ATI - MATERNAL NEWBORN

What is the expected weight loss for a breastfeeding mom?

2.2 pounds monthly

A pregnant client with a prepregnancy BMI of 38 should gain how much weight during pregnancy?

5 to 9.1 kg Rationale: An 11 to 20 lb weight gain during pregnancy is recommended for those with a prepregnancy BMI > 30

What is a nonpharmacological method of pain relief during the active stage of labor?

A warm shower Rationale: A warm shower helps to decrease labor pain. It stimulates the release of endorphins and increases circulation. Hydrotherapy is also an effective method of labor pain management

A nurse is teaching about preventing engorgement to a client who is planning to use formula to feed her newborn. Which of the following instructions should the nurse include? A. "Apply ice packs to your breasts." B. "Hand express milk from your breasts 3 times each day." C. "Try to avoid wearing a bra as much as possible throughout the day." D. "Request a prescription for medication to suppress lactation."

A. "Apply ice packs to your breasts." Rationale: Applying ice packs to the breasts can assist in reducing the discomforts of engorgement. Pumping or hand expressing can cause breast stimulation and continued milk production. The client should wear a well-fitted and supportive bra for the first 72 hours after delivery to assist with suppression of lactation. No medications are indicated for lactation suppression.

A nurse is providing discharge instructions to the parent of a newborn. Which of the following statements should the nurse include? A. "Crib slats should be less than 2.25 inches apart." B. "Bed sharing is recommended for safe sleep." C. "Place the newborn on their stomach for sleeping." D. "Place the crib next to the heating vent to keep them warm."

A. "Crib slats should be less than 2.25 inches apart." Rationale: Crib slats should be no more than 5.7 cm (2.25 in) apart to prevent injuries due to falls or entrapment of the infant's head between the slats. Room sharing, not bed sharing, is recommended for safe sleep. Bed sharing can increase the child's risk of suffocation and SIDS. Parents should always place the newborn on his back to sleep to decrease the risk of SIDS. Never place the crib next to a heating vent or radiator to prevent overheating and injury from burns.

A nurse in a provider's office is caring for a client who is in the first trimester of pregnancy. Which of the following psychological tasks should the nurse expect the client to accomplish during this trimester? A. Accepting the pregnancy B. Preparing for the end of the pregnancy C. Preparing for parenthood D. Accepting the baby

A. Accepting the pregnancy Rationale: Accepting the pregnancy is a psychological task that the client is expected to accomplish during the first trimester. Preparing for the end of pregnancy is a psychological task that the client is expected to accomplish during the third trimester. Preparing for parenthood is a psychological task that the client is expected to accomplish during the third trimester. Accepting the baby is a psychological task that the client is expected to accomplish during the second trimester.

A nurse is providing care to a client who is in labor. A fetal heart tracing shows early decelerations. Which of the following actions should the nurse take? A. Continue to monitor the fetal heart tracings B. Elevate the client's legs C. Increase the rate of the maintenance IV fluid D. Administer oxygen via facemask

A. Continue to monitor the fetal heart tracings Rationale: Early decelerations reflect fetal head compression and are a benign and normal finding during labor. Elevating the client's legs or increasing the rate of the IV maintenance fluid are appropriate for late decelerations. They also help to resolve maternal hypotension. Oxygen via facemask is appropriate for late or variable decelerations.

A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect? A. Dark red vaginal bleeding B. Increased platelet count C. Fetal Distress D. Decreased urinary output

A. Dark red vaginal bleeding Rationale: The nurse should expect this client with mild placental abruption to have minimal dark red vaginal bleeding.

A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which of the following findings should the nurse report to the provider? A. Frequent headaches B. Leukorrhea C. Epistaxis D. Periodic numbness of the fingers

A. Frequent headaches Rationale: The nurse should report frequent headaches to the provider. Frequent headaches, swelling of the face and fingers, visual disturbances, and epigastric pain are associated with preeclampsia. Leukorrhea (abundant amount of vaginal mucus) is a normal finding in pregnancy. Epistaxis is a common discomfort of pregnancy related to the increase of estrogen. Periodic numbness of the fingers is a common discomfort of pregnancy due to compression of the nerves.

A nurse is reviewing the lab findings of a 24-hour-old newborn. Which of the following findings should the nurse report to the provider? A. Hemoglobin 12 g/dL B. Platelet count 200,000 C. Total bilirubin 4 mg/dL D. Glucose 50 mg/dL

A. Hemoglobin 12 g/dL Rationale: The normal range is 14 - 24 g/dL

A nurse is reviewing the lab report of a newborn who has a blood type of B-negative. The mother's blood type is O+. The lab results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse anticipate? A. Hyperbilirubinemia B. Central Cyanosis C. Intracranial hemorrhage D. Cardiomyopathy

A. Hyperbilirubinemia Rationale: The nurse should identify that some infants of mothers with type O blood are at an increased risk for developing hyperbilirubinemia because the mothers possess naturally occurring A and B antibodies, which are transferred across the placenta to the fetus

A nurse is caring for a client in labor who has an epidural for pain relief. Which of the following is a complication of the epidural block? A. hypotension B. nausea/vomiting C. tachycardia D. respiratory depression

A. Hypotension Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of epidural anesthesia in order to decrease the likelihood of this complication.

A nurse is assessing a newborn 1 hour after birth. Which of the following findings should the nurse report to the provider? A. Jaundice of the sclera B. Respiratory rate 50/min C. Acrocyanosis D. Blood glucose 60 mg/dL

A. Jaundice of the sclera Rationale: If the newborn has jaundice within the first 24 hours of life, this can indicate a potentially pathological process such as hemolytic disease. Pathological jaundice can result in high levels of bilirubin, which can damage the neonatal brain.

A nurse is caring for a client who is at 24 weeks gestation and has a suspected placental abruption. Which of the following lab tests should the nurse expect the provider to prescribe? A. Kleihauer-Betke test B. Progesterone serum level C. Lecithin/sphingomyelin (L/S) ratio D. Maternal Alpha-fetoprotein (AFP)

A. Kleihauer-Betke test Rationale: A Kleihauer-Betke test can determine if fetal blood is in maternal circulation. This test is useful to determine if Rh- (D) immune globulin therapy should be given to a client who is Rh-. A progesterone serum level helps to determine if a client is pregnancy and if the pregnancy is ectopic. The L/S ratio is done as part of an amniocentesis to evaluate fetal lung maturity. The AFP tests for neural tube defects or chromosome disorders.

A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk of uterine atony? (Select all that apply.) A. Magnesium sulfate infusion B. distended bladder C. Oxytocin infusion D. Prolonged labor E. Small for gestational age newborn

A. Magnesium sulfate infusion B. Distended bladder D. Prolonged labor Rationale: Magnesium sulfate is a smooth muscle relaxant and can prevent adequate contraction of the uterus. After birth, clients can experience a decreased urge to void due to birth-induced trauma, increased bladder capacity, and anesthetics, which can result in a distended bladder. A distended bladder displaces the uterus and can prevent adequate contraction of the uterus. Also, prolonged labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus from contracting.

A nurse is assessing a client who reports that she might be pregnant. Which of the following findings should the nurse identify as a presumptive sign of pregnancy? A. Nausea in the morning B. Positive home pregnancy test C. Increased sensitivity of the cervix noted upon examination D. Gestational sac observed by transvaginal ultrasound

A. Nausea in the morning Rationale: Nausea is a presumptive sign of pregnancy - that is, a subjective symptom reported by the mom that could have a cause other than pregnancy

When an amniocentesis is performed, what nursing intervention should be performed?

Apply an external fetal monitor to the client Rationale: Fetal heart tones and uterine tone should be assessed prior to and throughout the procedure to establish a baseline and monitor for changes

A nurse is caring for an infant who begins displaying manifestations of neonatal abstinence syndrome NAS. What should be avoided when feeding the infant?

Avoid eye contact and talking during feedings Rationale: Infants with NAS have difficulty processing multiple forms of stimulation and can quickly become frustrated

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? SATA A. Yellow sclera B. Acrocyanosis C. Posterior fontanel larger than the anterior fontanel D. Positive Babinski reflex E. Two umbilical arteries visible

B, D, E Rationale: Yellow sclera is incorrect as it's an indication of hyperbilirubinemia and not expected. Acrocyanosis is an expected finding for the first 24 hrs after birth as poor peripheral perfusion leads to bluish discoloration in the newborn's hands and feet. The posterior fontanel is smaller than the anterior fontanel. Newborns should exhibit a positive Babinski reflex. The umbilical cord should have 2 arteries and 1 vein.

A nurse is caring for a client who is 12 hr postpartum. Which of the following interventions should the nurse implement for a patient with O+ blood type, third degree lacerations of the perineum and a Hemoglobin level < 10.5 g/dL? A. Encourage the client to use a hot pack on the perineum B. Administer ferrous sulfate orally C. Help the client apply a breast binder D. Administer Rh immune globulin

B. Administer ferrous sulfate orally Rationale: Patients should receive ferrous sulfate orally with a Hgb < 10.5 g/dL. A cold pack should be used on the perineum the first 24 hours with a third degree laceration. Rh immune globulin should be given within 72 hours of birth to clients who are Rh-negative and have a newborn who is Rh-positive

A nurse is caring for a client who is in active labor and whose birth plan requests only nonpharmacological pain relief strategies. Which of the following strategies should the nurse offer as a form of cutaneous stimulation? A. Breathing techniques B. Counter-pressure C. Biofeedback D. Use of a focal point

B. Counter-pressure Rationale: Cutaneous stimulation (stimulation of nerves via skin contact in an effort to reduce pain impulses to the brain) strategies include walking, effleurage (massage using circular stroking movement), water therapy, application of heat or cold

A nurse is caring for a client who is in labor. The nurse decides to switch from intermittent auscultation to continuous fetal monitoring. Which of the following data can be obtained from continuous electronic fetal monitoring? A. Determination of a baseline B. Determination of variability C. Presence of accelerations D. Presence of decelerations

B. Determination of variability Rationale: Continuous electronic fetal monitoring is required to determine variability since the nurse needs a monitor tracing to quantify variability

A nurse is caring for a client who is in labor and has received epidural analgesia. The client's blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Increase the rate of the primary IV infusion C. Position the client in a semi-Fowler's position D. Provide glucose via oral hydration IV

B. Increase the rate of the primary IV infusion Rationale: Late decelerations can be caused by uteroplacental insufficiency. The fetal heart tracing shows a gradual decrease in fetal heart rate with a return to baseline on uterine contractions. This could be related to maternal hypotension, which can be corrected with increased IV fluids to increase maternal blood volume. This improves uterine and cardiac perfusion as well. A client who has received epidural analgesia should not be assisted out of bed to the toilet or a bedside commode due to inhibited muscle control and the increased risk of falling. Maternal position influences both maternal hypotension and the fetal response to low blood pressure. Positioning the client in a lateral or Trendelenburg position improves maternal circulation. Hypotension is a function of low blood pressure rather than low blood glucose. The nurse should address low blood pressure through positioning and bolus IV fluids.

A nurse is preparing to help with a vacuum-assisted birth. Which of the following actions should the nurse plan to take? A. Instruct the client to stop pushing during contractions B. Inform the client that caput succedaneum resolves in a few days C. Monitor the newborn for decreased levels of bilirubin D. Identify that the newborn is at risk for facial palsy

B. Inform the client that caput succedaneum resolves in a few days Rationale: Caput succedaneum should be anticipated. The client should continue pushing during contractions. The newborn is at risk for hyperbilirubinemia following a vacuum-assisted birth. Newborns with a forcep-assisted delivery are at risk for facial palsy.

A nurse is assessing a 12-hour-old newborn notes mild jaundice of the face and trunk. Which of the following actions should the nurse take? A. Administer phytonadione IM B. Obtain a stat prescription for a bilirubin level C. Obtain a bagged urine specimen D. Perform a gestational age assessment

B. Obtain a stat prescription for a bilirubin level Rationale: Jaundice in the first 24 hours of life is pathologic. The nurse should notify the provider and obtain a stat prescription for a bilirubin level.

