the base of the uterus B. Measure the height of the fundus in fingerbreadths in relation to the umbilicus C. Place the client in a semi-Fowler's position prior to checking the uterus D. Massage the fundus with gentle palpation until it becomes soft to touch.

B. Measure the height of the fundus in fingerbreadths in relation to the umbilicus *Rationale:* The nurse should measure the height of the fundus in fingerbreadths and should expect the height to decrease 1 fingerbreadth in height daily after birth. The fundus should be about 3 fingerbreadths below the umbilicus by the third day postpartum.

A nurse is caring for a client who requests an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for the use of this device? A. Hypertension B. Menorrhagia C. History of multiple gestations D. History of thromboembolic disease

B. Menorrhagia *Rationale:* An IUD is a small plastic or copper device placed inside the uterus that changes the uterine environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia, severe dysmenorrhea, or a history of ectopic pregnancy.

A nurse is collecting data from a newborn who was born with meconium-stained amniotic fluid. Which of the following findings should the nurse report as an indication of meconium aspiration syndrome? A. High Apgar score B. Rapid respirations C. Flushed skin D. Elevated PO2

B. Rapid respirations *Rationale:* Newborns who have meconium aspiration syndrome are expected to have tachypnea due to the aspiration of meconium-stained amniotic fluid prior to birth. This aspiration can cause tachypnea and other indications of respiratory distress.

A nurse is reinforcing teaching with a client who is breastfeeding. Which of the following pieces of information should the nurse include? A. "You should allow your baby to nurse for a total of 20 min per feeding." B. "Your baby should have 5 wet diapers per day." C. "Your baby should have bursts of 15 sucks or swallows at a time." D. "You can expect your baby to have dark black stools for the first week of life."

C. "Your baby should have bursts of 15 sucks or swallows at a time." *Rationale:* A newborn will exhibit bursts of 15 to 20 sucks or swallows at a time. This is an indication that breastfeeding is effective.

A nurse is reinforcing teaching about toxoplasmosis with a client who is pregnant. Which of the following instructions should the nurse include? A. "To prevent toxoplasmosis, you will need to receive a measles, mumps, and rubella vaccination during your pregnancy." B. "You should avoid gardening during your pregnancy to decrease your risk of contracting toxoplasmosis." C. "You will get a body rash if you are infected with toxoplasmosis." D. "Toxoplasmosis is transmitted through a bite from an infected mosquito."

B. "You should avoid gardening during your pregnancy to decrease your risk of contracting toxoplasmosis." *Rationale:* Toxoplasmosis infection is potentially teratogenic to the fetus. It can be transmitted through contact with cat feces, which can be found in garden areas. It can also be transmitted through contact with uncooked meat.

A nurse in a prenatal clinic is collecting data from several clients. Which of the following client reports is an expected physiological adaptation to pregnancy? A. Spotting with urination B. Breast tenderness C. Thick, white vaginal discharge D. Facial swelling

B. Breast tenderness *Rationale:* Breast tenderness is common during the first and third trimesters of pregnancy. The nurse should explain to the client that this is expected and recommend a well-fitting, supportive bra to help alleviate the tenderness.

A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take? A. Monitor the client's contractions once every 30 minutes B. Encourage the client to use a rapid pant-blow breathing pattern C. Assist the client to void once every 3 to 4 hours D. Place the client in the lithotomy position

B. Encourage the client to use a rapid pant-blow breathing pattern. *Rationale:* The nurse should encourage the client to use a rapid pant-blow breathing pattern. This breathing pattern distracts the client, which can reduce the perception of pain.

A nurse is discussing potential complications of newborn hypothermia with a newly licensed nurse. Which of the following complications should the nurse include? A. Tachycardia B. Hypoglycemia C. Flushed skin D. Generalized petechiae

B. Hypoglycemia *Rationale:* Newborn hypothermia can cause hypoglycemia because anaerobic glycolysis can deplete glycogen stores.

A nurse is reinforcing teaching with a client who has come to the family-planning clinic requesting an intrauterine device (IUD). Which of the following pieces of information should the nurse reinforce with the client? A. "If you lose weight, you will need a refitting for your IUD." B. "An IUD provides protection from certain sexually transmitted infections." C. "Your risk for ectopic pregnancy increases with an IUD." D. "You shouldn't use an IUD if you want to have children later."

