411 Test 2 Practice Questions

After teaching a postpartum client about postpartum blues, the nurse determines that the teaching was effective when the client makes which statement? "I'll need to take medication to treat the anxiety and sadness." "I should call this support line only if I hear voices." "I might feel like laughing one minute and crying the next." "If the symptoms last more than a few days, I need to call my doctor."

"I might feel like laughing one minute and crying the next."

The nurse assesses the client and tells her the baby is at +1 station. Which is the best response by the nurse when asked by the client what this means concerning the location of the baby? 1 cm above the ischial spine. 1 cm below the ischial spine. 1 cm below the symphysis pubis. 1 cm above the symphysis pubis.

1 cm below the ischial spine.

The nurse observes four newborns. Which of the following characteristics, if noted by the nurse, are MOST common in a preterm infant? 1. Red, wrinkled skin, lanugo, and hypotonic muscles 2. Vernix caseosa, silky hair, and faical edema 3. Absent nose bridge, depressed fontanels, and absent lanugo 4. Mottled skin, meconium stools, and hypertonic muscles

1. Red, wrinkled skin, lanugo, and hypotonic muscles

The nurse is caring for a preterm infant and notes frothing and excessive drooling. Which additional assessment finding should the nurse prioritize and report immediately? Bright red blood from the mouth Severe cyanosis Bradycardia Vomiting

Severe cyanosis

A nurse is assessing a postpartum woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking hold phase of the postpartum period? She sits and rocks her infant for long interval She is eager to talk about her birth experience She has not asked for anything for pain all day She did her perineal care independently

She did her perineal care independently

The nurse is admitting a client who appears to be in advanced labor with imminent birth. Which action is a priority? Obtain a comprehensive obtestric history Determine plans for labor and the newborn Take blood pressure and determine if clonus or edema is present Assess use of drugs, alcohol, tobacco during pregnancy

Take blood pressure and determine if clonus or edema is present

An infant is born with an omphalocele. Which explanation by the nurse is the best description of the feeding plan for the infant? The infant will be fed breast milk because it is easier to digest and obtains protective properties. The infant will be fed by TPN to supply nutrients and keep the bowel from filling with air or stool. The infant will receive a continuous enteral feeding to maintain bowel activity. The infant will be NPO and given a pacifier to stimulate the sucking reflex.

The infant will be fed by TPN to supply nutrients and keep the bowel from filling with air or stool.

A nurse is preparing a client for rhythm strip testing. She places the woman into a semi-Fowler position. What is the appropriate rationale for this measure? To aid the woman as she pushes during labor To prevent supine hypotension syndrome To prevent the woman from falling out of bed To decrease the heart rate of the fetus

To prevent supine hypotension syndrome

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? Help the woman to sit up in a semi-Fowler's position. Turn her or ask her to turn to her side. Administer oxygen at 3 to 4 L by nasal cannula. Ask her to pant with the next contraction.

Turn her or ask her to turn to her side.

A postpartum woman has been unable to urinate since giving birth. When the nurse is assessing the woman, which finding would indicate that this client is experiencing bladder distention? Percussion reveals tympany. Bladder is nonpalpable. Uterus is boggy. Lochia is less than usual.

Uterus is boggy.

A nurse is assisting a postpartum client out of bed to the bathroom for the first time. Which interventions would be most appropriate? Select all that apply. Sit her in a chair after getting out of bed before going to the bathroom. Frequently ask the client how her head feels. Walk alongside the client to the bathroom. Elevate the head of the bed for several minutes before getting her up. Check her blood pressure after she stands up.

Walk alongside the client to the bathroom. Elevate the head of the bed for several minutes before getting her up. Frequently ask the client how her head feels.

During a newborn examination the nurse suspects spina bifida occula if what finding is present? Select all that apply a dimpling at the base of the spine abnormal tufts of the hair at the base of the spine discolored skin at the base of the spine head circumference above the 90th percentile continuous dribbling of urine

a dimpling at the base of the spine abnormal tufts of the hair at the base of the spine discolored skin

As the nurse examines the birth records, which newborn would the nurse expect to monitor closely for respiratory distress syndrome (RDS)? a term male newborn, born by a repeat cesarean birth, whose mother has diabetes mellitus a term female newborn, born vaginally, whose mother has chronic obstructive pulmonary disease the term female newborn, born by a mid-forceps assist, whose mother has hypothyroidism the term male newborn, born by cesarean birth, whose mother has respiratory allergies

a term male newborn, born by a repeat cesarean birth, whose mother has diabetes mellitus

A preterm newborn is noted to be cyanotic. Which laboratory test will the nurse prepare the infant for to determine if the cyanosis is due to respiratory or circulatory problems? angiography echocardiogram arterial blood gases chest x-rays

arterial blood gases

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior? bonding attachment being spoiled none of the above

attachment

a woman is admitted to the labor suite with contractions every 5 min lasting 1 min. She is post term and has oligohydraminos. What does this increase the risk of during birth? Macrosomia fetal hydrocephalus shoulder dystocia cord compression

cord compression

A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia? passage of the drug to the fetus headache following anesthesia excessive contractions of the uterus increased frequency of micturition

headache following anesthesia

A nurse is assigned to care for a high-risk newborn with a periventricular-intraventricular hemorrhage (PVH-IVH) in the home environment after discharge. For which condition should the nurse monitor the infant? spina bifida hydrocephalus formula intolerance urinary tract infection

hydrocephalus

Prior to discharge is an appropriate time to evaluate the client's status for preventive measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh-negative mother? indirect Coombs test CBC with differential titer screen ANA

indirect Coombs test

A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanel (fontanelle), cyanosis, and increased head circumference. These signs indicate the newborn has which complication? respiratory distress syndrome retinopathy of prematurity (ROP) cold stress intraventricular hemorrhage (IVH)

intraventricular hemorrhage (IVH)