A nurse is assessing a client who has placenta previa. Which of the following findings should the nurse expect? A. Painless, bright red bleeding B. Uterine hypertonicity C. Uterine tonicity D. Abdominal tenderness

A. Painless, bright red bleeding Rationale: Placenta previa is the placement of the placenta low in the uterus. Depending on the severity, manifestations include painless, bright red vaginal bleeding and a fundal height higher than expected for the gestational age. The presenting part is higher due to the placenta taking up space inside the lower part of the uterus. Uterine hypertonicity is a manifestation of placental abruption, not placenta previa. Uterine tonicity is normal with placenta previa; it does not cause contractions. Abdominal tenderness or pain is a manifestation of placental abruption, not placenta previa.

A nurse is assessing a client who has placenta previa. Which of the following findings should the nurse expect? A. Painless, bright red bleeding B. Board-like uterus C. Persistent uterine contractions D. Abdominal pain

A. Painless, bright red bleeding Rationale: Placenta previa is the placement of the placenta low in the uterus. Depending on the severity, manifestations include bright red vaginal bleeding and a fundal height higher than expected for gestational age. The presenting part is higher due to the placenta taking up space inside the lower part of the uterus.

A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy? A. Palpable fetal movement B. Chadwick's sign C. Positive pregnancy test D. Amenorrhea

A. Palpable fetal movement Rationale: Palpable fetal movements are a positive sign of pregnancy. Quickening (client's report of fetal movement) is a presumptive sign of pregnancy. Chadwick's sign (bluish discoloration of the cervix, vagina, and vulva that occurs at 6 to 8 wks of pregnancy), a positive pregnancy test, and amenorrhea are all probable signs of pregnancy.

A nurse is teaching a client who has active genital herpes simplex virus, type 2. Which of the following statements should the nurse include in the teaching? A. You will have a cesarean birth prior to the onset of labor B. Your baby will receive erythromycin eye ointment after birth to treat the infection C. You should take oral metronidazole for 7 days prior to 37 weeks gestation D. You should schedule a cesarean birth after your water breaks

A. You will have a cesarean birth prior to the onset of labor Rationale: Whenever possible, a cesarean birth should be scheduled prior to the onset of labor or rupture of membranes to reduce the risk of neonatal transmission of herpes. A client who has active herpes should receive a prescription for acyclovir.

A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend? A. Copper intrauterine device B. Oral contraceptives C. Vaginal Insert D. Injectable progestin

A: Copper intrauterine device Rationale: A copper intrauterine device that does not contain hormones is a safer choice for this client. A history of thrombophlebitis is a contraindication for the use of hormonal contraceptive methods such as oral combinations of estrogen and progesterone in pill form, vaginal inserts that release hormones continuously, and injectable progestins. Other options for this client include barrier methods and spermicides.

A nurse is monitoring a client who is receiving spinal anesthesia. The nurse should identify which of the following findings as a complication of the infusion? A. Maternal hypotension B. Fetal tachycardia C. Increased fetal heart rate variability D. Hypothermia

A: Maternal hypotension Rationale: Maternal hypotension is a common adverse effect of a spinal block. To prevent supine hypotension, the client should lie on their side or supine with a wedge under a hip to displace the uterus. Spinal anesthesia is more likely to cause fetal bradycardia than fetal tachycardia. Spinal anesthesia is more likely to cause minimal or a lack of fetal heart rate variability than increased fetal heart rate variability. Spinal anesthesia is more likely to cause a fever than hypothermia.

A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider? A. Fundal height 34 cm B. Report of decreased fetal movement C. Report of occasional ankle swelling D. BP 110/80 mmHg

B. Report of decreased fetal movement Rationale: Decreased fetal movement could be a complication related to fetal well-being. A decrease in fetal movement could indicate fetal distress. A client at 32 wks should have a fundal height about the same as the number of weeks gestation, plus or minus 2 cm. Occasional ankle edema is a common discomfort at 32 wks gestation. A BP of 110/80 is an expected finding.

A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? A. Administer antiviral medication B. Schedule an ultrasound examination C. Administer Haemophilus influenzae type b vaccine D. Schedule an indirect Coombs' test

B. Schedule an ultrasound examination Rationale: Serial ultrasound examinations should be scheduled to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, IUGR, fetal anemia and stillbirth. There are currently no antiviral medications to treat fifth disease. An indirect Coombs' test determines whether the client has antibodies to the Rh antigen.

What is the appropriate temperature of a newborn's bath water?

Between 38 C and 40 C (100 F to no more than 104 F) to prevent injuries

What is the Chadwick's sign?

Bluish discoloration of the cervix, vagina and vulva that occurs at 6-8 wks. The Chadwick's sign is a probably sign of pregnancy

A nurse is caring for a client who is at 38 weeks gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? A. Determine progression of dilation and effacement B. Perform Leopold maneuvers C. Complete a sterile speculum exam D. Prepare a Nitrazine paper test

B. Perform Leopold maneuvers Rationale: Using Leopold maneuvers assesses the position of the fetus to best determine optimal placement for the external fetal monitoring transducer. The client's dilation and effacement should be done prior to applying an internal monitor. Sterile speculum examination is only done by the provider and is not required for an external transducer. A Nitrazine paper test is performed to assess the pH level of vaginal fluids after the membranes have been ruptured.

A patient has been prescribed an iron supplement. Which foods would the nurse recommend to help increase the client's iron absorption?

Citrus fruits, strawberries, melons, tomatoes Rationale: Foods that have a high vit C content help increase the absorption of iron.

A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5 kg. The amount available is morphine oral solution 0.4 mg/mL. How many mL should the nurse administer? (Fill in the blank with the numeric value only, round the answer to the nearest hundredth, and use a leading zero if applicable. Do not use a trailing zero.) Show Explanation

Correct Answer: 0.25 To solve using the ratio and proportion method: Step 1: What is the unit of measurement the nurse should calculate? mg Step 2: Set up an equation and solve for X: mg x kg = X 0.04 mg x 2.5 kg = 0.1 mg Step 3: What is the unit of measurement the nurse should calculate? mL Step 4: What is the dose the nurse should administer? 0.1 mg Step 5: What is the dose available? 0.4 mg Step 6: Should the nurse convert the units of measurement? No Step 7: What is the quantity of the dose available? 1 mL Step 8: Set up the equation and solve for X. Have/Quantity = Desired/X 0.4 mg/1 mL = 0.1 mg/X X = 0.25 mL Step 9: Reassess to determine whether the amount to administer makes sense. If 0.4 mg/mL is available and the prescription is 0.1 mg, the nurse should administer morphine oral solution 0.25 mL. To solve using the "desired over have" method: Step 1: What is the unit of measurement the nurse should calculate? mg Step 2: Set up an equation and solve for X: mg x kg = X 0.04 mg x 2.5 kg = 0.1 mg Step 3: What is the unit of measurement the nurse should calculate? mL Step 4: What is the dose the nurse should administer? 0.1 mg Step 5: What is the dose available? 0.4 mg Step 6: Should the nurse convert the units of measurement? No Step 7: What is the quantity of the dose available? 1 mL Step 8: Set up the equation and solve for X. Desired x Quantity/Have = X 0.1 mg x 0.4 mg/1 mL = 0.25 mL X = 0.25 mL Step 9: Reassess to determine whether the amount to administer makes sense. To solve using dimensional analysis: Step 1: What is the unit of measurement the nurse should calculate? mg Step 2: Set up an equation and solve for X: mg x kg = X 0.04 mg x 2.5 kg = 0.1 mg Step 3: What is the unit of measurement the nurse should calculate? mL Step 4: What is the quantity of the dose available? 1 mL Step 5: What is the dose available? 0.4 mg Step 6: What is the dose the nurse should administer? 0.1 mg Step 7: Should the nurse convert the units? No Step 8: Set up the equation and solve for X. X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired 0.4 mg/1 mL x 0.1 mg = 0.25 mL X = 0.25 mL Step 9: Reassess to determine whether the amount to administer makes sense.

A nurse is assessing a client who has hyperemesis gravidarum. Which of the following findings should the nurse expect? A. Elevated serum potassium level B. Rapid weight gain C. Peripheral edema D. Presence of ketones in the urine

D. Presence of ketones in the urine Rationale: A patient with hyperemesis gravidarum (excessive N/V during pregnancy). These patients have inadequate dietary intake resulting in the breakdown of protein and stored fat causing the presence of ketones in the urine

A nurse is preparing to provide umbilical cord care for a newborn 12 hrs after delivery. Upon inspection, the nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take? A. Check the newborn's heart rate B. Place a pressure dressing on the cord stump C. Administer vitamin K D. Check the integrity of the cord clamp

D. Check the integrity of the cord clamp Rationale: The nurse should apply the clamp to the umbilical cord while detaching it from the placenta to stop blood flow from the cord to the placenta. If blood is coming from a vessel prior to the cord stump necrotizing, the nurse should ensure the cord clamp has not loosed or opened. If it has, a new clamp should be applied immediately.

A nurse is caring for a newborn immediately following birth. Which of the following actions should the nurse take first? A. Obtain the newborn's weight within 1-2 hrs after birth B. Instill erythromycin ophthalmic ointment in the newborn's eyes after the first breastfeeding to prevent infection C. Administer vitamin K to the newborn within 1 to 2 hours after birth to prevent bleeding D. Dry the newborn

D. Dry the newborn Rationale: The greatest risk to the newborn immediately after birth is heat loss, which can cause cold stress, respiratory distress, and hypoglycemia. Therefore, the first action the nurse should take is to dry the newborn to prevent heat loss from evaporation. The other answers are correct but not the priority

A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching? A. Apply the diaper tightly over the circumcision area. B. Remove the yellow exudate with each diaper change. C. Use prepackaged commercial wipes to clean the circumcision site. D. Encourage nonnutritive sucking for pain relief.

D. Encourage non-nutritive sucking for pain relief Allowing the newborn to suck on a pacifier is an effective form of nonpharmacological pain management.

A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect? A. Fundal height of 34 cm (13.4 in) B. Total pregnancy weight gain of 3.6 kg (8 lb) C. Gestational hypertension D. Fetal gastrointestinal anomaly

D. Fetal gastrointestinal anomaly Rationale: Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. GI malformations and neurological disorders are expected findings. Polyhydramnios will result in a fundal height greater than expected for gestational age and an increase in weight gain. Gestational hypertension causes oligohydramnios, which is a decrease in the amount of amniotic fluid surrounding the fetus.

A nurse is reviewing the provider's admission orders for a client who is at 37 weeks of gestation and is HIV positive. Which of the following orders should the nurse clarify with the provider? A. Intermittent ausculatation B. Biophysical profile C. Non-stress test NST D. Fetal scalp electrode

D. Fetal scalp electrode Rationale: The placement of a fetal scalp electrode is an invasive procedure that requires ruptured membranes. The electrode is inserted into the fetal scalp, which will increase the fetus's exposure to HIV and is contraindicated.