C. "Your risk for ectopic pregnancy increases with an IUD." *Rationale:* An IUD is a contraceptive device the provider inserts through the cervix into the uterus to prevent pregnancy. The IUD works by changing the lining of the uterus and fallopian tubes, making fertilization in the uterus more difficult. Consequently, an IUD increases the risk of ectopic pregnancy.

A nurse is reinforcing teaching about calcium intake with a client who is breastfeeding. Which of the following amounts of calcium is the daily recommended amount for a woman who is breastfeeding? A. 800 mg B. 400 mg C. 1,000 mg D. 2,000 mg

C. 1,000 mg *Rationale:* The nurse should instruct the client that 1,000 mg of calcium is recommended for women ages 19 and older, as well as those who are lactating. This amount of calcium is sufficient to meet the needs of the client and the infant because additional calcium is absorbed from the intestines.

A nurse is collecting data from a client who is 2 days postpartum. In which of the following locations should the nurse expect to locate the client's fundus? A. 3 cm above the umbilicus B. 1 cm above the umbilicus C. 3 cm below the umbilicus D. 1 cm below the umbilicus

C. 3 cm below the umbilicus *Rationale:* The client's fundus should descend about 1 to 2 cm every 24 hours; therefore, at 2 days postpartum, the client's fundus should be located 3 cm below the umbilicus.

A nurse in an antepartum clinic is collecting data from a client who is at 38 weeks of gestation. Which of the following findings should the nurse report to the provider? A. Leg cramps B. Insomnia C. Glycosuria D. Leukorrhea

C. Glycosuria *Rationale:* The nurse should identify that glycosuria is a potential indicator of gestational diabetes mellitus and should be reported to the provider.

A nurse is collecting data from a postpartum client and observes a steady trickle of bright red blood from the client's vagina. The uterus is palpated as firm, midline, and located 1 cm below the umbilicus. Which of the following actions should the nurse take? A. Massage the fundus B. Instruct the client to empty her bladder C. Notify the provider D. Teach the client how to perform a sitz bath

C. Notify the provider *Rationale:* Excessive vaginal bleeding in the presence of a contracted uterus is a sign of a vaginal or cervical laceration. The provider must be notified so the laceration can be repaired.

A nurse is monitoring a client who is receiving IV oxytocin for the induction of labor. The nurse identifies repetitive early decelerations on the fetal heart monitor. Which of the following actions should the nurse take? A. Increase the rate of the intravenous fluid infusion B. Discontinue the infusion of oxytocin C. Re-evaluate the FHR tracing in 15 minutes D. Request a prescription for an amnioinfusion

C. Re-evaluate the FHR tracing in 15 minutes *Rationale:* Early decelerations are a result of compression of the fetal head during contractions. They are benign and require no specific intervention. The nurse should reassess the fetal heart rate and contraction pattern in 15 minutes due to the infusion of oxytocin.

The nurse is reviewing the laboratory results of a term newborn. For which of the following findings should the nurse notify the provider? A. Hematocrit 55% B. Platelet count 250,000/mm^3 C. Serum glucose 120 mg/dL D. Arterial blood gas pH 7.35

C. Serum glucose 120 mg/dL *Rationale:* The expected reference range for serum glucose for a term newborn under 1 day old is 30 to 60 mg/dL. A laboratory result of 120 mg/dL is greater than the expected reference range and should be reported to the provider.

A nurse is reinforcing teaching about mastitis with a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I will limit breastfeeding to 5 minutes per breast." B. "I will not breastfeed if I start to have flu-like symptoms." C. "I will shop for an underwire nursing bra today." D. "I will avoid any of my family members who are ill."

D. "I will avoid any of my family members who are ill." *Rationale:* The client should avoid ill family members to decrease the risk of mastitis. While the causative organisms of mastitis tend to be bacterial, exposure to viral illnesses can compromise the immune system and leave the client vulnerable to mastitis.