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize? maternal hypotension and fetal tachycardia maternal hypertension and fetal tachycardia maternal hypertension and fetal bradycardia maternal hypotension and fetal bradycardia

maternal hypotension and fetal bradycardia

The use of breast milk for premature neonates helps prevent which condition? Turner syndrome Down syndrome necrotizing enterocolitis infantile respiratory distress syndrome

necrotizing enterocolitis

A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately? a sudden drop in hematocrit soft, flat anterior fontanels (fontanelles) pink skin with noted blue extremities intake and output for 8 hours

a sudden drop in hematocrit

_______________ labor is one that is completed in less than 3 hours.

precipitous

Which facial change is characteristic in a neonate with fetal alcohol spectrum disorder? wide, palpebral fissures large upper lip short, palpebral fissures well-developed philtrum

short, palpebral fissures

Which finding of the fetus during labor are reassuring? Select all that apply variability between 18-20 bpm late decelerations FHR baseline at 130 bpm repeated variable decelerations gradual increase in the fetal heart rate baseline

variability FHR baseline at 130 bpm

The nurse is caring for a client who received a dose of IV sedation, given by the charge nurse, 30 minutes prior. What action is appropriate? Assure the fetal heart tones are assessed every 2 to 3 hours via monitoring. Restrict the client's fluid to further prevent constipation from the medication. Remind the client to call for assistance before getting out of bed. Remind the client that medication will assist in relieving pain from contractions.

Remind the client to call for assistance before getting out of bed.

When describing the hormonal changes that occur after birth of a newborn, the nurse would identify a decrease in which hormone as being associated with breast engorgement? Progesterone Estrogen Prolactin Human chorionic gonadotropin (hCG)

Estrogen

The nursing instructor is conducting a class explaining the various causes of jaundice in a newborn. The instructor determines additional education is warranted after the class chooses which factor as being responsible for newborn jaundice? bilirubin overproduction decreased bilirubin conversion impaired bilirubin excretion bilirubin hyper excretion

bilirubin hyper excretion

The nurse is caring for a client in the transition phase of the labor process. Which client statement requires nursing action? "My contractions are really intense now." "My mouth and lips are so dry." "My lips and fingers are tingling." "I feel burning in my perineum."

"My lips and fingers are tingling."

A woman refuses to have an epidural block because she does not want to have a postdural puncture (spinal) headache after birth. What would be the nurse's best response? "The pain relief offered will compensate for the discomfort afterward." "Your health care provider knows what is best for you." "The anesthesiologist will do her best to avoid this." "Spinal headache is not a usual complication of epidural blocks."

"Spinal headache is not a usual complication of epidural blocks."

A woman who has been in labor for a few hours is now complaining of being hungry. Which response by the nurse would be best if the client asks for some food to eat? "I can get you something soft and easy to digest, like pudding." "You could have some hard candy to suck on." "What would you like to eat?" "You can have a protein supplement."

"You could have some hard candy to suck on."

The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner? Remain in bed for at least 30 minutes. Ambulate only with assistance from the nurse or caregiver. Sit on the edge of the bed with her feet dangling before ambulating. Ambulate within 15 minutes to prevent spinal headache.

Ambulate only with assistance from the nurse or caregiver.

The registered nurse has identified that the client's labor progress has slowed. Which nursing intervention, done by the LPN, is completed first? Assess the client's psyche Assess the strength of contraction Assess if the bladder is distended Assess the fetal heart rate

Assess if the bladder is distended

A newborn at 33 weeks' gestation has an Apgar score of 5 at 10 minutes of life. Which nursing action is a priority? Complete the Ballard score. Review the labor and birth records. Assess the Apgar score again in 5 minutes. Begin resuscitation measures.

Begin resuscitation measures.

The nurse is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. Which action should the nurse prioritize? Check the chart for the last void. Ask the client if the mass has always been present. Notify the health care provider about the mass. Assume this is part of the uterus.

Check the chart for the last void.

Placental perfusion increases with placental age. True False

False

The ratio of estrogen to progesterone remains constant throughout pregnancy into labor. True False

False

A pregnant client has opted for hydrotherapy for pain management during labor. Which measure should the nurse consider when assisting the client during the birthing process? Allow the client into the water only if her membranes have ruptured. Initiate the technique only when the client is in active labor. Ensure that the water temperature exceeds body temperature. Do not allow the client to stay in the bath for long.

Initiate the technique only when the client is in active labor.

When providing care to the newborn withdrawing from a drug such as cocaine or heroin, which drug is given to ease the symptoms and prevent complications? Morphine Ibuprofen Acetaminophen Aspirin

Morphine

The pain of labor is influenced by many factors. What is one of these factors? The woman has lots of visitors during labor. The woman has a high tolerance for pain. The woman has a high threshold for pain. The woman is prepared for labor and birth.

