340 week 6-10
The nursing assistant has entered vital signs for a group of clients the nurse is caring for. Which client would be a priority for assessment by the nurse? A heart rate of 74 in a client who is 18 hr status post postpartum hemorrhage A respiratory rate of 10 in a client who is 12 hr post cesarean on morphine patient-controlled anesthesia An oxygen saturation of 96% on room air in a client who is 2 days status post cesarean A temperature of 100.5°F in a client who is 22 hr post vaginal delivery
A respiratory rate of 10 in a client who is 12 hr post cesarean on morphine patient-controlled anesthesia
The nurse is making patient assignments for the shift. Which baby could be appropriately assigned to an LPN/LVN? An infant being admitted with hypoglycemia An infant scheduled to receive blood this shift A stable premature infant being fed every two hours An infant with rising bilirubin levels
A stable premature infant being fed every two hours
The nurse is assisting at Mrs. Sze's birth. She is a 36-year-old woman who has opted for an epidural. Mrs. Sze has been pushing for over 4 hours. She is exhausted, and her baby's head remains at the +3 station. The healthcare provider has attempted a vacuum extraction twice, but the suction cup has popped off both times. The nurse anticipates that the healthcare provider will do which action next? A mid-forceps-assisted birth A cesarean birth A low forceps-assisted birth A third attempt at vacuum extraction
A third attempt at vacuum extraction
It is now two hours since Mrs. Romero has delivered, and her epidural is wearing off. Once Mrs. Romero is able to move her legs and bear weight on them, you assist her to a sitting position, and then help her to the bathroom to void. She sits on the toilet for a few minutes but is unable to void.Based on her history, what is the most likely reason she is unable to void? A two hour second stage of labor. A urinary tract infection from the Foley catheter. Interference from stitches from her fourth degree repair. She is dehydrated because she has not been drinking very much.
A two hour second stage of labor.
Maternal risk factors may impact preterm labor. Which factor may increase this risk? African American ethnicity Primigravida Working while pregnant Hispanic ethnicity
African American ethnicity
A client is complaining of painful contractions, or afterpains, on her second postpartum day. The client asks why she is having these pains. Which response by the nurse is the most appropriate? "Afterpains tend to be worse after your second baby is born." "Afterpains occur because you have chosen to bottle-feed your newborn." "You are having afterpains because you also have diabetes mellitus." "Because this is your first baby, afterpains are to be expected."
"Afterpains tend to be worse after your second baby is born."
The nurse is explaining the stages of lochia to the newly delivered mother. Which statement by the nurse best describes lochia rubra to the mother? "It consists of tissue debris and blood." "It consists of placental fragments and blood." "It consists of a mixture of mucus, tissue debris, and blood." "It consists of mucus, placental fragments, and blood."
"It consists of a mixture of mucus, tissue debris, and blood."
What is the recommended daily caloric intake for a newborn? 140-160 mL/kg/day 8-10 bottles per day 100-115 kcal/kg/day 1 oz. of formula per day
100-115 kcal/kg/day
At what age is solid food generally introduced to infants? 4 months 15 months 12 months 8 months
4 months
The nurse is providing discharge teaching about newborn care to a mother. Which topics will be included? Select all that apply. Cord care Nutrition Day care Diapering Bathing
Cord care Nutrition Diapering Bathing
Which are risk factors associated with thrombophlebitis during the postpartum period? Select all that apply. Preterm delivery Cesarean birth Blood type A+ Hypercoagulability African American ethnicity
Cesarean birth Blood type A+ Hypercoagulability
Later on in your shift, you check on Ms. Maxwell on the postpartum unit. She tells you that her baby is doing well and that she is planning to formula feed. She asks you if all of her lab work has come back. You check her chart and note that her toxicology screen came back positive. Which positive lab 2019-2 Home Announcements Jump to Week Course Calendar Grades4 People Bookshelf® Library Help Desk Office 365 My Media Media Gallery Case Study : Intrapartum Hemorrhaging Due Jun 23 at 11:59pm Points 8 Questions 8 Available after Jun 3 at 12am Time Limit None Allowed Attempts Unlimited Instructions Return to Week Check your knowledge of the current concept by answering the following questions. Attempt History Attempt Time Score LATEST Attempt 1 5 minutes 4.5 out of 8 Score for this attempt: 4.5 out of 8 Submitted Jun 17 at 11:02am This attempt took 5 minutes. Question 1 1 / 1 pts You are working as a labor and delivery nurse in a downtown tertiary care hospital. The emergency department(ED) calls to alert you to an incoming ambulance. The ambulance was called to a homeless shelter after a pregnant resident reported having heavy vaginal bleeding. The ambulance crew arrives to labor and delivery pushing a gurney. On the gurney is 23-year-old Jaycee Maxwell. The emergency medical technician (EMT) tells you that Ms. Maxwell told them she is pregnant with her first baby and thinks she is due in two weeks. Per the EMT, Ms. Maxwell was using the restroom at the homeless shelter and cried out for help, reporting that she saw a large amount of blood in the toilet. Ms. Maxwells eyes are closed, and she is moaning. Her hands are gripping the blanket on the gurney. You explain to Ms. Maxwell that you will help the EMT crew move her from the gurney onto a labor and delivery bed. As you help move Ms. Maxwell to the bed, the EMT tells you her vitals are as follows: T 98.8°F, P 120 bpm, R32/min, BP 156/92 mmHg, and her Sp02 on room air is 97%. Ms. Maxwell has a left antecubital 16-gauge IV infusing normal saline at a rate of 250 mL/hr. As you move Ms. Maxwell to the bed, you note she has a small amount of dried blood on her thighs. Which nursing activities are appropriate at this point? Assist Ms. Maxwell to the bathroom to obtain a UA. Examine Ms. Maxwells cervix. Correct! Apply the external fetal heart rate monitor and tocodynanometer. Assist Ms. Maxwell to the bathroom to change into a gown. Your immediate goal is to begin assessment of fetal status and uterine activity. Based on her report of vaginalbleeding, you should not examine her cervix, as you do not know where her placenta is located. If she has a previa or marginal attachment, a cervical exam could worsen her bleeding. You should not assist her to the bathroom for a UA or a gown change until you have assessed the fetuss health. Question 2 0.5 / 1 pts The charge nurse has searched the computer system and located an ultrasound performed on Ms. Maxwell at the ED of another hospital in the same system. Which ultrasound reports would prompt you to check her cervix? Select all that apply. You Answered A 20-week ultrasound showing a low-lying placenta that gives a current EGA of 29 wks. An 8-week ultrasound showing an intrauterine pregnancy and left ovarian corpus luteum that gives a current estimated gestational age (EGA) of 36 wks. Correct! A 24-week ultrasound showing a fundal placenta that gives Ms. Maxwells fetus a current EGA of 41 weeks. Correct! A 36-week ultrasound showing a breech presentation and a low-lying placenta with the edge 4 cm from the cervical os. None of the above ultrasounds would make you feel comfortable checking her cervix at this time. A 36-week ultrasound that measured the placental edge as 4 cm from the cervical os is reassuring, although you must still exercise great care with a vaginal exam. A 24-week ultrasound with a fundal placenta provides evidence she does not have a previa or a low-lying placenta, and you could go ahead and check her cervix. A first trimester ultrasound does not provide enough information about the placental site to make it appropriate for you to check her cervix. A 20-week ultrasound with a low-lying placenta heightens your suspicions that she may currently have a low-lying placenta, a marginal previa or a previa; you would not check the cervix given this ultrasound result. Question 3 1 / 1 pts The charge nurse hands you an ultrasound that Ms. Maxwell had at 36 weeks showing a low-lying placenta with the edge 4 cm from the cervical os. The fetus was noted to be breech on that ultrasound. By this ultrasound, Ms. Maxwell is currently 38 weeks gestation. You check Ms. Maxwell's vital signs and obtain the following results: T 98.6°F, P 114 bpm, R 23/min, BP 160/92 mmHg, and her SpO2 on room air is 96%. The electronic fetal monitor shows the following: Uterine contractions every two minutes, lasting for 60-75 seconds. Fetal heart rate 170 bpm, minimal long term variability, deceleration to 140 bpm noted between contractions. You prepare an oxygen mask at 10 L and ask Ms. Maxwell to put it on. Ms. Maxwell is clearly uncomfortable with contraction pain, but she manages to ask, 'Why is something wrong?" What will you tell Ms. Maxwell? She needs oxygen because her SpO2 is too low. Her baby has fetal bradycardia, an indication her baby needs more oxygen. All pregnant women need supplemental oxygen. Correct! Her baby has fetal tachycardia, an indication her baby needs more oxygen. You explain to Ms. Maxwell that the oxygen is indicated due to her baby's tachycardia. Her own oxygenation is fine, as shown by a normal SpO2. Fetal bradycardia is diagnosed below 110 beats per minute. It is not true that all pregnant women need supplemental oxygen. Question 4 1 / 1 pts Ms. Maxwell continues to shiver. She looks at you and starts to cry. "Are you feeling okay?" you ask her. Ms. Maxwell turns white and says, "I think Im going to throw up." You encourage her to take slow deep breaths, and you place a cool cloth in her forehead. You check her vital signs, and they are as follows: T 97.3°F, P 97 bpm, R 23/min, BP 136/92 mmHg, and her SpO2 on room air 97% You know that Ms. Maxwells symptoms of nausea and shivering are most likely caused by: Select all that apply. Correct! Precipitous labor Heroin withdrawal Chorioamnionitis, or infection in the uterus Preeclampsia Shivering and nausea can be caused by advanced, precipitous labor, which is common in cases of placental abruption. Ms. Maxwells temperature is normal so you do not have any indication she has chorioamnionitis at this time. There is no evidence of heroin withdrawal. Preeclampsia presents as a severe headache, epigastricpain, and visual disturbances. Question 5 0.67 / 1 pts The attending health care provider arrives to evaluate Ms. Maxwell. After performing a vaginal exam, she states that Ms. Maxwell is 6 centimeters dilated, 100% effaced, and 0 station. The health care provider requests an amnihook and performs artificial rupture of membranes. The amniotic fluid is dark green and bloody. She inserts an intrauterine pressure catheter to monitor contractions and resting tone, and an internal scalp electrode to permit more detailed evaluation of the fetal heart rate.Based on your experience, you expect the health care provider will order which labs for Ms. Maxwell? Select all that apply. Correct! A urine toxicology screen Correct! A complete blood count A biophysical profile Correct! Liver enzymes You Answered A group B beta strep (GBS) culture After informed consent, a urine toxicology screen should be obtained as illegal drugs may precipitate a placental abruption. A complete blood count will provide information about Ms. Maxwells hemoglobin and hematocrit, as well as a platelet count. Liver enzymes will also assist in giving a more complete picture whether Ms. Maxwell has preeclampsia. While an ultrasound to confirm cephalic presentation might be useful (as the baby was breech at 36 weeks), a biophysical profile would not be useful at this time because Ms. Maxwell is in advanced labor and her amniotic membranes are already ruptured. It is unlikely the provider will order a GBS culture at this time, as Ms. Maxwell will certainly be delivered before the culture results would be available. Question 6 0 / 1 pts As the health care provider leaves the room, she asks you to place a Foley catheter. You explain to Ms. Maxwell what a Foley catheter is and why it is indicated at this time. Which statements by Ms. Maxwell indicate that she understands the need for a Foley catheter? Select all that apply. Correct Answer You need to make sure my kidneys are getting enough blood. Correct! You need to check my urine for protein. I know the hospital is too busy for you to help me to the bathroom. You Answered If I get up to go to the bathroom on my own, I might deliver my baby in the toilet. You Answered This is the only way to measure my urine output. Use of a Foley catheter is indicated for Ms. Maxwell as it will provide an accurate picture of her output. She should have an output of at least 30 mL/hr as an indication that her kidneys are sufficiently perfused. A catheterized urine specimen will also be more accurate as you dip for protein, as the urine will not be contaminated by vaginal bleeding or amniotic fluid. You are not inserting a Foley for convenience or because pregnant women in general are at risk of birthing in a toilet. Finally, while a Foley catheter is an accurate way to measure output, it is not the only way. A hat in the toilet would be accurate enough for a lower-risk patient. Question 7 0.33 / 1 pts You assess Ms. Maxwell and obtain the following data: T 99.1degrees°F, P 135 bpm, R 30/min, BP 142/86 mmHg, and her SpO2 on 10 L O2 by face mask is 99% Fetal heart tones 130/s with minimal variability and late decelerations Uterine contractions every two minutes, lasting 60-80 seconds, uterine resting tone 40 mmHg Ms. Maxwell's initial CBC comes back and indicates hemoglobin 9.2 g/dL, hematocrit 27.6%, and platelets 87,000/µl. What data supports the diagnosis of placental abruption? Select all that apply. Temperature of 99.1degreesF Correct! The abnormal uterine resting tone Correct! Late decelerations You Answered Fetal heart rate of 130 bpm Correct Answer Maternal pulse The uterine resting tone is between 20 and 25 mmHg in a normal uterus. The intrauterine pressure monitor is showing a resting tone of 40, which is high and demonstrates increased pressure in the uterus. Late decelerations are another indication of abruption as the fetus is not getting enough oxygen to handle the contractions. Ms. Maxwells pulse is tachycardic, indicating blood loss. The fetal heart rate of 130 is within normal range and does not indicate abruption on its own, although you will continue to watch closely. Although Ms. Maxwells temperature appears to be increasing, a temperature of 99.1 degrees°F would not be related to a placental abruption Question 8 0 / 1 pts Later on in your shift, you check on Ms. Maxwell on the postpartum unit. She tells you that her baby is doing well and that she is planning to formula feed. She asks you if all of her lab work has come back. You check her chart and note that her toxicology screen came back positive. Which positive lab results support Ms. Maxwells experience of having placental abruption? Opiates You Answered Benzodiazepines Marijuana Correct Answer Cocaine results support Ms. Maxwells experience of having placental abruption? Opiates Benzodiazepines Marijuana Cocaine
Cocaine 628
A preterm infant arrives in the nursery. Which initial assessments will the nurse make on this infant? Select all that apply. Complete blood count Blood glucose monitoring Core temperature readings Signs of respiratory distress Gestational age determination
Core temperature readings Signs of respiratory distress Gestational age determination
Luis Travers is 5 days old. He is kicking his feet, jerking his arms, and acting fussy. His father is shaking a colorful rattle to entertain him. Based on the assessment, which state does the home care nurse anticipate this baby will enter into next? Drowsy Active Quiet sleep Crying
Crying
Which tasks will strengthen a father's bond with a newborn? Select all that apply. Diapering Helping with household chores Bathing Feeding Planning activities with siblings
Diapering Bathing Feeding
The prenatal clinic nurse is designing a new prenatal intake information form for pregnant clients. Which question is best to include on this form to help ensure the health of the infant? What is the name of the baby's father? Do genetic diseases run in the family of the baby's father? Where was the father of the baby born? Are you married to the father of the baby?
Do genetic diseases run in the family of the baby's father?
The nurse is preparing a brochure on alternative therapies for nausea and vomiting during pregnancy. Which strategy would the nurse include? Drinking carbonated beverages Increasing fluids to 2,000 mL per day Adequate exercise Drinking ginger tea
Drinking ginger tea
A nurse has been called to a birth to assess the healthy term infant while the labor nurse continues to care for the mother. What is the second nurse's priority in providing immediate care for the infant? Drying the baby thoroughly to prevent heat loss Applying wrist bands for identification Initiating breastfeeding Obtaining the correct spelling of the baby's name for the birth certificate
Drying the baby thoroughly to prevent heat loss
What risk-reduction factor should be included in the collaborative teaching of preventing SIDS? Use only one loose blanket in infant's crib Encourage prone positioning for sleep Encourage tummy time for play Keep nursery temperature cooler than living space
Encourage tummy time for play
A client tells the nurse that her last period was from May 18 to 24. The nurse uses the Nägele rule to compute the expected date of birth. Based on this information, what would the nurse document as the expected date of birth? February 18 of the following year February 25 of the following year February 11 of the following year March 1 of the following year
February 25 of the following year
A nurse is caring for the newborn of a diabetic mother. What should be included in the nurse's plan of care for this newborn? Withhold feedings until intravenous glucose is given Provide glucose water exclusively Feed the infant soon after delivery Evaluate blood glucose levels at 12 hr after birth
Feed the infant soon after delivery
After you empty Mrs. Romeros bladder, her bleeding is normal and she is able to eat dinner and take a nap. Once she wakes up, you take the opportunity to perform a head-to-toe exam and initiate postpartum teaching.Her head-to-toe exam reveals the following:Breasts soft and non-tender, nipples intact Abdomen soft and non tender Uterus firm, 2 finger breadths below the umblilicus Bladder non palpable Perineal inspection reveals intact stitches that are gaping and you note marked fullness Moderate lochia rubra Negative Homans sign bilaterally. Does everything seem ok? Mrs. Romero asks you. Which findings give you cause for concern? Select all that apply. Her bladder cannot be palpated. Negative Homan sign Lack of breast changes Gaping stitches Marked fullness on her perineum
Gaping stitches Marked fullness on her perineum
A newborn has been admitted to the neonatal intensive care unit with sepsis. Which symptoms will the nurse note in an infant with sepsis? Select all that apply. Glucose instability Pallor Grunting Irritability Vomiting
Glucose instability Pallor Grunting Irritability
Ran Bin Rui is a 50-year-old retired professor of Mandarin languages who has had type 1 diabetes mellitus since she was 18 years old. She began receiving medical disability retirement benefits last year because she was no longer able to see well enough to correct students' written work. She also had to give up her hobby of doing calligraphy with watercolor paintings of birds. She has never married, but maintains a large supportive network of friends. The walls of her condominium are filled with her earlier paintings. Her only relative living nearby is her 30-year-old niece, Bi Jing Tan. The two women are close. Ms. Tan, who was recently diagnosed with lupus, visits her aunt at least weekly and runs errands for her. Dr. Rui is now legally blind due to diabetic retinopathy, although she still has some perception of light. Because she has lived in the same condominium for 20 years, she knows her neighbors, and they check in on her periodically. She continues to maintain her independence in cooking, laundry, and personal care activities. She jokes with you, her home health nurse, that she was born in the Year of the Tiger, and says she is still "fierce as a tiger." Dr. Rui has been your client for the past year, with home visits scheduled every two weeks. At each visit, you draw up her insulin and assess her well-being. Her normal finger stick blood glucose is 130 to 170 mg/dL. Her usual insulin dosage is Humulin 70/30 insulin 20 units every morning before breakfast and 10 units every evening before supper. When Dr. Rui answers the door at 11 a.m. this morning, you know immediately that she is not her usual self. Her speech is slurred; her face is pale with visible sweat. Her hand trembles as she extends a welcoming handshake. Knowing her history, what do you suspect is the most likely cause of her altered appearance? Hypotension Hypertension Hypoglycemia Hyperglycemia
Hypoglycemia
Mrs. Evelyn Park, 32 years old, has just delivered an 8 lb 10 oz baby boy, Steven. He is grunting and flaring his nostrils. Mrs. Park asks the nurse what is wrong with her baby. The nurse will base the response from which rationale? Tactile stimulation Hypoxia Nonshivering thermogenesis Chest retractions
Hypoxia
The nurse is caring for an infant who is small for gestational age (SGA). Which complications will the nurse assess this infant for during the nursing assessment? Select all that apply. Hypoxia Hyperbilirubinemia Hypoglycemia Aspiration Hypothermia
Hypoxia Hypoglycemia Aspiration Hypothermia
The nurse is assessing the nutritional status of a client at 12 weeks gestation. The nurse asks the client about her lifestyle and eating habits. Which characteristic from the assessment data will have the greatest impact on the client's nutrition? Marital status Age Income status Occupation
Income status
A client at 39 weeks' gestation is demonstrating signs of beginning labor. The nurse realizes that which hormonal action is occurring, resulting in the onset of labor? Decrease in corticosteroids Increase in progesterone Increase in estrogen Decrease in prostaglandins
Increase in estrogen
A nurse is caring for Maia Ngyuen, a 27-year-old client who is 41 weeks pregnant with her first child. Maia presents to the labor and delivery department after experiencing regular uterine contractions, which are now about 5 min apart. Maia's nurse is gathering a client gown for Maia when her amniotic fluid ruptures. The nurse notes that the fluid appears greenish. After notifying Maia's health care provider, what should Maia's nurse prepare for? Intubation of Maia's infant Surfactant replacement Emergency cesarean section Antibiotic administration to treat Maia's infection
Intubation of Maia's infant
What can the nurse do to lessen the anxiety a woman may be feeling as she goes through the second stage of labor? Select all that apply. Tell her to push harder Offer ice chips Keep her apprised of her progress Provide an antianxiety medication Praise her efforts
Keep her apprised of her progress Praise her efforts
Which incision is most commonly used for a cesarean delivery? High transverse Low transverse Classic Low vertical
Low transverse
During fetal circulation, most fetal blood is shunted away from which organ? Lungs Heart Kidneys Brain
Lungs
The nurse is interviewing Mrs. Barnes during her initial prenatal visit. Mrs. Barnes states that the first day of her last menstrual period was June 6, 2014. What is her estimated date of confinement (EDC) based on the Nägele rule? March 13, 2015 September 9, 2015 February 10, 2015 January 13, 2015
March 13, 2015
Which data would be most important for the nurse to note as part of an initial assessment of a newborn's history? Mother received morphine sulfate 4 mg IV 20 minutes before delivery Mother reports drinking a glass of wine with dinner each night Mother's age is 14 Mother's blood type is O negative
Mother received morphine sulfate 4 mg IV 20 minutes before delivery
The nurse is evaluating a new mother following a teaching session. The mother gently brushes the infant's cheek with her nipple and the newborn turns toward that side and opens the lips to suck. This demonstration of the rooting reflex is part of which assessment? Neuromuscular Apgar score Physical maturity assessment Vital signs
Neuromuscular
The nurse is performing a newborn assessment to determine gestational age. Which assessment findings does the nurse expect for a full-term infant? (Select all that apply.) Heart rate greater than 100 beats/min Opaque skin Plantar creases on the anterior two thirds of the sole A large amount of lanugo over the back Minimal ear cartilage
Opaque skin Plantar creases on the anterior two thirds of the sole
What are the factors that cause respiratory distress in the preterm infant? (Select all that apply.) Decreased levels of pancreatic lipase Open ductus arteriosus Insufficient surfactant Incomplete muscular coat of pulmonary vessels Increased secretion of glucose
Open ductus arteriosus Insufficient surfactant Incomplete muscular coat of pulmonary vessels
Which term describes a newborn's ability to respond to appealing stimuli, such as his mother's face? Habituation Familiarization Orientation Self-quieting
Orientation
The nurse is preparing for delivery of a newborn with a myelomeningocele. Which priority action will the nurse perform immediately after delivery of the newborn? Place a protective dressing on the defect. Obtain a footprint for the medical record. Place the identification band on the wrist and ankle. Administer antibiotics, per order.
Place a protective dressing on the defect.
The nurse is assessing the newborn at the client's bedside. Which symptoms would indicate the need to assess the client's blood glucose levels? Select all that apply. Poor feeding Excessive sleeping Tremors Temperature instability Excessive crying
Poor feeding Tremors Temperature instability
The nurse observes that the father of the newborn is reluctant to hold his new son. Which would be the most therapeutic response of the nurse at this time? State, "I notice you will not hold your baby." Provide instruction and demonstrate how to hold an infant. Ask the mother whether she is concerned about the father's reaction to the baby. Ignore the father's anxiety.
Provide instruction and demonstrate how to hold an infant.
You check Mrs. Abejundios vital signs: T 98.8°F, P 120 bpm, R 20/min, BP 118/68 mmHg, SpO2 on room air 97%. As the health care provider arranges for Mrs. Abejundio to go to the hospital triage unit for a blood transfusion, you are aware that which of her vital signs reflect her severe anemia? Respiratory rate Pulse Temperature Blood pressure
Pulse
Which action is most appropriate if a newborn's anti-abduction bracelet accidently comes off? Notify hospital security. Replace it according to policy. Complete an incident report. Leave it off for comfort.