A nurse is reinforcing teaching about newborn safety with a client who is postpartum. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will put bumper pads in the crib." B. "I will warm my baby's formula in the microwave on a low setting." C. "I will place my baby on his stomach to sleep." D. "I will purchase a firm mattress for the crib."

D. "I will purchase a firm mattress for the crib." *Rationale:* A firm mattress that leaves no gaps between it and the crib rails helps prevent suffocation and entrapment

A nurse is reinforcing teaching with a group of clients about pregnancy prevention during the postpartum period. Which of the following statements should the nurse include? A. "Non-lactating clients can ovulate immediately after giving birth." B. "Non-lactating clients ovulate in their third month postpartum on average." C. "Lactating clients can ovulate as early as their first month postpartum." D. "Lactating clients ovulate in their sixth month postpartum on average."

D. "Lactating clients ovulate in their sixth month postpartum on average." *Rationale:* Clients who breastfeed exclusively ovulate on average around the sixth month postpartum. If a client decides to breastfeed and supplement formula, she should be warned that a form of contraception should be used because ovulation may occur sooner.

A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse recommend? A. Discontinue therapy if a fine rash appears B. Place moisturizing lotion on the newborn's skin C. Supplement feedings with 1 oz. of glucose water every 4 hours D. Change the newborn's position every 2 to 3 hours

D. Change the newborn's position every 2 to 3 hours *Rationale:* The nurse should change the newborn's position every 2 to 3 hours to maximize skin exposure to the light.

A charge nurse is teaching newly licensed nurses about teratogens that affect fetal development. Which of the following is an example of a teratogen? A. Consuming caffeine during pregnancy B. Family history of a genetic disorder C. Gum disease in a pregnant client D. Drinking alcohol during pregnancy

D. Drinking alcohol during pregnancy *Rationale:* Alcohol is an outside substance that, if ingested by a client who is pregnant, can cause abnormal fetal development. Alcohol consumption during pregnancy can cause central nervous system disorders, abnormal craniofacial features, and cognitive impairment.

A nurse is preparing to perform a blood draw on a client during her first prenatal visit. The client reports an extreme fear of needles causing anxiety during blood draws or injections. Which of the following actions should the nurse take? A. Keep the room quiet during the blood draw B. Ask the client if she currently takes lithium C. Request a prescription for pre-procedure lorazepam D. Encourage the client to practice deep breathing exercises

D. Encourage the client to practice deep breathing exercises *Rationale:* Deep breathing exercises are an example of a behavioral intervention that can be effective in reducing a client's anxiety level during a procedure.

A nurse is caring for a client who is postpartum and has endometritis. Which of the following findings should the nurse report to the provider? A. Foul-smelling lochia B. Uterine pain with palpation C. Temperature 38.1°C (100.6°F) D. Oxygen saturation 93%

D. Oxygen saturation 93% *Rationale:* A decreased oxygen saturation can indicate sepsis, embolism, fluid overload, an adverse response to an antibiotic, or hemorrhage. The nurse should report oxygen saturations below 95% to the provider.

The nurse is reinforcing teaching with a client who is pregnant about how to take a prescribed iron supplement for anemia. Which of the following statements should the nurse make? A. "Eating strawberries and oranges will help your body absorb the iron better." B. "Take your iron pills in the morning if you notice they upset your stomach." C. "Take your iron with a cup of tea." D. "If you forget an iron pill, it is okay to take 2 doses together."

A. "Eating strawberries and oranges will help your body absorb the iron better." *Rationale:* Foods rich in vitamin C such as strawberries, citrus fruits, tomatoes, and melons assist with the absorption of iron. The client should be encouraged to eat these foods often during the pregnancy.

A client at 12 weeks of gestation reports practicing Hinduism. The provider states that the client needs more protein in her diet and suggests eating more meat. After the provider leaves the examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make? A. "Let's discuss other foods that are high in protein that you could substitute for meat." B. "Eating meat during pregnancy provides necessary protein and does not cause miscarriage." C. "Why do you think that eating animal products will cause you to have a miscarriage?" D. "Your doctor is recommending what is best for you and your baby."

A. "Let's discuss other foods that are high in protein that you could substitute for meat." *Rationale:* Many cultures have beliefs about food that the nurse should respect. Discussing nonanimal protein sources can help the client identify foods that do not conflict with her religious and cultural beliefs.