The woman is prepared for labor and birth.

The nursing instructor is teaching the students the basics of the labor and delivery process. The instructor determines the session is successful when the students correctly choose which action will best help to prevent infections in their clients? Replace soiled drapes and linen as needed. Strictly follow universal precautions. Thoroughly wash the hands before and after client contact. Clean the woman's perineum with a Betadine scrub.

Thoroughly wash the hands before and after client contact.

Which congenital condition is an immediate emergency requiring notification of the health care provider? Tracheoesophageal fistula Cleft palate Hypospadias Atrial septal defect

Tracheoesophageal fistula

A soft, boggy uterus that deviates from the midline suggests a full bladder interfering with uterine involution. True False

True

The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temp 97.7, and BP of 78/40. Which action should the nurse prioritize? document normal findings report tachypnea recheck BP in 15 min put warming blanket over infant

document normal findings

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? fetal baseline rate increasing at least 5 mm Hg with contractions fetal heart rate declining late with contractions and remaining depressed variable decelerations, too unpredictable to count a shallow deceleration occurring with the beginning of contractions

fetal heart rate declining late with contractions and remaining depressed

Which finding by the nurse may indicate increased inctracranial pressure in an infant? overflow voiding bulging fontanelle when crying high pitched cry minimal lower extremity movement

high pitched cry

The uterus returns to its normal size through a process called _________.

involution

nursing interventions for abruptio placentae

remain with client oxygen

The fetal heart rate is heard most clearly at the fetal ________.

back

When assessing a newborn, the nurse determines that the newborn is most likely experiencing respiratory distress syndrome (RDS) based on which finding? slightly diminished breath sounds see-saw respirations peripheral cyanosis respiratory distress occurring by 6 hours of age

see-saw respirations

The home health care nurse makes a visit to the pregnant clinic diagnosed with type 1 diabetes mellitus. The client states, "I have been nauseated for 24 hours." It is most important for the nurse to ask which question? Have you taken your insulin today? When did you eat last? What was your last blood sugar reading?

"Have you taken your insulin today?"

The nurse teaches a class about gonorrhea. Which client statement indicates the teaching is successful?

"I've heard that having gonorrhea can make you unable to have children."

The nurse instructs a group of expectant clients on how to recognize the onset of labor. The nurse knows further teaching is necessary is a client makes which statement? "My baby will move more when I go into labor." "I may feel a gush of water when I begin labor" "I may have blood tinged vaginal discharge"

"My baby will move more when I go into labor."

A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 a.m. and notes the following: moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR? 10:30 a.m. 11:30 a.m. 10:05 a.m. 11:15 a.m.

10:30 a.m.

A woman gave birth today at 1330. It is now 1430 and the nurse has completed the client's assessment. At which time would the nurse next assess the client? 1445 1500 1530 1830

1500

Which nursing action prevents a complication associated with the lithotomy position for the birth of the fetus? Placing a wedge under the hips Rubbing the client's legs Providing a paper bag Massaging the client's lower back

Placing a wedge under the hips

A nurse is assigned to care for a newborn with esophageal atresia. What preoperative nursing care is the priority for this newborn? Provide NG feedings only. Administer antibiotics and total parenteral nutrition as prescribed. Prevent aspiration by elevating the head of the bed, and inserting an NG tube to low suction. Document the amount and color of esophageal drainage.

Prevent aspiration by elevating the head of the bed, and inserting an NG tube to low suction.

The nurse is most correct to assess for transient tachypnea of the newborn (TTN) in which neonate? The large-for-gestational-age neonate The neonate born at 41 weeks' gestation The neonate whose mother received limited prenatal care The neonate delivered by cesarean section

The neonate delivered by cesarean section

During auscultation of the fetal heart rate (FHR) during labor, the nurse assesses a rate of 50 beats/minute. Which actions does the nurse take first?

Turns the client on the left side, administers oxygen by nasal cannula, and verifies IV access.

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next? fetal scalp stimulation application of vibroacoustic stimulation administration of oxygen by mask tactile stimulation

administration of oxygen by mask

During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia? uterine atony extreme diaphoresis delayed hemorrhage bladder distention

delayed hemorrhage

A client in the first stage of labor is admitted to a health care center. The nurse caring for the client instructs her to rock on a birth ball. The nurse informs her that this causes the release of certain natural substances, which reduces the pain. To which substance is the nurse referring? progesterone prostaglandins endorphins relaxin

endorphins

When the presenting part of the fetus reaches 0 station, __________ has occurred.

engagement

A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth? first 6 months first 3 to 5 days first month first 30 to 60 minutes

first 30 to 60 minutes

The nurse provides care for a client in the second stage of labor. The nurse notes the client is tiring after a few hours of pushing, and is no longer making progress. Which does the nurse anticipates the health care provider will ask for? Precipitate labor Placenta Previa Uterine dysfunction

forceps or vacuum

The newborn nursery nurse suspects a newborn of having neonatal abstinence syndrome. What assessment findings would most correlate with the diagnosis? positive Babinski and Moro reflexes frequent yawning and sneezing vigorous rooting and feeding cyanotic discoloration of the hands and feet

frequent yawning and sneezing

The nurse notifies the obstetrical team because the nurse suspects that the pregnant woman showing signs of amniotic fluid embolism. Which findings should the nurse assess? Select all that apply tachycardia hypertension pulmonary edema bleeding with bruising difficulty breathing

tachycardia, pulmonary edema bleeding with bruising difficulty breathing everything but hypertension because they'll be hypotensive

To assess the frequency of a woman's labor contractions, the nurse would time: the beginning of one contraction to the beginning of the next. the end of one contraction to the beginning of the next. the interval between the acme of two consecutive contractions. how many contractions occur in 5 minutes.

the beginning of one contraction to the beginning of the next.