Replace it according to policy.
Which bonding strategy would the nurse suggest for a postpartum mother and newborn after a cesarean delivery? Allowing family members to visit in the nursery Administering a narcotic analgesic Rooming-in Admitting the newborn to the nursery
Rooming-in
When initiating breastfeeding, the mother attempts to elicit which reflex in the newborn? Babinski Startle Rooting Palmar grasp
Rooting
Which early cues indicate a readiness for newborn feeding? (Select all that apply.) Rooting Lip smacking Crying Extending the tongue Sucking on fingers
Rooting Lip smacking Sucking on fingers Extending the tongue
The birth of the fetus ends which stage of labor? Fourth Second Third First
Second
If a pregnant woman is planning to travel by airplane, you realize, as the nurse, that she should understand what behaviors? Select all that apply Stand as long as possible. Stay hydrated. Take time to move around the cabin. Check with the airline to see if they have any specific travel restrictions during pregnancy. Travel by car instead; flying while pregnant is unsafe.
Stay hydrated. Take time to move around the cabin. Check with the airline to see if they have any specific travel restrictions during pregnancy.
Which are manifestations of an intraventricular hemorrhage? (Select all that apply.) Sudden drop in hemoglobin level Waxy color Onset of severe metabolic acidosis Hypotension Periods of apnea
Sudden drop in hemoglobin level Waxy color Onset of severe metabolic acidosis Hypotension
Which assessment data would alert the nurse that a newborn infant is experiencing dehydration? (Select all that apply) Urine-specific gravity 1.006 Low serum sodium Urine volume 2 mL/kg/hr Sunken anterior fontanel Poor skin turgor
Sunken anterior fontanel Poor skin turgor
The nurse is counseling a young couple pregnant with their first child. The nurse suggests that the couple enroll in the childbirth classes offered at their hospital. Which benefits will the nurse share with the couple regarding these classes? Select all that apply. Teaching about the process of childbirth Providing information about pregnancy Improving coping mechanisms during the birth Sharing feelings about pregnancy and birth Ensuring a painless labor and delivery
Teaching about the process of childbirth Providing information about pregnancy Improving coping mechanisms during the birth Sharing feelings about pregnancy and birth
In which phase of cellular division does the cell divide into two daughter cells, each containing its own nucleus with 46 chromosomes and the same genetic makeup as its parent? Telophase Interphase Metaphase Anaphase
Telophase
You assess Ms. Maxwell and obtain the following data: T 99.1degrees°F, P 135 bpm, R 30/min, BP 142/86 mmHg, and her SpO2 on 10 L O2 by face mask is 99% Fetal heart tones 130/s with minimal variability and late decelerations Uterine contractions every two minutes, lasting 60-80 seconds, uterine resting tone 40 mmHg Ms. Maxwell's initial CBC comes back and indicates hemoglobin 9.2 g/dL, hematocrit 27.6%, and platelets 87,000/µl. What data supports the diagnosis of placental abruption? Select all that apply. Temperature of 99.1degreesF The abnormal uterine resting tone Late decelerations Fetal heart rate of 130 bpm Maternal pulse
The abnormal uterine resting tone Late decelerations Maternal pulse
A nurse is caring for a couple whose infant has died. When planning care, what outcomes are most appropriate for the nurse to establish? Select all that apply. The couple acknowledges the grieving process. The couple demonstrates effective coping. The couple seeks clarity for the exact cause of death. The couple demonstrates acceptable grief. The couple seeks therapy for psychosocial wellness.
The couple acknowledges the grieving process. The couple demonstrates effective coping. The couple seeks therapy for psychosocial wellness.
The nurse formulates a diagnosis of fear related to fetal outcomes for a laboring client with fetal malpresentation. What is an appropriate client outcome to include in the care plan? The mother is able to verbalize understanding of the labor process. The mother identifies two support people for the birth. The mother safely delivers a viable newborn. The mother reports a decrease in fear and anxiety related to the birth.
The mother reports a decrease in fear and anxiety related to the birth.
The nurse is assessing a newborn right after birth. Which assessment will be most helpful initially in identifying an at-risk newborn? The newborn's color The newborn's Apgar score The newborn's respiratory efforts The mother's pregnancy history
The newborn's Apgar score
What is an appropriate way to describe colostrum? White Thick and creamy Lacks protein Present by day 4-5 postpartum
Thick and creamy
A postpartum client with an episiotomy reports perineal pain. What is the appropriate nursing intervention for this client? Select all that apply. Topical anesthetic spray Warm compresses Intermittently placed ice packs Frozen cabbage leaves Sitz baths
Topical anesthetic spray Intermittently placed ice packs Sitz baths
Which marker is used to determine the hydration status of a preterm infant? Abdominal girth Feeding frequency Urine output Respiratory rate
Urine output
Which behaviors are considered protective against sudden infant death syndrome (SIDS)? (Select all thatapply.) Use of pacifier while sleeping Breastfeeding Prone positioning Neutral ambient room temperature Use of sleeper pajamas
Use of pacifier while sleeping Breastfeeding Neutral ambient room temperature Use of sleeper pajamas
How is the adequacy of feeding often assessed in the newborn? Ability to burp Sleeping often Lack of crying Weight gain
Weight gain
What is the preferred type of pushing that will allow the woman and her fetus to maintain oxygenation? With a closed glottis Structured pushing With each contraction With an open glottis
With an open glottis
Which percentage of weight loss does the nurse anticipate for a newborn during the first week of life? 5% 15% 10% 20%
10%
The mother of a preterm infant asks why the baby has a tube in his mouth for feedings. What should the nurse explain to the mother about this feeding tube? "Your baby's nasal passages are misshapen and there is no other way to provide feedings at this time." "Your baby needs a stomach tube placed, so until that can be done, a tube is placed through his mouth." "Babies airways are obstructed so there is no other way to pass a tube into the stomach." "Babies are nose-breathers so the feeding tube should be placed through his mouth."
"Babies are nose-breathers so the feeding tube should be placed through his mouth."
A nurse is caring for a client who is pregnant with her first child. The nurse is providing the client with education about the prevention of SIDS. Which statements made by the nurse are correct? Select all that apply. "Breastfeed your baby if possible." "The temperature in your baby's room should be similar to your room." "It is best to co-sleep with your baby." "Place your baby on its back to sleep." "Tuck loose blankets under your baby's shoulders during sleep."
"Breastfeed your baby if possible." "The temperature in your baby's room should be similar to your room." "Place your baby on its back to sleep."
The nurse educator is providing instruction to maternal-newborn students. Which student statement indicates appropriate knowledge regarding the first step to initiate a newborn's first breath? "Thermal changes that stimulate the respiratory center." "Elastic recoil of the lungs." "Clamping and cutting the umbilical cord." "Squeezing the fetal thorax."
"Clamping and cutting the umbilical cord."
The nurse is teaching a postpartum client who is 4 days postvaginal delivery about self-care after she is discharged home. Which statement by the client indicates that more teaching is needed? "I'll be sure to call my healthcare provider if I have any red vaginal discharge." "I can strengthen my abdominal muscles by holding my urine for as long as I can stand it." "I'll keep this peri-bottle right on the bathroom sink so I don't forget to use it." "I can't wait to get home and start eating salads again!"
"I can strengthen my abdominal muscles by holding my urine for as long as I can stand it."
The nurse is caring for 4-hr-old Tyson Carter, who appears healthy and is feeding well by bottle. The nurse is performing the newborn assessment, teaching Tyson's parents about normal newborn care. The nurse includes teaching regarding how to hold Tyson, feed him, and diaper him. What incorrect statement made by Tyson's father would indicate that the nurse needs to reinforce the original teaching? "I can give the baby a bath every other day." "It is fine to use baby wipes without alcohol." "I should use powder daily to prevent skin breakdown." "I need to fold down the top of the diaper."
"I should use powder daily to prevent skin breakdown."
The nurse is evaluating teaching provided to the parents of a preterm infant who is being discharged. Which statement made by the mother indicates that additional teaching is required? "I will keep the baby dressed and covered at all times." "I will use warmed whole milk in the baby's bottle." "I will use formula with whey protein in the baby's bottle." "I will feed the baby slowly so choking does not occur."
"I will use warmed whole milk in the baby's bottle."
The nurse is providing education to a pregnant client who has asked for information regarding risk factors related to sudden infant death syndrome (SIDS). Which statements by the nurse are appropriate? Select all that apply. "If your child is female, the risk for SIDS increases." "If your child is born premature, the risk for SIDS increases." "If your child is exposed to smoke in the home, the risk for SIDS increases." "If your child shares your bed during sleep, the risk for SIDS increases." "If your family has a history of SIDS, the risk for SIDS increases."
"If your child is born premature, the risk for SIDS increases." "If your child is exposed to smoke in the home, the risk for SIDS increases." "If your child shares your bed during sleep, the risk for SIDS increases." "If your family has a history of SIDS, the risk for SIDS increases."
A nurse is caring for a couple that is grieving over the death of their infant, who is suspected to have died as a result of sudden infant death syndrome (SIDS). Which responses made by the nurse support the couple's psychosocial needs and provide the couple with collaborative therapy resources? Select all that apply. "Is there a pastor or clergy member you would like me to call?" "What funeral home would you like me to contact?" "I will provide you with a list of local grief counselors." "The infant loss support group meets every Tuesday." "I am sorry you are going through this. Would you like to talk to me about your child?"
"Is there a pastor or clergy member you would like me to call?" "I will provide you with a list of local grief counselors." "The infant loss support group meets every Tuesday." "I am sorry you are going through this. Would you like to talk to me about your child?"
The nurse is providing care to a postpartum woman who gave birth 1 day ago. Which physiologic response is considered normal in the early postpartum period? Increased motility of the gastrointestinal system Urinary urgency and dysuria Increase in heart rate Rapid diuresis
Rapid diuresis
Which events are signs of true labor? Select all that apply. Activity does not decrease contractions Regular contraction patterns Cervical dilation Contractions that become more intense Position change lessens contractions
Activity does not decrease contractions Regular contraction patterns Cervical dilation Contractions that become more intense
Ms. Hideki is a 19-year-old G1 P1 who is postpartum day 1 and Rh negative. Her newborn is tested and the results reveal that he is Rh positive. The nurse anticipates which order for Ms. Hideki? Infuse 1 unit of packed red blood cells. Consult with hematology. Administer RhoGAM 300 µg intramuscularly. Collect blood for complete blood count.
Administer RhoGAM 300 µg intramuscularly.
A postpartum client who is Rh-negative delivers a newborn who is Rh-positive. The nurse anticipates which order will come from the healthcare provider? Administer rubella vaccine on postpartum day 2. Send placenta to pathology. Infuse 2 units of packed red blood cells stat. Administer RhoGAM 300 µg intramuscularly.
Administer RhoGAM 300 µg intramuscularly.
You get a reading of a blood glucose reading of 40 mg/dL. What action should you take immediately? Take Dr. Rui's vital signs. Administer glucose or glucagon. Call 911. Ask Dr. Rui is she ate breakfast.
Administer glucose or glucagon.
Nursing responsibilities in the setting of a nonreassuring, or category III, electronic fetal monitor (EFM) tracing include: Select all that apply. Giving a narcotic analgesic as needed Administering oxygen Notifying the health care provider Giving a bolus of intravenous (IV) fluids Repositioning the mother
Administering oxygen Notifying the health care provider Giving a bolus of intravenous (IV) fluids Repositioning the mother
During an initial prenatal visit, the client discloses she has been taking valium, a benzodiazepine, daily for several years. She has a prescription but also uses her friend's prescription or buys it illegally, adding to the prescribed dose. Which action does the nurse anticipate from the healthcare provider when these findings are reported? Reporting the illegal drug use to law enforcement and a child welfare agency Recommending that the client cut down her valium use Admission to the hospital for medically supervised withdrawal Contacting the client's pharmacy for discontinuation of the valium prescription
Admission to the hospital for medically supervised withdrawal
The nurse is assessing clients in the prenatal clinic. Which are maternal risk factors for preterm labor? Select all that apply. African American ethnicity Maternal obesity Preterm premature rupture of membranes Intrauterine bleeding Maternal genital tract infection
African American ethnicity Preterm premature rupture of membranes Intrauterine bleeding Maternal genital tract infection
In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal delivery with a midline episiotomy. What would the nurse explain to the client as the most appropriate time for resuming sexual intercourse? After the postpartum follow-up visit with the healthcare provider In 3 weeks, when the episiotomy is completely healed Whenever the client is feeling amorous and desirable When the lochia flow and episiotomy pain have stopped
After the postpartum follow-up visit with the healthcare provider
The nurse caring for a preterm infant decides to plan interventions to address the potential for apnea of prematurity. Which information does the nurse use to make this decision? Select all that apply. Extended body posture Age 4 days Irregular breathing pattern Breathing through the nose 34 weeks gestation
Age 4 days Irregular breathing pattern 34 weeks gestation
The nurse is caring for a newborn who has been diagnosed with a metabolic disorder. Which formulas does the nurse anticipate may be prescribed for this newborn? Select all that apply. Isomil Enfamil Similac Alimentum Nutramigen
Alimentum Nutramigen
You perform a head-to-toe exam of Mrs. Turner and observe the following:Her lungs are clear to auscultation. She is alert and oriented times person, place, and time. Her breasts are soft and nontender. Her abdomen is soft and nontender, and you hear sluggish bowel sounds in all four quadrants. Her fundus is firm and 2 fingerbreadths below the umbilicus. Her incisions dressing is dry and intact. Homans sign is negative bilaterally.Her vital signs are: T 97.6° F, P 62 bpm, R 18/min, and BP 98/64 mmHg.You remove her Foley catheter and encourage Mrs. Turner to ambulate around the room and to the bathroom. She sits at the bed and dangles her legs before slowly standing and ambulating cautiously around the room. Just around here? she asks. You answer, Id start here. But if you feel good, I think we should get you in to the NICU to see your baby. Have you seen her yet? Mrs. Turner shakes her head. You tell her, The NICUs right next door. Do you want to head on over and see her? Mrs. Turners face lights up.You know Mrs. Turner needs to see her baby for a variety of reasons. How will Mrs. Turner going to see the baby help her physically? Ambulation will reduce her risk of deep vein thrombosis. Ambulation will increase her heart rate. Shell be able to breastfeed her baby. Ambulation will help normalize her bowel sounds. Ambulation will normalize her blood pressure.
Ambulation will reduce her risk of deep vein thrombosis. Ambulation will help normalize her bowel sounds.
In preparing a client for a nuchal translucency test (NTT), what should the nurse include in the teaching plan? Select all that apply. NTT is performed between 18 and 20 weeks' gestation. An amniocentesis may be needed after the NTT. There may be false-positive results. NTT is a noninvasive test. NTT is a screening test, not a diagnostic tool.
An amniocentesis may be needed after the NTT. There may be false-positive results. NTT is a noninvasive test. NTT is a screening test, not a diagnostic tool.
For which reason would the nurse add a urinary catheter to the delivery room table before a vaginal birth? An empty bladder provides more room on the pelvic floor. It is completed as a safety mechanism for the fetus. If the operative vaginal birth fails, the nurse must be prepared for a cesarean birth. It is added to enhance the woman's comfort during the last stage of labor.
An empty bladder provides more room on the pelvic floor.
The nurse is caring for a client in the second stage of labor. Which nursing action is most appropriate during this stage? It is not necessary to assess maternal vital signs in the second stage Assessing the fetal heart rate every 5-15 min Assessing the fetal heart rate every 30 min Assessing the maternal vital signs hourly
Assessing the fetal heart rate every 5-15 min
A nurse is caring for a client going into the fourth stage of labor. Which is the priority nursing assessment during this stage? Assessing pulse oximetry every 4 hr Assessing vaginal discharge every 4 hr Assessing vital signs every 1 hr Assessing the uterus
Assessing the uterus
Grace Cho had an uncomplicated vaginal birth 15 min ago. There is a gush of blood from her vagina, and the umbilical cord is growing longer. What would the nurse be expected to do in this situation? Assist in the delivery of the placenta Assist the health care provider in stopping the vaginal bleeding Inspect the perineum for lacerations Pull on the umbilical cord to remove it
Assist in the delivery of the placenta
The nurse is assisting the health care provider with the circumcision of a newborn client. Which nursing intervention is a priority to decrease the likelihood of a post-procedure infection? Obtain informed consent. Wrap the circumcised area with Vaseline gauze. Assist in providing education to parents about the procedure. Assist the provider with sterile supplies during the procedure.
Assist the provider with sterile supplies during the procedure.
A laboring client experiences an amniotic fluid embolism. The nurse should prepare to execute which nursing responsibility? Ordering vasopressors Assisting in the insertion of a central line Contacting pastoral care Vacuum extraction of the fetus
Assisting in the insertion of a central line
The nurse is caring for a pregnant client who was seen in the emergency department with symptoms of a foodborne illness. Which practice will the nurse instruct the client to do based on the client's symptoms? Limit tasting cake batter or cookie dough to a few times a week. Avoid eating medium-cooked hamburgers. Avoid eating cheese made from pasteurized milk. Select swordfish when ordering at a restaurant.
Avoid eating medium-cooked hamburgers.
A breastfeeding client reports that, occasionally, certain foods cause rashes or gastrointestinal upset in her infant. Which suggestion by the nurse would be most appropriate? Give the infant a thimble of baking soda. Give the infant diphenhydramine (Benadryl) before breastfeeding. Avoid spicy foods. Avoid foods the client suspects of causing distress.
Avoid foods the client suspects of causing distress.
The nurse is educating the parents about safety precautions for their newborn while in the hospital. Which topics should the nurse discuss with the parents? Select all that apply. Avoid leaving the newborn in the hospital room alone. Wash hands often to protect the newborn from germs. Bring the newborn to the nurses' station if parent feels weak or faint. Keep a hand on the newborn when out of the crib. Ask hospital staff for identification if they are not wearing it.
Avoid leaving the newborn in the hospital room alone. Wash hands often to protect the newborn from germs. Keep a hand on the newborn when out of the crib. Ask hospital staff for identification if they are not wearing it.
Ms. Burberry has been doing well and is at 32 weeks gestation. She is anxious and concerned that her fiancé will not make it home for the delivery. She is also worried because her sister had a premature infant at 33 weeks. What suggestions can you give to Ms. Burberry that may help her prevent premature labor? Select all that apply. Avoid prenatal breast preparation or nipple stimulation. Avoid lifting heavy objects for the remainder of the pregnancy. Take 2-3 rest periods per day. Engage in 30-60 minutes of cardio exercise three times a week to strengthen pelvic muscles. Engage in sexual activity frequently with her fiancé when he returns.
Avoid prenatal breast preparation or nipple stimulation. Avoid lifting heavy objects for the remainder of the pregnancy. Take 2-3 rest periods per day.
The nurse is assisting a new mother breastfeed a 2-day-old preterm infant, born at 36 weeks gestation. What should the nurse instruct the mother about breastfeeding this baby? Select all that apply. Burp the baby when alternating breasts Hold the baby like a football Burp the baby after every 10 min of feeding Do not feed for more than 45 min Hold the baby in a semi-seated position
Burp the baby when alternating breasts Hold the baby like a football Do not feed for more than 45 min
The nurse is instructing a pregnant client on the signs of impending labor. What should the nurse include as premonitory signs of labor? Select all that apply. Increased fatigue Burst of energy Bloody show Easier breathing Decreased vaginal discharge
Burst of energy Bloody show Easier breathing
The nursery has been informed of the completion of an uncomplicated vaginal delivery at 3:30 p.m. The nurse prepares for her assessment of the newborn. When should this assessment be performed? At change of shift By 5:30 p.m. By 6:30 p.m. By 4:30 p.m.
By 5:30 p.m.
The nurse educator is teaching a group of students about newborn thermogenesis. Which statement is appropriate for the educator to include in the presentation regarding brown adipose tissue? Brown adipose tissue has a depletion of blood supply in the fat layer. Brown adipose tissue is the same for the preterm newborn as for the term newborn. Brown adipose tissue can be found in the groin, legs, and arms of the newborn. Brown adipose tissue has a dense cellular content.
Brown adipose tissue has a dense cellular content.
What should be done when bottle-feeding a preterm infant? (Select all that apply.) Burp after 0.5-1.0 ounces of formula Feed in a football hold position Feed in a semi-sitting position Feed for no more than 30 min Use a single-hole soft nipple
Burp after 0.5-1.0 ounces of formula Feed in a semi-sitting position Feed for no more than 30 min Use a single-hole soft nipple
A laboring client suddenly sits up in bed, has dyspnea, becomes cyanotic, and has frothy sputum from her mouth. The nurse is unable to palpate a pulse. Which initial action by the nurse is the most appropriate? Position the client on her side with her feet elevated Call for assistance and start cardiopulmonary resuscitation (CPR) Obtain the client's blood pressure Assess the fetal heart rate
Call for assistance and start cardiopulmonary resuscitation (CPR)
The nurse should provide education regarding the signs of preterm labor. What clinical manifestations should be reviewed with the pregnant client? Select all that apply. Diarrhea Cervical dilation Abdominal pain Lower back pain Decreased vaginal discharge
Diarrhea Cervical dilation Abdominal pain Lower back pain
Mrs. Hernandez is a 24-year-old G1 P0 admitted to the hospital in active labor. She is 3 cm dilated and her healthcare provider performs an amniotomy to release her amniotic fluid. What is the nurse's role in this procedure? Cleanse and clean the client. Decrease the client's epidural dose. Document the characteristics of the amniotic fluid. Test the client's Bishop Score.
Document the characteristics of the amniotic fluid.
The nurse is performing a thorough fundal check during a postpartum assessment on a newly delivered mother. What components are included in a fundal assessment? Fundal location and potential fundal distention Fundal location and height Fundal consistency and height Fundal consistency, location, and height
Fundal consistency, location, and height
The nurse is assessing a newborn client 12 hr after delivery. Which assessment finding indicates a problem with the cardiopulmonary adaptation to extrauterine life? Grunting Hyperglycemia Hypotension Eupnea
Grunting
The parents of a preterm neonate ask why their baby gets cold so easily. The nurse responds with which explanation about preterm neonates? Can shiver to produce body heat Have minimal body fat to retain body heat Have blood vessels that are deep under the skin surface Lose heat faster because they lie in a fetal position
Have minimal body fat to retain body heat
The student nurse is assessing a newborn to determine whether the newborn is small for gestational age (SGA), appropriate for gestational age (AGA), or large for gestational age (LGA). Which items included in the physical examination of the newborn reflect appropriate understanding of this assessment process? Select all that apply. Head circumference Length Ballard assessment Weight Vital signs
Head circumference Length Ballard assessment Weight
A nurse is caring for a couple whose infant has died. The healthcare provider suspects the death is a result of sudden infant death syndrome (SIDS). When asking the couple about the circumstances surrounding the infant's death, what factors will the nurse focus on? Select all that apply. History of infant reflux Health of the couple Health of the infant History of infant congenital heart defects Infant's dietary intake
Health of the infant History of infant congenital heart defects Infant's dietary intake
What is the most common congenital anomaly in newborns? Metabolic diseases Hypothyroidism Sickle cell disease Hearing loss
Hearing loss
The nurse is preparing to discharge a postpartum client and will include information about thrombophlebitis in the discharge teaching. Which signs of thrombophlebitis must the nurse educate the client to assess after discharge from the hospital? Muscle soreness in her legs after exercise Local tenderness, heat, and swelling in the leg Bruising easily Varicose veins in her legs
Local tenderness, heat, and swelling in the leg
The nurse is preparing to discharge a postpartum client and will include information about thrombophlebitis in the discharge teaching. Which symptom will the nurse include in the discharge teaching for this topic? Local tenderness, heat, and swelling in the legs Bruises in the legs Varicose veins in the legs Muscle soreness in the legs after exercise
Local tenderness, heat, and swelling in the legs
Which description of lochia on a postpartum client's daily chart would require the nurse to notify the healthcare provider during the early postpartum period? Lochia has a fleshy odor. Lochia red and plentiful. White lochia noted today. Lochia contains large clots.