A nurse is assessing a client who is at 30 weeks gestation and has gestational hypertension. Which of the following findings should the nurse identify as an indication that the client needs a biophysical profile? A. Fundal heigh of 30 cm B. Fetal movement count 12 kicks in 12 hours C. Fetal heart rate 136/min D. Nonreactive nonstress test

D. Nonreactive nonstress test Rationale: When a non-stress test is nonreactive, the examiner will extend the duration of the test and use techniques such as vibroacoustic stimulation to try to elicit a response from the fetus. If the test is still nonreactive, the client should undergo a biophysical profile

A nurse is caring for a client who is attempting a trial of labor (TOL) after several cesarean births. The client reports a sudden onset of constant abdominal pain, and the nurse observes a prolonged deceleration on the FHR. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Place the client in a knee-chest position C. Plan to administer calcium gluconate D. Prepare for an emergency c-section

D. Prepare for an emergency c-section Rationale: Sudden onset of abdominal pain accompanied by a prolonged fetal deceleration in a laboring client who previously delivered by c-sect is a manifestation of uterine rupture which indicates an emergency cesarean delivery

A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min and respiratory rate of 36/min. The newborn has well-flexed extremities, responds to stimuli with a cry, and has blue hands and feet. Which Apgar score should the nurse assign to the newborn? A. 7 B. 8 C. 9 D. 10

C. 9 The nurse should use the Apgar scoring system to perform a quick assessment of the newborn at 1 minutes and 5 minutes after birth. The nurse should assign a score of 0, 1, or 2 to each of 5 categories. The nurse should assign a score of 2 for a heart rate >100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well-flexed extremities, which shows normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a score of 1 for blue hands and feet, which is known as acrocyanosis.

A nurse is providing care for a pregnant adolescent at 12 weeks gestation and verbalizes fear of gaining weight during pregnancy. Which of the following actions should the nurse take? A. Have the client watch a video on fetal growth and development during pregnancy. B. Supply pamphlets that discuss the importance of nutrition during pregnancy C. Explain how poor nutrition can prevent the baby from growing properly D. Provide examples of how eating will help maintain a healthy weight during pregnancy

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

A nurse is caring for a client who is in active labor and receiving an oxytocin infusion. The nurse notes tachysystole with a Category 1 fetal heart rate tracing. Which of the following actions should the nurse take? A. Discontinue oxytocin infusion and apply oxygen B. Increase oxytocin infusion rate by 2 mu/min C. Administer terbutaline 0.25 mg subq D. Reposition the client in a side-lying position and continue to monitor

D. Reposition the client in a side-lying position and continue to monitor Rationale: A Category 1 fetal heart rate tracing is an expected finding and does not represent fetal distress. The patient should be positioned in a side-lying position to optimize uteroplacental perfusion and continue to monitor the tracing for another 10 min to determine if tachysystole resolves

What is patient education for a patient in the first trimester to ease nausea and vomiting?

Eat crackers before getting out of bed in the morning Eat small meals with carbohydrates Have a small snack before bedtime Acupressure bands on the wrists might help Avoid brushing teeth right after eating and avoid fatty foods

A nurse is teaching about mastitis to a client who is postpartum and breastfeeding her newborn. What statement by the client indicates an understanding of the teaching?

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

What should be reported to the HCP during the second trimester?

Increased urinary frequency and urgency. This is a common finding during the first and third trimester due to fetal pressure on the bladder but during the second trimester should be reported to the HCP

What should be reported to the HCP as an indication of hypothermia or respiratory distress?

Mottling

What temperature should a hot water heater be set in the home of a newborn baby?

No more than 120 F (48.9 C) to avoid burns and scalding injuries.

What is a nursing intervention for variable decelerations or prolapsed cord?

Placing client in a knee-chest position

What patient education is given to a parent of a premature infant to promote optimal development?

Provide kangaroo care for the infant

A nurse is teaching new parents about newborn reflexes. Which reflex facilitates infant feeding?

Rooting

What conditions should the nurse report to the provider in a pregnant mom?

Spotting with urination which could indicate vaginal spotting or hematuria. Thick cottage-cheese-like or malodorous discharge (could indicate a yeast or bacterial infection). Facial edema (could indicate pregnancy-induced HTN or preeclampsia)

During the fourth stage of labor, what would a nurse anticipate with bladder distention?

The bladder fluctuates with palpation Rationale: With bladder distention, the bladder is suprapubic, round, bulging, dull to percussion and fluctuates like a balloon filled with water. The uterus is usually displaced to the right, boggy, and located well above the umbilicus

What foods should be avoided during pregnancy?

Those with a high level of mercury like swordfish, shark or king mackerel. High levels of mercury can harm the developing nervous system of the fetus. Consumption should be avoided prior to conception and until the cessation of breastfeeding

What nursing intervention is appropriate for a client at 26 weeks gestation who is experiencing constipation?

Walk for at least 30 minutes every day

A nurse is assessing a client at 34 weeks gestation with a cardiac disorder. When should the nurse notify the provider?

When client reports a frequent cough Rationale: A frequent cough could be an indication of cardiac decompensation

A nurse is teaching a client who is pregnant and has pregestational diabetes about dietary changes. What should the nurse include in the teaching?

Carbs should make up 55% of the diet Rationale: intake of simple carbs should be limited. The ideal diet is 55% carbs, 20% protein, 25% fat and < 10% saturated fat

A nurse enters a postpartum client's room and notices many visitors in the room, conversing loudly and taking turns holding the newborn. The newborn intermittently cries attempts to suck on her hands. After a few minutes, the newborn quiets, stares, and turns her head away when someone talks to her. What teaching should the nurse provide for this family? A) The newborn would benefit from skin-to-skin contact in a quiet environment B) The newborn's blanket should be removed so her movements will not be restricted C) The newborn's hat should be removed to avoid overheating D) The newborn should be discouraged from sucking on her hand since this habit can interfere with feeding.

A) The newborn would benefit from skin-to-skin contact in a quiet environment. Explanation: Staring and gaze eversion indicate the newborn is overstimulated and is "switching off" in an attempt to cope with excess stimuli. When this is observed, stimulation should be decreased and supportive measures such as skin-to-skin contact should be increased

A nurse is caring for a client who is in labor and asks her partner to perform effleurage. The client has on a monitor belt for electronic fetal monitoring. Which of the following instructions should the nurse provide to the client's partner? A. "Lightly stroke the upper thighs." B. "Steadily apply pressure to the sacrum." C. "Gently massaging the abdomen." D. "Firmly squeeze both hips."

A. "Lightly stroke the upper thighs." Effleurage involves lightly stroking or massaging the abdomen in rhythm with breathing to help relieve labor pain. However, when a monitor belt is in use, the sides of the abdomen, chest, or upper thighs are alternative locations for massage. Steadily applying pressure is known as counter-pressure and is used to help decrease lower back pain by relieving occiput pressure on the spinal nerves. Gently massaging the abdomen is therapeutic for pain relief; however, massage of the mid-abdominal area is not possible for this client due to the positioning of the monitor belt. Firmly squeezing both hips is a method of counter-pressure and is used to help relieve lower back pain by placing pressure on the hips.

A nurse is providing education to a client who is 4 weeks postpartum and is breastfeeding. The client asks about expected weight loss. Which of the following responses should the nurse make? A. "Losing 2.2 pounds each month would be acceptable." B. "Losing 4.4 pounds each month would be acceptable." C. "Losing 5.5 pounds each month would be acceptable." D. "Losing 6.6 pounds each month would be acceptable."

A. "Losing 2.2 pounds each month would be acceptable." Rationale: An important postpartum goal is for the client to lose the weight gained during pregnancy. An acceptable amount of weight loss for a client who is lactating is 1 kg (2.2 lb) per month. Clients who are not lactating should lose approximately 0.5 to 0.9 kg (1.1 to 2 lb) per week.

A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide? A. "You should slightly increase your exposure to sunlight" B. "You will need extensive dermatological treatment for this condition after you deliver your baby" C. "Your provider will schedule weekly lab testing to monitor your liver function" D. "Your provider will prescribe isotretinoin cream"

A. "You should slightly increase your exposure to sunlight." Rationale: Pruritus gravidarum is a condition of pregnancy that causes generalized itching without the presence of a rash. This occurs due to the stretching of the skin. Exposure to sunlight can reduce itching. Pruritus gravidarum will resolve without extensive treatment after delivery and has no effect on the liver. Isotretinoin cream is used to treat acne. It should not be prescribed to a client who is pregnant due to its teratogenic effects on the fetus.

A nurse is caring for a client in the third trimester of pregnancy who is scheduled to undergo a non-stress test. Which of the following actions should the nurse take prior to the test? A. Ask the client to drink a glass of orange juice B. Perform a vaginal examination C. Ensure client's hemoglobin is within the normal range D. Assess client to ensure there is no evidence of a UTI

A. Ask the client to drink a glass of orange juice Rationale: The nurse should give the client orange juice or a glucose preparation prior to this test. This should raise the client's blood glucose level and help promote fetal movement. A non-stress test involves the application of a fetal heart monitor and a tocodynamometer to track uterine contractions and fetal movement. There is no vaginal examination with this procedure. A non-stress test evaluates the fetal heart rate's response to uterine contractions and fetal movement. It does not involve the client's hemoglobin level or involve identifying indications of a urinary tract infection in the client.

A nurse is preparing to obtain a newborn's temperature. Which of the following methods should the nurse use? A. Axillary B. Temporal C. Tympanic D. Rectal

A. Axillary Rationale: An axillary temp is the most accurate and safe way to obtain a newborn's temp. The nurse should check the temp after obtaining respirations and pulse since the baby may cry or struggle when the nurse holds the arm in place.

A nurse is caring for a client at 32 weeks gestation who is experiencing preterm labor. Which of the following medications should the nurse plan to administer? A. Betamethasone B. Misoprostol C. Methylergonovine D. Poractant alfa

A. Betamethasone Rationale: The nurse should plan to administer betamethasone IM, a glucocorticoid, to stimulate fetal lung maturity and prevent respiratory depression. Misoprostol is used to stimulate uterine contractions for a client who is undergoing labor induction. Methylergonovine is used to stimulate uterine contractions for a client who is experiencing postpartum hemorrhage. Poractant alfa, a synthetic lung surfactant, is given to a preterm newborn who is experiencing respiratory distress.

A nurse is caring for a client who is at 36 weeks gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? A. Biophysical profile B. Amniocentesis C. Cordocentesis D. Kleihauer-Betke test

A. Biophysical profile Rationale: A positive contraction test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound. An amniocentesis is used to determine lung maturity, detect congenital anomalies, and diagnose fetal hemolytic disease. A cordocentesis is used to identify fetal blood type and RBC when there is a risk of isoimmune hemolytic anemia. The Kleihauer-Betke test is used to determine the amount of fetal blood in maternal circulation when there is a risk of Rh-isoimmunization.

A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take? A. Place the unwrapped newborn on the mother's bare chest. B. Supplement with formula until breast milk comes in. C. Bathe newborn under running water. D. Perform routine care such as bathing, weighing, eye prophylaxis, and a vitamin K injection before the first feeding.

A. Place the unwrapped newborn on the mother's bare chest. Rationale: Skin-to-skin contact will maintain the newborn's temperature and illicit instinctive newborn feeding behaviors. Breastfed infants should not be fed anything except breast milk unless deemed medically necessary. Newborns should never be bathed under running water. The temperature of the water could change and cause burns or cold stress in the newborn. Additionally, routine cares like bathing, weighing, eye prophylaxis, and Vit K IM should be delayed until the completion of the first breastfeeding.

A postpartum nurse is providing care to a breastfeeding client who has a perineal hematoma. Which of the following breastfeeding positions should the nurse recommend? A. Side-lying B. Clutch hold C. Across-the-lap D. Cross-cradle

A. Side-lying Rationale: A side-lying position allows the client access to her baby, facilitates latching, and reduces pressure on the hematoma.