The two primary types of fetal lie are longitudinal and _________.

transverse

A nurse is assessing a newborn. The nurse suspects that the newborn was exposed to drugs while in utero based on which findings? Select all that apply. frequent yawning tremors coordinated sucking respirations of 43 breaths per minute nasal flaring

tremors frequent yawning nasal flaring

A nurse is caring for a client who has had a c section with general anesthesia. The nurse would assess the woman closely for which possible complication? maternal hypotension uterine atony inadequate pain block pruritis uterine atony

uterine atony -postpartum hemorrhage

A nurse is providing care to a postpartum woman. Documentation of a previous assessment of a woman's lochia indicates that the amount was moderate. The nurse interprets this as reflecting approximately how much? Over 50 ml 10 to 25 ml Under 10 ml 25 to 50 ml

25 to 50 ml

The nurse provides care for a 4lb 10oz (2100.13g) infant delivered at 32 weeks gestation. The nurse notes the infant has mottling of the skin, and lab values indicate metabolic and respiratory acidosis. The nurse recognizes these findings are signs of which problem? Cold stress Respiratory distress syndrome Perinatal asphyxia Hypovolemia

Cold stress

The nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize in response? Print a copy of the instructions for the doula to sign Continue with the admission assessment Determine what activities the doula is qualified to handle Ask the client who she would like to see first

Continue with the admission assessment

The nurse assesses the fundus of a client 12 hours after delivery of a 7lb 2oz (3,240g) newborn. Which action should the nurse take if the fundus is noted to be approximately 1cm above the the umbilicus? Tell them to void Document the results in the client's record. Assess the lochia color and amount

Document the results in the client's record.

Which sign appears early in a neonate with respiratory distress syndrome? poor capillary filling time (3 to 4 seconds) bilateral crackles tachypnea more than 60 breaths/minute pale gray skin color

tachypnea more than 60 breaths/minute

A client in labor has requested the administration of opioids to reduce pain. At 2 cm cervical dilation (dilatation), she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do? Explain to the client that opioids should only be administered an hour or less before birth. Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. Refuse to administer opioids because they can develop dependency in the client and the fetus. Agree with the client, and administer the drug immediately to keep the pain manageable.

Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor.

Which finding might be seen in a neonate suspected of having an infection? increased energy decreased temperature flushed cheeks increased activity level

decreased temperature

A nurse is assessing a newborn for jaundice. The nurse would first notice jaundice at which area? arms legs trunk face

face

A nurse is describing how the fetus moves through the birth canal. Which component would the nurse identify as being most important in allowing the fetal head to move through the pelvis? sutures fontanelles frontal bones biparietal diameter

sutures

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? transthoracic echocardiogram noninvasive arterial studies of the right leg venous duplex ultrasound of the right leg venogram of the right leg

venous duplex ultrasound of the right leg

A pregnant client is admitted to the labor and birth unit in the first stage of labor. The nurse reviews a pregnant client's birth plan. Which response from the client would indicate to the nurse that further teaching is indicated? "We will hire a doula for our labor support" "My 6 year old son will be in the birthing room too" "I would like the baby's father to cut the umbilical cord" "I will remain in my bed for my labor and birth like last time"

"I will remain in my bed for my labor and birth like last time"

When assessing a postpartum woman, the nurse would find which factor to be most significant in identifying possible postpartum hemorrhage? blood pressure cardiac output pulse rate hematocrit

pulse rate

should you apply oxygen to someone who has a protruding umbilical cord

yes

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? normal response to the body converting back to prepregnancy state thromboembolic disorder of the lower extremities infection hormonal shifting of relaxin and estrogen

thromboembolic disorder of the lower extremities

Which environmental consideration is most helpful to promoting comfort when the neonate is withdrawing from alcohol and drugs? Play soothing music Provide a dark, quiet environment Incorporate a massage Offer tactile stimulation

Provide a dark, quiet environment

A birth room nurse notes the presence of thick green amniotic fluid with the rupture of membranes during a vaginal birth. What nursing action is a priority at this time? Repeat pharyngeal suctioning and stimulation of the newborn. Perform pharyngeal suctioning with intubation. Vigorously suction the pharynx until there is strong newborn crying. Wipe the nares and then posterior pharynx immediately and gently.

Wipe the nares and then posterior pharynx immediately and gently.

A new mother is concerned that the infant is not eating enough and will not have enough energy. The nurse explains that storage of which substance will provide energy in the first 24 hours after birth? glucose protein brown fat carbohydrate

glucose

The nurse is caring for an infant born to a mother with cocaine use disorder during her pregnancy. The nurse would likely notice that this infant: cries when touched. has facial deformities. weighed above average when born. sleeps for long periods of time.

cries when touched.