Lochia contains large clots.
Which modifiable risk factors for preterm labor will you incorporate into Ms. Burberrys client education? Select all that apply. Being African American Physically demanding work Maternal age Altered nutrition Use of alcohol during pregnancy
Physically demanding work Altered nutrition Use of alcohol during pregnancy
A client delivered her infant daughter 2 hours ago. She had an episiotomy to facilitate delivery. Which action is most appropriate for the nurse at this time? Help the client take a sitz bath Place an ice pack on the perineum Apply a heat lamp to the perineum Administer an analgesic medication as ordered
Place an ice pack on the perineum
After suctioning to clear the airway of a term neonate who appears in good condition after a spontaneous vaginal delivery, which action would the nurse perform next? Put identification bracelets on each wrist Obtain the neonate's weight Instill erythromycin in the baby's eyes Place the neonate skin to skin with the mother
Place the neonate skin to skin with the mother
The nurse knows that what conditions are contraindications to sexual activity during pregnancy? Select all that apply. Placenta previa Nausea There are no contraindications. Signs of preterm labor Premature rupture of membranes
Placenta previa Signs of preterm labor Premature rupture of membranes
The newborn goes through several behavioral states as it neurologically adapts to extrauterine life. The nurse observes the newborn awake and alert in its crib and reacting to auditory stimuli. Which behavior state will the nurse document in the medical record for this client? Crying state Drowsy and dozing Active alert Quiet alert
Quiet alert
By which means can newborns lose heat? (Select all that apply.) Radiation Convection Evaporation Irradiation Conduction
Radiation Convection Evaporation Conduction
A client is told that her pelvic diameters are slightly contracted. The client asks the nurse what this means for her vaginal birth plan. Which response by the nurse is the most appropriate? "Yes, you can deliver vaginally." "You will have a trial of labor first; a cesarean delivery will occur if the trial is not successful." "It might be possible, but I would count on a cesarean delivery." "You will have to have a cesarean delivery."
"You will have a trial of labor first; a cesarean delivery will occur if the trial is not successful."
A pregnant client has delivered her first child at 36 1/2 weeks gestation and the baby weighs 5 lbs 3 oz. Which statement by the nurse is appropriate? "The baby was right on time and she was born at term." "You delivered a near-term baby." "Your baby is doing well for a preterm infant." "The baby's skin looks good for being post-term."
"Your baby is doing well for a preterm infant."
The nurse is caring for several postpartum families. Which parent may not wish to have their child circumcised due to cultural or religious beliefs? Select all that apply. 31-year-old Muslim mother 20-year-old Caucasian mother 27-year-old Asian mother 30-year-old Jewish couple 34-year-old Hispanic female
20-year-old Caucasian mother 34-year-old Hispanic female 27-year-old Asian mother
The nurse is caring for four newborns. The nurse would question a health care provider's order for circumcision for which newborn? 35-week male newborn 38-week male twins 40-week male with a fifth digit on the left toe 39-week male weighing 8 lb 4 oz.
35-week male newborn
The nurse receives the end-of-shift report for a group of postpartum clients. The nurse giving the report states that one of the clients had a vaginal delivery at 2:00 pm, the client's bladder was emptied by straight catheterization at delivery, and she has not yet voided spontaneously. At what time will the nurse assuming care report the client's inability to void? 12:00 am 8:00 pm 2:00 am 4:00 pm
8:00 pm
Which diagnostic test can be used to screen for spina bifida cystica? Complete blood count Basic metabolic panel Alpha-fetoprotein Glucose tolerance test
Alpha-fetoprotein
The rubella vaccine is contraindicated for which postpartum client? HIV-positive single parent Diabetic 40-year-old mother Breastfeeding mother Cesarean section client with twins
HIV-positive single parent
Which element will the nurse include when assessing the neuromuscular maturity of an infant who is 4 hours old? Amount of breast bud tissue Heel-to-ear extension Development of the genitalia Skin appearance
Heel-to-ear extension
A pregnant client tells the nurse that eggs, tofu, and nuts are her main protein sources. Based on this data, which dietary regimen is the client following? Vegan Low carbohydrate Lactovegetarian Lacto-ovovegetarian
Lacto-ovovegetarian
The nurse is counseling a breastfeeding client on nutritional intake. The client asks which foods she should avoid while breastfeeding. What should the nurse advise to the client? All chocolate and spices Any foods containing lysine (e.g., tomatoes) Cabbage and other gas-producing foods None, except those to which the client is allergic
None, except those to which the client is allergic
The nurse is preparing to admit Mrs. Johnson, a 33-year-old G3 P3, to the postpartum floor after a vaginal birth. Which products will the nurse ensure she has access to for perineal care? Cabbage leaves, lanolin, and Tylenol Toilet paper, perineal pads, and lanolin Peri-bottle, anesthetic spray, and ice packs Tea bags, emesis basin, and toothbrush
Peri-bottle, anesthetic spray, and ice packs
A family reports having financial difficulties and is worried about purchasing formula for their newborn. Which community resource will the nurse suggest for this family? Women, Infants, and Children (WIC) program Supplemental Nutrition Assistance Program (SNAP) Nurse home-visiting program New-parent support group
Women, Infants, and Children (WIC) program
The nurse is caring for a client who had a classical uterine incision for her cesarean birth. The nurse knows that the client understands implications for future pregnancies that are secondary to her classical uterine incision when the client makes which statement? "The risk of rupturing my uterus is too high for me to have any more babies." "The next time I have a baby, I can try to deliver vaginally." "I can only have one more baby." "Every time I have a baby, I will have to have a cesarean delivery."
"Every time I have a baby, I will have to have a cesarean delivery."
If the placenta is not delivered within _____ min of giving birth, it must be manually removed. 5 10 30 60
30
What percentage of a pregnant client's daily caloric intake should be carbohydrates? 30-40% 55-60% Pregnant women should restrict their carbohydrate consumption. 15-20%
55-60%
Marjorie Stanton has just delivered a 7 lb 8 oz baby girl. The newborn's heart rate is 120 beats/min, her respiratory pattern is weak, she is well flexed, she has coughed, and her color is blue and pale. What is the appropriate Apgar score for this newborn that the nurse will document? 9 7 10 3
7
A newborn at 1 min after a vaginal delivery has a heart rate of 140, has prompt response to stimulation with crying, is pink with blue hands and feet, has a lusty cry, and maintains minimal flexion with sluggish movement. What will the nurse record as the Apgar score? 7 10 9 8
8
Which instructions should be included in parent education about newborn skin care? (Select all that apply.) A mild soap may be used for bathing. Avoid using powders on the baby. Lotions are needed to moisten the skin. Baby wipes should contain alcohol. Bathing should be done daily.
A mild soap may be used for bathing. Avoid using powders on the baby.
The following neonates are admitted to the nursery, the nurse should withhold the scheduled initial feeding on which newborn? A neonate with a sustained heart rate of 118 beats/min A neonate with an axillary temperature of 97.5 F A neonate with a sustained respiratory rate of 68 breaths/min A neonate who is small for gestational age (SGA)
A neonate with a sustained respiratory rate of 68 breaths/min
A newborn at 7 days of age has lost 3 ounces since birth. How would the nurse characterize this weight loss? Indicates failure to thrive An emergency situation An expected finding Indicates milk allergy
An expected finding
The nurse is auscultating the fetal heart rate (FHR) with a Doppler for a client in active labor, and determines that it is 90 beats/min. What action will the nurse take first? Reposition the mother Call the health care provider Apply a continuous electronic fetal monitor Take the mother's blood pressure
Apply a continuous electronic fetal monitor
While educating a pregnant client about nutrition, which statement by the nurse is the most appropriate? "Swordfish is not safe to eat as it can be toxic to the baby." "Venison, or any wild game, should be avoided until after the baby is born." "Farm-fresh eggs should be avoided because they are high in mercury." "Shrimp can be eaten several times per week."
"Swordfish is not safe to eat as it can be toxic to the baby."
During a home visit, a postpartum client complains of a reddened, swollen, and tender breast 10 days after delivery. Once this complaint is confirmed on assessment, which response by the nurse is the most appropriate? "You should mention this to your health care provider at your two-week follow-up appointment." "The symptoms you describe indicate an inflammatory or infectious process. You will need to see your provider immediately." "You will need to stop breastfeeding your newborn." "This is normal breast engorgement. You have nothing to worry about."
"The symptoms you describe indicate an inflammatory or infectious process. You will need to see your provider immediately."
The father of a preterm infant with a profound hearing loss is upset because the coordinator of a local early intervention program for child services contacted the parents. The father states, "no government agency is going to control the care" that his child receives. Which is the nurse's most appropriate response to this father? "Not using this agency to help your child could be a form of neglect." "These programs are mandated under the Individuals with Disabilities in Education Act and will help your baby learn and grow." "Most of these agencies do not have any money to control the care that the children need." "These agencies exist in name only and really don't do much to provide the care and support that a child like yours needs."
"These programs are mandated under the Individuals with Disabilities in Education Act and will help your baby learn and grow."
The nurse is talking to the parents of a newborn, who is peacefully resting on his mother's chest after delivery. The mother would like to know when she can feed the baby. Which response by the nurse is the most appropriate? "Within the first hour of life." "After admission to the newborn nursery." "Once blood glucose has been assessed." "After the baby's first bath."
"Within the first hour of life."
Carly Starnes is 29-year-old G2 P2 whom the nurse is assessing on postoperative day 2 after a low transverse cesarean birth. She reports she has not had a bowel movement since her admission 3 days ago and is feeling constipated. Ms. Starnes tells the nurse that she has never experienced constipation before and would like to know why it is happening. Which response bythe nurse is most appropriate? "I will ask the provider if we can stop the intravenous solution because that is likely the cause." "All postpartum women have this problem because of the prenatal vitamins." "Your symptoms are likely due to the Tylenol #3 you are taking to manage your pain." "I see that you are taking Colace and it is likely the problem."
"Your symptoms are likely due to the Tylenol #3 you are taking to manage your pain."
How does meconium aspiration syndrome (MAS) present? There are no visible symptoms. As severe respiratory distress As severe jaundice As severe hypoglycemia
As severe respiratory distress
Which laboratory value indicates hypoglycemia in newborns? Below 45 mg/dL Below 55 mg/dL Below 60 mg/dL Levels vary and are based on the newborn's weight.
Below 45 mg/dL
While caring for a client in active labor, the nurse notes a gradual decline in the fetal heart rate, beginning with the onset of a contraction and followed by a gradual return to baseline by the end of the contraction. Which response by the nurse is appropriate? Administer oxygen Continue to monitor Notify the health care provider Prepare for operative delivery
Continue to monitor
The nurse is teaching parents to keep the newborn's crib away from the air conditioning vent. What type of heat loss is the nurse trying to prevent in the newborn? Convection Evaporation Conduction Radiation
Convection
How is retinopathy of prematurity treated? (Select all that apply.) Cryotherapy Laser photocoagulation Lens replacement surgery Corrective lenses Beta-blocker eye drops
Cryotherapy Laser photocoagulation
The nurse observes several interactions between a mother and her newborn daughter. Which maternal behaviors will the nurse document as positive indications of mother-infant bonding? Select all that apply. Cuddles her daughter close to her Does not make eye contact with her daughter Encourages the father to hold the baby Talks and coos to her daughter Requests the nurse take the baby to the nursery for her feedings
Cuddles her daughter close to her Talks and coos to her daughter
Which statement correctly describes the transition phase of the first stage of labor? The fetus descends into the maternal pelvis and rotates internally Dilation reaches 8-10 cm, ending the first stage of labor Longest stage, lasting 8-10 hr Onset of labor through cervical dilation of 3 cm
Dilation reaches 8-10 cm, ending the first stage of labor
Leah Wilson is a 28-year-old client who is 30 hr post cesarean delivery of a healthy 7 lb 4 oz. male infant. When performing the initial assessment, the nurse notes that she has an oral temperature of 102.4°F; she is complaining of general weakness, malaise, and chills; and she states that her vaginal discharge "smells bad." Based on these findings, what does the nurse report to the health care provider? A wound infection Endometritis Normal postsurgical inflammation A urinary tract infection
Endometritis
The nurse is providing care to a newborn client immediately following delivery. The client is experiencing hypothermia due to which specific cause? Conduction Evaporation Radiation Convection
Evaporation
A client is experiencing a hypertonic pattern of uterine contractions. How often are her contractions occurring? Every 3-5 min Every 2 min or less Less than 6-8 min between contractions Less than 5 min apart
Every 2 min or less
While feeding an infant, the nurse notices white, adherent patches on the infant's gums and buccal cavity. Which action should the nurse take at this time? Document this normal finding Further evaluate for yeast infection Verify that vitamin K (AquaMEPHYTON) was given at delivery Assess for maternal history of herpes simplex
Further evaluate for yeast infection
A pregnant client has two living children, one delivered at 41 weeks and the other at 39 weeks gestation, and has had two spontaneous abortions. How would the nurse describe this client's pregnancy history using the acronym GTPAL? G5 T2 P0 A2 L2 G5 T1 P1 A2 L3 G3 T2 P0 A2 L2 G4 T2 P2 A0 L2
G5 T2 P0 A2 L2
Which are causes for apnea of prematurity? (Select all that apply. Gastroesophageal reflux Neuronal immaturity Irregular breathing patterns Altered lung vessel musculature Obstructive apnea
Gastroesophageal reflux Neuronal immaturity Irregular breathing patterns Obstructive apnea
The nurse is preparing to teach the mother of a newborn using a parent teaching form. When teaching about breastfeeding, what will the nurse include? Select all that apply. Getting the baby to latch properly When to feed the baby Proper feeding positions How to use a breast pump Feeding the baby from a bottle
Getting the baby to latch properly When to feed the baby Proper feeding positions How to use a breast pump
The nurse is performing an assessment on a newborn who is 1 hr old. The nurse notes the following on the newborn's skin: meconium staining, poor turgor, and a peeling and leathery appearance. Which gestational age is most appropriate for the nurse to document in the medical record based on these assessment findings? 37 completed weeks 38-41 completed weeks 34-36 completed weeks Greater than 42 weeks
Greater than 42 weeks
A nurse is caring for a couple whose infant son recently died from sudden infant death syndrome (SIDS). The infant's father appears withdrawn and refuses to acknowledge the infant's death when the nurse discusses the infant with the couple. Which collaborative therapy is most appropriate to help the infant's family in the grieving process? Cognitive behavioral therapy Grief counseling Antidepressant medication Antianxiety medication
Grief counseling
The nurse is assessing newborn baby Thomas, who is 1 hr old. Which assessment finding does the nurse report to the healthcare provider? Grunting Nasal secretions Brief periods of apnea Coughing
Grunting
A mother asks the nurse how she will know if her newborn is having difficulty breathing. The nurse would instruct the mother to monitor for which symptom? Select all that apply. Grunting Central cyanosis Retractions Nasal flaring Crying
Grunting Central cyanosis Retractions Nasal flaring
The nurse is teaching new parents about the newborn's sensory capacities. Which items will the nurse include in the teaching session to these new parents? Select all that apply. Habituation Orientation Active alert Crying Self-quieting
Habituation Orientation Self-quieting
While the health care provider is completing the repair of Mrs. Romero?s fourth degree laceration, you begin your initial assessment.Mrs. Romero?s vital signs are T 98.8°F, P 70 bpm, R 20/min, and BP 90/66 mmHg.You palpate her fundus and note it is boggy and 1+ fingerbreadths above her umbilicus.You alert her health careprovider, who pauses the repair to wait while you massage her uterus and expel three golf ball size clots.You anticipate your next action to be: Manually remove additional clots from her lower uterine segment Provide 600 mg ibuprofen PO Hang a bag of lactated Ringer solution with oxytocin Replace her Foley catheter
Hang a bag of lactated Ringer solution with oxytocin
Which discomforts can the nurse tell a woman she might experience during her pregnancy? Select all that apply. Dry mouth Heartburn Nasal stuffiness and nosebleeds Leg cramps Excessive energy
Heartburn Nasal stuffiness and nosebleeds Leg cramps
The nurse is making a visit to the home of a preterm infant to evaluate the success of care provided while hospitalized. Which observation indicates that additional teaching or care is required? Parents take turns holding the baby when crying or fussy Mother holds the baby en face Infant has lost 1% of body weight since discharge Father changes the baby's diaper without difficulty
Infant has lost 1% of body weight since discharge
An infant with an omphalocele is admitted to the special care nursery (SCN). Which assessments will the nurse conduct for this infant based on the diagnosis? Select all that apply. Input and output Glucose levels Temperature Respiratory rate and effort Abdominal girth
Input and output Temperature Respiratory rate and effort
Which option is appropriate for providing relief of perineal pain after a vaginal delivery? Warm compresses Tea bags Frozen cabbage leaves Intermittently placed ice packs
Intermittently placed ice packs
A parent asks, "How long should I warm the baby's bottle in the microwave before feeding?" What is an appropriate response by the nurse? "I will ask the healthcare provider to speak with you about this." "It's best to feed the baby while the formula is still very cold." "It is best to warm the bottle in a container of warm water." "About one minute per ounce will warm the bottle sufficiently."
It is best to warm the bottle in a container of warm water."
Which exercise can the nurse recommend to a pregnant woman to strengthen her perineal muscles? Pelvic tilt exercises Partial sit-ups Swimming Kegel exercises
Kegel exercises
Mrs. Emma Turner is a 29-year-old gravida 2 para 1 who presents to labor and delivery at 30 weeks gestation reporting heavy, bright red vaginal bleeding. She was diagnosed with a complete placenta previa during a22-week ultrasound, and she has known since then that she will need to deliver her baby via cesarean section. Her first baby was born three years ago via a normal spontaneous vaginal delivery. She is accompanied by herhusband, Kyle Turner. You are assigned to take care of Mrs. Turner. You knock and enter Mrs. Turners labor room. She is in bed crying softly. You introduce yourself to Mrs. Turner and her husband and place the external fetal heart monitor and the external tocodynamometer onto her abdomen and fasten them into place with straps. You transfer Mrs. Turner to the recovery room and begin your postpartum assessment. Mrs. Turner is resting comfortably because her regional anesthesia is still providing her with excellent pain relief.Hows my baby? she asks you. You relay to her what you have heard from the NICU, which is that her baby is doing very well considering she was born at 30 weeks gestation.You assess Mrs. Turner. Her vital signs are: T 99.6° F, P 109bpm, R 15/min, and BP 116/68 mmHg. You gently locate her fundus at the umbilicus. Her dressing is intact. She is unable to move her legs. She has a moderate amount of bright red lochia on her peri-pad. You noteblood-tinged urine in her Foley catheter.Im glad my baby is doing well, Mrs. Turner tells you. How am I doing? Is everything okay?Based on the above information, what concerns you regarding Mrs. Turners health status? Postpartum hemorrhage Infection Lacerated bladder Paralysis
Lacerated bladder
A client is discharged from the hospital and plans to breastfeed for 6 months. Which community resource will the nurse recommend to increase the likelihood of successful breastfeeding after discharge? Lactation consultant Home visiting nurse New-parent support group Pediatrician
Lactation consultant
Which nursing intervention is appropriate in the care of an infant with respiratory distress syndrome (RDS)? Maintain a neutral thermal environment Perform a complete gestational age assessment Perform chest physiotherapy twice a day Suction meconium from airway as needed
Maintain a neutral thermal environment
Jeremy was born at 35 weeks' gestation weighing 4,025 g (8 lb 14 oz.) and shows no signs of being a high-risk newborn. Based on the nursing assessment, which classification is most appropriate for Jeremy? Moderately preterm and large for gestational age (LGA) Term and small for gestational age (SGA) Healthy and in no need of special care Late preterm and hypoxic
Moderately preterm and large for gestational age (LGA)
The nurse is caring for a client experiencing her first pregnancy. The client's cervix is dilated at 8 cm, the fetus is at +1 station, and the client has no analgesia or anesthesia. What is the priority for the nurse? Providing frequent perineal cleansing Applying extra blankets for warmth Offering encouragement and support Giving frequent sips of water
Offering encouragement and support
What are the indicators that require electronic fetal monitoring (EFM)? Select all that apply. Oxytocin administration Maternal complications of pregnancy Fetal complications Labor augmentation Primigravida status
Oxytocin administration Maternal complications of pregnancy Fetal complications Labor augmentation
The health care provider completes the repair of the fourth degree laceration. You inspect Mrs. Romeros perineum to obtain a baseline assessment. What will be your next step after completing the assessment of herperineum? Perform a rectal exam to ensure there are no stitches in her rectum. Assist her to a sitting position to apply pressure to the wound. Place an icepack on the area. Review with Mrs. Romero that she should try to not have a bowel movement until her perineum starts to heal.
Place an icepack on the area.
Which interventions promote thermoregulation in the preterm infant? (Select all that apply.) Place incubator away from cold external walls Cover the infant's head with a cap Measure oxygen saturation Warm and humidify oxygen Warm formula before feeding
Place incubator away from cold external walls Cover the infant's head with a cap Warm and humidify oxygen Warm formula before feeding
What state best describes a newborn who is not fussing, is fixating on and following objects, and is reacting to auditory stimuli? Active sleep Quiet alert Crying state Active alert
Quiet alert
A postpartum client who will be formula-feeding her baby wants to return to her prepregnancy weight as soon as possible. Which teaching point is most appropriate for the nurse to include based on the client's desire to lose weight post pregnancy? Reduce daily caloric intake by 300 calories a day. Eat 200 additional calories per day. Experiment with low-carbohydrate, high-protein diets. Limit dairy products and protein.
Reduce daily caloric intake by 300 calories a day.
A postpartum client, who will be bottle-feeding her baby, wants to return to her prepregnancy weight as soon as possible. Which practice should the nurse instruct this client to do regarding weight loss after pregnancy? Limit dairy products and protein. Experiment with low-carbohydrate, high-protein diets. Reduce daily caloric intake by 300 calories a day. Eat 200 additional calories per day.
Reduce daily caloric intake by 300 calories a day.
Which statement regarding the postpartum diet is most appropriate for a client who is formula-feeding her newborn? Eat only when very hungry. Reduce the caloric intake by 300 kcal. Increase the caloric intake by 300 kcal. No dietary changes are required.
Reduce the caloric intake by 300 kcal.
The nurse is caring for a preterm infant in the newborn intensive care unit (NICU) who is 2 hours old. Which complication will the nurse monitor this infant for based on the diagnosis of prematurity? Bronchopulmonary dysplasia Meconium aspiration syndrome Respiratory distress syndrome Patent ductus arteriosus
Respiratory distress syndrome
The nurse is creating a teaching plan for the parents of a preterm infant scheduled for discharge in 2 days. Which aspects of care should the nurse emphasize when instructing these parents? Select all that apply. Signs of infection or illness Schedule for routine vaccinations Feeding techniques Swaddling to keep the hands away from the face Growth and development expectations
Signs of infection or illness Schedule for routine vaccinations Feeding techniques Growth and development expectations
At birth, what is a newborn's stomach able to digest? Meconium Simple carbohydrates Nothing Complex carbohydrates
Simple carbohydrates
A nursing responsibility while preparing a woman for a cesarean birth would be which action? Explaining the risks involved Explaining the details of the procedure Supporting the woman and her partner Obtaining informed consent
Supporting the woman and her partner
How do newborns produce heat? Through their central nervous system By shivering Newborns are unable to produce heat. Through the use of brown fat
Through the use of brown fat
As the health care provider leaves the room, she asks you to place a Foley catheter. You explain to Ms. Maxwell what a Foley catheter is and why it is indicated at this time. Which statements by Ms. Maxwell indicate that she understands the need for a Foley catheter? Select all that apply. You need to make sure my kidneys are getting enough blood. You need to check my urine for protein. I know the hospital is too busy for you to help me to the bathroom. If I get up to go to the bathroom on my own, I might deliver my baby in the toilet. This is the only way to measure my urine output.
