ATI RN Maternal Newborn A

A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take? a. Ensure the parent's identification band number matches the newborn's identification band number b. Ask the parent to verify their name and date of birth c. Check the newborn's security tag number to ensure it matches the newborn's medical record d. Match the newborn's date and time of birth to the information in the parent's medical record

a. Ensure the parent's identification band number matches the newborn's identification band number The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the number on the parent's identification band to the number on the newborn's identification band.

For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis. Each finding may support more than one disease process.

Decreased temperature is associated with hypoglycemia and sepsis. Yellow sclera and oral mucosa are associated with hyperbilirubinemia and sepsis. Poor feeding is associated with hypoglycemia, hyperbilirubinemia and sepsis. Ecchymosis caput succedaneum is associated hyperbilirubinemia. Respiratory distress is associated with hypoglycemia and sepsis. Lethargy is associated with hypoglycemia and sepsis.

A nurse in a clinic is caring for a 16-year-old adolescent. Exhibit 1: Hx and Physical Adolescent is sexually active with two current partners.IUD in placeReports not using condoms during sexual activity.History of type 1 diabetes mellitus Exhibit 2: RN Notes Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours. Reports painful urination and pain during sexual intercourse with minimal vaginal itching. Tenderness with palpation to lower abdomen, guarding abdomen observed. Greenish vaginal discharge observed. Reports last menstrual period was 3 weeks ago as normal period lasted 4 days. Exhibit 3: VS 1300: Blood pressure 118/72 mm Hg, Heart rate 100/min, Respiratory rate 20/min, Temperature 38.3° C (101° F)

Abdominal Pain - Gonorrhea Greenish discharge - Trichomoniasis, Gonorrhea Diabetes - Candidiasis Pain on urination - Trichomoniasis, Gonorrhea, Candidiasis Absence of condom use - Trichomoniasis, Gonorrhea

A nurse is caring for a newborn. Exhibit 1: Medical hx @1600: Apgar score 9 at 1 min and 9 at 5 min. Birth weight 4,706g (10lb 6oz). Gestational age 40 weeks. Difficult vaginal birth with shoulder dystocia. Exhibit 2: RN note @1700: Newborn is active and moves all extremities except for right arm. No spontaneous movement of the right arm noted. Right arm remains at side during Moro reflex. Exhibit 3: Physical Exam Absent Moro reflex noted in right arm. Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's palsy) paralysis.

Educate the parents to begin range of motion exercises on the affected arm after 1 week is indicated. Passive ROM exercises of the arm are indicated to restore function of the extremity. The initiation of these exercises is delayed for approximately 1 week to prevent additional injury to the brachial plexus. Assess for grasp reflex in the affected extremity is indicated. With Erb-Duchenne paralysis, only the upper arm is affected. The function of the wrists and fingers should be unaffected; the nurse should assess for a palmar grasp reflex. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt is indicated. Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved by pinning the sleeve to the shirt. Instruct parents to limit physical handling for 2 weeks is contraindicated. Parents and guardians should participate in the physical care of their newborn to increase parental-infant attachment. Providing education and practice opportunities for the parents will decrease their fears of injuring the newborn and increase confidence and bonding.

Exhibit 1: Medical hx Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth weight 3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min and 9 at 5 min. Maternal history of methadone use during pregnancy. Exhibit 2: VS @0700: Heart rate 156/min. Respiratory rate 58/min. Temperature 37.2° C (98.9° F) Oxygen saturation 98% on room air @1100: Heart rate 160/min. Respiratory rate 60/min. Temperature 37.3° C (99.2° F) Oxygen saturation 96% on room air Exhibit 3: Phys Exam Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation. Increased muscle tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Several loose stools today. Exhibit 4: Diagnostic Results Maternal urine toxicology screen positive for opiates (-). Newborn urine toxicology screen positive for opiates (-

Respiratory findings is incorrect. The newborn's respiratory rate is within the expected reference range of 30 to 60/min. There is no indication the newborn has an alteration in respiratory status; therefore, this finding does not need to be reported to the provider. Temperature is incorrect. The newborn's temperature is within the expected reference range of 36.5° to 37.5° C (97.7° to 99.5° F). Therefore, this finding does not need to be reported to the provider. Oxygen saturation is incorrect. The newborn's oxygen saturation is within the expected reference range of greater than 94%; therefore, this finding does not need to be reported to the provider. Central nervous system findings is correct. The newborn is displaying inconsolability, high-pitched cry, increased muscle tone, tremors, hyperactive Moro reflex, and excessive sucking. These findings are manifestations of NAS and should be reported to the provider. Gastrointestinal findings is correct. The newborn is displaying poor feeding and loose stools. These findings are manifestations of NAS and should be reported to the provider.