A nurse is performing an initial physical assessment of a newborn following a vaginal birth. Which of the following findings should the nurse report to the provider? A. Small, pinpoint, reddish-purple spots on the chest B. Bluish coloring of the feet C. Overlapping suture lines D. White, cheese-like substance covering the skin

A. Small, pinpoint, reddish-purple spots on the chest Rationale: Petechiae are commonly found above the neck if the umbilical cord was around the newborn's neck at birth. Petechiae in any other circumstance should be reported because it can indicate infection or a low platelet count

The guardian of a 3 day old female newborn tells the nurse that he noticed a small amount of blood-tinged mucus discharge on the newborns labia. Which of the following responses should the nurse make? A. The blood-tinged mucus is a result of pseudomenstruation B. The blood-tinged mucus indicates a UTI C. The blood-tinged mucus is due to uric acid crystals D. The blood-tinged mucus is a result of the initial genital examination

A. The blood-tinged mucus is a result of pseudomenstruation Rationale: Pseudomenstruation is a result of the loss of maternal hormones at birth resulting in vaginal discharge with withdrawal bleeding. It is an expected finding in female newborns

A nurse is caring for a newborn who is receiving treatment for jaundice with traditional phototherapy lights. Which of the following interventions should the nurse perform? A. Turn the newborn every 2 hr B. Apply lotion twice daily C. Feed the newborn 1 oz of glucose water q 2hrs D. Dress the newborn in a diaper and a thin cotton t-shirt

A. Turn the newborn every 2 hr Rationale: Phototherapy lowers serum bilirubin levels by converting bilirubin accumulated in the skin to a form that is excreted in the newborn's urine and stools. The infant must be turned every 2 to 3 hours to maximize skin exposure, which promotes bilirubin breakdown. Hydration should be maintained through breastfeeding or formula-feeding, both of which promote the excretion of bilirubin. Glucose water and plain water do not promote bilirubin excretion. The infant should be clothed only in a diaper to maximize skin exposure. Ointments, creams, and lotions should be avoided because they have the potential to absorb heat and cause burns.

A nurse at a family-planning clinic is preparing to teach a class about how to use a diaphragm. Which of the following pieces of information should the nurse plan to include in the teaching? A. Use spermicidal jelly whenever you use your diaphragm B. Insert the diaphragm about 8 hrs before sexual activity C. You should remove the diaphragm 30 min after intercourse D. A diaphragm comes in a single size and does not require fitting

A. Use spermicidal jelly whenever you use your diaphragm Rationale: A diaphragm is a barrier device that helps prevent pregnancy. Use of a diaphragm alone is not 100% effective in preventing pregnancy, but the accompanying use of spermicidal jelly increases the effectiveness. The diaphragm should be inserted up to 6 hrs before intercourse. Women should wait at least 6 hrs after intercourse to remove the diaphragm. They come in several sizes and must fit correctly to work effectively. If client's weight changes significantly, they may require a different size.

A nurse is caring for a client at 37 weeks gestation who is undergoing a nonstress test. The fetal heart rate (FHR) is 130/min without accelerations for the past 10 min. Which of the following actions should the nurse take? A. Use vibroacoustic stimulation on the client's abdomen for 3 sec B. Report the nonreactive test result to the provider immediately C. Request a prescription for an internal fetal scalp electrode D. Auscultate the FHR with a Doppler transducer

A. Use vibroacoustic stimulation on the client's abdomen for 3 sec Rationale: The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR. The nurse will determine a nonstress test to be nonreactive after 40 minutes of continuous monitoring without accelerations in the FHR despite vibroacoustic stimulation. The client should have an internal fetal scalp electrode during labor to monitor the FHR. The external fetal monitor is recording the FHR. Therefore, it is not necessary for the nurse to auscultate the FHR with a Doppler.

A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or an abruptio placenta? A. Uterine tone B. Fetal distress C. Hypotension D. Amount of blood loss

A. Uterine tone Rationale: The uterus will be relaxed, soft, and painless if the bleeding is caused by placenta previa. With abruptio placenta, the uterus will be firm and board-like, and the client will complain of pain. Fetal distress and hypotension may be present in both conditions. The amount of blood loss is not diagnostic of the cause of the bleeding.

A nurse is caring for a client who experienced a fetal loss. When initiating communication with this client, which of the following statements should the nurse make? A. "I understand how you feel." B. "I'm here for you if you would like to talk." C. "It is better that the loss happened now, before you got to know the baby." D. "You are young and can have other children."

B. "I'm here for you if you would like to talk." Rationale: This is a therapeutic statement because it acknowledges the client's loss and invites her to share her thoughts and feelings. A is a nontherapeutic statement because the nurse should not presume to know how the client feels after a fetal loss. The nurse should never deny the bond that many pregnant women feel with the fetus throughout pregnancy. C and D are nontherapeutic statements because it gives unwanted reassurance that has no basis. Furthermore, the nurse should never assume that any other child could take the place of the lost child.

A nurse is teaching a client who is pregnant about nonstress testing. Which of the following pieces of information should the nurse include? A. "This invasive test presents minimal risk to the fetus." B. "If the test is positive, that means your baby's heart rate is healthy." C. "This test only measures fetal movement." D. "The fetus won't move during the test."

B. "If the test is positive, that means your baby's heart rate is healthy." Rationale: The fetal heart rate is considered healthy if the results of nonstress testing are positive. If the test is negative, fetal health may be affected, and further testing may be necessary to rule out poor oxygen perfusion of the fetus. Nonstress testing is noninvasive and causes no risk to either the client or the fetus. It can be used as a screening procedure in all pregnancies. The test measures the response of the fetal heart rate to fetal movement. The fetal heart rate should increase by about 15 beats/min when the fetus moves and should remain increased for about 15 seconds. The test would be identified as nonreactive if there is no fetal movement during the testing period or if the fetal heart rate variability is under 6 beats/min.

A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which of the following instructions should the nurse include in the teaching? A. Stand under a hot shower with your breasts exposed. B. Place ice packs on your breasts. C. Wear a loose fitting, comfortable bra. D. Limit fluid intake to 1 L per day.

B. "Place ice packs on your breasts." Rationale: The nurse should instruct the client to place ice packs on her breasts using a "15 minutes on and 45 minutes off" schedule to decrease swelling of the breast tissue as the body produces milk. Warm water running over the breasts can stimulate milk production. The client should wear a well-fitting, supportive bra to provide comfort as the breasts fill with milk. The client should drink 2 to 3 L of fluid per day to promote normal bowel function.

A client at a routine prenatal care visit asks the nurse if developing vaginal yeast infections is common during pregnancy. Which of the following responses should the nurse make? A. "Have you discussed this with your doctor yet?" B. "The hormonal changes of pregnancy change the acidity of the vagina, making yeast infections more common" C. "Women who are already prone to vaginal yeast infections get them during pregnancy" D. "Why are you concerned about yeast infections during pregnancy?"

B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common." Rationale: This is an information-seeking question; therefore, the therapeutic response is an answer that provides the client with the information she requested. A and C are close-ended responses that discourage further communication. Asking "why" questions typically makes clients feel defensive.

A nurse is caring for a primigravid client who is at 8 weeks gestation with twins. The client states that even though she and her husband planned this pregnancy, she is experiencing ambivalent feelings about it. Which of the following responses should the nurse make? A. "Have you told your husband about these feelings?" B. "These feelings are quite normal at the beginning of pregnancy." C. "Perhaps you should see a counselor to discuss these feelings." D. "I am quite concerned about these feelings. Could you explain more?"

B. "These feelings are quite normal at the beginning of pregnancy." Rationale: This client needs reassurance that these feelings are normal and that there is no reason for concern. This nontherapeutic response puts the client's feelings on hold and insinuates that there is a problem that needs to be resolved. This is an inappropriate response because the client's feelings are normal, and there is no reason for concern.

A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. Which of the following statements should the nurse make? A. "The fetus will be turned internally." B. "You will receive medication to relax your uterus prior to the procedure." C. "The external version will be performed in the clinic." D. "It is not necessary to continuously monitor the fetal heart rate pattern."

B. "You will receive medication to relax your uterus prior to the procedure." Rationale: A client who is scheduled to undergo an external cephalic version often receives a tocolytic prior to the procedure to allow the uterus to relax. A relaxed uterus allows an easier version by the provider. This action is appropriate for internal version. With external version, the provider attempts to turn the fetus around externally and not internally. External version is a high-risk procedure that is performed in a hospital setting in the event of an emergency. During the external version, the fetal heart-rate pattern is monitored continuously because the fetus is at risk of bradycardia and variable decelerations. The nurse also monitors the fetal heart rate for at least 60 minutes following the procedure.

A nurse is planning care for a client in labor who is positive for HIV. Which of the following actions should the nurse take after the baby is born? A. Encourage the mother to breastfeed B. Administer the hepatitis B vaccine prior to discharge C. Implement contact and droplet precautions when providing care to the infant D. Collect a cord blood specimen to test for the presence of HIV

B. Administer the hepatitis B vaccine prior to discharge Rationale: Infants who are exposed to HIV should receive all routine vaccinations. Remember Hep B requires parental consent. Infants who are infected with HIV can receive all inactivated vaccinations. In the US and Canada, breastfeeding should be avoided by mothers who are HIV-positive. The nurse should use standard precautions when caring for a newborn who has been exposed to HIV. To test a newborn for the presence of HIV, a sample of the newborn's blood must be obtained. Maternal antibodies will be present in the cord blood and can affect the test results.

A nurse is assessing a pregnant client at 26 weeks gestation who report an episode of dizziness after lying on her back on the couch. Which of the following actions should the nurse take? A. Request a prescription for preeclampsia lab studies B. Advise the client to lie on her side C. Request an ultrasound to evaluate fetal wellbeing D. Advise the client to add a calcium supplement to her diet.

B. Advise the client to lie on her side Rationale: Dizziness after a pregnant client lies flat on her back is a sign of supine hypotension, which is caused by compression of the vena cava from the weight of the pregnant uterus. Pregnant women should be advised to avoid lying in a supine position.

A nurse is caring for a recently delivered newborn whose mother had gestational diabetes. What action should the nurse take within 1 hr after birth? A. Administer the hepatitis B (HBV) vaccine B. Assess the newborn's blood glucose level C. Bathe the newborn D. Perform a screening for congenital heart disease

B. Assess the newborn's blood glucose level Rationale: Newborns whose mothers have diabetes have a greater risk of developing hypoglycemia due to the cessation of the fetal blood glucose supply and fetal hyperinsulinemia. Blood glucose levels should be assessed within 1 hour after birth, followed closely, and treated promptly when needed. There is no indication to administer the vaccine within 1 hour after birth. The baby should not bathe the newborn until the newborn's temperature has stabilized in the extra-uterine environment. Ideally, the nurse should place the infant in skin-to-skin contact with the mother for at least 1 to 2 hours after birth. Alternatively, the nurse can place the newborn under a radiant heat source and assess its temperature every hour until it is stabilized. The nurse should use a pulse oximeter to screen for congenital heart disease 24 to 48 hours after birth. If the nurse performs the screening prior to 12 hours after birth, acrocyanosis might alter the results.

A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform? A. Obtain a rectal temperature B. Assess the newborn's blood glucose level C. Bath the newborn D. Place the infant in front of a heater vent

B. Assess the newborn's blood glucose level Rationale: Infants who become cold attempt to generate heat through increased muscular and metabolic activity. This process increases glucose consumption and puts the newborn at risk of hypoglycemia. The nurse should not obtain a rectal temperature from a newborn due to the risk of rectal perforation. Bathing will increase heat loss. Infant shouldn't be bathed until temperature has stabilized within the normal range. An infant placed in front of a heater vent can incur heat loss through convection. Additionally, there is a potential fire risk from the bassinet linens and the vent.

A nurse is providing teaching for new parents about formula feeding. Which of the following instructions should the nurse include? A. The bedtime bottle can be placed in the crib after the infant is 6 months of age. B. Discard opened cans of formula after 48 hr refrigeration C. Powdered and concentrated formula can be reconstituted with tap water straight from the faucet D. Bottles and nipples can be hand-washed in hot, soapy water.

B. Discard opened cans of formula after 48 hr refrigeration. Rationale: Opened cans and prepared bottles of formula must be refrigerated and discarded after 48 hours due to the risk of bacterial contamination. Infants should NOT be left alone when feeding. If they fall asleep with their bottle in their mouth they are more prone to choking and tooth decay. Tap water needs to be STERILIZED prior to reconstituting formula by boiling tap water for 2 minutes, cooling, and mixing formula (use within 30 minutes). Bottles, nipples, and caps must be boiled for 5 mins prior to the first use. After that, the feeding equipment can be placed in the dishwasher for cleaning. If no dishwasher is available, the feeding equipment must be boiled between uses!