You need to make sure my kidneys are getting enough blood. You need to check my urine for protein.
You reassure Mrs. Turner that the babys heart rate is within normal limits and that you are observing only a scant amount of blood at this time.Mrs. Turner asks what they should expect over the next few hours. What is your best response? Select all that apply. In a couple of minutes, Ill help you to the shower to clean off the blood. I need to check your cervix to see if it is dilated. Would you like something to eat? You should not take any Tums right now. We will continue to monitor the babys heart rate and watch for bleeding.
You should not take any Tums right now. We will continue to monitor the babys heart rate and watch for bleeding.
A nurse is caring for a client who delivered a healthy, term baby girl 8 hours ago. The nurse is providing the client information about sudden infant death syndrome (SIDS) as a part of discharge instructions. The client asks the nurse, "Why does breastfeeding help to prevent my child from developing SIDS?" Which response by the nurse is the most appropriate? "Breastfed infants are thought to breathe easier than infants who are fed formula." "Breastfed infants are thought to be larger than infants who are fed formula." "Breastfed infants are thought to arouse easier from sleep than infants who are fed formula." "Breastfed infants are thought to sleep longer than infants who are fed formula."
"Breastfed infants are thought to arouse easier from sleep than infants who are fed formula."
The nurse is interviewing Linda Youngblood, a pregnant client who is in her second trimester. Which is an appropriate assessment question for the nurse to ask? "What is your labor plan?" "Have you considering enrolling in childbirth classes?" "How are you getting relief from your lower back pain?" "Are you aware we will test you for Group B Strep today?"
"How are you getting relief from your lower back pain?"
How much more percentage of oxygen is carried in fetal hemoglobin when compared with adult hemoglobin? 75 50 10 25
50
Which are treatment options for mastitis? Select all that apply. Antibiotics "Resting" the breast Increased intake of milk products Bed rest Breastfeeding
Antibiotics Bed rest Breastfeeding
Which vital sign is critical to assess after administration of an epidural? Pulse Blood pressure Respirations Temperature
Blood pressure
The nurse is assessing a newborn infant. Which assessment finding would indicate the need for immediate intervention? Central cyanosis Nasal flaring Retractions Grunting
Central cyanosis
What does the nurse apply to the circumcision site after the procedure is completed? Neosporin bandage Vaseline gauze Adhesive dressing Drainage tube
Vaseline gauze
A new mother overhears the nurse tell the health care provider the Apgar score of the newborn she just delivered. The mother asks the nurse, "What does that score mean?" What is the nurse's best response? "It is a score we assign only to newborns who appear to be in respiratory distress." "It is a score used in nursing. It's a bit complicated and not necessary for you to understand." "It is a score we assign to all newborns that indicates gestational age." "It is a score we assign to all newborns that reveals a newborn's adaptation to birth."
"It is a score we assign to all newborns that reveals a newborn's adaptation to birth."
The nurse is caring for a pregnant client in labor whose birth plan states "no pharmacologic pain interventions" during the labor and delivery process. Which statement by the nurse supports the client's birth plan? "I will have the anesthesiologist come in to talk to you about the benefits of an epidural." "Let me know when you begin to feel uncomfortable. We can change your position and refocus your breathing to help manage the discomfort." "I am going to start an IV because once you enter transition, you will need me to administer something to take the edge off the pain." "No one is ever able to labor without needing some form of oral analgesic."
"Let me know when you begin to feel uncomfortable. We can change your position and refocus your breathing to help manage the discomfort."
The nurse is rounding on her clients and their babies and conversing with each of them as she assesses the infants. Which statement from a new mother would require further assessment of bonding and attachment? "Do you think you can take him to the nursery on your way out? I am so tired I can't stand it." "Look at that baby screaming. She's mean as a snake, just like her daddy." "Thank goodness you're here. She's been really fussy and I feel like I'm not feeding her enough." "Be careful! I'm really scared of that big plastic clamp getting pulled on!"
"Look at that baby screaming. She's mean as a snake, just like her daddy."
The nurse is teaching a new mother about the normal stooling pattern of a newborn. Which statement by the client indicates appropriate understanding of the teaching session? "Meconium is loose, golden yellow." "Meconium is sticky, greenish black." "Meconium is hard, pale brown." "Meconium is soft, pale yellow."
"Meconium is sticky, greenish black."
The nurse is evaluating client teaching about labor contractions. Which statement by the client indicates that the teaching has been effective? "My contractions are three minutes apart, counting from the beginning of one contraction to the end of the next contraction." "My contractions are three minutes apart, counting from the beginning to the end of the same contraction." "My contractions are three minutes apart, counting from the end of one contraction until the beginning of the next contraction." "My contractions are three minutes apart, counting from the beginning of one contraction until the beginning of the next contraction."
"My contractions are three minutes apart, counting from the beginning of one contraction until the beginning of the next contraction."
A community health nurse is teaching a group of pregnant clients regarding sudden infant death syndrome (SIDS) and the causes associated with the syndrome. Which statement is appropriate for the nurse to include in the teaching session? "SIDS is thought to be caused by newborn apnea." "SIDS is thought to be caused by infant immunizations." "SIDS is thought to be caused by respiratory disease." "SIDS is thought to be caused by a combination of factors."
"SIDS is thought to be caused by a combination of factors."
The nurse in a prenatal care setting is caring for a woman at 39 weeks' gestation. The healthcare provider is going to strip the client's membranes. The client asks the nurse what this will do. What would be the best response by the nurse? "Stripping the membranes will help stimulate the fetus." "Stripping the membranes releases progesterone that will prevent preterm labor." "Stripping the membranes will cause the fetus to drop lower in the pelvis." "Stripping the membranes releases prostaglandins that may help labor begin."
"Stripping the membranes releases prostaglandins that may help labor begin."
The mother of a preterm infant asks why the baby is scheduled for audiology testing 180 days after birth when information on the Internet states that this testing should be done by age 3 months. Which response by the nurse is most appropriate? "It doesn't matter when it is performed as long as it is completed within 1 year of birth." "The physician must have calculated the date for the testing incorrectly." "The baby's age has been corrected and is based upon expected date and not actual date of delivery." "The information on the Internet is incorrect."
"The baby's age has been corrected and is based upon expected date and not actual date of delivery."
A father asks how the bilirubin lights make the newborn's bilirubin level go down. What is the best reply by the nurse? "The lights prevent more bilirubin from being released into your baby's body." "Exposing the skin to the air helps get rid of the jaundice. The bililights really just keep the baby warm while this occurs." "The bililights help convert the bilirubin to a form the baby can get rid of." "The bililights release a substance in the body that attacks the bilirubin and destroys it."
"The bililights help convert the bilirubin to a form the baby can get rid of."
At a routine prenatal visit, the nurse and the client are discussing methods of establishing fetal well-being while discussing what to expect in labor. The client asks, "I read online that the fetal monitor has high sensitivity and low specificity. What does that mean?" What is the nurse's best response? "The electronic monitor doesn't do anything for the baby. Its main use is to provide evidence in lawsuits over bad outcomes." "The monitor is very good in reassuring us that the baby is doing well but not so good at confirming that the baby is compromised. If the monitor looks good, we know the baby is okay. If we see signs of a problem, the baby is often doing well anyway." "That's a very complicated question and it's nothing for you to worry about. The midwife will decide whether monitoring is appropriate for your baby." "The fetal monitor can tell us with certainty if the baby is in trouble and needs to be delivered right away by cesarean."
"The monitor is very good in reassuring us that the baby is doing well but not so good at confirming that the baby is compromised. If the monitor looks good, we know the baby is okay. If we see signs of a problem, the baby is often doing well anyway."
The healthcare provider has performed an amniotomy on a client in labor. The client did not understand the healthcare provider's explanation of the procedure and asks the nurse what effects the procedure will have. What is the nurse's best response? "I will call the provider back so you can ask whatever questions you have." "Another name for this procedure is stripping the membranes." "That procedure was to identify where the baby is in relation to the narrowest part of your pelvis." "The provider has ruptured the amniotic membrane in order to stimulate your labor."
"The provider has ruptured the amniotic membrane in order to stimulate your labor."
The nurse is teaching a new mother how to change her newborn's diaper. The new mother becomes upset when she sees blood on the diaper. Which explanation is the most appropriate for the nurse to provide to the new mother? "This is caused by a withdrawal of the maternal hormones and is a normal occurrence." "Your baby must have cystitis. I will notify the nurse practitioner immediately." "This indicates neonatal candidiasis. We will send you home with a medication to treat this." "Your baby must have experienced some birth trauma."
"This is caused by a withdrawal of the maternal hormones and is a normal occurrence."
The nurse is at the bedside of a client in active labor, reviewing the fetal heart tracing. There is moderate variability; no decelerations below baseline; and periodic accelerations are evident. The client asks how the tracing looks. What is the nurse's best response? "The baby is having a little difficulty. Let's turn you on your side to see whether we can improve his circulation." "This tracing looks very good. The baby is showing all the signs of well-being." "There is no way to tell the baby's status from this tracing. We will have to monitor him for another hour and re-evaluate it." "You might need a cesarean."
"This tracing looks very good. The baby is showing all the signs of well-being."
You find that Dr. Rui's temperature is 98.2° F, her heart rate is 120 beats per minute, weak and thready, her respirations are 24 breaths per minute and regular, and her blood pressure is 80/50 mmHg. Fifteen minutes after giving her the glucose tablets, you take her blood glucose reading again, and it has risen to 80 mg/dL. Dr. Rui tells you that she took her usual insulin dose this morning and ate breakfast. Soon afterward, she vomited her breakfast. After that event, she had such difficult thinking and concentrating that she did not remember her morning glucometer reading. "Do I have to go to the hospital?" she asks. What is your response to her question? "I will call your endocrinologist and let her decide if you need hospitalization." "Your hypoglycemia has been treated. Can you get a neighbor or your niece to come stay with you for the next 12 hours?" "Hypoglycemia can always be treated at home, so there will never be a reason for you to consider seeking hospitalization." "I will call ahead to the hospital, so that they expect you. I can drive you there."
"Your hypoglycemia has been treated. Can you get a neighbor or your niece to come stay with you for the next 12 hours?"
At what intervals will the nurse assess newborn Apgar scoring? 1 min and 5 min 1 min and 10 min 5 min and 7 min 10 min and 20 min
1 min and 5 min
What is the maximum length of time a vacuum extractor can be used without increasing the risk of injury to the fetal scalp? 10 min 5 min 15 min 30 min
10 min
How many mL of fluid should the postpartum mother intake per day to stay well hydrated? 500 2,000 1,500 1,000
2,000
The sperm and ovum each contain how many autosomes? 46 24 22 44
22
Baby Gonzalez, a 3-day-old preterm infant in the neonatal intensive care unit, is prescribed to receive 150 mL of intravenous fluid for every kilogram of weight. This morning Baby Gonzalez weighed 1850 g. How much fluid should the nurse provide Baby Gonzalez? 832.5 mL 138.8 mL 555.5 mL 277.5 mL
277.5 mL
There are four laboring clients on the labor and delivery unit. Which client demonstrates the highest risk of a prolapsed cord? 38 weeks, 3 cm dilated, 80% effaced, 0 station, intact membranes 39 weeks, 9 cm dilated, 100% effaced, +1 station, ruptured membranes 38 weeks, 3 cm dilated, 50% effaced, -5 station, ruptured membranes 40 weeks, 8 cm, 75% effaced, 0 station, intact membranes
38 weeks, 3 cm dilated, 50% effaced, -5 station, ruptured membranes
A client who has undergone a vacuum-assisted birth asks the nurse how long the swelling on the infant's head will remain. Which would be the best response by the nurse? 12-24 hours 48-72 hours 8-12 hours 5-7 days
48-72 hours
Oligohydramnios is diagnosed when the amniotic fluid is less than which percent expected for gestational age? 80 65 50 35
50
Which amount of blood loss constitutes a postpartum hemorrhage after a vaginal birth? 250 mL 500 mL 1,000 mL 1,500 mL
500 mL
The nurse would be concerned if the postpartum client has not voided within how much time after delivery? 12 hr 24 hr 6 hr 1 hr
6 hr
A nurse is teaching a postpartum client about the normal voiding pattern of a newborn. Which information should the nurse provide to the client during this teaching session? 8-10 wet diapers per day by the end of the first week 6-8 wet diapers per day by the end of the first week 4-6 wet diapers per day by the end of the first week 2-4 wet diapers per day by the end of the first week
6-8 wet diapers per day by the end of the first week
A newborn weighs 7 lb (3.17 kg) at birth. At 2 weeks of age, the newborn has returned to the original birth weight. What is the expected weight for this formula-fed infant at 4 weeks of age? 7 lb 7 oz (3.37 kg) 8 lb 14 oz (4.02 kg) 8 lb 7 oz (3.82 kg) 7 lb 14 oz (3.57 kg)
7 lb 14 oz (3.57 kg)
The attending health care provider enters Mrs. Turners room to evaluate her. He looks at the fetal monitor and evaluates her chux, which shows a very scant amount of bright red blood. He tells Mrs. Turner that he is concerned that if her bleeding continues or worsens, we may need to deliver your baby. He orders steroids to enhance the maturity of the babys lungs. You anticipate he will also order which additional interventions? Select all that apply. A complete blood count and a type and screen A breast pump for colostrum collection Intravenous access and fluids A neonatology consult Internal fetal and uterine monitors
A complete blood count and a type and screen Intravenous access and fluids A neonatology consult
The nurse is caring for a postpartum client 8 hr after a vaginal birth. On assessment, the nurse finds the client's fundus to be firm, but she continues to have heavy vaginal bleeding. Based on the assessment findings, what is causing the heavy bleeding? A hematoma Uterine atony A laceration Endometritis
A laceration
The nurse is discharging a postpartum client with a newborn infant. Which safety measure will the nurse ensure prior to the official discharge of the infant? A properly installed infant car seat A baby monitoring system Cabinet locks on all base units A dishwasher to sanitize all bottles
A properly installed infant car seat
The attending health care provider arrives to evaluate Ms. Maxwell. After performing a vaginal exam, she states that Ms. Maxwell is 6 centimeters dilated, 100% effaced, and 0 station. The health care provider requests an amnihook and performs artificial rupture of membranes. The amniotic fluid is dark green and bloody. She inserts an intrauterine pressure catheter to monitor contractions and resting tone, and an internal scalp electrode to permit more detailed evaluation of the fetal heart rate.Based on your experience, you expect the health care provider will order which labs for Ms. Maxwell? Select all that apply. A urine toxicology screen A complete blood count A biophysical profile Liver enzymes A group B beta strep (GBS) culture
A urine toxicology screen A complete blood count Liver enzymes
An infant of a diabetic mother (IDM) is admitted to the newborn nursery. Which nursing intervention has highest priority at this time? Clean the umbilical cord Administer vitamin K (AquaMEPHYTON) intramuscularly Complete a gestational age assessment Assess the infant's blood glucose level
Assess the infant's blood glucose level
You are working as a labor and delivery nurse in a downtown tertiary care hospital. The emergency department(ED) calls to alert you to an incoming ambulance. The ambulance was called to a homeless shelter after a pregnant resident reported having heavy vaginal bleeding. The ambulance crew arrives to labor and delivery pushing a gurney. On the gurney is 23-year-old Jaycee Maxwell. The emergency medical technician (EMT) tells you that Ms. Maxwell told them she is pregnant with her first baby and thinks she is due in two weeks. Per the EMT, Ms. Maxwell was using the restroom at the homeless shelter and cried out for help, reporting that she saw a large amount of blood in the toilet. Ms. Maxwells eyes are closed, and she is moaning. Her hands are gripping the blanket on the gurney. You explain to Ms. Maxwell that you will help the EMT crew move her from the gurney onto a labor and delivery bed. As you help move Ms. Maxwell to the bed, the EMT tells you her vitals are as follows: T 98.8°F, P 120 bpm, R32/min, BP 156/92 mmHg, and her Sp02 on room air is 97%. Ms. Maxwell has a left antecubital 16-gauge IV infusing normal saline at a rate of 250 mL/hr. As you move Ms. Maxwell to the bed, you note she has a small amount of dried blood on her thighs. Which nursing activities are appropriate at this point? Assist Ms. Maxwell to the bathroom to obtain a UA. Examine Ms. Maxwells cervix. Apply the external fetal heart rate monitor and tocodynanometer. Assist Ms. Maxwell to the bathroom to change into a gown.
Apply the external fetal heart rate monitor and tocodynanometer.
A nurse performs a cervical exam on a client with ruptured membranes and palpates a loop of umbilical cord. What is the initial nursing action? Preparing an amnioinfusion to try and float the cord up into the uterus Applying firm pressure on the presenting part to relieve cord compression Stopping oxytocin administration immediately Giving the mother oxygen via face mask at 15 L/min
Applying firm pressure on the presenting part to relieve cord compression
Which action may be recommended to soften engorged breasts before breastfeeding? Taking a pain medication before nursing Cooling breasts with ice packs 1 hr before nursing Applying warm compresses to breasts before nursing Applying frozen cabbage leaves after nursing
Applying warm compresses to breasts before nursing
During the initial exam, a newborn estimated at 40 weeks gestation weighs 7 lb 8 oz (3,550 g). Which classification is most appropriate for this newborn based on birth weight and gestational age? Appropriate for gestational age Small for gestational age Large for gestational age Premature
Appropriate for gestational age
Which amount of maternal weight loss is expected immediately after childbirth? None; it generally takes 3 months to lose any pregnancy weight. Approximately 12 lb (5.4 kg) Approximately 20 lb (9 kg) The weight of her baby
Approximately 12 lb (5.4 kg)
"Ive never been anemic before, even when I was having heavy periods," Mrs. Abejundio tells you. "Why were my iron levels always fine then but not now? Shouldnt they be higher since Im not having my period right now?" What will you tell Mrs. Abejundio? Select all that apply. As a smoker, you have more red blood cells than nonsmokers. Pregnant women are easily dehydrated, which causes anemia. You are conserving iron because your periods have stopped, but its not enough. Your body used up most of your iron in the first trimester of pregnancy. Hemodilution causes a reduced hematocrit.
As a smoker, you have more red blood cells than nonsmokers. You are conserving iron because your periods have stopped, but its not enough. Hemodilution causes a reduced hematocrit.
Mrs. Yumihara admits that sometimes she fantasizes about not being a mother and not having a baby to take care of. She follows up this statement with more tears. This prompts you to wonder whether Mrs. Yumihara has ever considered hurting herself or her baby. When you ask this, Mrs. Yumihara denies having such thoughts.However, if she had admitted to considering hurting herself or the baby, what is the next logical question to ask her as part of a risk assessment? Ask Mrs. Yumihara if she has been talking with her friends. Ask Mrs. Yumihara if she gets any ideas from television shows. Ask Mrs. Yumihara if she has a specific plan of harm. Ask Mrs. Yumihara if she also thinks about leaving her husband.
Ask Mrs. Yumihara if she has a specific plan of harm.
The nurse is providing newborn teaching to Farrah Aziz, a 32-year-old female who speaks very little English. The nurse teaches Farrah about complications the newborn may experience, and when Farrah should contact the health care provider. Farrah appears confused when the nurse asks whether she has questions. What should the nurse do to ensure Farrah understands the teaching? Repeat the information, speaking more slowly. Have Farrah's 12-year-old niece share the information. Ask for assistance from an interpreter. Speak louder to ensure that Farrah hears the information.
Ask for assistance from an interpreter.
The midwife asks the nurse to assist the laboring client with McRoberts maneuver to help with shoulder dystocia. Which nursing action is appropriate with this maneuver? Ask the client to abduct and flex her hips Rotate the fetal shoulder 180 degrees Apply suprapubic pressure for 5 min Apply firm pressure to the fundus until the shoulder releases
Ask the client to abduct and flex her hips
The nurse is assessing a client who delivered 3 hours ago. On completing a fundal assessment, the nurse notes the fundus is situated toward the left side of the client's abdomen. Which action is appropriate? Call the client's health care provider for direction Straight-catheterize the client for half the volume of urine Ask the client to empty her bladder Straight-catheterize the client immediately
Ask the client to empty her bladder
After delivery, baby Mai-Ling was thoroughly cleaned, dried, swaddled, and placed in a preheated warmer. Shortly after, the nurse helps Mai-Ling's mother with breastfeeding techniques for Mai-Ling. The nurse notes that Mai-Ling is not feeding well and is displaying tremors. Which assessment is appropriate to conduct on Mai-Ling at this time? Assess for hyperthermia Assess for urinary retention Assess for meconium stool Assess for hypoglycemia
Assess for hypoglycemia
The nurse is caring for a preterm infant with an endotracheal tube who is receiving nutritional support through a central line. What actions should the nurse take to reduce this infant's risk of developing an infection? Select all that apply. Assess heart rate Perform hand hygiene before and after providing care Monitor respiratory rate Secure central line infusion with tape Suction every 2 hr
Assess heart rate Perform hand hygiene before and after providing care Monitor respiratory rate
The charge nurse has searched the computer system and located an ultrasound performed on Ms. Maxwell at the ED of another hospital in the same system. Which ultrasound reports would prompt you to check her cervix? Select all that apply. A 20-week ultrasound showing a low-lying placenta that gives a current EGA of 29 wks. An 8-week ultrasound showing an intrauterine pregnancy and left ovarian corpus luteum that gives a current estimated gestational age (EGA) of 36 wks. A 24-week ultrasound showing a fundal placenta that gives Ms. Maxwells fetus a current EGA of 41 weeks. A 36-week ultrasound showing a breech presentation and a low-lying placenta with the edge 4 cm from the cervical os. None of the above ultrasounds would make you feel comfortable checking her cervix at this time.
A 24-week ultrasound showing a fundal placenta that gives Ms. Maxwells fetus a current EGA of 41 weeks. A 36-week ultrasound showing a breech presentation and a low-lying placenta with the edge 4 cm from the cervical os.
The nursery nurse has just received the morning report. Which newborn will the nurse consider the priority assessment? A 3-hr-old newborn with nasal flaring and grunting, respirations of 60 A 3-hr-old newborn who is sleeping with heart rate of 130, respirations 40, with periods of apnea lasting 5-8 s A 5-hr-old newborn awake with heart rate of 140 beats/min, temperature 98.8 degrees F, respirations of 50 and irregular A 6-hr-old newborn who has a positive startle reflex; respirations of 44 and irregular
A 3-hr-old newborn with nasal flaring and grunting, respirations of 60
The nurse is reviewing the status of clients on the mother-baby unit for the evening shift and notes that several clients have not been out of bed since giving birth. Which client would be a priority for the nurse to assist with ambulation? A 31-year-old status post-vaginal birth 2 hr ago with a prepregnant BMI not calculated in the prenatal record A 25-year-old 18 hr status postcesarean with a prepregnant BMI of 18 An 18-year-old 4 hr status post-vaginal birth with a prepregnant BMI of 22. A 38-year-old 24 hr status postcesarean client with a prepregnant body mass index (BMI) of 33.
A 38-year-old 24 hr status postcesarean client with a prepregnant body mass index (BMI) of 33.
