Ati maternity

A nurse is contributing to the plan of care for a newborn following a vaginal birth. Which of the following information should the nurse include when helping to develop the newborn's plan of care? (Select all that apply.)

1.Maternal group B streptococcus GBS status maternal GBS status is revelent information feom the prenatal record that the nurse should include in the newborn's plan of care. If the mothers is GBS positive and has not received antibiotic therapy, the newborn os at risk for neonatal morbidity and mortality. 2. Apgar Score: the nurse or birth attendant documents an Apgad Score at 1 and 5 min following birth to determine how the newborn has adjusted to extrauterine life and whether intervention is necessary. 3. The type birth: of labor and birth is revelent information to include in the newborn's plan of care for planning assential data collection and intervention.

A nurse is caring for a client who is 48 hr postpartum following a vaginal birth. Which of the following findings should the nurse report to the provider? (Select all that apply.)

1.Warm, tender area on the calf is correct. The nurse should report a warm, tender area on the calf, because this can indicate deep-vein thrombosis. 2.Dysuria is correct. The nurse should report dysuria, because this can indicate a urinary tract infection. 3.Cracked nipples is correct. The nurse should report cracked nipples, because this is caused by breastfeeding difficulties and can lead to mastitis.

The nurse is planning to perform a blood collection via heel stick on a newborn. After performing hand hygiene and donning gloves, which of the following actions should the nurse plan to take next?

A:Wrap the newborns heel with a clotb moistened worh warm water. According to evidence based practice, the nurse should first warm the newborn's heel by applying a cloth moietened with warm water for 5-10min. This woll allow dilation of the vessels in the area in order to obtain an adequate sample.

A nurse is contributing to the plan of care for a client who is ag 18 weeks gestation and has jusg learned that the fetus has trisomy 21. Which of the followinv resources should the nurse recommend for the client?

Aaswer: genetic counseling. A fetus that has trisomy 21 (down syndrome) had an extra chromosome. Therefore, the nurse should recommend genetic counseling to provide the client further education about the prognosis and treatment of the condition. As well as offer support guidance.

A nurse is reinforcing teaching about breastfeeding with a client who has a 12-hr-old newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

Answer: "I should wake up my baby to feed during the night." Parents should awaken the newborn to feed every 3hr at night for the first 24 to 48hr after birth. Once the newborn is gaining weight, edequately progressing to demand feeding is safe.

A nurse is preparing to administer phytonadione to a newborn. The nurse should plan to administer this medication by which of the following routes?

Answer: intramuscular The nurse should adminster phytonadione intramusculary to the new born to prevent hemorrhage intli the newborn gastrointestinal sustem can produce its own vitamin K

A nurse is collecting data from a 28-year-old client who is requesting a prescription for an oral contraceptive. Which of the following information in the client's history should the nurse identify as a contraindication for the use of oral contraceptives?

Answer:Frequuent headaches with visual changes: Frequent headaches with visual changes can indicate a cardiovascular condition, such as hypertension. A cardiovascular disorder is a contraindication for oral contraceptive use because the combination can increase the risks of cerebrovascular accident, myocardial infarction, and thromboembolism.

The nurse is collecting data from a client who gave birtb 18hr ago. Which of the following findings should the nuese identify as an indication of a postpartum complication.

Correct answer: Fundus is palpable at 2cm above the imbilicus. The fundus should be located at the level of the umbilicus diring a the first 24 hr postpartum and decreases 1cm each day after that. A fundis thaf is palpable at higher than expected level could be an indication of uterine atony, which can result im maternal hemorrahage.

A nurse is contributing to the plan of care for a client who is pregnant and has intermittent constipation. Which of the following interventions should the nurse recommend in the plan?

Drink 2 litters of water per day. Client should drink 2l of water per day to decrease reabsorption of fluid and prevent drying of stool, which causes constimapation.

A nurse is caring for a client following a cesarean birth. Which of the following actions should the nurse take to decrease the client's risk of developing thrombophlebitis?

Have the client ambulate several times each day. CORRECT The nurse should instruct the client to ambulate several times each day to increase circulation in the lower extremities and prevent thrombophlebitis.

A nurse is caring for a client who is in preterm labor and is receiving betamethasone. Which of the following actions should the nurse take?

Inject the medication into the client's vastus lateralis muscle. CORRECT The nurse should administer the medication IM into the vastus lateralis muscle and administer a second dose 24 hr later.

A nurse is reinforcing discharge teaching with a client who has mastitis of the left breast. Which of the following instructions should the nurse include?

Pump the affected breast frequently. Is CORRECT Keeping the breast empty through breastfeeding or pumping will help to prevent the growth of bacteria due to milk stasis and increase comfort.

A nurse is collecting data from a client who is receiving magnesium sulfate IV for preeclampsia. The nurse should identify which of the following findings as an indication of toxicity to report to the provider?

Respiratory rate 10/min Respiratory depression is an indication of magnesium toxicity. The nurse should report this finding to the provider.

A nurse is assistinv with the neuromuscular assessment of a newborn by eliciting primitive reflexes. Which of the follwoing image indicates a characteristic response of a tonic neck reflex.

The nuse should identify the tonic reflex when the newborn head is quckkh turned to one side, the arm and leg on the same side extend, while the arm and lev on the opposite side flex.