A newborn is diagnosed with an omphalocele. What will the nurse prioritize in the care plan during the preoperative period? care for the infant in a sterile isolette swaddle the newborn in sterile newborn blankets place the infant in a sterile bowel bag place the covered infant under the radiant warmer

place the infant in a sterile bowel bag

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor? labor less than 3 hours placenta removed via manual extraction multiparity hemoglobin of 11.5 mg/dl (115 g/L)

placenta removed via manual extraction

During a home visit with new parents, the nurse also assessed the new father's adaptation to his new role. Which statement would indicate that he is in the expectation phase? "I didn't realize all that went into being a dad. I wasn't prepared for this" "It'll be fun to have a baby in the house, but things shouldn't change too much" "I've learned how to diaper and bathe the baby so I can be a really involved dad" "I may not be a pro at helping out with the baby, but I enjoy being involved"

"It'll be fun to have a baby in the house, but things shouldn't change too much"

An infant is born with respiratory depression. The provider begins actions to maintain effective ventilation. When would the nurse initiate chest compressions? When there is no cardiac activity detectable When no spontaneous respiratory effort is visible When the pulse oximetry reading is less than 80% When the HR is less than 60 BPM

When the HR is less than 60 BPM

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place priority on preparing the client for which intervention? artificial rupture of membranes a cesarean birth a precipitous birth a forceps or vacuum assisted birth

a forceps or vacuum assisted birth

A nurse is providing care to a woman in labor. The nurse determines the client has moved into the active phase based on which assessment findings. Select all that apply a. cervical dilation at 6 cm b. contractions every 1 to 2 minutes c. cervical effacement of 90% d. contractions lasting up to 60 sec e. strong desire to push

a. cervical dilation at 6 cm d. contractions lasting up to 60 sec

Which measure would the nurse expect to be included in the plan of care for an infant of a mother with diabetes who has a serum calcium level of 6.2 mg/dl (1.55 mmol/l)? administration of calcium gluconate initiation of oral feedings infusions of intravenous glucose initiation of phototherapy

administration of calcium gluconate

nursing actions for prolapse cord

apply oxygen remain with client apply pressure to the fetal presenting part and off cord

A nurse is completing the physical assessment of a woman admitted to the unit. Which information would the nurse expect to include as part of the physical assessment? a. current pregnancy history b. fundal height measurement c. support system d. estimated date of birth e. membrane status f. contraction pattern

b. fundal height measurement e. membrane status f. contraction pattern

A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn? bringing the newborn into the room talking about how the nurse held her own newborn while on the birthing table showing a video of parents feeding their babies allowing the mother to pick the best time to hold her newborn

bringing the newborn into the room

A woman arrives in the L&D unit with contractions 5 to 8 minutes apart and dilated at 1 cm. 30 minutes later she is in active labor and 8 cm. The nurse prepares for a precipitate birth and monitors the woman for which priority assessment caused by rapid birth? assess bladder for fullness check perineal area frequently for bleeding assess the woman's breathing and intervene if necessary assess and administer pain medication as needed

check perineal area frequently for bleeding

A nurse is caring for a newborn who was diagnosed with an imperforate anus. Assessment reveals drooling, copious bubbles of mucus in mouth, rattling respirations, and abdominal distention. During feeding, the newborn coughs and becomes cyanotic. Which action by the nurse would be appropriate? clear the airway suction the throat give gavage feedings prepare for endotracheal intubation

clear the airway

A client at 32 weeks gestation has been admitted to the labor and birth unit with preterm labor. Which medication would the nurse be likely to administer to reduce the risk of complications in the preterm newborn? magnesium sulfate nifedipine indomethacin corticosteroids

corticosteroids

A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using? pain pathway blockage massage abdominal imagery effleurage

effleurage

A client who gave birth by cesarean birth 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be: using a breast pump to facilitate removal of stagnant breast milk. encouraging the client to wear a supportive bra.

encouraging the client to wear a supportive bra.

Which intervention would be least effective in caring for a woman who is in the transition phase of labor? encouraging the woman to ambulate providing one-to-one support having the client breathe with contractions urging her to focus on one contraction at a time

encouraging the woman to ambulate

________ or swelling of the breast tissue occurs usually 2 to 4 days after birth.

engorgement

A woman with hydramnios has just given birth. The nurse recognizes that the infant must be assessed for which condition? ankyloglossia torticollis clubfoot (congenital talipes equinovarus) esophageal atresia

esophageal atresia

The instructor determines the session is successful when the students correctly choose which time interval to assess the fetal heart rate of clients who are in the active phase of labor? every 45 to 60 minutes every 2 to 4 hours every 10 to 15 minutes every 15 to 30 minutes

every 15 to 30 minutes

The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition? bile-stained emesis intermittent tachypnea high-pitched, shrill cry expiratory grunting

expiratory grunting

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? whenever the couple wishes usually within a couple weeks generally within 3 to 6 weeks generally after 12 weeks

generally within 3 to 6 weeks

A newborn requires resuscitation secondary to asphyxia. The resuscitation team frequently assesses the newborn's response and continues resuscitation efforts based on which assessment finding? vigorous cry heart rate of 70 beats/min respiratory rate 50 breaths/min pink tongue

heart rate of 70 beats/min

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse? an improperly positioned baby during feedings too much milk being retained mastitis normal findings in breastfeeding mothers