A new father shares his concern regarding how the baby will bond with him. He states, "I read in the baby book that feeding time is the best time to bond with your baby. My wife is breastfeeding our baby, so how can I bond with our son?" Which other ways of connecting and strengthening the father's relationship with his son can the nurse teach the father? Select all that apply. Bathing the baby Holding and talking to his son Watching over him as he sleeps in the crib Changing the baby's diaper Talking to his wife while she is breastfeeding the baby
Bathing the baby Holding and talking to his son Changing the baby's diaper
An infant is born after an uneventful labor with Apgar scores of 5 and 6. Within 10 min of birth the infant has no respirations and is centrally cyanotic. What is the nurse's initial action? Repeat the Apgar test again in 10 min Assess vital signs Administer a glucose feeding Begin neonatal resuscitation
Begin neonatal resuscitation
A pregnant client asks the nurse when the one hour post-prandial glucola test will be performed to screen for gestational diabetes. The nurse responds that this test is usually done at how many weeks gestation? Between 16 and 20 Between 24 and 28 Between 20 and 24 Between 12 and 16
Between 24 and 28
Which measurement is appropriate for the nurse to use to determine whether the cervix is favorable for induction? Bishop Score Apgar score Fetal heart rate Premature rupture of the membranes (PROM)
Bishop Score
Which gastrointestinal or genitourinary changes develop in the postnatal recovery period? Select all that apply. Diarrhea Bladder distention Constipation Diuresis Hemorrhoids
Bladder distention Constipation Diuresis
The cervix of a client in active labor who received epidural anesthesia 4 hr ago is now completely dilated, and the client is ready to begin pushing. Before the client begins to push, what would the nurse assess? Fetal heart rate variability Cervical dilation again Status of membranes Bladder status
Bladder status
A 25-year-old first-time mother is admitted to the labor room. She is 3 cm dilated and 80% effaced, and the head is at 0 station. Contractions occur every 10 min, lasting 20-30 s. Membranes are intact. Admitting vital signs are blood pressure 112/70, pulse 80 bpm, respirations 16, temperature 98.8°F, and fetal heart rate 148. What should the nurse monitor? Temperature, blood pressure, and contractions every 4 hr and fetal heart rate hourly Contractions, blood pressure, and fetal heart rate every 15 min Contractions, effacement and dilation of cervix, and fetal heart rate every hour Blood pressure hourly and contractions and fetal heart rate every 30-60 min
Blood pressure hourly and contractions and fetal heart rate every 30-60 min
The nurse is assisting with the administration of an epidural to a laboring client. The nurse ensures that which intervention is included after the procedure? Placing client in prone position Suctioning Increasing intravenous fluids Blood pressure monitoring
Blood pressure monitoring
Which premonitory signs may occur before the onset of labor? Select all that apply. Bloody show Nesting Loss of cervical mucus plug Braxton Hicks contractions Lightening
Bloody show Nesting Loss of cervical mucus plug Braxton Hicks contractions Lightening
What does the nurse assess before transitioning the newborn from a radiant warmer to an open crib? Body temperature First feeding Body weight Oral secretions
Body temperature
The nurse is determining the effectiveness of care provided to a 10-day-old preterm infant. Which measurement indicates that nutritional support has been effective? Body weight changed from 2600 g to 2700 g between days 5 and 10 Body weight changed from 2200 g birth weight to 1760 g on day 10 Body weight changed from 2200 g birth weight to 1810 g on day 10 Body weight changed from 2600 g to 2500 g between days 5 and 10
Body weight changed from 2600 g to 2700 g between days 5 and 10
What is commonly seen in newborns who experience shoulder dystocia during delivery? Hydrocephalus Brachial plexus injury Ankle fracture Delayed growth
Brachial plexus injury
The nurse is providing care to a client diagnosed with mastitis. Which teaching topic is the priority for this client? Pump from both breasts and discard the milk. Stop breastfeeding totally to allow the infection to heal. Breastfeed from both breasts. Nurse the infant only from the uninvolved breast.
Breastfeed from both breasts.
The nurse is preparing information for a breastfeeding class. What information is appropriate for the nurse to include in the teaching session regarding maternal nutrition during breastfeeding? Select all that apply. Breastfeeding women should consume 8-10 8-oz glasses of fluid daily. A poor diet can decrease milk supply. Breastfeeding women should increase their protein intake. Calcium intake should be decreased while breastfeeding. Breastfeeding women should increase their caloric intake by 150 kcal daily
Breastfeeding women should consume 8-10 8-oz glasses of fluid daily. A poor diet can decrease milk supply. Breastfeeding women should increase their protein intake. Breastfeeding women should increase their caloric intake by 150 kcal daily
The nurse is preparing information for a breastfeeding class. Which information should the nurse include regarding maternal nutrition during breastfeeding? Select all that apply. Calcium intake should be decreased while breastfeeding. Breastfeeding women should increase their caloric intake by 200 kcal daily. Breastfeeding women should increase their protein intake. A poor diet can decrease milk supply. Breastfeeding women should consume 8-10 (8 oz) glasses of fluid daily.
Breastfeeding women should increase their protein intake. A poor diet can decrease milk supply. Breastfeeding women should consume 8-10 (8 oz) glasses of fluid daily.
What long-term complication can occur in a preterm infant being mechanically ventilated with high oxygenconcentrations? Bronchopulmonary dysplasia Chronic bronchitis Pulmonary hypertension Pulmonary hypertension
Bronchopulmonary dysplasia
Before Ms. Burberry leaves the clinic after her examination, what will you include in her client education? Select all that apply. Call if she experiences an increase in urinary frequency or begins to run a fever. Call if contractions are regular and 10 minutes apart or closer. False labor pains can be relieved by resting on your side, taking a warm bath, or walking. Call if she has pelvic pain or bleeding. Decrease fluid intake in the last weeks of pregnancy to help with edema.
Call if she experiences an increase in urinary frequency or begins to run a fever. Call if contractions are regular and 10 minutes apart or closer. False labor pains can be relieved by resting on your side, taking a warm bath, or walking. Call if she has pelvic pain or bleeding.
A nurse is caring for a couple whose infant has died from sudden infant death syndrome (SIDS). Which nursing interventions are appropriate for the nurse to implement? Select all that apply. Calling the parents' church leader after a request from the parents. Calling the hospital chaplain and requesting his presence immediately. Offering to contact a grief counselor to help the parents Calling the police to begin the death investigation. Offering to contact the parents' other children to discuss the infant's death.
Calling the parents' church leader after a request from the parents. Offering to contact a grief counselor to help the parents
Other than the vomiting episode, you ask Dr. Rui if she has noted any other symptoms of illness. She tells you that she has noticed a yellow, cheese-like discharge from her vagina. "It doesn't smell," she adds, "but the whole area is very itchy." Based on her description, what condition do you suspect she has? E. Coli vaginitis Vaginismus Candida albicans vaginitis Vestibulitis
Candida albicans vaginitis
Which of the following must be ruled out before labor may be augmented with an amniotomy or oxytocin? Cephalopelvic disproportion Full-term pregnancy status Vertex positioning of the fetus Twin gestation
Cephalopelvic disproportion
A pregnant client is admitted to the hospital in premature labor. The nurse anticipates which of the following assessment findings? Headache Decreased fetal movement Cervical dilation Elevated blood pressure
Cervical dilation
The nurse is assessing the power of the uterine muscle during the labor process. The nurse can expect to assess which changes as a result of this process? Cervical effacement Cervical lengthening A slowing of uterine contractions An increase in maternal blood pressure
Cervical effacement
The healthcare provider of a client at 40 weeks' gestation has ordered Cytotec for labor induction. The nurse is aware that Cytotec will produce which change for this client? Rupture membranes Cervical ripening Decrease anxiety Decrease pain
Cervical ripening
You prepare to assess Mrs. Burberrys cervix. What measurement of the cervix at 32 weeks would be a concern for possible preterm labor anddelivery? Cervix is firm and a fingertip dilated. Cervix is less than 1 at 32 weeks and intact. Cervix is softening at 32 weeks but not dilated. Cervix is greater than 1 cm at 32 weeks with softening.
Cervix is greater than 1 cm at 32 weeks with softening.
The nurse is caring for a postpartum client. Which factors may interfere with the client's ability to breastfeed? Select all that apply. Twin infants Cesarean birth Postpartum hemorrhage Smoking Alcohol use
Cesarean birth Postpartum hemorrhage Smoking Alcohol use
The nurse is interviewing a mother who has concerns about her infant's nutrition status. What should the nurse include in the infant's nutritional assessment? Select all that apply. Chest circumference Allergy testing Physical examination 24-hr feeding diary Height and weight
Chest circumference Physical examination 24-hr feeding diary Height and weight
Which data would be considered normal during an initial nursing assessment of a term newborn? Chest circumference 38 cm, head circumference 31.5 cm Chest circumference 32.5 cm, head circumference 36 cm Chest circumference 31.5 cm, head circumference 33.5 cm Chest circumference 30 cm, head circumference 29 cm
Chest circumference 31.5 cm, head circumference 33.5 cm
The nurse evaluates the diet of a pregnant client and finds that it is low in zinc. The nurse knows that zinc intake should increase during pregnancy to promote protein metabolism. Which food does the nurse suggest to the client to increase her intake of zinc? Bananas Cabbage Yogurt Chicken
Chicken
The nurse is preparing a checklist of educational topics for discharge teaching of new parents. Which topics will the nurse include? Select all that apply. Maintaining a strict feeding schedule Circumcision care Skin and bathing care Infant swaddling How to use a bulb syringe
Circumcision care Skin and bathing care Infant swaddling How to use a bulb syringe
The nurse is assisting a postpartum client in the bathroom. What teaching would the nurse use to help promote hygiene and comfort? Cleansing the vulva and perineum with a spray bottle of warm water after voiding Wiping from back to front to prevent urinary tract infection Explaining to only do a sitz bath once home to ensure privacy Wiping with toilet paper instead of patting to ensure cleanliness
Cleansing the vulva and perineum with a spray bottle of warm water after voiding
The nurse reviews a postpartum client's chart and notes the client may have Percocet for pain. The nurse will monitor for which complication of the medicine? Increased respirations Constipation Frequent urination Dry mouth
Constipation
During the fourth stage of labor, the client's assessment includes BP 110/60 mmHg and P 90 bpm. The fundus is firm and midline, and halfway between the symphysis pubis and the umbilicus. What should be the nurse's priority action? Continue to monitor Turn the client onto her left side Massage the uterine fundus Place the bed in Trendelenburg position
Continue to monitor
The nurse is working with a student nurse during assessment of a 2-hr-old healthy newborn. Which action of the student nurse demonstrates an understanding of the neonatal assessment? Listens to lung sounds when the newborn is crying Stimulates the newborn so the newborn will be alert for the assessment Counts respirations and apical heart rate for 1 full minute Obtains a blood pressure first
Counts respirations and apical heart rate for 1 full minute
A client who was admitted for induction of labor is now exhibiting a hypertonic contraction pattern. Which is an appropriate nursing intervention? Have the client ambulate in the hall. Decrease oxytocin and notify the healthcare provider. Ask the client to begin pushing and bear down. Assist the client to the restroom to void.
Decrease oxytocin and notify the healthcare provider.
Four hours after a vaginal delivery, the nurse is assisting a primiparous client, who had an epidural anesthesia, to the bathroom to void. The client states that she feels dizzy when sitting up on the side of the bed. Which rationale will the nurse use when explaining this phenomenon to the client? Decreased blood volume in the vascular system Effects of the anesthetic during labor Hemorrhage during the delivery process Effects of analgesics used during labor
Decreased blood volume in the vascular system
The nurse assesses excessive oral and nasal secretions in a newborn and begins suctioning. Which complication of mechanical suctioning will the nurse monitor for? Decreased heart rate Increased temperature Decreased level of consciousness Increased blood pressure
Decreased heart rate
A client has just completed the second stage of labor. Which are the priority nursing assessments before placental delivery? Select all that apply. Assessment indicating that the umbilical cord is shortening Documenting a gush of blood from the vagina Assessing the shape of the uterus as it changes from a disk shape to a globe Assessment indicating that the top of the uterus is dropping down to the level of the symphysis pubis Assessing that the umbilical cord is lengthening
Documenting a gush of blood from the vagina Assessing the shape of the uterus as it changes from a disk shape to a globe Assessing that the umbilical cord is lengthening
The student nurse is creating a poster that describes the changes from fetal to neonatal circulatory patterns. Which structures will the student nurse indicate are no longer required for neonatal circulation? Select all that apply. Ductus arteriosus Foramen ovale The ductus venosus Umbilical vein Umbilical artery
Ductus arteriosus Foramen ovale The ductus venosus
When does maternal-infant bonding occur? During the mother's pregnancy When an infant first makes eye contact with his mother During the first 30-60 min after birth During a process called "finger tipping"
During the first 30-60 min after birth
Which characteristics does the nurse anticipate when assessing a newborn infant born at 33 weeks gestation? Full sole creases, nails extending beyond fingertips, scarf sign shows elbow beyond the midline Testes located deep in the scrotum, rugae cover the scrotum, vernix covering the entire body One-centimeter breast bud, peeling skin and veins not visible, rapid recoil of legs and arms to extension Ear cartilage remains folded over, lanugo present over much of the body, some flexion of arms and legs at rest
Ear cartilage remains folded over, lanugo present over much of the body, some flexion of arms and legs at rest
A client who is 6 hr status post a precipitous vaginal birth of an 8 lb 14 oz. baby has pressed the call bell to report severe and worsening perineal pain and pressure. What will the nurse look for when assessing this client? Select all that apply. Ecchymosis Nausea Visible outline of a mass on the perineum Fever Tachycardia
Ecchymosis Visible outline of a mass on the perineum Tachycardia
The nurse is planning a teaching session on nutrition for a pregnant client. The nurse knows that several factors will influence the client's acceptance of nutritional intervention. Which factors would be most important for the nurse to consider when preparing her teaching information? Lifestyle and marital status Age and political affiliation Economics and culture Culture and geographic location
Economics and culture
What actions support the nurse's plan of care for the goal of preventing SIDS? (Select all that apply.) Educating about reducing risk factors for SIDS Providing support for smoking cessation Promoting a safe sleep environment Encouraging the use of formula Collaborating with family to create goals
Educating about reducing risk factors for SIDS Providing support for smoking cessation Promoting a safe sleep environment Collaborating with family to create goals
Alicia, a term infant, was born 30 min ago by cesarean section because of congenital diaphragmatic hernia diagnosed during pregnancy. Alicia is experiencing profound respiratory distress, persistent pulmonary hypertension, and cyanosis. Which action by the nurse can optimize Alicia's lung function? Elevate the head and chest on the affected side Elevate the feet on the affected side Place an orogastric tube to full suction Administer surfactant, per order
Elevate the head and chest on the affected side
During the fourth stage of labor, what can the nurse do to help the mother avoid bladder distention? Palpate her fundus. Encourage her to void every 2 hours. Pour cold water over the perineum. Encourage her to get out of bed as soon as possible.
Encourage her to void every 2 hours.
Mrs. Lee, a healthy 24-year-old G1 P1, had an uncomplicated vaginal birth 24 hours ago. The nurse palpates her uterine fundus and finds that it is located above her umbilicus. Which action is the most appropriate for the nurse to do? Massage it until it softens. Encourage her to void. Do nothing. The uterus is exactly where it should be. Encourage her to walk so that her fundus descends deeper into her pelvis.
Encourage her to void.
Mrs. Yumihara begins to believe that there is something wrong with her. You assure her that many other women suffer from postpartum depression, and that many of those women have overcome it. Mrs. Yumihara informs you that she feels disappointed about the fact that nobody warned her that this sort of thing could happen after pregnancy. Although she knows that it has to do with hormonal imbalances, she asks you if there are ways to prevent postpartum depression. How might postpartum depression be prevented? Select all that apply. Encouraging the client to talk about her anxieties or concerns regarding the pregnancy, prior to childbirth. Dispelling myths about perfect motherhood and maternal instincts. Close monitoring for signs and symptoms of depression. Providing client education about PPD during pregnancy. Sending the client home early from the hospital with the baby.
Encouraging the client to talk about her anxieties or concerns regarding the pregnancy, prior to childbirth. Dispelling myths about perfect motherhood and maternal instincts. Close monitoring for signs and symptoms of depression. Providing client education about PPD during pregnancy.
Which actions related to contraception would the nurse include in discharge planning for a postpartum client? Select all that apply. Ensure the client receives a prescription for the contraception method of her choice. Recommend a contraception method for the client. Assess the client's contraception preference. Provide information about the client's choices. Answer questions from the client about contraceptive methods.
Ensure the client receives a prescription for the contraception method of her choice. Assess the client's contraception preference. Provide information about the client's choices. Answer questions from the client about contraceptive methods.
Which is the correct definition of a puerperal infection? Fever of 100.5°F or higher within the first 10 days after childbirth Fever of 104°F or higher within the first 10 days after childbirth Fever higher than 99°F occurring within the first 48-72 hr after childbirth Fever of 100.4°F or higher occurring during the first 48 hr after childbirth
Fever of 100.5°F or higher within the first 10 days after childbirth
While doing a presentation to new graduate nurses who will be working in the newborn nursery, the instructor discusses ways to prevent hypothermia in the newborn. Which techniques should the instructor include? Select all that apply. Establishing kangaroo care between the newborn and the parents Preheating warmers and blankets before use Applying an insulated cap when placing the newborn in an open crib Putting lotion on newborn while under radiant warmer Placing a shirt on newborn under radiant warmer
Establishing kangaroo care between the newborn and the parents Preheating warmers and blankets before use Applying an insulated cap when placing the newborn in an open crib
During the latent and active phases of labor, how often in general should maternal vital signs, excluding temperature, be assessed for low-risk women? Every 4 hr Every 60 min Every 15 min Every 2 hr
Every 60 min
Which are the metabolic functions of the placenta? Select all that apply. Excretion Fetal gas exchange Nutrition Red blood cell production Hormone production
Excretion Fetal gas exchange Nutrition
A laboring client at term is experiencing a prolonged second stage of labor. She has made no progress for more than 2 hours. The fetal scalp is visible between contractions. The client says, "I just can't push any longer, please help me!" The nurse notifies the healthcare provider and anticipates the need to perform which action? Provide perineal hygiene Provide emotional support Expect an instrument-assisted delivery Encourage the client to empty her bladder
Expect an instrument-assisted delivery
Sheila Barton had a cesarean birth 24 hr ago. She has not gotten out of bed and reports she is still exhausted. How can the nurse provide the best care for Mrs. Barton in this situation? Explain how important it is for her to get up and walk as soon as possible. Explain that she needs to rest and she should stay in bed as long as she can. Offer her more pain medication to relieve her discomfort. Offer her a large meal to improve her energy.
Explain how important it is for her to get up and walk as soon as possible.
The nurse is assessing a pregnant client, Joy Stevens, who has come to the clinic for her 20-week prenatal checkup. Ms. Stevens has gained more than 30 lb. (13.6 kg) over her prepregnancy weight. The nurse takes a 24-hour diet recall history and learns that Ms. Stevens has eaten a doughnut for breakfast, a slice of pizza for lunch, and a hamburger with French fries for dinner. What recommendations does the nurse make to Ms. Stevens about her nutrition? There is no recommendation to be made because nutrition counseling is not the nurse's responsibility. Explain that she should focus on eating healthier foods, including fruits and vegetables. Tell her to go on a diet. Tell her she needs to exercise more since her food intake does not seem like too much.
Explain that she should focus on eating healthier foods, including fruits and vegetables.
Jasmine Williams complains of severe constipation at her regular prenatal visit. The nurse takes a nutritional history, and Ms. Williams divulges that she has been eating clay. What is the nurse's most appropriate response? Prescribe a laxative. Tell Ms. Williams eating clay is disgusting and she should stop. Refer Ms. Williams to a mental health professional. Explain the health effects pica can have on Ms. Williams and her baby.
Explain the health effects pica can have on Ms. Williams and her baby.
Mrs. Meyers has just received a positive pregnancy test. The nurse notices that she smells like cigarettes even though she noted in her paperwork she is not a smoker. The nurse asks her again if she smokes, and she confesses she smokes less than half a pack a day. What type of information can the nurse provide to her? Tell her it is okay as long as she is not smoking more than 10 cigarettes a day. Tell her she should not be pregnant if she is a smoker. Refer her to a 12-step rehabilitation program. Explain to her the negative effects that cigarettes could have on her pregnancy and refer her to a smoking cessation program.
Explain to her the negative effects that cigarettes could have on her pregnancy and refer her to a smoking cessation program.
Ms. Burberry confirms her understanding that she needs to stay hydrated, then asks, Can you also tell me how can I tell the difference between a real contraction versus a false contraction? What difference in the quality of false labor contractions versus true labor contractions will you share with Ms. Burberry? True labor will not start before 38 weeks gestation. False contractions gradually get more intense. False contractions do not change vaginal discharge. True labor pains can be relieved with walking or a warm bath.
False contractions do not change vaginal discharge.
The nurse is providing education to parents who have chosen to formula-feed their infant. What topics are appropriate to include? Select all that apply. Feeding the infant safely Stressing that milk allergies may occur Storing formula properly Introducing solids at the appropriate age Reading preparation directions on formula packaging
Feeding the infant safely Storing formula properly Reading preparation directions on formula packaging Introducing solids at the appropriate age
Labor induction is indicated in which maternal or fetal conditions? Select all that apply. Transverse fetal lie Fetal compromise Infection Unfavorable cervix Preeclampsia
Fetal compromise Infection Preeclampsia
The nurse is caring for a client who is scheduled for induction of labor. Which conditions are indications for induction? Select all that apply. Preterm labor Fetal demise Preeclampsia Post-term gestation Multiple gestation
Fetal demise Preeclampsia Post-term gestation
Which description best describes the orientation of the long axis of the fetus? Fetal attitude Fetal position Fetal presentation Fetal lie
Fetal lie
Which information will be a part of the admission assessment for a client in the first stage of labor? Select all that apply. Fetal status Status of the amniotic membranes Status of the nuchal cord Degree of cervical dilation and effacement Onset, frequency, and intensity of contractions
Fetal status Status of the amniotic membranes Degree of cervical dilation and effacement Onset, frequency, and intensity of contractions
The nurse is assessing baby boy Henry, who is 2 hr old. She notes that Henry's plantar creases cover his entire foot. Based on this information, what does the nurse determine Henry's gestational age to be? 32 weeks Preterm 36 weeks Full term
Full term
The charge nurse hands you an ultrasound that Ms. Maxwell had at 36 weeks showing a low-lying placenta with the edge 4 cm from the cervical os. The fetus was noted to be breech on that ultrasound. By this ultrasound, Ms. Maxwell is currently 38 weeks gestation. You check Ms. Maxwell's vital signs and obtain the following results: T 98.6°F, P 114 bpm, R 23/min, BP 160/92 mmHg, and her SpO2 on room air is 96%. The electronic fetal monitor shows the following: Uterine contractions every two minutes, lasting for 60-75 seconds. Fetal heart rate 170 bpm, minimal long term variability, deceleration to 140 bpm noted between contractions. You prepare an oxygen mask at 10 L and ask Ms. Maxwell to put it on. Ms. Maxwell is clearly uncomfortable with contraction pain, but she manages to ask, 'Why is something wrong?" What will you tell Ms. Maxwell? She needs oxygen because her SpO2 is too low. Her baby has fetal bradycardia, an indication her baby needs more oxygen. All pregnant women need supplemental oxygen. Her baby has fetal tachycardia, an indication her baby needs more oxygen.
Her baby has fetal tachycardia, an indication her baby needs more oxygen.
Maria Abejundio a 24-year-old gravida 2 para 1 who presents to the midwifery clinic for a prenatal visit at 30 weeks gestation. Her ethnic background is Mexican-American. She is accompanied by her 14-month-old son and her husband Michael Abejundio, who is African American. Her pregnancy has been complicated by a marginal placenta previa. Mrs. Abejundio is a smoker, but she has cut down her use from 1 pack per day to a half a pack per day. She denies having any vaginal bleeding or contractions. "How are you feeling?" you ask Mrs. Abejundio. "Im pretty tired," she replies, "I spend so much time chasing my son around, but I do try to nap when he naps." You assess Mrs. Abejundios vital signs: T 98.8°F, P 83 bpm, R 16/min, BP 116/68 mmHg. Her Sp02 on room air is 97%. The attending health care provider orders a complete blood count and a one-hour 50-gram glucola challenge test drawn for her third trimester labwork. The results of Mrs. Abejundios laboratory results indicate: Hematocrit 30%; Hemoglobin 10 g/dL; Platelets 142,000 × 103/µl; One hour glucose tolerance test 126. You review her labs from her first prenatal visit; her blood type is AB+. Which of these results indicates a possible source of Mrs. Abejundios fatigue? Select all that apply. Her hematocrit level Her platelet count Her one hour glucose test Blood type AB+ Her hemoglobin level
Her hematocrit level Her hemoglobin level
You assist Mrs. Romero into a comfortable side-lying position, and she successfully breastfeeds her baby. After 15 minutes, you obtain Mrs. Romeros permission to take a set of vital signs and check her fundus.Her vital signs are T 99.8°F, P 126 bpm, R 20/min, and BP 100/58 mmHg. Her fundus is not immediately palpable, but as you massage her lower abdomen, you feel it become firm although it deviates to the right side. You note a moderate amount of lochia rubra on the chux. Which assessment findings give you cause for concern? Select all that apply. Her pulse is increasing. Her uterus deviates to the right side. Mrs. Romero should have lochia alba. The uterine fundus firms with massage. Her temperature indicates pyelonephritis.