A nurse is reinforcing teaching with a client about squatting exercises during pregnancy. Which of the following statements should the nurse include? A. "These exercises should be done for 15 minutes each day to strengthen the perineal muscles." B. "Squatting exercises can tone your abdomen, helping you lose weight faster following delivery." C. "Practicing squatting exercises during pregnancy will reduce lower back pain during labor." D. "Doing squatting exercises 3 times per week will improve your overall fitness."

A. "These exercises should be done for 15 minutes each day to strengthen the perineal muscles." *Rationale:* Squatting exercises help stretch the perineum, allowing stretching during delivery and improving functional efficiency after delivery.

A nurse is reinforcing teaching about weight gain during pregnancy for a client who is a primigravida of normal pre-pregnancy weight. Which of the following statements should the nurse include? A. "You should plan to gain 25 to 35 pounds during your pregnancy." B. "You should plan to gain 11 to 20 pounds during your pregnancy." C. "Because you started pregnancy at a normal BMI and weight, your weight gain is not limited as long as you follow a healthy, balanced diet." D. "Because you are of normal weight prior to pregnancy, you are encouraged to gain 28 to 40 pounds during pregnancy."

A. "You should plan to gain 25 to 35 pounds during your pregnancy." *Rationale:* A client of normal prepregnancy weight should plan to gain 11.3 to 15.9 kg (25 to 35 lb) during pregnancy. Weight gain is primarily for maternal tissue growth during the first and second trimesters and fetal tissue growth during the third trimester.

A nurse is caring for a 12-hour-old newborn who is asymptomatic and has a blood glucose level of 32 mg/dL. Which of the following actions should the nurse take? A. Advise the parent to feed the newborn B. Give the newborn 60 mL (2 oz.) of glucose water C. Recheck the newborn's glucose level in 4 hours D. Initiate phototherapy for the newborn

A. Advise the parent to feed the newborn *Rationale:* The nurse should identify a blood glucose level of 32 mg/dL in a 12-hour-old newborn as borderline hypoglycemia. This level should be treated by offering the newborn carbohydrates such as breast milk or formula; therefore, the nurse should advise the parent to feed the newborn.

A nurse is caring for a client following a forceps-assisted birth. The nurse should identify which of the following findings as a complication of this procedure? A. Pelvic hematoma B. Retained placenta C. Infertility D. Uterine inversion

A. Pelvic hematoma *Rationale:* Pelvic hematoma is a collection of blood in the connective tissue. Clients experience pain and pressure in the vaginal area. Hematoma is associated with forceps-assisted births, episiotomy, and primigravidity.

A nurse is assisting with the care of a newborn who has hyperbilirubinemia and is scheduled to receive phototherapy. Which of the following actions should the nurse take? A. Place an opaque mask over the newborn's eyes B. Apply lotion to the newborn's skin twice daily C. Dress the newborn in a diaper and t-shirt D. Check the newborn's temperature twice daily

A. Place an opaque mask over the newborn's eyes *Rationale:* The nurse should cover the newborn's eyes with an opaque mask to prevent retinal damage from the ultraviolet light used in phototherapy.

A nurse is measuring the body length of a newborn. Which of the following actions should the nurse take? A. Place the newborn on a flat surface B. Position the newborn with the knees bent C. Extend the newborn with the arms overhead D. Measure the newborn from the neck to the heel

A. Place the newborn on a flat surface *Rationale:* The newborn should be placed on a flat surface because this offers support and gives the nurse the ability to place the legs in an extended position in order to measure the full length of the body.

A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take? A. Place the unwrapped newborn on the mother's bare chest B. Feed the infant 5 to 15 mL of 5% glucose water to assess the suck/swallow reflex C. Bathe the newborn under running warm water before feeding D. Administer vitamin K and eye prophylaxis prior to feeding

A. Place the unwrapped newborn on the mother's bare chest *Rationale:* Skin-to-skin contact will maintain the newborn's temperature and elicit instinctive newborn feeding behaviors.