mastitis

A labor and birth nurse is admitting a client in active labor. Which factor(s) in the maternal history will lessen the neonate's risk for developing respiratory distress syndrome (RDS)? Select all that apply. maternal hypertension preterm birth ruptured membranes absent prenatal care maternal age maternal opioid abuse disorder

maternal opioid abuse disorder maternal hypertension ruptured membranes

The perinatal nurse is assessing a large-for-gestational age infant born by breech birth and notes that the infant is irritable and does not move the right arm. For what would the nurse assess? brachial plexus injury cranial nerve trauma midclavicular fracture phrenic nerve injury

midclavicular fracture

nursing interventions for eclampsia

monitor BP oxygen remain with client titrate magnesium sulfate

The nurse is orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? select all that apply nasal flaring respiratory rate of 75 breaths per min Bluish coloration of hands and feet chest retractions heart rate of 120 BPM

nasal flaring respiratory rate of 75 chest retractions

A premature infant in the neonatal intensive care unit exhibits worsening respiratory distress and is noted to have abdominal distention, absent bowel sounds, and frequent diarrhea stools that are positive for hemoccult. What diagnosis would be most likely to correlate with the symptoms? respiratory distress syndrome necrotizing enterocolitis garamycin-resistant bacteria rotavirus infection

necrotizing enterocolitis

A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior? negative attachment positive attachment negative bonding positive bonding

negative attachment

the nurse enters the room and notices that the infant is in the crib against the window. What type of heat loss may this infant suffer? Conduction Radiation Convection Evaporation

radiation

In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. women on antineoplastic medications women who had difficulties with breastfeeding in the past women using street drugs women on antithyroid medications women with more than one infant

women on antithyroid medications women on antineoplastic medications women using street drugs

can a mother with a history of mastectomy breastfeed?

yes

if the mom feels like something is wrong with the baby should she be assessed

yes

A nursing instructor is teaching about newborn congenital disorders and realizes that the student needs further instruction after making which statement? "All congenital disorders can be diagnosed at birth." "Hydrocephalus may not be diagnosed until after a few weeks or months of life." "Congenital defects may be caused by genetic or environmental factors." "Hydrocephalus may be recognized at birth."

"All congenital disorders can be diagnosed at birth."

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? "My mom always used dibucaine." "I already have some pads with witch hazel at home." "Sitz baths worked the last time." "I only eat a low-fiber diet."

"I only eat a low-fiber diet."

The nurse provides instruction to a new parent on how to care for the newborn's umbilical cord. The nurse determines teaching is effective is the parent makes which statement? Select all that apply "I will clean the cord and the skin around it with water." "I'll put petroleum jelly on it" "I'll give her a tub bath tomorrow" "I will allow the cord to fall off on its own."

"I will clean the cord and the skin around it with water.""I will allow the cord to fall off on its own."

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? "It might take up to a week for your bowels to return to their normal pattern." "Let me call your health care provider about this problem." "That's unusual. Are you making sure to eat enough?" "I'll get a laxative prescribed so that you can move your bowels."

"It might take up to a week for your bowels to return to their normal pattern."

The nurse is monitoring the client's vital signs and notes: 100.2oF (37.9oC), heart rate 82, respiratory rate 17, and blood pressure 124/78. The client has recently had an epidural. What is the best response when the client's partner asks if she is getting sick? "She's dehydrated and needs something to drink." "The fever may be due to the epidural." "Have you been exposed to any illnesses recently?" "We will continue to monitor the situation."

"The fever may be due to the epidural."

A woman required an episiotomy and it was repaired by the birth attendant. Which instruction will the nurse give to the woman? "You will have to keep a sterile dressing on the area for 48 hours." "The stitches used will absorb on their own." "Try applying some warm compresses to the area for pain relief." "You will need an injection of a local anesthetic periodically until it heals."

"The stitches used will absorb on their own."

During a postpartum home visit, a woman tells the nurse that her hip joints are sore, just like they were when she was pregnant. Which information would the nurse likely include when teaching the woman about this condition. Select all that apply "You will probably need to take an opioid pain medicine for a few weeks" "This soreness should go away in about 6 to 8 weeks" "Let me show you how to use good body mechanics to lessen the problem" "It is important to lie down on your back at least 3 times a day" "It's important to get this checked out with an x ray just to make sure"

"This soreness should go away in about 6 to 8 weeks" "Let me show you how to use good body mechanics to lessen the problem"

The nurse makes a home visit to a postpartum client and the two week old infant. The client is breastfeeding and tells the nurse the baby nurses 8-9 times per day, has regained all of the lost birth weight, has 6-8 wet diapers per day, and usually has one bowel movement per day. Which response by the nurse is best? "Your baby is doing very well. Keep up the good work!" "Your baby should be gaining more weight" "Your baby should have at least 3 bowel movements a day"

"Your baby is doing very well. Keep up the good work!"

A mother choosing to breast-feed requires an additional _______ calories per day.

500

A neonate is being admitted to the observational nursery with the diagnosis of post maturity. What would the nurse expect to find with this gestational age variation? select all that apply A. Meconium-stained skin and fingernails B. Abundant lanugo C. decreased breast tissue D. Thin umbilical cord E. Peeling, wrinkled skin F. abundant vernix caseosa G. Few sole creases

A. Meconium-stained skin and fingernails D. Thin umbilical cord E. Peeling, wrinkled skin

A nurse is caring for a neonate with transient tachypnea of the newborn. Which is the prioritynursing intervention? Perform gentle suctioning. Administer IV fluids; gavage feedings. Maintain adequate hydration. Monitor for signs of hypotonia.