Her pulse is increasing. Her uterus deviates to the right side.
The nurse in the special care nursery (SCN) is caring for a newborn diagnosed with a congenital diaphragmatic hernia (CDH). Based on the diagnosis, in which position will the nurse place this infant? Side-lying on the unaffected side Supine High Fowler on the affected side Prone
High Fowler on the affected side
Ms. Burberry asks, What are some things that can put me at risk for having this baby too early? Maybe if I can understand this better, I can prevent this from happening to me again. What risk factors will you discuss with Ms. Burberry? Select all that apply. History of an early pregnancy loss History of previous preterm labor or birth Premature rupture of membranes (PROM) Multiple gestations Inadequate prenatal care
History of previous preterm labor or birth Premature rupture of membranes (PROM) Multiple gestations Inadequate prenatal care
What information does the nurse provide to new parents during discharge teaching? (Select all that apply.) Promoting toddler safety Holding the newborn Diaper changing Positioning the infant on its back to sleep Using a bulb syringe
Holding the newborn Diaper changing Positioning the infant on its back to sleep Using a bulb syringe
You give Dr. Rui three glucose tablets. While you wait 15 minutes to check on the effect of the tablets, you take her vital signs. What do you expect to find, based on her being hypoglycemic? Elevated temperature Slowed respiratory rate Hypertension Hypotension Rapid pulse
Hypotension Rapid pulse
You are reviewing the teaching you have provided with Mr. and Mrs. Abejundio. Which statement by Mrs. Abejundio indicates she understands your teaching? I can take my iron pills with cranberry juice. I can stop taking the iron pills when I have more energy. If my stool turns black, I should stop taking my iron pills. The iron pills will fix my anemia right away.
I can take my iron pills with cranberry juice.
You explain Mrs. Abejundios blood results to her and her husband. "Maybe that's why youve been so tired," Mr. Abejundio says. "I keep telling you to rest more." He gives her a hug. "You say my blood work shows that I have anemia. How will that affect me during my pregnancy?" Mrs. Abejundio asks. You explain the effect of iron deficiency anemia on pregnancy and birth.You know Mrs. Abejundio understands the risks posed to her pregnancy when she makes which statements? Select all that apply. I could bleed too much when I give birth. I will tire more easily. I am more susceptible to infection. I will gain too much weight with my pregnancy.
I could bleed too much when I give birth. I will tire more easily. I am more susceptible to infection.
A postpartum client tells the nurse that she would like to know about a birth control method she can start before discharge. What is an appropriate response from the nurse? "You may be able to have a birth control injection before discharge." "Why don't you ask the doctor. She will be here soon." "You should take the pills. They work the best." "You will need to wait 6 weeks before starting any method."
Local tenderness, heat, and swelling in the leg
What are the chief discomforts a woman may experience during the initial postpartum period? Select all that apply. Severe cramping Nipples bleeding from nursing Perineal discomfort Hunger Exhaustion
Perineal discomfort Hunger Exhaustion
Mrs. Yumihara is reluctant to answer your questions, but she does her best and provides you with a well-informed assessment. You learn that Mrs. Yumihara used to battle with depression when she was in her twenties, but that she never took any medications for it, given her cultural background. She explains, the depression passed on its own. Knowing this, you find it necessary to screen Mrs. Yumihara for more risk factors that may contribute to the probable diagnosis of postpartum depression. Through the second part of yourscreening, Mrs. Yumihara makes a lot of noticeable statements. Which of Mrs. Yumiharas statements could be interpreted as risk factors for PPD? Select all that apply. I wish my older son was more loving toward his baby brother. I wish I had this baby when I was younger. My body doesnt look the same as it used to. I could really use more support at home. It would be nice if I had more friends and family around to see the baby.
I wish I had this baby when I was younger. My body doesnt look the same as it used to. I could really use more support at home. It would be nice if I had more friends and family around to see the baby.
What are the signs that the placenta is about to deliver? Select all that apply. Decreased contraction pain Increased contraction pain Change in shape of the uterus from a disk to a globe Change in shape of the uterus from a globe to a disk Lengthening of the umbilical cord
Increased contraction pain Change in shape of the uterus from a disk to a globe Lengthening of the umbilical cord
The nurse caring for a 1-day-old preterm infant asks the parents to return to the neonatal intensive care unit because the infant is awake. Which is the most appropriate action for the nurse when the parents arrive in the unit? Ask the parents to complete admission assessment forms Instruct the parents on newborn care Leave the parents to hold the baby Discuss the extent of care that the infant will need while hospitalized
Instruct the parents on newborn care
A pregnant client reveals she practices pica. What is the nurse's primary concern about pica in caring for this client? Preterm labor Interference with proper nutrition Fetal death Placenta previa
Interference with proper nutrition
The nurse is caring for Baby Wilson, a 33-week-gestation preterm infant who experienced birth asphyxia. For which potential complication should the nurse plan interventions for Baby Wilson? Patent ductus arteriosus Anemia Intraventricular hemorrhage Hypotension
Intraventricular hemorrhage
The most recent arterial blood gas results for a preterm infant indicate the development of acidosis. For which complications should the nurse plan care for this infant? Select all that apply. Intraventricular hemorrhage Patent ductus arteriosus Anemia Gastroesophageal reflux Apnea of prematurity
Intraventricular hemorrhage Patent ductus arteriosus
Which formula preparation is appropriate for an infant with an allergy to cow's milk? Isomil Similac Good Start Gentle Plus Enfamil
Isomil
A home health nurse is visiting a client who recently delivered a healthy, term baby boy. The nurse is providing postpartum care and observation of the newborn. The client tells the nurse, "I think my son sleeps longer when he is placed on his tummy for naps." What response by the nurse is most correct? It is fine to place your son on his tummy for naps as long as you are in the same room with him. It is fine to place your son on his tummy for naps but not for sleep at night. It is not acceptable to place your son on his tummy for sleep because this can make your son lose his protective reflexes. It is not acceptable to place your son on his tummy for sleep because this can make your son spit up and he can aspirate.
It is not acceptable to place your son on his tummy for sleep because this can make your son lose his protective reflexes.
Why should the prenatal nurse counsel a pregnant woman to avoid eating undercooked meat? It would put her at risk for toxoplasmosis. It would put her at risk for mercury poisoning. It would put her at risk for Listeria monocytogenes. It would put her at risk for Salmonella poisoning.
It would put her at risk for toxoplasmosis.
The nurse is receiving the change of shift report from the night nurse, and one newborn she will be caring for has been determined small for gestational age (SGA). Which data obtained during the physical assessment supports this diagnosis? Select all that apply. No passage of meconium for 48 hr Head circumference below the 20th percentile Length below the 10th percentile Weight below the 10th percentile Difficulty feeding
Length below the 10th percentile Weight below the 10th percentile
The nurse is caring for a woman after a cesarean delivery with a low transverse incision. What are the advantages of a low transverse uterine incision versus a classical incision for a cesarean birth? Select all that apply. More appropriate for preterm births or multiple gestations Less likely to rupture with subsequent pregnancies Involves less blood loss Can extend downward into the cervix Easier to repair surgically
Less likely to rupture with subsequent pregnancies Involves less blood loss Easier to repair surgically
The nurse is caring for Sara Jenkins, a 29-year-old G2 P0010, who is 8 cm dilated and 90% effaced with the fetal head at -2 station on direct occiput posterior position. The fetal monitor shows significant variable decelerations. The nurse performs a vaginal exam and detects a prolapsed cord. What is the nurse's initial action? Place the client in reverse Trendelenburg position. Lift the presenting part off of the prolapsed cord. Go to the nurses' station and call the healthcare provider. Replace the section of cord that is protruding from vagina.
Lift the presenting part off of the prolapsed cord.
The nurse is providing discharge teaching to a group of parents in the newborn nursery. What signs are included as early indicators of readiness to feed in the newborn? Select all that apply. Crying Lip smacking Extending the tongue Rooting Sucking on fingers
Lip smacking Extending the tongue Rooting Sucking on fingers
Which are characteristics of a preterm infant's skin? (Select all that apply.) Little subcutaneous fat Reddened Cyanotic Translucent Blood vessels visible
Little subcutaneous fat Reddened Translucent Blood vessels visible
While caring for a preterm infant, the nurse notes that the ventilator settings need to be adjusted to ensure adequate oxygenation. What should the nurse suspect is occurring with this infant? Bronchopulmonary dysplasia Patent ductus arteriosus Apnea of prematurity Anemia
Patent ductus arteriosus
The nurse manager determines that a staff nurse is implementing interventions to prevent infection in a 2-day-old preterm infant. Which actions did the nurse manager see the staff nurse perform? Select all that apply. Maintained separate equipment for the infant Changed the incubator according to planned schedule Performed 3-min scrub with antimicrobial soap before providing care Assessed gastric residual before providing scheduled tube feeding Repositioned the infant every hour
Maintained separate equipment for the infant Changed the incubator according to planned schedule Performed 3-min scrub with antimicrobial soap before providing care Repositioned the infant every hour
The nurse is developing a plan of care for an infant born at 28 weeks' gestation. What would be a realistic goal for this infant to be achieved within one week? Drinking from a bottle Recognizing the parents Maintaining respiratory rate at 30-60 breaths/minute Maintaining her body temperature in a bassinet
Maintaining respiratory rate at 30-60 breaths/minute
The nurse is caring for a client, Mrs. Lin, who is a vegetarian. Mrs. Lin is concerned that she is not eating well enough to support her growing baby. How should the nurse counsel Mrs. Lin? Nutritional counseling is not a part of the nurse's responsibilities. Make her aware of alternative sources of protein, and recommend she increase her calcium intake by 300 mg. Reassure her that vegetarians who are pregnant get all the nutrition they need. Tell her she has to eat meat while she is pregnant, and take an iron supplement.
Make her aware of alternative sources of protein, and recommend she increase her calcium intake by 300 mg.
What risk factors put an otherwise healthy infant at risk for the development of SIDS? (Select all that apply.) Male infants Exposure to smoke Family history of SIDS High-birth-weight infants Co-sleeping infants
Male infants Exposure to smoke Family history of SIDS Co-sleeping infants
The nurse is caring for an infant diagnosed with gastroschisis. The parents ask the nurse how this condition occurs. The nurse will base the response on which risk factors associated with this anomaly? Select all that apply. Malrotation of the intestine Meconium ileus Decreased abdominal capacity Enlarged stomach Intestinal atresia
Malrotation of the intestine Decreased abdominal capacity Intestinal atresia
A mother who gave birth to a baby boy vaginally after Pitocin augmentation 2 weeks ago returns to the office concerned because her lochia flow has increased; it is red but not foul-smelling. The nurse suspects subinvolution. Which items in the client's history may have caused this occurrence? Hypertension Manual removal of the placenta Placenta previa Vaginal delivery
Manual removal of the placenta
You inform Mrs. Yumihara that it appears as though she is suffering from postpartum depression. She becomes tearful again, and tells you that she wants to feel happy and enjoy the baby stage. Mrs. Yumihara appears to be very anxious upon hearing this diagnosis. What can you tell her to help put the postpartum depression inperspective? Every woman gets postpartum depression, especially after having two children. Many women experience postpartum depression due to hormones. Postpartum depression only lasts for a couple of days. Postpartum depression is nothing to worry about.
Many women experience postpartum depression due to hormones.
The nurse is assessing a postpartum client and finds the client's uterus to be boggy. Which nursing action is the priority? Administer oxytocin Notify the health care provider Massage the fundus until firm No action needed; a soft uterus is a normal assessment
Massage the fundus until firm
The nurse is assessing a postpartum client and finds the client's uterus to be boggy. Which intervention would be the most appropriate nursing action? Administer oxytocin. No action needed, as this is a normal assessment. Massage the fundus until firm. Notify the healthcare provider.
Massage the fundus until firm.
In assessing a client who delivered 2 hours ago, the nurse notices heavy bleeding with large clots. Which initial response is most appropriate? Massaging the fundus firmly Preforming bimanual compressions Notifying the health care provider Administering uterotonic medications
Massaging the fundus firmly
Which are factors that may classify a newborn as high risk? (Select all that apply.) Maternal age of more than 30 First pregnancy Maternal age of less than 17 Preterm labor Placenta previa
Maternal age of less than 17 Preterm labor Placenta previa
After reviewing the maternal record, the nurse is performing an assessment of a newborn. Which maternal factors may contribute to the birth of an at-risk infant? Select all that apply. Maternal narcotic use Long, difficult labor Diabetes Type of delivery Maternal history of infection
Maternal narcotic use Long, difficult labor Diabetes Maternal history of infection
A laboring client at 39 weeks' gestation has been pushing for 2 hours. The nurse anticipates that the healthcare provider may choose to use forceps to assist in the delivery. What criteria must be met to consider forceps? Select all that apply. Membranes must be ruptured. Cephalopelvic disproportion should be present. Adequate maternal anesthesia should be provided. The cervix must be fully dilated. The maternal bladder should be full.
Membranes must be ruptured. Adequate maternal anesthesia should be provided. The cervix must be fully dilated.
The nurse is preparing to administer RhoGam to a postpartum client. Which nursing interventions are appropriate when giving this medication? Select all that apply. Monitoring for adverse effects of medication Verifying Rh status of the mother and newborn Verifying the client's identity Reminding the mother to avoid caffeine for 12 hr Checking the lot number and expiration date of the medication
Monitoring for adverse effects of medication Verifying Rh status of the mother and newborn Verifying the client's identity Checking the lot number and expiration date of the medication
The nurse is reviewing the histories of four new prenatal clients. Which maternal risk factor could indicate the need for antenatal testing? Mother with twin pregnancy Maternal age of 25 Maternal history of depression Mother who is a vegan
Mother with twin pregnancy
What brings you in today, Mrs. Turner? you ask.I know I have a previa, she responds. My doctor has told me to take it easy and not to have intercourse. I have been following those directions, but when I got up to use the bathroom today, I wiped and saw bright red blood on the tissue.Her eyes fill with tears and her husband reaches out and squeezes her hand.Is that the only time you have bled during your pregnancy? you ask.She nods her head and takes a breath. Im so scared. I just hope my baby will be okay.You obtain permission to evaluate her chux. You take a look and notice a small amount of bright red blood on the chux. You take Mrs. Turners vitalsigns: T 98.8°F, P 124 bpm, R 24/min, and BP 116/72 mmHg.The fetal heart rate is 140/s with averagelong-term variability and no decelerations.Uterine activity is one contraction in 10 minutes, lasting 25 seconds.Her urine dip shows 2+ blood, trace proteinuria, and no ketones.Mrs. Turner is tachycardic. What is the most likely explanation for this? Mrs. Turner has acute blood loss. Mrs. Turner is anxious. Mrs. Turner is in preterm labor. Mrs. Turner is hypovolemic.
Mrs. Turner is anxious.
You ask Mrs. Yumihara to describe the feeding method for the baby, and she reports that she stopped breastfeeding because she feels like she lacks a bond with this baby. My first child was different, she said. We bonded right away. Mrs. Yumihara begins to cry again. My husband is disappointed in me, I just know it. And the other day I couldnt even remember what time to feed the baby. Isnt that horrible? You try to calm Mrs. Yumihara down by listening and acknowledging what she says. In the back of your mind, however, you begin to wonder if Mrs. Yumihara has postpartum depression. What are some specific signs or symptoms that Mrs. Yamihara has expressed that are indicative of postpartum depression? Select all that apply. Mrs. Yumihara has stopped nursing. Mrs. Yumihara is tearful during the exam. Mrs. Yumihara made statements of failure. Mrs. Yumihara already had a first child. Mrs. Yumihara admits to having a poor memory.
Mrs. Yumihara has stopped nursing. Mrs. Yumihara is tearful during the exam. Mrs. Yumihara made statements of failure. Mrs. Yumihara admits to having a poor memory.
Mrs. Yumihara wants to know how she can work through the postpartum depression. She so desperately wants to be a good, happy mother. What are some healthy steps that Mrs. Yumihara can take to mitigate and manage the postpartum depression? Select all that apply. Mrs. Yumihara should continue talking to you, the nurse, on a regular basis for advice and help. Mrs. Yumihara should seek professional help from a behavioral health provider. Mrs. Yumihara should seek assistance with self and infant care. Mrs. Yumihara should work through the PPD on her own. Mrs. Yumihara should talk to her husband about the PPD.
Mrs. Yumihara should seek professional help from a behavioral health provider. Mrs. Yumihara should seek assistance with self and infant care. Mrs. Yumihara should talk to her husband about the PPD.
A client is complaining of painful contractions, or afterpains, on her second postpartum day. The nurse knows that which condition could increase the severity of afterpains? Multiparity Bottle-feeding Diabetes Primiparity
Multiparity
A nurse is caring for a client having a precipitous delivery in the emergency department. The nurse anticipates which possible effects on the neonate? Select all that apply. Neonatal intracranial hemorrhage Decreased intracranial trauma Hypoxia Shoulder dystocia Spinal compression
Neonatal intracranial hemorrhage Hypoxia
What is the identifiable cause of sudden infant death syndrome (SIDS)? Infant prematurity Respiratory distress syndrome Congenital anomaly No known etiology
No known etiology
The nurse is preparing an educational brochure about nonpharmacologic pain relief measures during childbirth. What is considered an advantage of these methods? Minimally invasive No side effects Slowing of the labor process Eliminates the need for medications
No side effects
The nurse is caring for a woman in the first stage of labor. The fetal position is left occiput anterior. The woman's membranes rupture. Which nursing action is most appropriate at this time? Perform a vaginal exam. Measure the amount of fluid. Note the time of rupture and the quality (color, odor, approximate amount) of the fluid Notify the health care provider.
Note the time of rupture and the quality (color, odor, approximate amount) of the fluid
The nurse is caring for a client in the recovery room 2 hr after a cesarean birth. The client is committed to breastfeeding and wants to be as involved in the baby's care, as possible. She rates her pain at 9 on a 1-10 scale and is declining "drugs" because she "hates to feel drunk." What can the nurse do to ease the client's discomfort? Offer her intravenous nonsteroidal anti-inflammatory agents (NSAIDs) and explain their mechanism of action Respect her decision and hold all narcotics Teach her progressive relaxation Give hydromorphone as ordered, as pain control is a priority.
Offer her intravenous nonsteroidal anti-inflammatory agents (NSAIDs) and explain their mechanism of action
The nurse is caring for a client whose baby is at +5 station and is feeling overwhelmed by perineal burning. Which action is a priority for the nurse at this time? Giving frequent sips of water Offering encouragement and support Applying extra blankets for warmth Providing frequent perineal cleansing
Offering encouragement and support
The nurse is caring for a primigravid client whose cervix is dilated at 8 cm; the fetus is at +1 station; and the client has no analgesia or anesthesia. Which action would be a priority for the nurse? Providing frequent perineal cleansing Giving frequent sips of water Offering encouragement and support Applying extra blankets for warmth
Offering encouragement and support
Ms. Burberry comes to the clinic at 32 weeks with fears of premature labor. What nursing actions will you perform to assess for premature labor? Select all that apply. Palpate the abdomen for signs of contractions and measurement of the fundus Ultrasound for assessment of fetus Urine test Vaginal exam to determine if the cervix is dilating A complete set of maternal vital signs and fetal heart tones
Palpate the abdomen for signs of contractions and measurement of the fundus Ultrasound for assessment of fetus Vaginal exam to determine if the cervix is dilating A complete set of maternal vital signs and fetal heart tones
The WIC (Women, Infants, and Children) program provides low-income pregnant women with vouchers for what? Select all that apply. Childcare Peanut butter Dairy foods Fruits and vegetables Prenatal care
Peanut butter Dairy foods Fruits and vegetables
The nurse is trying to determine whether a newborn is appropriate for gestational age (AGA). Which data collected during the physical assessment will help the nurse determine this classification for the newborn? Plantar creases present on anterior two thirds of sole Anterior and posterior fontanels nonbulging Umbilical cord moist to touch Milia present on bridge of nose
Plantar creases present on anterior two thirds of sole
The nurse is conducting a gestational age assessment on a newborn. Which physical assessment finding would the nurse record during this assessment? Umbilical cord moist to touch Plantar creases present on anterior two thirds of the sole Anterior and posterior fontanelles not bulging Milia present on bridge of nose
Plantar creases present on anterior two thirds of the sole
Mrs. Yumihara is hesitant to discuss her postpartum depression with her husband, but she assures you that she will tell him about it. She is also concerned about seeing a behavioral health provider, and asks you what the provider will do with her. You explain that there are a variety of interventions that a behavioral health provider may use. Which is NOT an appropriate intervention for postpartum depression? Journaling Play therapy Medication management Suicidal and risk assessments
Play therapy
Which are the early signs of hypoglycemia in a newborn? (Select all that apply.) Nasal flaring Poor feeding Tremors Temperature instability Grunting
Poor feeding Tremors Temperature instability
Why is a preterm infant at risk for aspiration? (Select all that apply.) Poor sucking Poorly developed gag reflex Extended body position Poor swallowing Incompetent cardiac sphincter
Poor sucking Poorly developed gag reflex Poor swallowing Incompetent cardiac sphincter
The client about to have a forceps-assisted delivery asks what complications can occur. The nurse understands that which event is a potential maternal complication of a forceps delivery? Maternal hypertension Erb palsy Uterine rupture Postpartum infection
Postpartum infection
The nurse is assessing the general appearance of a newborn. Which data will the nurse document as part of this assessment? Select all that apply. Posture at rest Relationship of head size to body Lung sounds Apgar scoring Rectal temperature
Posture at rest Relationship of head size to body
A new mother reports an income level just above the guidelines for receiving WIC (Women, Infants, and Children) assistance. She has decided to formula-feed her newborn. What type of formula preparation would the nurse suggest using for bottle feeding? Concentrated formula Powdered formula The client should breastfeed. Ready-to-feed formula
Powdered formula
Ms. Maxwell continues to shiver. She looks at you and starts to cry. "Are you feeling okay?" you ask her. Ms. Maxwell turns white and says, "I think Im going to throw up." You encourage her to take slow deep breaths, and you place a cool cloth in her forehead. You check her vital signs, and they are as follows: T 97.3°F, P 97 bpm, R 23/min, BP 136/92 mmHg, and her SpO2 on room air 97% You know that Ms. Maxwells symptoms of nausea and shivering are most likely caused by: Select all that apply. Precipitous labor Heroin withdrawal Chorioamnionitis, or infection in the uterus Preeclampsia
Precipitous labor
The nurse will recommend pelvic rest and no sexual activity for what types of complications during pregnancy? Select all that apply. Premature rupture of membranes Signs of preterm labor Placenta previa Gestational diabetes Twin gestation
Premature rupture of membranes Signs of preterm labor Placenta previa
The nurse is providing education to a pregnant client who continues to smoke during pregnancy. Which complications will the nurse share with this client? Select all that apply. Prematurity Low birth weight Abruptio placentae Hypotension Preterm rupture of membranes
Prematurity Low birth weight Abruptio placentae Preterm rupture of membranes
What is the most likely cause of newborn vernix caseosa at birth? Hypoglycemia Hypoxia Preterm Large for gestational age (LGA)
Preterm
The nurse is educating parents about safety precautions for their newborn. Which topics are appropriate for the nurse to discuss before discharge? Select all that apply. Proper way to heat a bottle Supine positioning for sleep Proper use of an infant car seat Using "tummy time" for play Prone positioning for sleep
Proper way to heat a bottle Supine positioning for sleep Proper use of an infant car seat
Alicia Norris, a 19-year-old primigravida at 31 weeks gestation, is being transferred to the nurse's unit in preterm labor. She is worried about the baby's prognosis and is concerned about missing work. What is the nurse's responsibility to Ms. Norris at this time? Administering anti-anxiety medications Providing emotional support Contacting her employers to secure work release Restricting family visitors
Providing emotional support
Marina Sopova is a healthy 34-year-old G2 P1001 at 39 weeks gestation planning a trial of labor after a cesarean birth for her last delivery. She has come to labor and delivery reporting uncomfortable contractions for a whole day and being unable to sleep last night. The midwife's exam reveals that her cervix is 3 cm, 50% effaced, and the baby is at -2 station. The baby's heart rate is 144 beats/min and contractions are palpable every 5-7 min. What can the nurse anticipate doing for Marina at this time? Discuss the possibility of cesarean delivery Assist with artificial rupture of membranes Begin an oxytocin drip Push fluids by mouth
Push fluids by mouth
Rachel Aronson is recovering from a long second stage and extensive perineal repair after labor and birth with her first baby. She had made her desire to breastfeed clear, but her newborn was not able to take the breast immediately. She is exhausted. Which action by the nurse is the most appropriate? Reassure her that it takes some time for the baby to learn to take the breast Give her newborn a bottle so that Mrs. Aronson can sleep Ask her permission to take her baby to the nursery so that she can get some sleep Have the lactation consultant come to educate her on breastfeeding techniques
Reassure her that it takes some time for the baby to learn to take the breast
Marina Sopova has been in the second stage of labor with her first baby for almost 2 hours. The nurse has made her as comfortable as possible, but now she is panicking. She feels she is losing control and wants a cesarean section. Which action by the nurse is the most appropriate response? Reassure her, praise her efforts, and keep her apprised of her progress Offer her ice chips and tell her the baby will come when it is ready Prepare the operating room and call the anesthesiologist for an epidural Offer her an antianxiety medication to help calm her down
Reassure her, praise her efforts, and keep her apprised of her progress
The nurse receives report on Mrs. O'Malley, a 29-year-old G2P2 who is on postoperative day 1 from a planned repeat cesarean birth. The following information is in the report: Vital signs are stable, breastfeeding well, has positive bowel sounds, tolerated clear liquids well, and ambulated twice today. The nurse anticipates an order for which type of diet? Full liquids Clear liquids Soft diet Regular diet
Regular diet
Janna Hall is having a nonstress test because she has recently been diagnosed with gestational diabetes. Her results indicate a nonreactive test. What is the nurse's initial nursing action? Repeat the nonstress test. Contact the operating room for urgent cesarean section. Notify the provider and administer oxygen. Administer oxytocin.