A nurse is collecting data from a client who is at 34 weeks of gestation and has a cardiac disorder. The nurse should notify the provider about which of the following findings? A. The client reports a frequent cough. B. The client reports that none of her shoes fit anymore. C. The client reports a weight gain of 2 lb in a 2-week period. D. The client reports leg cramps in the evening.

A. The client reports a frequent cough. *Rationale:* A frequent cough could be an indication of cardiac decompensation and should be reported to the provider.

A nurse collecting data from a full-term newborn who is demonstrating the Moro reflex. Which of the following movements are expected responses to this reflex? (Select all that apply.) A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward C. Arms and legs adducting D. Arms falling backward after startling E. Head turning to the right

A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward *Rationale:* These are expected components of the Moro reflex. This response is present at birth and absent by 6 months of age in neurologically intact infants.

A nurse is reinforcing teaching with the guardian of a newborn who is scheduled to undergo a circumcision. Which of the following pieces of information should the nurse include in the teaching? A. "Wash your child's penis with soap starting on day 3 after the circumcision." B. "Apply the diaper loosely over the penis." C. "Your baby's glans penis will be bright red after the circumcision." D. "Remove the yellow exudate that will appear on the glans penis 24 hours following the circumcision."

B. "Apply the diaper loosely over the penis." *Rationale:* The nurse should instruct the guardian to apply the diaper loosely over the newborn's penis to avoid creating pressure at the circumcision site.

A nurse is collecting data from a client who is at 20 weeks of gestation and reports frequent episodes of indigestion and heartburn. Which of the following instructions should the nurse reinforce with the client? A. "Limit your intake of food to twice per day." B. "Decrease your intake of spicy foods." C. "Rest in a supine position for a few minutes after eating." D. "Increase your intake of water and carbonated beverages."

B. "Decrease your intake of spicy foods." *Rationale:* Spicy foods cause gastric irritation, which might increase during pregnancy as a result of various physiological changes.

A nurse is contributing to the plan of care for a client who is at 34 weeks of gestation and has preeclampsia with severe features. Which of the following interventions should the nurse include as the priority action following a seizure? A. Provide a peaceful, relaxing environment for the client B. Administer oxygen to the client at 10 L/min via face mask C. Place blankets on the raised side rails of the client's bed D. Insert an indwelling urinary catheter for the client

B. Administer oxygen to the client at 10 L/min via face mask. *Rationale:* The priority intervention the nurse should include when using the airway, breathing, and circulation (ABC) approach to client care is to administer oxygen to the client at 10 L/min via face mask.

A nurse is caring for a client who reports that her last menstrual period (LMP) began on July 8. Based on Naegele's rule, which of the following is the client's expected date of birth (EDB)? A. April 1 B. April 15 C. October 15 D. October 1

B. April 15 *Rationale:* According to Naegele's rule, the EDB is predicted by counting back 3 months from the first day of the last menstrual period and adding 7 days.

A nurse is assisting with the care of a client who is in labor. She received meperidine for pain 1 hour prior to entering the second stage of labor. Which of the following actions should the nurse take? A. Assess the client's reflexes B. Assess the newborn for respiratory depression C. Assess the client for bradycardia D. Assess the newborn for signs of opiate withdrawal

B. Assess the newborn for respiratory depression *Rationale:* Meperidine should not be administered to laboring clients who are expected to deliver within 4 hours of the medication administration. This medication crosses the placenta and causes respiratory depression in the newborn, peaking 2 to 3 hours after administration. Narcan is ineffective at reversing the respiratory depression caused by this medication.

A nurse is reinforcing discharge teaching about bathing with the parent of a newborn. Which of the following instructions should the nurse include? A. Shake cornstarch inside the newborn's diaper after bathing B. Clean the newborn's face first using water C. Wash the newborn's umbilical cord with a mild soap D. Avoid massaging the newborn's scalp when washing the hair

B. Clean the newborn's face first using water *Rationale:* The parent should proceed from the cleanest parts of the newborn's body to the most soiled areas. The face should be washed first before the eyes, ears, and nose. The parent should clean the newborn's genital area last.