Administer IV fluids; gavage feedings.

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response? Ask the client when she last changed her perineal pad. Vigorously massage the fundus. Immediately call the primary care provider. Have the charge nurse review the assessment.

Ask the client when she last changed her perineal pad.

Which documentation in the health record is most correct for the third stage of labor? Begins with the time of placental delivery and ends 48 hours later. Begins with the time of placental delivery and ends when the health care provider is satisfied that there are no placental fragments. Begins with the time of full cervical dilation (dilatation) and ends with the delivery of the fetus. Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta.

Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta.

The nurse is preparing a young couple for the upcoming birth of their child, and the mother expresses concern for needing pain medications and the effects on the fetus. When counseling the couple about pain relief, the nurse would incorporate which information in the teaching about measures to help to decrease the requests for pain medication? Continuous support through the labor process helps decrease the need for pain medication. Lying on an ice pack can help decrease the need for pain medication. Sitting in a hot tub helps decrease the need for pain medication. A quick epidural can replace the need for pain medication.

Continuous support through the labor process helps decrease the need for pain medication.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next? Administer Rh immunoglobulins intramuscularly. Ask if the client received rH immunoglobulins during the pregnancy. Determine the newborn's blood type and rhesus. Determine if this is the client's first baby.

Determine the newborn's blood type and rhesus.

The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize? Call the primary care provider, and obtain a reduced dose of meperidine. Give the meperidine because she needs pain relief now. Call the anesthetist from the nurse's station to retry the epidural. Encourage her through the contractions, explaining why she cannot receive any pain medication.

Encourage her through the contractions, explaining why she cannot receive any pain medication.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? Apply ice packs for 40 minutes continuously. Use ice packs for a week after birth. Ensure ice pack is changed frequently. Apply ice packs directly to the perineal area.

Ensure ice pack is changed frequently.

When caring preoperatively for a neonate with a diagnosed tracheoesophageal fistula, which symptoms are anticipated? Select all that apply. Elevated heart rate Cyanosis Excessive drooling Bradypnea Frothing Heartburn with feedings

Excessive drooling Cyanosis Elevated heart rate Frothing

The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize? Green-colored fluid in the vagina Irregular contractions Possible maternal infection Fetal heart rate

Green-colored fluid in the vagina

A multiparous woman at 39 weeks arrives at the unit stating she is in labor. Upon pelvic examination the nurse documents a softening of the cervix at 3 cm dilation. Which nursing action is best? Have the client rest in bed on her left side send the client home and return if contractions increase admit the client directly to labor and delivery area Have the client ambulate in the hall

Have the client ambulate in the hall

A nurse is developing a plan of care for a woman who has had a spontaneous vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on which of the following? Select all that apply Labor of 1.5 hours Labor induction with oxytocin Forceps birth third stage of labor of 10 min Hemoglobin 10.0

Labor of 1.5 hours Labor induction with oxytocin Forceps birth

At birth, a neonate is diagnosed with brachial plexus palsy. The parent asks how the nurse knows the neonate's positioning of the arm is a result of the palsy and not just a preferred position. The nurse would show the parent that the neonate has asymmetry of which neonatal reflex? Babinski rooting Moro stepping

Moro

A woman gave birth vaginally approximately 12 hours ago and her temperature is 100.8. Which action is most appropriate for the nurse? Continue monitoring the woman's temp every 4 hours, this finding is normal Obtain a urine culture, the woman most likely has a UTI Inspect the perineum for hematoma formation Notify the health care provider about this elevation

Notify the health care provider about this elevation

The client comes to the hospital in labor. The membranes rupture at 0410. Which action does the nurse take first? Contacts health care provider for immediate delivery Documents admission and notes the time of ruptured membranes Identifies the amniotic fluid by performing a nitriazine test Observes the amniotic fluid for any signs of infection or meconium.

Observes the amniotic fluid for any signs of infection or meconium.

The nurse is caring for a neonate with epispadias. In which location will the nurse assess the anomaly? On the dorsal end of the penis On the anterior scrotum At the distal end of the testes On the ventral surface near the chordee

On the dorsal end of the penis

The nurse provides care for a client in active labor and who is 6cm dilated. The client is now ready for epidural anesthesia. Which position will the nurse assist the client? On the left side, shoulders parallel, legs flexed, and back arched. Modified knee chest with upper leg flexed and lower leg extended A sitting position with back straight and feet supported on a stool

On the left side, shoulders parallel, legs flexed, and back arched.

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention? Bladder is nonpalpable. Uterus is firm. Percussion reveals dullness. Lochia is less than usual.

Percussion reveals dullness.

Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths? Sitz baths cause perineal vasoconstriction and decreased bleeding. Sitz baths increase the blood supply to the perineal area. Sitz baths may lead to increased postpartum infection. The longer a sitz bath is continued, the more therapeutic it becomes.

Sitz baths increase the blood supply to the perineal area.