Repeat the nonstress test.
A client undergoing labor induction is uncomfortable with contractions and declines analgesia, preferring to walk and change positions frequently. The nurse notes frequent gaps in the fetal heart rate tracing and sections showing wide disparities in baseline fetal heart rate. What is the nurse's best response to these findings? Reposition the ultrasound transducer Continue to monitor Notify the health care provider of a suspected fetal arrhythmia Position the mother on her left side for maximum uteroplacental circulation
Reposition the ultrasound transducer
The nurse is caring for a client who does not speak English and who requires discharge instruction. Which nursing action is the most appropriate for this client? Providing written instructions in English Requesting an interpreter for assistance Informing the client that she will get instructions from the Health Department Speaking slowly and loudly
Requesting an interpreter for assistance
The nurse is assessing a sleeping, 1-hr-old newborn. Which data would necessitate the need to notify the healthcare provider? Brief periods of apnea lasting less than 5 seconds Respirations 78 breaths/min Temperature 97.9°F Heart rate 122 beats/min
Respirations 78 breaths/min
The nurse is preparing a teaching session for the new staff during orientation to the newborn intensive care unit (NICU). Which information should the nurse include about the causes of death for premature infants? Select all that apply. Malabsorption syndromes Respiratory infections Neurologic defects Retinopathy of prematurity Sudden infant death syndrome
Respiratory infections Neurologic defects Sudden infant death syndrome
Which is a common cause of late-onset postpartum hemorrhage? Retained placental fragments Endometritis Operative vaginal delivery Labial laceration
Retained placental fragments
A postpartum client reports having difficulty voiding. Which strategies would the nurse suggest to promote urine elimination? Select all that apply. Running water in the sink Administering docusate sodium (Colace) as ordered Encouraging voiding in the shower or during a sitz bath Administering pain medication Ensuring privacy when voiding
Running water in the sink Encouraging voiding in the shower or during a sitz bath Administering pain medication Ensuring privacy when voiding
Juanita Botella is a 30-year-old woman who is pregnant with her first child. She has decided to take a prenatal class offered at the local hospital on the risks and prevention of sudden infant death syndrome (SIDS). In class, Mrs. Botella admits to smoking half of a pack of cigarettes every other day. What other health history factor would place Mrs. Botella's infant at higher risk for SIDS? Placenta previa Previous miscarriage SIDS within family Gestational diabetes
SIDS within family
The nurse is making a first visit to the home of a preterm infant diagnosed with bronchopulmonary dysplasia. On what should the nurse focus during this visit? Select all that apply. Level of sensory stimulation Safe use of oxygen in the home Infection control practices Parental involvement in care Frequency of oral feedings
Safe use of oxygen in the home Infection control practices
Which are clinical manifestations of congenital diaphragmatic hernia? (Select all that apply.) Scaphoid abdomen Absent breath sounds on the affected side Barrel-shaped chest Concave chest Protruding abdomen
Scaphoid abdomen Absent breath sounds on the affected side Barrel-shaped chest
The nurse is assessing a newborn baby girl while her mother sleeps. The nurse assesses an increased pulse and respiratory rate and an increase in mucus secretions that is causing the newborn to regurgitate. Based on the assessment findings, which period of activity will the nurse document for this client? Second period of reactivity Fourth period of reactivity Third period of reactivity First period of reactivity
Second period of reactivity
Sarah Martinez is a 34-year-old client who delivered a 10 lb 8 oz. female infant with vacuum assistance at 3:00 a.m. this morning. During the nurse's postpartum assessment, the nurse notes that the client's heart rate is 136 beats/min and her blood pressure is 94/50 mmHg. Ms. Martinez states that she has changed her peri-pad four times in the past hour. Which assessment is the most appropriate for the nurse to perform at this time? To reassess the blood pressure in 15 min To palpate the fundus To review the chart for total blood loss during delivery To elevate the client's feet and legs
To palpate the fundus
Leticia Burberry is a 21-year-old gravida 2 para 0 single, African American female. Her first pregnancy at age 15 ended with a spontaneous abortion (SAB). No causative factor for the SAB was identified, and no further treatment was needed. Ms. Burberry is nervous and anxious over this planned pregnancy. She is confused about the symptoms of true labor versus false labor and will require emotional support and education. Her fiancé is in the military and is not available for daily emotional support. What risk factors apply to Ms. Burberry? Check all that apply. She is African American. She is experiencing domestic violence at home. Her fiance is in the military. She is of low socioeconomic status.
She is African American. Her fiance is in the military.
The next day, you are taking care of Mrs. Romero once again. You enter her room and ask her how she isdoing.Ok, I guess, she says. I did get some sleep earlier, but my baby is crying and wanting to breastfeed all the time. I dont think she is getting any milk. Do you think I should give her some formula? She sighs. Maybe I should just let her cry it out. My aunt says I am spoiling her by holding her too much. What is your bestresponse? You should feed her on a schedule so you can rest. She wants to breastfeed all the time because she is not getting any milk. She is cluster feeding. Crying is good for her because it opens her lungs.
She is cluster feeding.
Which topics are included in the discharge teaching for a postpartum client? Select all that apply. Signs and symptoms of illness Follow-up instructions Maternal self-care Activity Newborn care
Signs and symptoms of illness Follow-up instructions Maternal self-care Activity Newborn care
Dr. Rui's niece responds to the voicemail message that you left for her. She is able to come over right away, drive her aunt to her same-day appointment, and monitor her for the rest of the day. What information should you review with Ms. Tan regarding her aunt's condition? Signs that Dr. Rui is worried about her independence Symptoms that Dr. Rui's vaginal infection is getting worse Symptoms that Dr. Rui is developing a urinary infection Signs and symptoms that indicates Dr. Rui is having another hypoglycemic reaction
Signs and symptoms that indicates Dr. Rui is having another hypoglycemic reaction
What areas of the health history should the nurse focus on when assessing an infant for SIDS? (Select all that apply.) Sleep patterns Exposure to smoke Breathing patterns Family history of SIDS Maternal history of miscarriage
Sleep patterns Exposure to smoke Breathing patterns Family history of SIDS
Which recommendation is appropriate when educating parents about safe sleeping for the newborn? Sleeping on the back Sleeping in an infant car seat Co-sleeping with parents Sleeping on the tummy
Sleeping on the back
The nurse is conducting a newborn assessment for baby girl Roper, born 2 hr ago. The newborn's weight, head circumference, and length all fall below the 10th percentile. Which classification will the nurse document in the medical record for this newborn? Small for gestational age Postterm Large for gestational age Appropriate for gestational age
Small for gestational age
The nurse is caring for Joyce Stanley, who just gave birth an hour ago. Which nursing assessment requires further evaluation? Complaints of feeling chilly Soft uterine fundus Mild uterine cramping Moderate amount of lochia rubra
Soft uterine fundus
The nurse performs a gestational age assessment, as part of the newborn assessment, to evaluate physical characteristics. Which data will the nurse collect as part of the gestational assessment for this newborn? Scarf sign Square window sign Sole creases Startle reflex
Sole creases
A mother asks the nurse when she can breastfeed her infant who has just been born. Which response by the nurse is the most appropriate? Before the first bath Soon after birth, before the infant is taken to the nursery After all prophylactic medications have been administered in the nursery After the first bath
Soon after birth, before the infant is taken to the nursery
The nurse is caring for a primigravida in the second stage of labor who feels the urge to push. The client has had no analgesia or anesthesia. Which position might the nurse suggest for pushing? Dorsal recumbent Squatting Lithotomy Standing in the shower
Squatting
The new mother of a preterm infant asks why kangaroo care is important to do when holding the baby. Which responses by the nurse are most appropriate when explaining this care technique to the mother? Select all that apply. Promotes digestion Stabilizes vital signs Improves infant oxygenation Enhances bonding Supports body temperature regulation
Stabilizes vital signs Improves infant oxygenation Enhances bonding Supports body temperature regulation
The nurse observes a new mother bottle-feed her preterm infant and notes a slight bluish tinge around the baby's mouth. Which action should the nurse take first? Determine amount of urine output Assess respiratory rate Measure heart rate Stop the feeding
Stop the feeding
Although Mrs. Yumihara agrees to see a behavioral health provider, she also expresses interest in learning about natural, nonpharmacological alternatives for managing the postpartum depression, because, for cultural reasons, she doesn't want to have to take medication. What are some nonpharmacological options for Mrs.Yumihara? Select all that apply. Stress management activities, such as meditation Candle-lighting ceremony Energy work Exercise Acupuncture
Stress management activities, such as meditation Energy work Exercise Acupuncture
The nurse is completing the assessment of the gestational age of baby girl Samuels. Which action is appropriate for the nurse to take when assessing the Babinski reflex for this newborn? Stroke the infant's cheek Stroke the lateral aspect of the infant's sole from the heel upward Place a gloved finger in the infant's mouth Startle the infant while on the warmer
Stroke the lateral aspect of the infant's sole from the heel upward
Why are the mouth and oropharynx of a newborn suctioned before the nose is suctioned? Because newborns breathe through their mouths To prevent the newborn from aspirating any contents of the nasopharynx The order is unimportant To allow the newborn to cry
To prevent the newborn from aspirating any contents of the nasopharynx
"Thank goodness a pill will fix my anemia," Mrs. Abejundio says. You explain that the iron supplements will help, but Mrs. Abejundio should also incorporate some dietary changes to improve her anemia. You ask Mrs. Abejundio to recall everything she has had to eat and drink in the past 24 hours. She begins with last nights dinner. Dinner: cheeseburger, sweet potato fries, salad made of spinach and tomatoes Breakfast: sugary flakes breakfast cereal with milk, a glass of milk Morning snack: string cheese, pear Lunch: bean burrito on flour tortilla, tortilla chips, soda Which dietary suggestions would improve Mrs. Abejundios iron intake? Select all that apply. Take her iron pill with milk at breakfast. Substitute a hard-boiled egg for her string cheese. Suggest she add ground beef to her burrito. Replace her spinach salad with an iceberg lettuce mix. An extra serving of milk will help increase her iron.
Substitute a hard-boiled egg for her string cheese. Suggest she add ground beef to her burrito.
Which may be assessed in the fetus with a prolapsed umbilical cord? Select all that apply. Fetal heart rate accelerations Sustained fetal bradycardia Variable decelerations Increased uterine contractions Late decelerations
Sustained fetal bradycardia Variable decelerations
Which common side effect is associated with the use of vacuum extraction? Fetal hair loss Fetal distress Memory loss Swelling of the scalp
Swelling of the scalp
A new mother is upset and states, "My baby is calm as long as I cuddle and hold her. Once I put her down in the crib, she starts to cry." Based on the new mother's description, which sensory capacity is the baby experiencing? Orientation sensory capacity Tactile sensory capacity Habituation sensory capacity Quieting sensory capacity
Tactile sensory capacity
Darius Jackson was just delivered at 31 weeks gestation. He has no visible medical issues that might require immediate attention. Which action is the nursing priority related to his gestational age at birth? Take extra care to ensure his airways are clear. Do nothing outside of normal protocol. Take extra care to ensure he is warm. Place him immediately with his mother.
Take extra care to ensure he is warm.
Jasmine Harper gave birth 12 hr ago and successfully bonded with her newborn. Which activity can the nurse recommend to best encourage attachment between Jasmine and her daughter? Bathing Swaddling Talking to the baby while making eye contact Diapering
Talking to the baby while making eye contact
The nurse is assessing a breastfeeding mother with engorged breasts. Which intervention should the nurse teach the breastfeeding mother? Applying ice Applying a breast binder Teaching how to express her breasts in a warm shower Administering bromocriptine
Teaching how to express her breasts in a warm shower
The nurse is caring for a postpartum client who had a cesarean delivery 1 day ago. Which nursing interventions will help prevent stasis of lung fluids and respiratory infection? Select all that apply. Teaching the client to cough correctly Providing education about the use of an incentive spirometer Monitoring the client's urinary output Encouraging healthy meals and fluid intake Encouraging the client to breathe deeply
Teaching the client to cough correctly Providing education about the use of an incentive spirometer Encouraging the client to breathe deeply
After Mrs. Abejundio sees her health care provider, she checks in with you before she leaves the clinic. She says, "I want to take good care of myself and the baby. Is there anything else I can do to help the iron pills work better?" How should you respond to Mrs. Abejundio? Tell her that taking iron with a vitamin C source, such as orange juice, will help her body absorb it better. Suggest she drink milk when she takes her iron pill. Explain that Mrs. Abejundios blood work shows she is deficient in Vitamin C. Advise her to grind up her iron tablet and mix it with orange juice.
Tell her that taking iron with a vitamin C source, such as orange juice, will help her body absorb it better.
The nurse is performing a Ballard gestational age assessment for baby boy Jefferys, born 1.5 hr ago. Which will the nurse assess during the physical characteristic portion of this examination? Rooting reflex Babinski reflex The amount of breast tissue Scarf sign
The amount of breast tissue
You are performing a 24-hour chart check on Mrs. Romeros chart. You note that her prenatal labs are asfollows:Blood type A negative, antibody screen negativeRubella immuneOne-hour glucola 125HIV negativeYou know that she may be a candidate for a rho(D) immune globulin (RhoGAM) injection, and you check her chart and the babys chart for more information. What result confirms that Mrs. Romero needs rho(D) immune globulin(RhoGAM)? Mrs. Romeros indirect Coombs is positive. The babys blood type is B positive. The babys blood type is O negative. The babys blood type is A negative.
The babys blood type is B positive.
Which definition describes the term involution? Bladder distention Palpation of the uterine fundus The descent of the uterine fundus into the pelvis A boggy or soft fundus
The descent of the uterine fundus into the pelvis
A nurse is involved in investigating the death of an infant. ASIDS-related death is suspected. What is true regarding the process of investigating this type of death? The focus of the investigation does not involve the infant's family. The focus of the investigation involves determining the cause of infant death. The focus of the investigation is to determine blame for the infant's death. The focus of the investigation is on the infant's parental behavior.
The focus of the investigation involves determining the cause of infant death.
Which is the best indication of health in the unborn fetus? The fetus' sex The fetus' culture The health of the fetus' mother The health of the fetus' father
The health of the fetus' mother
A nurse is caring for a newborn whose mother had no prenatal care. What information does the nurse understand as true regarding a newborn born without prenatal care? The health of the infant is based on the prenatal care of the mother. The mother of the infant is likely of low socioeconomic status. The mother of the infant is likely to belong to a minority culture. The health of the infant is independent of the prenatal care of the mother.
The health of the infant is based on the prenatal care of the mother.
The nurse is caring for a newborn who is small for gestational age (SGA). The newborn's parents ask the nurse how this happened. Which rationales will the nurse use to respond to these parents? Select all that apply. The newborn had intrauterine exposure to bacteria. The newborn weighs less than 2,500 g (5.5 lb). The newborn's head circumference is in the 50th percentile. The newborn's weight falls below the 10th percentile. The newborn may have suffered from intrauterine growth restriction (IUGR).
The newborn's weight falls below the 10th percentile. The newborn may have suffered from intrauterine growth restriction (IUGR).
"I remember when my sister-in-law took iron pills during her pregnancy," Mrs. Abejundio says. "She got really nauseated and then constipated. I hope that doesnt happen to me." How will you respond? Select all that apply. The prescribed stool softener may help prevent constipation. There is no way to avoid an upset stomach with iron pills. You should start with a small dose of iron and increase over time. Your stool may turn black. Taking iron pills with food reduces iron absorption.
The prescribed stool softener may help prevent constipation. You should start with a small dose of iron and increase over time. Your stool may turn black. Taking iron pills with food reduces iron absorption.
A nurse is preparing a brochure about different types of antenatal testing. Which indicators, related to a fetal nonstress test (NST), are appropriate to include? Select all that apply. The test is used to assess fetal heart rate pattern and oxygenation status. The test is easy to perform and has no known side effects. A rise in the fetal heart rate is associated with fetal movement. A nonstress test (NST) usually takes 2-3 hours for completion. A reactive NST has two accelerations that are 15 beats above baseline for 15 s in 20-40 min.
The test is used to assess fetal heart rate pattern and oxygenation status. The test is easy to perform and has no known side effects. A rise in the fetal heart rate is associated with fetal movement. A reactive NST has two accelerations that are 15 beats above baseline for 15 s in 20-40 min.
A woman has just delivered an 8 lb, 8 oz baby boy. After the delivery, the nurse notices that the mother is chilly and her fundus has relaxed. The nurse administers the oxytocin ordered by the health care provider. What is the expected assessment finding for this client? The baby cries The uterus becomes firm The mother states she feels warmer now The mother falls asleep
The uterus becomes firm
The nurse is assessing a newborn right after birth. Which assessment will be most helpful initially in identifying an at-risk newborn? The newborn's Apgar score The mother's pregnancy history The newborn's color The newborn's respiratory effort
The newborn's Apgar score
A preterm male newborn is admitted to the nursery. Which assessment findings support the diagnosis of prematurity? Select all that apply. Minimal lanugo Thin skin Covered in vernix caseosa Undescended testes Flexed extremities
Thin skin Covered in vernix caseosa Undescended testes
Why does a preterm infant lose body heat? (Select all that apply.) Flexed body position Thinner skin Inefficient constriction of blood vessels Less subcutaneous tissue Higher body surface to body weight ratio
Thinner skin Inefficient constriction of blood vessels Less subcutaneous tissue Higher body surface to body weight ratio
The nurse is preparing an education program on breastfeeding. What is the appropriate timeframe to include in regards to the recommendation for exclusive breastfeeding? Through 6 months of age Exclusive breastfeeding is not recommended. 2 yr old 1 yr old
Through 6 months of age
How is chorionic villus sampling (CVS) beneficial for a pregnant woman and her fetus? Occurs before 8 weeks gestation Noninvasive testing procedure Time in which results become available No risk to developing fetus
Time in which results become available
Renee Romero is an 18-year-old gravida 2 para 1001 who just had a successful vaginal birth after a previous cesarean section. She had an epidural and a Foley catheter, which was removed prior to second stage pushing. After 2 hours of pushing, her health care provider obtained her consent and placed a vacuum to assist with the birth. Mrs. Romero had a fourth degree perineal laceration that the health care provider is in the process of repairing when you take over Mrs. Romeros care from her labor and delivery nurse. She has plain lactated Ringer solution infusing via IV. You hang the oxytocin and bolus the IV fluid, which is her third liter of fluid. You massage Mrs. Romeros uterus; it is now firm, and the fundus is at the umbilicus. The health care provider is continuing to repair her fourth degree laceration.The nursery nurse has finished her evaluation of Mrs. Romeros baby girl. She weighed 7 lbs 4oz, and her appearance is consistent with 38 weeks estimated gestational age. The nurse tells you that her vital signs are all normal and that she gave the baby her vitamin K injection and the erythromycin ointment.The baby is swaddled in a blanket and has her fist by her face. The baby touches her cheek with her fists, and you recognize the baby is rooting and showing signs of being ready to breastfeed. Mrs. Romero is in semi-Fowler position for the repair. You tell Mrs. Romero that the baby is showing signs she would like to nurse. She says, Oh, good. I want to breastfeed her. I was not able to breastfeed my last baby. What is your next step? To assist Mrs. Romero to breastfeed her baby. To assess the baby for signs of hypoglycemia. To check the babys blood glucose level before she breastfeeds. To give the baby formula because Mrs. Romero is having her repair done.
To assist Mrs. Romero to breastfeed her baby.
What indications would call for a woman to have an ultrasound test during the first trimester of pregnancy? Select all that apply. To verify location of the pregnancy To confirm pregnancy viability To determine gender of the fetus To estimate amniotic fluid volume To assist with amniocentesis
To verify location of the pregnancy To confirm pregnancy viability To assist with amniocentesis
Ms. Burberry tells you that she has concerns about being able to recognize the true signs of labor, especially because her first pregnancy ended in a spontaneous abortion. What are some of the classic differences you can explain that will clarify the difference between true labor and false labor? Select all that apply. True labor contractions will not be relieved by rest, a warm bath, or repositioning. False labor contractions are random and do not increase in intensity. True labor contractions continue to increase in duration and intensity. False labor contractions are not regular. False labor contractions will cause a change in the cervix.
True labor contractions will not be relieved by rest, a warm bath, or repositioning. False labor contractions are random and do not increase in intensity. True labor contractions continue to increase in duration and intensity. False labor contractions are not regular.v
How can the nurse enhance the bonding process between parents and their newborn? Select all that apply. Turn down the room lights. Delay the administering of eye prophylaxis. Immediately administer eye prophylaxis. Create a quiet space for the parents and newborn. Turn up the room lights.
Turn down the room lights. Delay the administering of eye prophylaxis. Create a quiet space for the parents and newborn.