A nurse is preparing to perform a heel stick on a newborn. Which of the following actions should the nurse take? A. Wrap a cold compress around the newborn's foot B. Restrain the newborn's foot C. Make the puncture at the inner aspect of the heel D. Apply pressure to the big toe

B. Restrain the newborn's foot *Rationale:* The nurse should restrain the newborn's foot with a free hand. This is done to prevent the newborn from moving around so that the nurse can quickly get an accurate heel stick.

A nurse is caring for a client who had a cesarean birth 36 hours ago and is experiencing pain due to gas. Which of the following strategies should the nurse recommend? A. Sip a carbonated beverage throughout the day B. Rock in a rocking chair C. Lie flat in bed with the legs extended D. Use a straw when drinking fluids

B. Rock in a rocking chair *Rationale:* The nurse should recommend that the client rocks in a rocking chair, ambulates in the hallways, and lies on her left side to assist with intestinal motility and to expel flatulence.

The nurse is reinforcing discharge teaching with the guardians of a newborn about how to use a bulb syringe. Which of the following statements by a guardian indicates an understanding of the teaching? A. "I should insert the bulb syringe deep in the back of the baby's mouth to obtain mucus." B. "I should place the tip in the baby's nose first and then the mouth." C. "I should insert the bulb syringe at the corners of the baby's mouth to suction the cheek pockets." D. "I should place the bulb tip in the baby's mouth before squeezing the bulb."

C. "I should insert the bulb syringe at the corners of the baby's mouth to suction the cheek pockets." *Rationale:* The tip of the bulb syringe should be inserted into the corner of the mouth, and secretions should be suctioned from the pockets of the cheeks. The guardians should avoid inserting the bulb syringe tip into the middle of the mouth because it can cause the child to gag.

A nurse is reinforcing teaching about the use of nitrous oxide analgesia for pain control with a client who is in labor. Which of the following statements by the client indicates an understanding of the teaching? A. "Nitrous oxide could make my baby sleepy when he is born." B. "I should inhale the nitrous oxide between contractions." C. "I will feel the effects of the nitrous oxide almost immediately." D. "Nitrous oxide can make me feel disoriented."

C. "I will feel the effects of the nitrous oxide almost immediately." *Rationale:* The effects of nitrous oxide are felt within 1 minute of inhalation.

A nurse is assisting with the care of a client who has been experiencing mild contractions for a few days. The nurse places an external fetal monitor on the client. The client asks, "What will the monitor show you?" Which of the following responses should the nurse make? A. "It will indicate if you are in active labor." B. "It will measure your heart rate." C. "It indicates if your baby is receiving an adequate amount of oxygen." D. "It indicates the intensity of the contractions you are currently having."

C. "It indicates if your baby is receiving an adequate amount of oxygen." *Rationale:* A fetal monitor is a reliable tool that indicates the amount of oxygen the fetus is receiving and measures changes in the fetal heart rate during any kind of stress, including contractions, spontaneous fetal movement, or cord compression. It gives the nurse and provider a snapshot of whether the fetal heart rate is increasing or decreasing, which shows if the fetus is in distress.

A nurse is reinforcing teaching with a client who has hemorrhoids following a vaginal birth. Which of the following statements should the nurse include in the teaching? A. "You should apply the peripad from back to front." B. "You should wipe the perineum dry after using the squeeze bottle." C. "You should apply witch hazel after voiding or defecating." D. "You should use anesthetic cream once daily in the morning."

C. "You should apply witch hazel after voiding or defecating." *Rationale:* The nurse should instruct the client to pat the perineum dry and then apply witch hazel after voiding or defecating.

A nurse in an outpatient setting is reinforcing education with a client who is pregnant. Which of the following statements should the nurse include in the teaching? A. "During the last trimester, you should sleep mainly on your back." B. "During the second trimester of pregnancy, you will notice increased urinary frequency and urgency." C. "You will probably first notice your baby moving when you are around 20 weeks of gestation." D. "You should plan to gain 40 to 45 lb during your pregnancy."

C. "You will probably first notice your baby moving when you are around 20 weeks of gestation." *Rationale:* Fetal movement is typically noted by a pregnant client at 18 to 20 weeks of gestation. Multiparous clients might notice the movement earlier.