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider? A. Varicose veins B. Double vision C. Leukorrhea D. Flatulence

B. Double vision Rationale: Double vision, blurred vision, or visual disturbances are signs of potential complications associated with preeclampsia. The nurse should report this finding to the provider. Varicose veins are caused by the relaxation of the smooth muscle walls of the veins and pelvic vasocongestion. Leukorrhea is a hormonal production of an abundant amount of mucus. Varicose veins and leukorrhea are common manifestations associated with pregnancy. Flatulence is a common manifestation associated with pregnancy. Progesterone causes reduced gastrointestinal motility.

A nurse is assessing a client who is pregnant, and reports increased nasal stuffiness. The nurse should inform the client that which of the following hormones is responsible for this discomfort? A. Relaxin B. Estrogen C. Progesterone D. Human chorionic somatomammotropin (HCS)

B. Estrogen Rationale: Estrogen increases vascularity and connective tissue growth. Nasal stuffiness, a common discomfort during pregnancy, results from the increased vascularity of the mucus membranes within the nasal passages

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

B. Hypoglycemia Rationale: Newborn hypothermia can cause hypoglycemia because anaerobic glycolysis can deplete glycogen stores. Newborn hypothermia can cause bradycardia and irritability. Hyperthermia can cause tachycardia. Newborn hypoglycemia can cause central cyanosis and cool, mottled skin. Hyperthermia can cause flushed skin. Generalized petechiae can indicate a clotting disorder; this condition is not caused by hypothermia.

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

B. Menorrhagia Rationale: An IUD is contraindicated for women who have menorrhagia (abnormally heavy bleeding during menstruation), severe dysmenorrhea (painful abd. cramps w/menstruation), or a Hx of ectopic pregnancy

A nurse is providing teaching about formula feeding to the guardian of a newborn. Which of the following pieces of information should the nurse include? A. Boil bottles and nipples for 20 min after each use B. Mix 1 scoop of powdered formula with 2 oz. of water C. Store prepared bottles in the refrigerator for up to 4 days D. Warm formula by heating bottles in the microwave on the lowest setting

B. Mix 1 scoop of powdered formula with 2 oz. of water that has been boiled for 1-2 min Rationale: Nipples and bottles should be boiled for 5 min before initial use. After, they can be handwashed in hot, soapy water or in the dishwasher after each use. Prepared bottles should be stored in the fridge no longer than 48 hours. Warm cold bottles by placing the bottle under warm running tap water or in a pan of hot water.

A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include? A. Wear a tight-fitting bra or breast binders B. Place fresh cabbage leaves on your breasts C. Apply warmth to the breasts D. Express milk from the breasts

B. Place fresh cabbage leaves on your breasts. Rationale: After 3 days postpartum, the client's breasts can become swollen and distended because of congestion of the vascular structures of the breasts. Fresh cabbage leaves can be applied to engorged breasts to help relieve breast discomfort. Breastfeeding moms can also use this nonpharmacological pain method to relieve engorgement. The coolness of the leaves and the phytoestrogens exert a therapeutic effect on engorged breasts. Replace wilted leaves. Wearing a tight-fitting bra or breast binders alleviate engorgement and swelling. Application of warmth to the breasts should be avoided because heat can stimulate milk production. An ice pack should be used to relieve engorged breasts. Milk should not be expressed from the breasts. This intervention would increase milk production rather than decrease it.

A nurse is caring for a client who is in labor. The nurse observes late decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Decrease the rate of the client's maintenance IV fluid B. Place the client in a left lateral position C. Apply oxygen at 2 L/min nasal cannula D. Prepare the client for an amniocentesis

B. Place the client in a left lateral position Rationale: The nurse should identify that decelerations of the fetal heart rate with an onset beginning after a contraction has started that persist beyond the end of the contraction are considered late decelerations. Later decelerations indicate an interruption in fetal oxygenation. A lateral position improves blood flow to the uterus and intervillous spaces. Repositioning the client is a component of intrauterine resuscitation. C isn't the protocol for late decelerations as 2 L/min via nasal cannula doesn't give enough oxygen.

A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of the following actions should the nurse take to promote development? A. Rapidly advance oral feedings. B. Position the naked newborn on the parent's bare chest C. Provide frequent periods of visual and auditory stimulation D. Discourage the use of pacifiers

B. Position the naked newborn on the parent's bare chest Rationale: Positioning the naked newborn on the parent's bare chest can decrease stress in the parent and the newborn. This action can help maintain thermal stability, raise oxygen saturation, increase feeding strength, and promote breastfeeding. The nurse should assess the newborn to determine how well she will tolerate feedings and gradually make changes. Rapidly advancing feedings can lead to fluid retention, hyponatremia, vomiting, diarrhea, and apnea. Newborns need uninterrupted periods of sleep to promote self-regulation. Light and sounds are adverse stimuli and can increase stress in a newborn who is premature. Nonnutritive sucking can decrease oxygen use and energy, which can lead to decreased restlessness.

A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? A. Retract the foreskin B. Sponge bathe the newborn every other day C. Use antimicrobial soap D. Maintain the bath water temperature at 36°

B. Sponge bathe the newborn every other day Rationale: Daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The parents should sponge bathe the infant until the cord stump has detached and the area has healed. In uncircumcised males, the foreskin adheres to the glans of the penis. Parents should not attempt to retract the foreskin before 3 years of age. Parents should wash the penis with soap and water. Parents should avoid using antimicrobial soaps and instead use soap with a neutral pH and no preservatives to protect the acid mantle of the newborn's skin. Parents should maintain the bath water temperature between 38° and 40°C (100° and 104°F).

A nurse is caring for a client who is 20 weeks gestation. The client asks the nurse what the baby looks like at this point. Which of the following answers by the nurse provides an accurate response? A. Lanugo has disappeared B. The fetus resembles a human C. The arms and leg buds are noticeable D. Subcutaneous fate gives the body a wrinkled appearance

B. The fetus resembles a human Rationale: By 20 wks gestation, the fetus resembles a very thin human. Lanugo covers the body at this fetal age. Leg and arm buds become noticeable between 5-6 wks gestation. A lack of subcutaneous fat makes the body appear wrinkly.

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

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

A nurse is assessing a client at 37 weeks gestation who has a suspected pelvic fracture due to blunt abdominal trauma. Which of the following findings should the nurse expect? A. Bradycardia B. Uterine Contractions C. Seizures D. Bradypnea

B. Uterine Contractions

A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? A. Lochia serosa vaginal discharge B. Vaginal pressure C. Intermittent vaginal pain D. Yellow exudate vaginal discharge

B. Vaginal pressure Rationale: Vaginal pressure should be reported. It happens due to blood that has leaked into the tissues. A client with a vaginal hematoma will report persistent vaginal or rectal pain and lochia rubra. Lochia serosa will be present in a client who is 4 to 10 days postpartum.

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

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

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

B: Assess the newborn for respiratory depression Rationale: Meperidine should not be administered to laboring clients who are expected to deliver within 4 hours of medication administration. Meperidine crosses the placenta and causes respiratory depression in the newborn (peaks 2 - 3 hours after administration). Narcan is ineffective at reversing the respiratory depression caused by this medication. Meperidine does not affect the client's reflexes. It reduces the transmission of pain impulses through stimulation of the mu and kappa opioid receptors. Meperidine can cause tachycardia, nausea, vomiting, dizziness, and altered mental status. Neonatal abstinence syndrome occurs in newborns who are exposed to opioids over a long period of time during pregnancy. A client receiving an opiate during labor would not lead to opiate dependence in the newborn.

A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following medications should the nurse have available at the client's bedside? A. Naloxone B. Calcium gluconate C. Protamine sulfate D. Atropine

B: Calcium gluconate Rationale: The nurse should have calcium gluconate available for a client who is receiving magnesium sulfate by continuous IV infusion in case of magnesium sulfate toxicity. The nurse should monitor the client for a RR of ≤12/min, muscle weakness, and depressed deep-tendon reflexes. Naloxone should be available for a client who is receiving opioid medication in case of respiratory depression. Protamine sulfate should be available for a client who is receiving heparin in case of hemorrhage. Atropine should be available for a client who is receiving medications that can lead to asystole or sinus bradycardia, such as beta-adrenergic blockers.

A nurse is assessing a client who is at 12 weeks gestation and has a hydatidiform mole. Which of the following findings should the nurse expect? A. Hypothermia B. Dark brown vaginal discharge C. Decreased urinary output D. Fetal heart tones present

B: Dark brown vaginal discharge Rationale: A hydatidiform mole (a molar pregnancy) is a benign proliferative growth of the chorionic villi that gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grape-like clusters. Client's temperature should be within the expected reference range. Client would have increased urinary output due to the elevated maternal blood volume and pressure of the uterus on the maternal bladder. Fetal heart tones would not be present because a viable embryo or fetus is not present.

A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse perform first? A. Check for a full bladder B. Massage the fundus C. Measure vital signs D. Administer carboprost IM

B: Massage the fundus Rationale: The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The primary cause of early postpartum bleeding is uterine atony, which is manifested by a relaxed, boggy uterus. Thus, the greatest risk for this client is hemorrhage. The nurse should massage the client's fundus first. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. A full bladder can cause uterine atony. Vital signs are important but will not help in identifying the reason for this client's bleeding. Administering carboprost is an appropriate action for managing postpartum hemorrhage. However, there is another action the nurse should take first.

A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take? A. Encourage the client to ambulate B. Provide a sitz bath with warm water for the client C. Instruct the client to perform Kegel exercises D. Apply anesthetic cream topically each hour while the client is awake

B: Provide a sitz bath with warm water for the client Rationale: The nurse should provide a client who is postpartum with a sitz bath to decrease episiotomy discomfort. The use of a sitz bath provides warm, moist, direct heat to the incision area, which helps relieve the pulling and stinging associated with the healing incision. The warm water increases blood flow to the area through vasodilatation, which also promotes healing and comfort. The nurse should encourage the client to ambulate and perform Kegel exercises to strengthen perineal muscles although they won't help with episiotomy discomfort. Topical anesthetic cream should be applied no more than three to four times per day.

A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect? A. Fetal cardiac anomalies B. Renal agenesis C. Fetal neural tube defects D. Fetal hydrocephalus

B: Renal agenesis Rationale: Oligohydramnios is a volume of amniotic fluid that is <300 mL during the third trimester of pregnancy. This occurs when there is a renal system dysfunction or obstructive uropathy. The absence of fetal kidneys will cause oligohydramnios. Fetal cardiac anomalies, fetal neural tube defects and fetal hydrocephalus do not affect the volume of amniotic fluid.

A nurse is teaching a client during the client's first prenatal visit. Which of the following instructions should the nurse include? A. "A fetal stethoscope can first detect your baby's heart rate at 22 weeks." B. "After week 16, we can see if your baby is a boy or a girl." C. "A Doppler device can detect your baby's heart rate at 12 weeks." D. "You will first feel the baby move at about 8 weeks."

C. "A Doppler device can detect your baby's heart rate at 12 weeks." Rationale: The nurse should be able to detect the fetal heartbeat with a Doppler device toward the end of the first trimester, often as early as 10 weeks of gestation. The nurse should be able to hear fetal heart tones with a fetoscope by the end of the sixteenth week of gestation. Typically, the sex of the fetus is distinguishable on a sonogram by the end of the twelfth week. Quickening (feeling fetal movement) is typically possible at 14 to 16 weeks in multiparous clients; however, it is sometimes not possible until week 18 or later in nulliparous clients.

A nurse is providing teaching about the rubella immunization to a client who is 24 hours postpartum. Which of the following client statements indicates an understanding of the teaching? A. "I should not breastfeed for at least 3 days after receiving this immunization." B. "I will need a second rubella booster when I see my midwife at 6 weeks postpartum." C. "I should be careful to avoid becoming pregnant within the next month." D. "This vaccine will be given into my arm muscle."