A client at 6 weeks' gestation asks the nurse what foods she should eat to help prevent neural tube disorders in her growing baby. The nurse would recommend which foods? Milk, yogurt, and cheese Bananas, avocados, and coconut Spinach, oranges, and beans Pork, beans, and poultry

Spinach, oranges, and beans

The nurse has completed assessing the vital signs of several clients who are from 36 to 48 hours postpartum. For which set of vital signs should the nurse prioritize? Temp: 99.6, HR: 90, RR: 18, BP: 112/67 Temp: 97, HR: 80, RR: 20, BP: 120/72 Temp: 100.2, HR: 65, RR: 22, BP: 130/78 Temp: 98.6, HR: 74, RR: 16, BP: 150/85

Temp: 98.6, HR: 74, RR: 16, BP: 150/85

A nurse is concerned that a 1-day-old newborn is becoming ill and may be septic. What sign of distress would validate the nurse's concerns? Erythema toxicum Respiratory rate of 40 breaths/min Heart rate of 152 beats/min Temperature instability

Temperature instability

The nurse notes in a newborn's chart that the newborn has been diagnosed with physiological jaundice. The nurse recognizes that physiological jaundice is determined by what criteria? The jaundice occurred within the first 24 hours of life The bilirubin peaked between days 3 and 5 days after birth The bilirubin level rose 6 mg/dL to 13 mg/dL over the last 24 hours The conjugated bilirubin is higher than the unconjugated bilirubin

The bilirubin peaked between days 3 and 5 days after birth

The client may spend the latent phase of the first stage of labor at home unless which occurs? The contractions vary in length and intensity The client begins back labor The client passes the bloody show The client experiences a rupture of membranes

The client experiences a rupture of membranes

The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action? The client is afebrile. The client requires assistance to ambulate in the hallway. The fundus is located 2 fingerbreadths above the umbilicus. The client is having a moderate amount of rubra lochia. Bowel sounds are active.

The fundus is located 2 fingerbreadths above the umbilicus.

Which assessment finding within the first 24 hours of birth requires immediate health care provider notification? The skin is jaundiced. The neonate slept for 18 hours. Milia is noted on the nose. The neonate ate 1 to 2 oz of formula.

The skin is jaundiced.

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 ml with each hourly void. How would the nurse interpret this finding? The urinary output is inadequate suggestive of urinary retention. The urinary output is above expected levels. The urinary output is inadequate and the mother needs to drinks more fluids. The urinary output is normal.

The urinary output is normal.

Effacement occurs when the fetal presenting part begins to descend into the maternal pelvis. True False

True

The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event? Uteroplacental insufficiency Cord compression Maternal fatigue Maternal hypotension

Uteroplacental insufficiency

The nurse is caring for a 22-hour-old neonate male and notes on assessment at the beginning of the shift: Apgar score of 9, nursing without difficulty, and appeared healthy. As the nurse's shift goes on, subsequent assessment reveals his sclera and skin have begun to take on a yellow hue. The nurse would report this as a possible indication of what condition? hypoxia heroin withdrawal hypoglycemia hemolytic disease

hemolytic disease

The nurse is admitting to the nursery a newborn of a mother who continued to drink alcohol during her pregnancy. Which finding does the nurse predict to encounter on the newborn's assessment? above average birth weight lethargic and sleepy large head circumference hyperactive and irritable

hyperactive and irritable

A 32 weeks' gestation newborn is admitted to the neonatal intensive care unit. The assessment reveals a pale dyspneic newborn with marked tremors, a bulging anterior fontanel (fontanelle), and a high-pitched cry. What diagnosis best correlates with the assessment findings? respiratory distress syndrome persistent pulmonary hypertension of the newborn meconium aspiration syndrome periventricular-intraventricular hemorrhage

periventricular-intraventricular hemorrhage

the nurse observes the staff member palpate a clients uterine contractions. the nurse determines the staff member is using the correct technique if which observation is made?

places one hand on the abdomen over the fundus and presses gently with the fingertips

A maternity nurse is aware that the fetal head is the presenting part in complete extension position. Which type of birth should the maternity nurse anticipate? prolonged labor and possible cesarean birth a forceps-assisted vaginal birth a normal labor and a spontaneous vaginal birth precipitous labor and birth

prolonged labor and possible cesarean birth

When caring for a neonate receiving phototherapy, the nurse should remember to: massage the neonate's skin with lotion. decrease the amount of formula. reposition the neonate frequently. dress the neonate warmly.

reposition the neonate frequently.

the nurse knows a preterm infant is at greatest risk for developing which disorder?

respiratory distress syndrome

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring? the presenting fetal part not visible insertion by any staff cervical dilation of 1 cm rupture of membranes

rupture of membranes

duration is always measured in ______

seconds

A nurse has been assisting a client who has been in labor. The nurse determines the client is moving into the transition phase based on which assessment findings? select all that apply apprehension mixed with excitement cervical dilation at 6 cm cervical effacement of 70% irritability with restlessness strong desire to push

strong desire to push irritability with restlessness

first sign of postpartum hemorrhage

tachycardia

the school nurse attends a soccer game at the local high school. the nurse sees a pregnant woman grab her throat, indicating she is choking, and is unable to speak. which action is best for the nurse to take?

the nurse stands behind the woman and performs chest thrusts

A nurse is assessing a newborn diagnosed with fetal alcohol spectrum disorder. Which findings would the nurse expect to assess? Select all that apply. macrocephaly maxillary hyperplasia poor hand-eye coordination thin upper lip altered plantar crease pattern

thin upper lip poor hand-eye coordination