A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure? A. Send a sample of amniotic fluid to the laboratory to screen the client for chlamydia B. Send a sample of amniotic fluid to the laboratory to test for an elevated Rh-negative titer C. Administer immune globulin to the client to prevent fetal isoimmunization D. Administer intravenous antibiotics to prevent an infection

C. Administer immune globulin to the client to prevent fetal isoimmunization *Rationale:* Because the client is Rh-negative, Rh immune globulin is administered after the procedure to prevent fetal isoimmunization or help ensure maternal antibodies will not form against any placental red blood cells that might have accidentally been released into the maternal bloodstream during the procedure.

A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal findings is a potential risk factor for pathological hyperbilirubinemia? A. Placenta previa B. Multiple gestation C. Infection D. Anemia

C. Infection *Rationale:* Blood group incompatibilities, maternal infection, maternal diabetes, and the administration of oxytocin during labor are potential risk factors for the development of hyperbilirubinemia in newborns.

A nurse is discussing the expected changes of pregnancy with a client who is at 8 weeks of gestation. Which of the following findings should the nurse tell the client to report to the provider during the first trimester? A. Breast tenderness B. Urinary frequency C. Persistent vomiting D. No fetal movement

C. Persistent vomiting *Rationale:* Intermittent nausea and vomiting during the first trimester are common. However, the nurse should inform the client that persistent vomiting suggests hyperemesis gravidarum and increases the risk of fluid and electrolyte imbalance. In this situation, maternal and fetal health might be compromised, and the symptoms should be reported to the provider. The cause of hyperemesis gravidarum is unknown but might result from human chorionic gonadotropin (hCG) levels. The client should be encouraged to eat dry crackers upon awakening, eat 5 to 6 small meals daily, and avoid fried, odorous, or spicy foods.

A nurse is reinforcing teaching with a client who is at 32 weeks of gestation and reports regular alcohol use during her pregnancy. The nurse should inform the client that her child is at risk for which of the following characteristics? A. Large head size B. Increased weight C. Poor coordination D. Hypoactive reflexes

C. Poor coordination *Rationale:* A newborn who has fetal alcohol syndrome will have poor coordination. Other manifestations include learning disabilities, vision and hearing problems, and heart, kidney, and bone issues.

A nurse in an antepartum clinic is collecting data from a client who is 2 weeks postpartum and reports vaginal discharge. Which of the following discharge characteristics should the nurse expect? A. Dark red uterine discharge B. Pinkish-brown vaginal discharge C. Yellowish-white uterine discharge D. Bright red vaginal discharge

C. Yellowish-white uterine discharge *Rationale:* Lochia alba is yellow to white uterine discharge. This is present about 10 to 14 days following birth and can persist up to 8 weeks. Lochia alba consists of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria.

A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse reinforce with the client about the treatment plan? A. "Your partner needs to be cultured and treated with metronidazole only if his cultures are positive." B. "Only you will need to take the metronidazole, but you should not have intercourse until your culture is negative." C. "If both you and your partner are treated simultaneously, you may continue to engage in sexual intercourse." D. "You and your partner need to take the medication and use a condom during intercourse until cultures are negative."

D. "You and your partner need to take the medication and use a condom during intercourse until cultures are negative." *Rationale:* Trichomonas vaginalis is the organism that causes the sexually transmitted infection trichomoniasis. Both men and women can be infected with trichomoniasis. Clinical findings in women include yellowish to greenish, frothy, mucopurulent, copious discharge with an unpleasant odor, as well as itching, burning, or redness of the vulva and vagina. Trichomoniasis can be treated easily with metronidazole. However, for the treatment to work, both sexual partners must receive treatment to prevent reinfection. The nurse should also instruct the client to use condoms during sexual intercourse while being treated.

A nurse is caring for a client who is using patterned-paced breathing during the first stage of labor. The client reports a lightheaded feeling and tingling of the fingers. Which of the following actions should the nurse take? A. Instruct the client to hold her breath and bear down B. Ensure the client's breathing rate is more than twice her normal rate C. Apply counter-pressure to the client's lower back D. Assist the client in breathing into a paper bag

D. Assist the client in breathing into a paper bag *Rationale:* This client is experiencing respiratory alkalosis from hyperventilation, which is a possible adverse effect of patterned-paced breathing. To correct hypocarbia, the client should breathe into a paper bag or her cupped hands, rebreathing CO2 and reversing the respiratory alkalosis.