C. "I should be careful to avoid becoming pregnant within the next month." Rationale: While the chances of fertility in the first 4 weeks postpartum are low, clients who receive a rubella immunization must be additionally careful to avoid pregnancy either through maintaining abstinence or through using an effective contraceptive. The rubella vaccine is a live virus vaccine and can cause birth defects. The rubella vaccine is a live virus vaccine, but the live attenuated rubella virus is not passed via breastmilk. However, it can be spread via other bodily fluids such as urine. If there are other family members who are immunocompromised, the vaccine should not be administered to the client. A single rubella vaccine postpartum is adequate for most non-immune clients. If a client also receives RhoGAM postpartum, the client should be tested 3 months postpartum to verify immunity. The rubella vaccine is administered as the MMR vaccine subcutaneously.

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

C. "I will feel the effects of the nitrous oxide almost immediately." Rationale: The effects of nitrous oxide are felt within 1 minute of inhalation. Nitrous oxide does not appear to cause neonatal sedation or a difference in Apgar scores. The client should inhale nitrous oxide through a face mask as the contraction begins and use it during the contraction. Nitrous oxide induces a feeling of relaxation and decreases the client's perception of pain. It does not cause feelings of disorientation.

A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching? A. I will use an infant carrier when I drive to places close to the house B. I will tie my baby's pacifier around his neck with a piece of yarn C. I will place my baby on his back when putting him to sleep D. I will keep my baby's crib close to heat vents to keep him warm

C. "I will place my baby on his back when putting him to sleep." Rationale: Newborns should always sleep on their back to prevent SIDS. Cribs should never be placed close to a heat source due to the risk of crib linens catching on fire. Newborns should always be placed in an approved car seat while driving. Infant carriers are not approved safety seats for motor vehicles. Never tie any type of string or cord around the newborn's neck due to the risk of strangulation.

A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching? A. You should supplement your baby with formula until you notice that your breasts become firm and full B. You should adhere to a schedule when feeding your baby to ensure she is getting enough to eat C. Your milk supply will noticeably increase in volume around the third or fourth day after delivery D. It is typical for your nipples to hurt for the first few weeks while you are breastfeeding

C. "Your milk supply will noticeably increase in volume around the third or fourth day after delivery." Rationale: As the colostrum transitions to mature breast milk, the volume of milk produced will also increase. Typically, the postpartum client will notice that 72 to 96 hours after delivery her breasts feel fuller and firmer and that milk is leaking from her nipples. Colostrum is present in a mother's breasts before the newborn is delivered. Unless there is a medical indication, there is no need for formula supplementation. Newborns and infants should be breastfed on demand. Adhering to a strict timing for feedings can lead to a failure to meet nutritional needs of the newborn/infant. Painful nipples during breastfeeding are an indication that the newborn is not correctly latched onto the breast. The baby should be removed from the breast and re-latched. Breastfeeding clients should report only a tugging sensation on their nipples.

A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure? A. Screen the client for chlamydia B. Test the client's blood for Rh antibodies C. Administer immune globulin to the client to prevent fetal isoimmunization D. Administer prophylactic antibiotics

C. Administer immune globulin to the client to prevent fetal isoimmunization Rationale: Because the client is Rh-negative, Rh immune globulin is administered after the procedure to prevent fetal isoimmunization or help ensure maternal antibodies will not form against any placental red blood cells that might have accidentally been released into the maternal bloodstream during the procedure. The provider screens the client for chlamydia during a pelvic examination rather than through an amniocentesis. Testing the client's blood for Rh antibodies is done at the beginning of pregnancy and repeated at 28 weeks. This diagnostic test is performed on the client's blood rather than amniotic fluid. The provider performs the amniocentesis with sterile technique; although infection is a risk with any invasive procedure, the routine administration of prophylactic antibiotics is not indicated.

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

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

A nurse is caring for client who is at 26 wks gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure? A. Monitor the FHR B. Assess uterine activity C. Administer oxygen via a nonbreather mask D. Start a bolus of IV fluids

C. Administer oxygen via a nonbreather mask Rationale: When using the ABC approach, the nurse should place the priority on administering oxygen to the client via a nonbreather mask at 10 L/min to ensure adequate oxygenation to the fetus. All other interventions are relevant but not the priority.

A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take? A. Give the patient a warm sitz bath B. Have the patient sit on a soft pillow C. Apply cold ice packs to the client's perineum D. Give the patient a suppository

C. Apply cold ice packs to the client's perineum Rationale: A third-degree laceration extends from the perineum to the external sphincter of the rectum. This can cause severe discomfort. Cold ice packs are used on the perineal area during the first 24 hours to decrease edema, pain, and discomfort. Warm sitz baths are appropriate after the first 24 hours postpartum. A cool sitz bath is recommended within the first 24 hours to reduce edema and promote comfort. The nurse should encourage the client to sit on firm surfaces and avoid soft pillows and donut pillows because they separate the buttocks and decrease venous blood flow, resulting in more pain and discomfort to the perineal area. The use of suppositories or enemas is contraindicated for a client who has a third-degree perineal laceration due to the severity of the laceration.

A nurse is assessing a client who delivered vaginally 8 hours ago. The nurse notes that the client's fundus is 2 fingerbreadths above the umbilicus and has shifted to the left, and there is a large amount of lochia rubra on the perineal pad. Which of the following actions should the nurse take first? A. Administer analgesia B. Administer prostaglandin C. Assist the client to the toilet D. Obtain a blood specimen for Hct and Hgb

C. Assist the client to the toilet Rationale: Evidence-based practice indicates that the nurse should first help the client empty her bladder. Displacement of the fundus to the left indicates that the cause of the excessive bleeding is uterine atony due to bladder distention, so this action is the nurse's priority. The nurse should administer analgesia because pain can prevent the client from emptying her bladder. The nurse should administer a prescribed prostaglandin preparation to help control the bleeding. The nurse should obtain a blood specimen for Hct and Hgb to monitor the systemic effect of the client's blood loss and the effectiveness of treatment. However, evidence-based practice indicates that another action is the priority before these.

The parents of a child with phenylketonuria (PKU) ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns responsible for PKU? A. X-linked recessive B. X-linked dominant C. Autosomal recessive D. Autosomal dominant

C. Autosomal recessive Rationale: PKU is inherited by autosomal-recessive gene patterns. In these types of disorders, neither parent may actually have the disorder, but both mother and father must carry and contribute a variant gene for it to occur. Other autosomal-recessive disorders are cystic fibrosis and sickle cell anemia. Rationale A: In X-linked recessive disorders, the abnormal gene is carried on the X chromosome. In males, only 1 copy of the abnormal gene is required for the disorder to be expressed in males since the Y chromosome does not carry the disorder. Females must have 2 copies of the gene. Examples of this type of disorder are hemophilia and color blindness. Rationale B: In X-linked dominant disorders, the abnormal gene is carried on the X chromosome. Only 1 copy of the abnormal gene is necessary for the disorder to occur. However, males are more likely to be severely affected due to the homozygous expression. There are only a few disorders that follow this pattern of inheritance. Examples include vitamin D-resistant rickets and Rett syndrome. Rationale D: In these disorders, only 1 copy of the variant gene is necessary for the disorder to occur. Examples of this type of disorder are neurofibromatosis and Treacher Collins syndrome.

A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer? A. Protamine sulfate B. Naloxone C. Calcium gluconate D. Flumazenil

C. Calcium gluconate Rationale: The nurse should discontinue the magnesium sulfate infusion immediately and prepare to administer calcium gluconate IV to reverse the effects of magnesium sulfate and to prevent cardiac and respiratory arrest. Protamine sulfate helps reverse the effects of heparin, not magnesium sulfate. Naloxone is an opioid reversal agent. It does not reverse the effects of magnesium sulfate. Flumazenil reverses the effects of benzodiazepines such as lorazepam and alprazolam, not magnesium sulfate.

A nurse is caring for a client who is in the first stage of labor. Which of the following findings should the nurse identify as a cause for concern? A. Pink, mucoid vaginal discharge B. Brownish vaginal discharge C. Contractions lasting 100 seconds D. Contractions occurring every 4 to 5 minutes

C. Contractions lasting 100 seconds Rationale: Contractions during the first stage of labor range from 45 to 80 seconds. They should not exceed 90 seconds. Pink, mucoid vaginal discharge describes bloody show and is an expected finding. Brownish vaginal discharge could be the result of cervical trauma from vaginal exams or recent intercourse.

A nurse is caring for a client who has eclampsia and just had a tonic-clonic seizure. After turning the client's head to the side, which of the following actions should the nurse take next? A. Administer magnesium sulfate B. Insert an indwelling urinary catheter C. Give oxygen at 10 L/min via face mask D. Reduce environmental stimuli

C. Give oxygen at 10 L/min via face mask Rationale: The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to administer oxygen to help stabilize the client's respiratory status. The nurse should administer magnesium sulfate to prevent further seizure activity. The nurse should insert an indwelling urinary catheter to monitor the client's fluid output. Fluids should be restricted for a client who has eclampsia, but the client's output should be at least 25 mL/hr. The nurse should reduce environmental stimuli to help prevent further seizure activity and to promote rest following the seizure; however, there are other actions the nurse should take first.

A nurse is planning care for a client who is 35 weeks gestation. Which of the follow lab tests should the nurse obtain? A. Rubella titer B. Blood type C. Group B streptococcus B-hemolytic D. 1-hour glucose tolerance test

C. Group B streptococcus B-hemolytic Rationale: A Group B strep test should be done at 35-37 wks to screen for infection. Prophylactic antibiotics should be given during labor for those positive for GBS. At the first prenatal visit, the Rubella titer and blood type should be done. The 1-hour glucose tolerance test should be done at 24-28 wks.

A nurse is teaching a client at 13 weeks gestation about the treatment of incompetent cervix with cervical cerclage. Which of the following statements by the client indicates an understanding of the teaching? A. I am sad that I won't be able to get pregnancy again B. I can resume having sex as soon as I feel up to it. C. I should go to the hospital if I think I may be in labor. D. I should expect bright red bleeding while the cerclage is in place.

C. I should go to the hospital if I think I may be in labor. Rationale: Cervical cerclage prevents premature opening of the cervix. The client should go immediately to a facility for evaluation if she experiences any manifestations of labor while the cerclage is in place. Premature uterine contractions might require tocolytic therapy.

A nurse is assessing a newborn. Which of the following findings should the nurse identify as an indication of recent maternal heroin use? A. Large for gestational age B. Hypotonicity C. Incessant crying D. Craniofacial anomalies

C. Incessant crying Rationale: Manifestations of neonatal abstinence syndrome due to maternal heroin use include incessant crying, jitteriness, hyperactivity, poor feeding, tachycardia, and increased wakefulness with frequent yawning and sneezing.

A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn? A. Placenta previa B. Multiple gestation C. Infection D. Anemia

C. Infection Rationale: Blood group incompatibilities, maternal infection, maternal diabetes, and the administration of oxytocin during labor are potential risk factors for the development of hyperbilirubinemia in newborns. Placenta previa, multiple gestations and anemia are not potential risk factors for hyperbilirubinemia in newborns.

A nurse is performing a physical assessment of a newborn. Which of the following actions should the nurse take? A. Measure the newborn's length from the top of the neck to the heel. B. Leave the newborn's diaper on C. Measure the circumference of the newborn's head with a tape measure just above the eyebrows D. Measure the newborn's chest circumference below the nipple line

C. Measure the circumference of the newborn's head with a tape measure just above the eyebrows Rationale: Shortly after birth, the nurse should measure the circumference of the newborn's head at its largest diameter, which is around the occipitofrontal area. The nurse should measure the newborn's length from the top of the head to the heel. The nurse should remove the newborn's diaper and clothing to measure weight. The nurse should measure the newborn's chest circumference at the nipple line, not below it.