You start Mrs. Turners IV in her left forearm with an 18 gauge needle and begin administering lactated Ringer solution at 125 mL/hr. The lab tech comes in and draws Mrs. Turners blood. You recheck her vital signs: T 98.6°F, P 120 bpm, R 19/min, and BP 120/78 mmHg.The fetal heart rate is 140/s with minimal long-term variability. Mrs. Turner has a contraction, which traces well on the monitor, and the fetal heart rate shows a late deceleration following the contraction.You look at Mrs. Turner and notice shes wrinkling her nose. I feel really weird down there, she tells you. You tug back on the sheets to check her perineum and a blood clot the size of a dinner plate slides out of her vagina onto the chux. You wipe it away and observe brisk red bleeding from her introitus.As you page the health care provider, what steps will you take to improve the oxygen blood flow to thebaby? Turn her to her left side. Turn down her IV rate to prevent pulmonary edema. Apply compression stockings to her lower extremities. Place her in Trendelenburg position.
Turn her to her left side.
A pregnant client is lactose intolerant. Which strategy does the nurse suggest to the client to ensure that she consumes adequate protein? Select all that apply. Use soymilk to replace cow's milk. Mix milk with fruit juices. Eat two servings of cream cheese every day. Tofu can be used to replace cottage cheese. Add milk to soup and custards.
Use soymilk to replace cow's milk. Tofu can be used to replace cottage cheese.
Which strategies are appropriate for the nurse to implement to promote ambulation for a client recovering after a cesarean delivery? Select all that apply. Using a folded sheet as an abdominal splint Encouraging fluid intake to prevent constipation Administering an analgesic 30 min before walking Providing encouragement to the mother Teaching turning, coughing, and deep breathing
Using a folded sheet as an abdominal splint Administering an analgesic 30 min before walking Providing encouragement to the mother
If the nurse administers the ripening agent Cervidil or Prepidil to a pregnant client, which situations can the nurse expect to be associated with the drug? Select all that apply. The need for more oxytocin during labor Uterine tachysystole Postpartum hemorrhage Nonreassuring fetal status Difficulty in administration
Uterine tachysystole Postpartum hemorrhage Nonreassuring fetal status
The nurse is caring for four postpartum clients. The nurse would question a provider's order for administering the rubella vaccine to which client? Vaginal delivery, HIV-positive Cesarean section delivery, received 1 unit of blood Breastfeeding mother of twins Caucasian with negative rubella titer
Vaginal delivery, HIV-positive
The night shift nurse gets report on four clients who delivered between 7:00 a.m. and 8:00 a.m. that morning. The nurse is going to assess which client first? Vaginal delivery, episiotomy, has not voided since delivery Cesarean section, pain medication 30 min ago, tolerated clear liquids Vaginal delivery, ambulating well, docusate sodium (Colace) due in 30 min Cesarean section, twins, breastfeeding, requests assistance with nursing
Vaginal delivery, episiotomy, has not voided since delivery
A 3-week-old preterm infant is diagnosed with anemia. Which intervention does the nurse expect the healthcare provider will prescribe for this infant? Infusions of fresh frozen plasma Vitamin E supplements Arterial blood gas analysis every 2 hr Serum electrolyte levels every hour
Vitamin E supplements
The nurse is caring for a pregnant client whose family has a very low income. The nurse discusses the Women, Infants, and Children (WIC) program with the client. Which services provided by this program should the nurse include in her teaching? Select all that apply. All pregnant women are able to utilize the services of WIC. WIC provides nutritional education and counseling to women. WIC can provide food stamps for low-income women. WIC provides vouchers for certain foods. WIC services continue after pregnancy.
WIC provides nutritional education and counseling to women. WIC provides vouchers for certain foods. WIC services continue after pregnancy.
You call to make a same-day appointment for Dr. Rui to see her primary health care provider to diagnose and treat her vaginal infection. What self-care interventions should you review with Dr. Rui to prevent reoccurrence? Select all that apply. After voiding, wipe from back to front. Douche regularly. Wear cotton underwear. Avoid wearing nylon pantyhose. Avoid wearing tight jeans.
Wear cotton underwear. Avoid wearing nylon pantyhose. Avoid wearing tight jeans.
The nurse is providing care to a family who recently welcomed a second baby. The couple also has a 4-year-old son. Which behavior would indicate regression for the son? Wetting the pants during a hospital visit Asking to hold the baby with mom's help Yelling at the father for holding the baby Giving the baby a present while visiting
Wetting the pants during a hospital visit
A client is in the recovery room after completing a cesarean birth. She is stable and alert. What should be the nurse's focus for teaching during this time? Future birth control options When to follow up with her healthcare provider What to expect during the postpartum period How to bathe the newborn
What to expect during the postpartum period
You inform Mrs. Yumihara that you will need to ask her some questions about her health history. Having worked with this client and her husband before, you know that there are cultural parameters and that sometimes Mrs. Yumihara feels as though medical questions are invasive. You do your best to explain to Mrs. Yumihara that it is important for you to ask these questions to make sure she, her husband, and the new baby are safe and healthy. She agrees to go along with the health history assessment, and you make a conscious effort to be delicate with the way you ask the questions. Which question is NOT consistent with a health history assessment for postpartum depression? Have you ever been diagnosed with a behavioral health condition? Do you have a history of drug or alcohol abuse? Has there been a history of depression or bipolar disorder in your family? What was your age of menarche?
What was your age of menarche?
A nurse is caring for Zoe Hernandez, a 3-hr-old newborn. The nurse understands that Zoe's parents require teaching regarding newborn care. What time does the nurse determine is best to perform this teaching? When Zoe is in the nursery, allowing the parents time alone to hear the teaching. When Zoe is sleeping, allowing the parents quiet time to absorb the teaching. When performing Zoe's newborn assessment, allowing the parents to visualize the teaching. When performing the postpartum assessment, allowing the parents an opportunity to hear both infant and postpartum teaching.
When performing Zoe's newborn assessment, allowing the parents to visualize the teaching.
Why might it be difficult for the prenatal nurse to recognize bulimia in a pregnant woman? Bulimia does not cause pregnancy-related problems. Pregnancy hides weight gain. Women with bulimia are often very underweight. Women with bulimia are often a normal weight.
Women with bulimia are often a normal weight.
The mother of Tommy Hamilton, a 5-day-old preterm infant, wants to know when the baby will no longer need tube feedings so she can start feeding the baby. Which response from the nurse is most appropriate? "Tommy will tolerate bottle feedings when he stops sucking on the pacifier." "Bottle feedings can be started when his belly stops gurgling so much before receiving a feeding." "Tommy can start bottle feedings when his belly doesn't increase in size after feedings." "Bottle feeding can start when Tommy has a gag reflex."
"Bottle feeding can start when Tommy has a gag reflex."
The father of a preterm infant is upset and fears the baby is going to be paralyzed. Which response by the nurse is appropriate? "As long as a brain hemorrhage does not occur, the infant will not develop paralysis." "Brain cells and nerve impulse pathways increase and develop between the second and fourth months of gestation, so there is little chance your child will be paralyzed." "Since the period of most rapid brain growth and development occurs during the third trimester, the infant may have mobility problems." "Paralysis will only occur if a cerebral aqueduct is blocked, causing hydrocephalus."
"Brain cells and nerve impulse pathways increase and develop between the second and fourth months of gestation, so there is little chance your child will be paralyzed."
The nurse is assessing a pregnant client's understanding of her preterm labor. What questions are appropriate for the nurse to include with education? Select all that apply. "Do you have any questions about your pediatrician?" "Can you share with me what you know about the risks of preterm delivery?" "Tell me what you understand about causes of preterm labor." "How is this affecting your pregnancy? What concerns do you have?" "We will be doing fetal monitoring. Have you learned about this already?"
"Can you share with me what you know about the risks of preterm delivery?" "Tell me what you understand about causes of preterm labor." "How is this affecting your pregnancy? What concerns do you have?" "We will be doing fetal monitoring. Have you learned about this already?"
A postpartum client who delivered 2 days ago has developed endometritis. Which entry would the nurse expect to find when reviewing this client's medical record? "Cesarean birth performed secondary to arrest of dilation." "Vaginal delivery with epidural anesthesia." "Client has history of pregnancy-induced hypertension." "Rupture of membranes occurred 2 hr prior to delivery."
"Cesarean birth performed secondary to arrest of dilation."
Carmelina Picagli, a 22-year-old primigravida, has been admitted to the labor and birth unit in the active phase of the first stage of labor at term. She is healthy; has had an uneventful pregnancy; plans an unmedicated labor; and wants to remain as active as possible. Which order would the nurse suspect has been entered in error? "Continuous electronic fetal monitoring" "Fetal heart rate check Q 30 minutes" "Vitals signs Q 4 hr" "Activity as tolerated"
"Continuous electronic fetal monitoring"
The nurse provides education to new parents about recommendations for the infant's sleeping position. Which nursing documentation note is appropriate? "Informed parents that the infant should sleep in the car seat until 1 month old." "Prone position recommended for sleeping when in crib." "Discussed placing infant on back when sleeping." "Encouraged sleeping in the same bed with parents for 1 month."
"Discussed placing infant on back when sleeping."
The prenatal clinic nurse is caring for an 18-year-old client who is at 10 weeks gestation in her first pregnancy. The client is 64 in. (1.6 m) tall and weighs 115 lb (52 kg). The client asks the nurse why she is supposed to gain so much weight during the pregnancy. What is the best response by the nurse? "Inadequate weight gain delays lactation after delivery." "Gaining 25 to 35 pounds is recommended for healthy fetal growth." "It's what your certified nurse-midwife recommended for you." "Weight gain is important to ensure that you get enough vitamins."
"Gaining 25 to 35 pounds is recommended for healthy fetal growth."
The nurse is providing education to Mr. Johnson, a new father to baby Anna, who is 2 days old. The nurse is teaching Mr. Johnson about proper bottle-feeding. Which statement by the nurse is appropriate for the nurse to include in the teaching session? "Propping the bottle while feeding Anna will decrease the chance of choking." "Holding the bottle upright will improve Anna's bowel function." "Feeding Anna from the bottle will decrease her risk of otitis media." "Holding Anna in an upright position reduces the amount of air she swallows."
"Holding Anna in an upright position reduces the amount of air she swallows."
The nurse in a prenatal clinic is caring for a client in her second trimester of pregnancy. What statement made by the client would indicate that she understands the daily calorie allowance for a pregnant woman? "I am eating an additional 300 calories per day." "Since I am eating for two now, I have increased my calories by 500, or 250 kilocalories for each of us." "Since the nausea has decreased I am eating 3,000 calories per day." "I continue to eat the same number of calories as I did before I was pregnant."
"I am eating an additional 300 calories per day."
The nurse is evaluating teaching about normal newborn care. Which statement by the parents indicates that further teaching is needed? "I will cleanse the baby's diaper area after each soiled diaper." "It is okay if I give the baby a bath every other day." "I can use powder to help prevent diaper rash." "I will fold down the top of the diaper so it will not cover the cord."
"I can use powder to help prevent diaper rash."
Esperanza Jimenez is 16 weeks postpartum and breastfeeding exclusively. She is concerned that she has only lost 15 of the 20 lb (6.8-9 kg) she gained while pregnant. Which statement to the nurse indicates that Mrs. Jimenez requires further education? "I don't want to reduce my calories too much because it may affect my milk supply." "I should drastically cut my calories so I can lose the rest of my baby weight." "I know it could take up to a year to lose the rest of my baby weight." "I should exercise a little more."
"I should drastically cut my calories so I can lose the rest of my baby weight."
The nurse is evaluating a new mother's knowledge of breastfeeding after a teaching session. Which statement indicates the need for further teaching? "If it's in the refrigerator, I can keep the breast milk for up to 8 days." "I should warm the breast milk in the microwave for 30 seconds." "It will stay good for up to 3-4 months in the freezer." "Fresh breast milk can stay out at room temperature for 4-10 hours."
"I should warm the breast milk in the microwave for 30 seconds."
The nurse is discussing exercise during pregnancy with a client who is at 30 weeks gestation. Which statement made by the client would require further assessment by the nurse? "I hold on to the handles when I am on the treadmill." "When I do my exercise video, I stop if I feel tired." "I walk on the treadmill for 4 hours a day." "I am swimming 20 minutes each day at the YMCA."
"I walk on the treadmill for 4 hours a day."
Alisha Kimble, a 27-year-old G2 P1001, has just arrived in the labor and birth unit for a scheduled external cephalic version at 38 weeks' gestation with a transverse lie. She is talking from the bathroom to the nurse about the procedure as she puts on her gown. Which statement from Alisha alerts the nurse that the client needs further teaching on what to expect from the procedure? "I will have an ultrasound done after the procedure." "I will be starting labor after the procedure." "The procedure is uncomfortable." "I will need to get an IV started for the procedure."
"I will be starting labor after the procedure."
The nurse is caring for a client who will be having a cesarean delivery. Which statement by the client would cause the nurse to determine that the client does not understand what to expect during a cesarean delivery? "I will receive a blood transfusion during surgery." "I may be given an antacid before surgery." "An indwelling (Foley) catheter will be inserted before surgery." "My husband can be present during birth."
"I will receive a blood transfusion during surgery."
Leah Wilson is a 28-year-old woman who is 3 days post-cesarean delivery resulting in a healthy 7 lb 4 oz. boy, little Ted. The nurse is completing a client teaching at the bedside. Which statement by the client indicates that more teaching is needed? "If I develop a temperature above 100.4° F, I'll call our healthcare provider right away." "We'll bring little Ted back to see our healthcare provider in about 10 days." "I'll call the healthcare provider if Ted's circumcision wound starts to smell bad." "If my baby turns yellowish, it's just from the formula he's eating."
"If my baby turns yellowish, it's just from the formula he's eating."
Ms. Tan arrives, and hugs her aunt. The three of you talk about recognizing the signs and symptoms of hypoglycemia and how triggers such as vomiting could cause this. Ms. Tan says, "If my aunt vomits again, or looks pale and sweaty, I will check her blood glucose." What statement suggests that Ms. Tan understands what she needs to do to correct her aunt's blood glucose if necessary? "If my aunt's blood glucose is high, I will give her glucose tablets." "If my aunt's blood glucose is low, I will give her glucose tablets." "If my aunt's blood glucose is low, I will call 911." "If my aunt's blood glucose is low, I will check it again in 15 minutes."
"If my aunt's blood glucose is low, I will give her glucose tablets."
A postpartum client who had a vaginal delivery is about to be discharged. The client asks the nurse how soon she can begin training for an upcoming running marathon. Which response by the nurse is most appropriate? "Check with your personal trainer and see what he or she advises." "You'll have to wait another three months to be sure your lochia has stopped before you start exercising at all." "It's best to wait until you've had your six-week follow-up appointment and your healthcare provider clears you to exercise that strenuously." "You can start running again as soon as you feel better."
"It's best to wait until you've had your six-week follow-up appointment and your healthcare provider clears you to exercise that strenuously."
After delivering a healthy baby boy 2 days ago, 32-year-old Erica Chambers is now being discharged after a brief hospitalization. The nurse is providing discharge teaching to Ms. Chambers regarding the prevention of SIDS. Which statement by the nurse is not correct and will not be included in the discharge teaching? "Place your baby on his back to sleep." "Do not allow anyone to smoke around your baby." "Keep your baby's nursery temperature at 85 degrees." "Breastfeeding is preferred over formula for your baby."
"Keep your baby's nursery temperature at 85 degrees."
Lenny Jackson, a 1-month-old preterm infant, is scheduled for laser photocoagulation surgery to treat retinopathy of prematurity. Lenny's father wants to know what the long-term effect of this health problem will be. What should the nurse explain to Lenny's father? "Lenny could be facing early blindness." "Most problems resolve without long-term vision effects." "Lenny will have profound vision deficits." "Surgery will need to be repeated throughout Lenny's life."
"Most problems resolve without long-term vision effects."
A client is going to have a cephalic version at 38 weeks' gestation for a breech presentation. Which statement by the client indicates appropriate understanding of the procedure? "After the baby is turned, I must remain in bed." "My baby's head will be turned slightly to make the delivery easier." "The procedure cannot be stopped even if my baby shows signs of distress." "My baby will be turned to a head-down position."
"My baby will be turned to a head-down position."
A nurse is caring for a pregnant client during a routine prenatal visit. While performing the assessment, which statement by the client may indicate the infant is at a greater risk for sudden infant death syndrome (SIDS)? "My father was diagnosed with diabetes last year." "I delivered my first baby vaginally." "I miscarried my fist pregnancy at ten weeks." "My sister died during infancy while we were sleeping."
"My sister died during infancy while we were sleeping."
The nurse is providing education to a mother who is initiating breastfeeding. How does the nurse explain the process of the "let-down" reflex? "Oxytocin is released, leading to the let-down of milk." "Estrogen levels increase during pregnancy to cause this." "Progesterone may cause this effect." "Prolactin stimulates milk production."
"Oxytocin is released, leading to the let-down of milk."
A client asks, "Why do I need an ultrasound and all of these tests while I am pregnant?" Which response by the nurse is the most appropriate regarding the purpose of antenatal testing? Select all that apply. "Ultrasounds are painless and your insurance will pay for it." "Tests such as ultrasounds can help screen for birth defects." "I will ask the doctor to explain these tests to you later." "These tests help us see how your baby is growing and developing." "These tests help make sure your baby is healthy."
"Tests such as ultrasounds can help screen for birth defects." "These tests help us see how your baby is growing and developing."
The nurse is assessing a 2-week-old infant in the office. Which statement by the parent would indicate the need for further assessment of infant feeding patterns? "The baby usually has two wet diapers a day." "The baby has a dirty diaper about once a day, sometimes twice." "The baby burps after taking about 20 mL of formula." "I feed the baby about every 3 to 4 hours."
"The baby usually has two wet diapers a day."
The new mother of Timothy Henderson, an infant born at 30 weeks gestation, asks why the baby only receives medication once a day. What should the nurse respond to this mother? "The medication can cause diarrhea and lead to dehydration." "The kidneys aren't fully developed and it takes longer for the drugs to leave the body." "Protective cells did not cross from the placenta into the baby before delivery and the medication works faster." "There isn't enough glucose in the baby's body to metabolize the medications."
"The kidneys aren't fully developed and it takes longer for the drugs to leave the body."
A pregnant client in her first trimester is scheduled for an abdominal ultrasound. Which statement by the nurse most accurately reflects the reason for early ultrasound during pregnancy? "The test will help to determine the gender of your baby." "The test will help determine how many weeks pregnant you are." "The test will help to determine whether you have enough amniotic fluid." "The test will help determine if your baby is in good position for delivery."
"The test will help determine how many weeks pregnant you are."
The nurse is assessing a 2-day-old infant in the hospital. The parents express concern when the nurse informs them that the newborn has lost 2% of its birth weight. Which response by the nurse is the most appropriate? "I will let you speak with the healthcare provider about this. We may need to notify the hospital, also." "This is concerning because we expect the newborn to gain one pound per day." "This is an expected finding. Most infants will regain this weight within 2 weeks after birth." "This is okay. We expect babies to lose about half of their weight in the first few days of life."
"This is an expected finding. Most infants will regain this weight within 2 weeks after birth."
Baby Jennifer is at the healthcare provider's office for her 1-week well-baby checkup. As the nurse assesses the baby before the healthcare provider sees her, Jennifer's mother, who is breastfeeding, says she is concerned because her baby has lost 4 ounces from her original birth weight. Which response by the nurse is most appropriate to Jennifer's mom? "Your baby might be very ill. I will notify the healthcare provider immediately." "This could indicate you are eating something the baby doesn't agree with." "This is expected and the baby should regain all weight by the next visit." "Your baby may be suffering from failure to thrive."
"This is expected and the baby should regain all weight by the next visit."
Todd is a healthy newborn, delivered an hour ago. In the delivery room, his mother asks the nurse about the benefits of breastfeeding. Which response by the nurse is most appropriate? "Didn't you talk about this with your doctor when you were pregnant?" "I will call the healthcare provider so you can discuss this with her." "The baby could have more colic with breastfeeding, but it is free." "This may help your baby be healthier, and you could have less bleeding after delivery."
"This may help your baby be healthier, and you could have less bleeding after delivery."
During a postnatal home health visit, you teach Ms. Henderson, a 31-year-old woman, about the importance of supine positioning for infant sleep for the prevention of SIDS. Ms. Henderson tells you that her infant does not like sleeping on his back and only sleeps on his tummy. What is your best response when explaining to Ms. Henderson the importance of supine positioning for infant sleep? "This position is protective in preventing suffocation." "This position decreases aspiration should your baby spit up." "This position prevents digestive problems, which can contribute to SIDS." "This position will allow your child to sleep longer."
"This position is protective in preventing suffocation."
Angelique Chambers is a 31-year-old primigravida who is being admitted to the labor and birth unit for induction of labor for post-dates pregnancy. While the nurse is taking her history, she tells the nurse that she is worried about how long it will take and she is afraid it will be too tiring and painful. She asks if it wouldn't just be easier to have a cesarean now. Which response from the nurse is most appropriate? "The process of inducing your labor could take several days and be very uncomfortable. Would you like to speak to your obstetrician about the process?" "Vaginal birth is usually the safest for the mother and baby. Cesarean surgery carries several risks, has a longer recovery, and can cause complications in future pregnancies. We only recommend it if the benefits clearly outweigh the risks." "You should avoid having a cesarean at all costs. Your body is designed to give birth vaginally and there is no doubt you can do it." "That will be so much more convenient for you. Then you can schedule the delivery of your next baby by repeat cesarean and you won't even have to go through all this."
"Vaginal birth is usually the safest for the mother and baby. Cesarean surgery carries several risks, has a longer recovery, and can cause complications in future pregnancies. We only recommend it if the benefits clearly outweigh the risks."
A client who had a cesarean section asks the nurse why she needs to ambulate. What is an appropriate response by the nurse? "Walking will help prevent blood clots in your legs." "You can ask the doctor when he comes." "It will help you feel better to get out of your room." "The doctor wrote orders for you to walk three times a day."
"Walking will help prevent blood clots in your legs."
A client who had a cesarean section asks the nurse why she needs to ambulate. Which response by the nurse is the most appropriate? "You can ask the doctor when she comes." "Walking will help prevent blood clots in your legs." "The doctor wrote orders for you to walk three times a day." "It will help you feel better to get out of your room."
"Walking will help prevent blood clots in your legs."
John is a 4-week-old infant who is being breastfed. His mother asks the nurse about his weight gain and what she should expect. Which statement by the nurse is the most appropriate? "We expect John to gain about half an ounce each day." "John should gain an ounce a day until he is about 1 year old." "John's weight will fluctuate each day, so it is hard to answer." "John will lose weight for a few months because he is breastfeeding."
"We expect John to gain about half an ounce each day."
Janice Johnson is being admitted to the hospital in early labor. When completing her admission assessment, which question would allow the nurse to evaluate Janice's emotional state? "How do you like this hospital?" "Have you chosen a name for the baby yet?" "What are your expectations of your current pregnancy?" "Walking may take your mind off the contractions."
"What are your expectations of your current pregnancy?"
birth control method she can start before discharge. What is an appropriate response from the nurse? "You may be able to have a birth control injection before discharge." "Why don't you ask the doctor. She will be here soon." "You should take the pills. They work the best." "You will need to wait 6 weeks before starting any method."
"You may be able to have a birth control injection before discharge."
Ms. Willis, who is 35 weeks pregnant, is scheduled for a prenatal visit today. The nurse plans to provide education about the premonitory signs of labor. Which statement is appropriate to include in the teaching? "Expect to see bleeding each day from now on." "You may notice that you breathe easier when the baby drops down into your pelvis." "Your swelling will start to go away now." "Watch for less urinary frequency as a sign of labor."
"You may notice that you breathe easier when the baby drops down into your pelvis."
The nurse is teaching a postpartum client about her nutritional needs. What statement is appropriate to include? "Because you are breastfeeding, you will need fewer calories." "You should continue to take your prenatal vitamins." "Drinking cold water is what will help hydrate you." "Limit fluid intake so you won't have problems with swelling."
"You should continue to take your prenatal vitamins."