A nurse is contributing to the plan of care for client who is in the active stage of labor and expresses a desire to use nonpharmacological methods of pain relief. Which of the following interventions should the nurse include? A. Encourage the client to listen to music B. Instruct the client how to use informational biofeedback C. Ask the client to reconsider using a regional anesthetic D. Assist the client into a warm shower

D. Assist the client into a warm shower *Rationale:* Assisting the client into a warm shower is a nonpharmacological method used to decrease labor pain. This method stimulates the release of endorphins and increases circulation. Research supports the use of hydrotherapy as an effective method of labor pain management.

A nurse is reinforcing teaching about dietary recommendations to prevent neural tube defects. Which of the following recommendations should the nurse include? A. Take a multivitamin every day B. Decrease consumption of mercury-containing fish C. Increase consumption of dairy products D. Begin taking a folic-acid supplement

D. Begin taking a folic-acid supplement *Rationale:* Adequate amounts of folic acid are necessary for fetal neural tube development. All women of childbearing age and intention should take a folic acid supplement of 0.4 mg.

A nurse is providing care for a pregnant adolescent at 12 weeks of gestation who verbalizes a fear of gaining weight during her pregnancy. Which of the following actions should the nurse perform? A. Have the client watch a video on fetal growth and development during pregnancy B. Supply pamphlets that discuss the importance of nutrition during pregnancy C. Reinforce how poor nutrition can cause her baby not to grow properly D. Give examples of how eating well will help her to maintain a healthy weight during pregnancy

D. Give examples of how eating well will help her to maintain a healthy weight during pregnancy *Rationale:* Adolescents are typically preoccupied with self and lack the ability to understand outcomes that will occur in the future. Effective teaching for this age group should mainly focus on benefits to client and positive outcomes that will occur in the near future.

An adolescent reports abdominal cramping due to dysmenorrhea. Which of the following analgesics should the nurse expect the provider to prescribe? A. Fentanyl B. Acetaminophen and oxycodone C. Acetaminophen and hydrocodone D. Ibuprofen

D. Ibuprofen *Rationale:* To treat dysmenorrhea, providers prescribe NSAIDs such as ibuprofen and naproxen. Providers also recommend exercise and dietary changes such as reducing salt and sugar intake and following a low-fat, vegetarian diet.

A nurse is assisting with the care of a client who is in the early stage of labor and has preeclampsia with severe features. Which of the following interventions should the nurse perform? A. Assess the fetal heart rate and contractions hourly B. Encourage oral intake of clear, low-sodium fluids C. Instruct the client to ambulate during the early phase of labor D. Implement seizure precautions

D. Implement seizure precautions *Rationale:* The nurse should identify that clients who have preeclampsia with severe features are at risk for seizures. The nurse should keep the side rails of the client's bed up and ensure oxygen and suction are readily available.

A nurse is caring for a client who is 3 days postpartum and has chosen to bottle feed the newborn. During examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take? A. Encourage the client to pump the breasts. B. Instruct the client to take a warm shower twice per day. C. Tell the client to massage the breasts. D. Instruct the client to apply cold compresses.

D. Instruct the client to apply cold compresses. *Rationale:* To help relieve breast engorgement, the client should apply cold compresses for about 15 min every hour. The client can also try applying fresh, cold cabbage leaves to the breasts.

A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. The client's temperature measures 101.9°F (38.8°C) 3 hours following delivery. B. Lochia is red with small clots and mucus 2 days after delivery. C. Client reports abdominal pain 48 hours after delivery when the newborn is breastfeeding. D. The fundus feels soft and is a fingerbreadth below the umbilicus 72 hours after delivery.

D. The fundus feels soft and is a fingerbreadth below the umbilicus 72 hours after delivery. *Rationale:* The fundus will rise to the height of the umbilicus about 1 hour after delivery and remains there for about 24 hours. It should decrease by 1 fingerbreadth per day and become more firm. A soft fundus on day 3 that has not dropped could indicate uterine atony and should be reported to the provider.