A nurse is calculating a pregnant client's estimated date of delivery using Naegele's rule. The client's last menstrual period started on January 20. Which of the following is the client's expected date of delivery? A. October 13 B. November 13 C. October 27 D. November 27

C. October 27 Rationale: Naegele's rule involves subtracting 3 months from the first day of the last menstrual period and adding 7 days. An expected date of delivery of October 13 would follow a last menstrual period date of January 6. An expected date of delivery of November 13 would follow a last menstrual period date of February 6. An expected date of delivery of November 27 would follow a last menstrual period date of February 20.

A nurse is assessing a postpartum client who has preeclampsia and notes a boggy uterus and excessive uterine bleeding. The nurse should plan to administer which of the following medications? A. Terbutaline B. Magnesium sulfate C. Oxytocin D. Methylergonovine

C. Oxytocin Rationale: Oxytocin is a uterotonic medication that causes the uterus to contract and reduces excessive uterine bleeding. Terbutaline is a tocolytic medication that causes uterine relaxation and is used to treat preterm labor. It is not an appropriate medication to treat uterine atony. Magnesium sulfate is a tocolytic medication used to treat preterm labor and decrease the risk of eclamptic seizures. It is not an appropriate medication to treat uterine atony. Methylergonovine is a uterotonic medication that has an adverse effect of hypertension. Therefore, this medication is contraindicated for a client who has preeclampsia.

A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. What is the first step? A. Facing the client's feet, use the fingertips to palpate the cephalic prominence B. Gently grasp the lower uterine segment between the thumb and forefingers and press in slightly C. Palpate the client's abdomen with the palms to determine which fetal part is in the uterine fundus D. Use the palms of the hands to determine the location of the smooth fetal back

C. Palpate the client's abdomen with the palms to determine which fetal part is in the uterine fundus Rationale: This step identifies the lie (transverse of longitudinal) and presentation (cephalic or breech) of the fetus. The second step is D, the third step is B and the fourth step is A.

A nurse is caring for a client who had a precipitous delivery. Which of the following assessments is the priority during the fourth stage of labor? A. Obtaining the client's temperature B. Inspecting the client's perineum C. Palpating the client's fundus D. Checking the client for hemorrhoids

C. Palpating the client's fundus Rationale: Remember, 4th stage of labor is after placental delivery and 2 hrs postpartum. The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. A precipitous delivery follows a labor of <3 hours. Regardless of the cause of the rapid delivery, uterine atony can result, causing postpartum hemorrhage. The nurse should palpate the fundus and massage as needed to monitor for and reduce the risk of hemorrhage. The nurse should monitor the client's temperature and check for hemorrhoids during the fourth stage of labor, however, another assessment is the priority. The nurse should assess the client's perineum, especially if an episiotomy or laceration is present; however, another assessment is the priority.

A nurse is teaching the guardian of a newborn about car seat safety. Which of the following pieces of information should the nurse include? A. Position the child's car seat forward-facing at 1 yr of age B. Place the retainer clip 2 in above the newborn's umbilicus C. Place the shoulder harness in the slots that are level with the newborn's shoulders D. Position the newborn's car seat at a 20-degree angle in the vehicle

C. Place the shoulder harness in the slots that are level with the newborn's shoulders Rationale: The car seat should be rear-facing until the child is 2 years old. The retainer clip should be level with the newborn's armpits. The car seat should be at a 45-degree angle in the vehicle.

A nurse is caring for a client who is 32 weeks gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications? A. Excessive bleeding B. Oligohydramnios C. Premature rupture of membranes D. Proteinuria

C. Premature rupture of membranes Rationale: A pregnant client with gonorrhea is at an increased risk of premature rupture of membranes, chorioamnionitis, preterm birth, neonatal sepsis and IUGR. The client is not at increased risk for the other complications.

A nurse is teaching a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include? A. Urinary hesitancy B. Hematuria C. Stress incontinence D. Loss of libido

C. Stress incontinence Rationale: The nurse should teach the client that stress incontinence can occur due to the shrinking of the uterus, vulva, and distal portion of the urethra. Urinary incontinence and uterine displacement can occur because of common age-related changes but are not necessarily a result of menopause-related changes. The nurse should teach the client that urinary frequency, not hesitancy, can occur due to the shrinking of the uterus, vulva, and distal portion of the urethra. The nurse should teach the client that hematuria is a manifestation of irritation to the bladder mucosa and might indicate a urinary tract infection. It is not an expected change associated with menopause. The nurse should teach the client that vaginal dryness can occur with menopause due to the vaginal walls becoming thinner and drier, delaying lubrication. This can lead to painful intercourse.

A nurse is teaching a client who is in the third trimester of pregnancy and has herpes genitalis. Which of the following instructions should the nurse include? A. Clean the lesions twice a day with hydrogen peroxide B. Apply a hot compress to the affected areas. C. Talk with your doctor about a prescription for acyclovir to treat your symptoms D. Expect to receive penicillin prior to delivery

C. Talk with your doctor about a prescription for acyclovir to treat your symptoms Rationale: Acyclovir is an antiviral that helps reduce the manifestations of a genital herpes simplex infection. However, topical acyclovir is a Category C pregnancy risk med so provider and client should weigh the risks and the benefits of the therapy. Penicillin treats bacterial infections, not viral infections.

A nurse is assessing newborn circumcised 24 hours ago. Which of the following findings should the nurse report to the provider? A. A scant amount of serosanguineous drainage in the newborn's diaper B. The circumcision site is covered in yellow exudate C. The newborn has urinated once since the circumcision D. The newborn fusses during each diaper change

C. The newborn has urinated once since the circumcision Rationale: It is expected that the newborn should void 2-6 times daily during the first 24-48 hrs after birth and then 6-8 times daily starting on the third day.

A nurse is providing education about continuous heparin therapy for a client who is 18 hours postpartum and has developed a deep vein thrombosis (DVT). Which of the following statements should the nurse include in the teaching? A. An adverse effect of this medication is drowsiness B. This medication will require frequent monitoring of WBC levels C. Use a soft toothbrush to brush your teeth gently D. Avoid taking acetaminophen while receiving this medication.

C. Use a soft toothbrush to brush your teeth gently Rationale: An adverse effect of heparin is increased risk of bleeding.

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

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

A nurse is teaching a client about breastfeeding. Which of the following client statements indicates an understanding of the teaching? A. "I should consume about 700 extra calories a day while breastfeeding." B. "I will introduce bottle feeding of pumped breast milk when my baby is 2 weeks old." C. "I may notice increased cramping when I am feeding my baby." D. "I will place my baby on a strict feeding schedule to help establish a good feeding pattern."

C: "I may notice increased cramping when I am feeding my baby." Rationale: The client may notice an increase in uterine cramping while breastfeeding due to the release of oxytocin, which causes uterine muscle contraction. A client who is breastfeeding requires an additional 500 calories per day to support lactogenesis. The client should not introduce an artificial nipple to the newborn until breastfeeding is well established (approximately 3 -4 wks). The client should breastfeed on demand rather than a strict feeding schedule. Forcing a newborn to wait for a feeding can lead to weight loss and failure to thrive.

A nurse is teaching a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching? A. I know not to eat anything after midnight B. I will have medication given to me to cause contractions C. I should press the button on the handheld marker when my baby moves D. I will stimulate my breast to cause contractions

C: "I should press the button on the handheld marker when my baby moves." Rationale: The purpose of the test is to assess fetal well-being. The client should press the button on the handheld marker when she feels fetal movement. There is no reason for the client to be NPO for this test. The client is encouraged to eat prior to the test in order for the fetus to be more active. When the fetus is asleep, the nurse often offers the client orange juice to stimulate the fetus. Oxytocin is used to induce contractions for an oxytocin challenge test. Nipple stimulation is needed for a contraction stress test.

A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the following findings should the nurse expect? A. heel creases covering the bottom of the feet B. good flexion C. abundant lanugo D. dry, parchment-like skin

C: Abundant lanugo Rationale: Newborns who are premature have abundant lanugo (fine hair), especially over their back. Newborns who are premature demonstrate hypotonia and a relaxed posture, have few heel creases, and have abundant vernix caseosa (a thick whitish substance, covering and protecting their skin in utero).

A nurse is assessing a client on the first postpartum day. Findings include the following: fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following actions should the nurse take? A. report vital signs to the provider B. massage the fundus C. ask client when she last voided D. administer oxytocin agent

C: Ask the client when she last voided Rationale: Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be firm at the midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void. A slight maternal temperature increase is commonly seen in the first 6 to 10 days postpartum. A pulse of 52/minute is within the expected range. The nurse should massage the fundus when it is boggy, not firm. Administering an oxytocic agent is not an appropriate intervention. Oxytocic agents are given to clients who have increased lochia rubra or a boggy fundus to promote uterine contractions.

A nurse is caring for a client who is receiving magnesium sulfate IV. Which of the following medications should the nurse have available as an antidote to magnesium sulfate? A. Betamethasone B. Terbutaline C. Calcium gluconate D. Indomethacin

C: Calcium gluconate Rationale: Calcium gluconate should be kept available as the antidote for magnesium sulfate toxicity. Betamethasone is administered to help mature the lungs of the premature fetus before delivery. Terbutaline is a smooth muscle relaxer administered to inhibit uterine contractions in premature labor. Indomethacin relaxes uterine smooth muscle and is administered to stop preterm labor.

A nurse is caring for a client at 35 weeks gestation who has severe pre-eclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status? A. Blood pressure B. Intake and output C. Daily weight D. Severity of edema

C: Daily weight Rationale: Evidence-based practice indicates that daily weight is the most accurate assessment to determine a client's fluid and electrolyte status. The nurse should assess the client's blood pressure to evaluate circulatory status. The nurse should assess the client's intake and output to evaluate fluid status. The nurse should assess the severity of the client's edema to evaluate fluid status.

A nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects? A. Diarrhea B. Thromboembolism C. Fetal asphyxia D. Oliguria

C: Fetal asphyxia Rationale: Oxytocin may cause tachysystole, which can lead to uteroplacental insufficiency. Inadequate oxygen transfer to the placenta will result in fetal asphyxia or inadequate oxygen to the fetus. Diarrhea and thromboembolism are not adverse effects of oxytocin administration. Oxytocin can have adverse effects that include fetal asphyxia, water intoxication, hypotension, and abruptio placenta. Oliguria is not a likely complication of oxytocin administration.

A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings should the nurse expect? A. Breast engorgement B. Hypothermia C. Urinary retention D. Rupture of membranes

C: Urinary retention Rationale: After delivery, many clients have a reduced urge to urinate. This can result from birth trauma, a larger bladder capacity after birth, analgesia, pelvic soreness, an episiotomy, and other factors. Breast engorgement does not generally become problematic until 3 to 5 days after birth. Hypothermia is unlikely during the fourth stage of labor. The nurse should measure the client's temperature at this time, then Q4H first 8 hours, and then at least Q8H after that. The client might feel chilly during this stage; if so, the nurse should provide a warmed blanket. Rupture of membranes occurs spontaneously or via amniotomy prior to the second stage of labor.

A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make? A. "You will not get pregnant while you are breastfeeding, so you will not need any birth control" B. "A birth control pill that contains only estrogen is available for use while you are breastfeeding" C. "Condoms are the only method of contraception that is appropriate while you are breastfeeding" D. "A progestin-only pill or injection is available for use while you are breastfeeding"

D. "A progestin-only pill or injection is available for use while you are breastfeeding." Rationale: Progestin-only injections, implants, and birth control pills are acceptable options for clients who are breastfeeding, although some experts recommend waiting until 6 weeks postpartum to initiate the medication.

A nurse is assessing a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements? A. "Prolactin is increasing the blood supply to your uterus, and you are feeling blood vessel engorgement." B. "You probably have a small blood clot in your uterus, which is causing the uterus to contract in order to expel it." C. "Your breasts are secreting a hormone that enters the bloodstream and causes your abdominal muscles to contract." D. "The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract."

D. "The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract." Rationale: Oxytocin is released in response to breastfeeding. This hormone also causes the uterus to contract, which decreases the risk for postpartum hemorrhage and increases involution.

A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make? A. "This is an attempt by your body to retain the fluid gained during pregnancy." B. "This is caused by an increase in your estrogen hormonal levels." C. "This is caused by the increased pressure on your veins in your lower legs." D. "This is a source of your fluid loss after delivery."

D. "This is a source of your fluid loss after delivery." Rationale: Postpartum diuresis is the loss of the remaining pregnancy-induced increase in blood volume. The loss of excess tissue fluid begins within 12 hours after birth. Fluid loss by urination and perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum period. Postpartum diuresis is attributed to decreased estrogen levels, the removal of increased venous pressure in the lower extremities, and the loss of the remaining pregnancy-induced increase in blood volume. Fluid loss by urination and perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum period. Urine output can exceed 3000 mL/day during the first 2 to 3 days postpartum.

A nurse is preparing a client who is in labor for the insertion of an intrauterine pressure catheter. The client asks why this type of monitoring is needed. Which of the following responses should the nurse make? A. "This type of monitoring will allow us to measure the frequency of contractions." B. "We normally use an intrauterine pressure catheter for all our patients." C. "This type of monitoring monitors fetal heart rates." D. "This type of monitoring will allow us to measure the intensity of your contractions."

D. "This type of monitoring will allow us to measure the intensity of your contractions." Rationale: A tocotransducer can monitor the frequency and duration of contractions, but only an intrauterine pressure catheter can monitor the intensity of contractions. Although the intrauterine pressure catheter will show the frequency of contractions, the external tocotransducer is also an adequate and noninvasive method of timing contractions. Intrauterine pressure catheters are invasive monitoring equipment and used only when deemed necessary for high-risk labors. A intrauterine pressure catheter monitors the frequency, intensity, and duration of contractions. The ultrasound transducer and spiral electrode will monitor fetal heart tones.

A nurse is teaching a client who is at 12 weeks gestation and has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? A: "Breastfeed your newborn to provide passive immunity." B: "Abstain from sexual intercourse throughout the pregnancy." C: "You will be in isolation after delivery." D: "You should continue to take zidovudine throughout the pregnancy."

D. "You should continue to take zidovudine throughout the pregnancy." Rationale: The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmitting HIV to her newborn. The client can transmit HIV through breast milk therefore should bottle-feed. The client can continue to have sexual intercourse during pregnancy, as long as a condom is used. The client and her newborn will only require standard precautions after delivery.

A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse include in the teaching? A. Consume foods served at warm temperatures B. Instruct the patient to brush her teeth immediately after eating C. Instruct the client to not eat salty and tart foods D. "You should eat dry foods that are high in carbohydrates when you wake up."

D. "You should eat dry foods that are high in carbohydrates when you wake up." Rationale: The nurse should instruct the client to eat foods that are high in carbohydrates such as dry toast or crackers upon waking or when nausea occurs. The nurse should instruct the client to eat foods served at cool temperatures to decrease nausea and vomiting. The nurse should instruct the client to avoid brushing her teeth immediately after eating to decrease vomiting. The nurse should instruct the client to eat salty and tart foods during periods of nausea.

While caring for a client who is in active labor, a nurse notes late decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Administer methyl-prostaglandin IM B. Encourage the client to use the shower C. Place the client in a supine position D. Apply oxygen at 10 L/min via nonbreather face mask

D. Apply oxygen at 10 L/min via nonbreather face mask Rationale: Late decelerations are caused by uteroplacental insufficiency and require interventions to increase oxygen flow to the fetus. Administering oxygen to the client will increase the amount of oxygen available to the fetus.

A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take? A. Instruct the client to pant B. Place the client supine C. Initiate hydrotherapy D. Apply pressure to the client's sacral area during contractions

D. Apply pressure to the client's sacral area during contractions The nurse should provide counter-pressure to the sacral area with a palm or a firm object, such as a tennis ball, during contractions. Counter-pressure lifts the fetal head away from the sacral nerves, which decreases pain. The nurse should instruct the client to pant during contractions to prevent pushing or bearing down before the cervix is completely dilated during the transition phase of labor. Panting will not alleviate back pain during the latent phase of labor. The nurse should not place the client supine during labor because this will increase her back pain. The nurse should initiate hydrotherapy when the client is in the active phase of labor or approximately 5 cm (2 in) dilated. The use of hydrotherapy during the latent phase of labor can prolong the labor process.

A nurse is caring for a client who is postpartum and is having difficulty voiding. Which of the following actions should the nurse take first? A. Place the client's hands in warm water B. Administer an analgesic to the client C. Pour water from a squeeze bottle over the client's perineum D. Assist the client to the bathroom

D. Assist the client to the bathroom Rationale: The greatest risk to this client is an injury from a distended bladder. Assisting the client to the bathroom encourages spontaneous voiding. If this is unsuccessful, the nurse can try the other techniques to promote voiding.

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurse's priority? A. Perform Nitrazine testing B. Assess the fluid C. Check cervical dilation D. Begin FHR monitoring

D. Begin FHR monitoring Rationale: The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being. All of the other interventions should be performed but the priority action should be to begin the FHR monitoring.

A nurse is counseling a female client who expresses a desire to conceive in the near future. Which of the following dietary recommendations should the nurse make to prevent neural tube defects? A. Take a probiotic daily B. Drink a glass of orange juice every day C. Limit your exposure to the sun D. Begin taking a folic acid supplement

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

A nurse is providing teaching to a client who is at 8 weeks gestation about manifestations to report to the provider during pregnancy. Which of the following pieces of information should the nurse include in the teaching? A. Nausea upon awakening B. Leg cramps while sleeping C. Increased white vaginal discharge D. Blurred or double vision

D. Blurred or double vision Rationale: A client who is pregnant should report experiencing blurred or double vision, as these could be a manifestation of gestational hypertension or preeclampsia. A client who is pregnant can have nausea upon awakening due to changes in hormone levels; experience leg cramps while sleeping due to the compression of the pelvic nerves by the enlarged uterus; can have an increase in vaginal discharge due to hyperstimulation of the cervix from an increase in hormones.

A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department? A. Bacterial vaginosis B. Trichomoniasis C. Candidiasis D. Gonorrhea

D. Gonorrhea Rationale: Gonorrhea is often asymptomatic. The client might have purulent endocervical discharge. Gonorrhea is one of the infectious conditions on the Nationally Notifiable Infections list and should be reported to the community health department, which will report the infection to the CDC. Bacterial vaginosis, also known as vaginitis, is the most common vaginal infection. Manifestations include report of a "fishy odor" and vaginal discharge that appears thin, watery, gray, white, or milky. Pruritus is a vaginal infection that does not require reporting; however, it should be treated with metronidazole or clindamycin cream. Trichomoniasis can be asymptomatic. Manifestations include greenish to yellowish mucopurulent, frothy, malodorous discharge. This vaginal infection does not require reporting. Candidiasis, also known as a yeast infection, is the second-most common vaginal infection. Manifestations include a client report of thick, cottage cheese-like discharge and vaginal itching and doesn't require reporting.

A nurse is providing education to a female client of child-bearing age. The nurse should state that which of the following structures expels the mature ovum? A. Blastocyst B. Fallopian tube C. Corpus luteum D. Graafian follicle

D. Graafian follicle

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

D. Have the client breathe into a paper bag Rationale: The nurse should recognize that the client is experiencing respiratory alkalosis from hyperventilation, which is a possible adverse effect of patterned-paced breathing. To correct hypocarbia, the client should breathe into a paper bag or her cupped hands, rebreathing CO2 and correcting the respiratory alkalosis.

A nurse is caring for a client who is 3 days postpartum and has chosen to formula-feed her newborn. During an examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take? A. Use a breast pump to express the milk B. Take a warm shower C. Massage breasts D. Instruct the client to apply cold compresses

D. Instruct the client to apply cold compresses Rationale: To help relieve breast engorgement, the client should apply cold compresses for about 15 minutes every hour. The client can also try applying fresh, cold cabbage leaves to the breasts to relieve pain associated with engorgement. Breastfeeding moms can also use this alternative pain relief measure for engorgement. A client who is formula-feeding her newborn needs to decrease milk production. Pumping her breasts, taking warm showers, and breast massages will all increase milk production.

A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement? A. Self-hypnosis B. Biofeedback C. Acupuncture D. Slow-paced breathing

D. Slow-paced breathing Rationale: Slow-paced breathing is an easy technique for the client to learn quickly and practice immediately. It provides distraction, which can help reduce the perception of pain. The pattern is In-2-3-4/Out-2-3-4/In-2-3-4/Out-2-3-4. Repeating this cycle slows the client's breathing to about half of its usual rate, which can help relax the client and improve oxygenation. Self-hypnosis and biofeedback can help relieve labor pain, but clients might not be able to perform if they haven't already learned from specially trained practitioners. Specially trained practitioners perform acupuncture, so this is not something the nurse can initiate.

A nurse is performing an admission assessment of a client who just arrived at the labor and delivery unit. Which of the following findings should the nurse identify as the priority? A. The client reports a pain level of 8 on a scale from 0 to 10 during contractions B. The client's blood pressure is 148/92 mmHg C. The client's temperature is 38.3 C (101 F) D. The fetal heart rate is 90/min

D. The fetal heart rate is 90/min. Rationale: Fetal bradycardia indicates that this client is at greatest risk for fetal consequences due to a cardiac disorder or infection, leading to hypoxia and asphyxiation; therefore, this is the priority finding. The nurse should intervene to help ease the client's pain, recheck the client's blood pressure in 30 minutes after the client has relaxed and between contractions to help rule out preeclampsia and notify the provider and perform a thorough assessment to rule out an infection such as chorioamnionitis; however, another assessment finding is the priority.

A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump following a cesarean birth. Which of the following findings should the nurse report to the provider? A. Respiratory rate of 15 B. Temperature of 99.1 C. Dizziness D. Urine output 20 mL/hr

D. Urine output 20 mL/hr Rationale: Opioid analgesics such as morphine can cause urinary retention. The client should have a urinary output of at least 30 mL/hr. The nurse should report this finding to the provider. Opioid analgesics can cause respiratory depression. However, this respiratory rate is within the expected reference range. This temperature is within the expected reference range. Dizziness is a common adverse effect of receiving opioid analgesics. The nurse should instruct the client to sit on the side of the bed before getting up, assist the client with ambulation, and implement general safety measures. However, it is not necessary to report this finding to the provider.

A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take? A. Offer the newborn glucose water between feedings B. Keep the newborns eye patches on during feedings. C. Apply barrier ointment to the newborn's perianal D. Use a photometer to monitor the lamp's energy.

D. Use a photometer to monitor the lamp's energy Rationale: The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective.

A nurse is preparing to perform a heel stick on a newborn. Which of the following actions should the nurse take? A. Don sterile gloves B. Puncture the center aspect of the newborn's heel C. Elevate the newborn's heel prior to the procedure D. Warm the heel with a warm washcloth prior to the procedure

D. Warm the heel with a warm washcloth prior to the procedure Rationale: Warming the heel with a warm washcloth 5-10 min prior enhances blood flow to the heel. Clean not sterile gloves should be worn. The outer aspect of the newborn's heel should be punctured to avoid nerves and vessels. Place the heel in a dependent position to enhance blood flow.

A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? A. Anemia B. Frequent UTIs C. Previous cesarean birth D. Pelvic inflammatory disease

D: Pelvic inflammatory disease (PID) Rationale: An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and the placenta causing the fetus to begin developing in this area. The most common site is within a fallopian tube, but ectopic pregnancies can occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, PID increases a clients risk. Anemia, frequent urinary tract infections or prior cesarean birth does not place the client at an increased risk.