A nurse is caring for a newborn who is 48 hours old. Exhibit 1: VS Day 2, 0900: Heart rate 174/min, Respiratory rate 88/min, Temperature 36.1° C (97.0° F), Oxygen saturation 97% on room air Exhibit 2: Diagnostic Results Day 1, 0800: Newborn results Blood type: A+, Urine toxicology screen: positive marijuana Day 2, 0800: Newborn results, Total bilirubin 10 mg/dL (1.0 to 12.0 mg/dL) Day 2, 0915: Blood glucose: 38 mg/dL (expected value greater than 40 to 45 gm/dL Exhibit 3: RN Notes Day 2, 0900: Newborn awake, alert, and crying. Loosely wrapped in one blanket. Mild tremors noted. Yellow discoloration of mucus membranes and sclera noted. Respirations 88/min, no retractions, grunting, or nasal flaring noted. Diaper changed for small amount of urine and transitional stool.

Upon recognizing and analyzing newborn findings of temperature below the expected range, respiratory rate above the expected range, and hypoglycemia, the nurse's priority hypothesis is that this newborn is most likely experiencing cold stress. It is important to generate solutions and take actions that address cold stress. Therefore, the nurse should monitor the newborn's temperature and glucose levels because a newborn experiencing cold stress is at risk for developing metabolic acidosis. To evaluate the client's response to these interventions, the nurse should monitor the newborn's temperature and glucose levels.

Exhibit 1: RN note @ 0900: Client reports a small amount of bright red blood in their underwear upon awakening. Client denies contractions or abdominal pain. External fetal monitor applied. @0930: Client passed large amount of bright red blood from vagina. Denies pain. Uterine tone soft and nontender to palpation. Contraction pattern: no contractions noted. Fetal heart rate pattern: Fetal heart rate baseline 135/min. Moderate variability. No decelerations noted. Exhibit 2: VS @0900: Temperature 36.2°C (97.2° F)Pulse rate 78/min. Respiratory rate 20/min. Blood pressure 112/64 mmHg. Fetal heart rate 132/min @0930: Pulse rate 82/min. Blood pressure 116/60 mmHg. Fetal heart rate 160/min Exhibit 3: Medical hx G4P3. 30 weeks gestation. Previous pregnancies delivered via cesarean section

When generating solutions, inserting a large bore intravenous catheter is indicated. Clients who have third trimester vaginal bleeding may experience a sudden hemorrhage and require fluid resuscitation or the administration of blood products. The nurse should weigh perineal pads. Weighing perineal pads after use will provide a more accurate assessment of the volume of blood loss that the client is experiencing. When generating solutions, the nurse should not administer methotrexate or assess for cervical dilation because it is contraindicated for this client. Methotrexate is an antimetabolite and folic acid antagonist which destroys rapidly dividing cells. It can be administered during pregnancy to medically resolve an ectopic pregnancy during the first trimester. Assessing cervical dilation is contraindicated for any pregnant client who is experiencing vaginal bleeding. Manipulation of the cervix during the examination may result in further damage to the placenta and compromise the well-being of the client and fetus.

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first? a. A client who is at 11 weeks of gestation and reports abdominal cramping b. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand c. A client who is at 20 weeks of gestation and reports constipation for the past 4 days d. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week

a. A client who is at 11 weeks of gestation and reports abdominal cramping When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first.

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider? a. BUN 25 mg/dL b. Serum creatinine 0.8 mg/dL c. urine output of 280 mL within 8 hr d. urine negative for ketones

a. BUN 25 mg/dL The nurse should report an elevated BUN to the provider since it can indicate dehydration.

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect? a. Decreased platelet count b. Increased erythrocyte sedimentation rate (ESR) c. Decreased megakaryocytes d. Increased WBC

a. Decreased platelet count A client who has ITP has an autoimmune response that results in a decreased platelet count.

The nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform? a. Reassess the client in 2 hr b. Administer simethicone c. Assist the client to empty their bladder d. Instruct the client to lie on their right side

c. Assist the client to empty their bladder The nurse should assist the client to empty their bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage.

A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include? a. Shortness of breath when climbing stairs b. Swelling of feet and ankles at the end of the day c. Headache that is unrelieved by analgesia d. Braxton Hicks contractions

c. Headache that is unrelieved by analgesia A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider.

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client? a. percutaneous umbilical blood sampling b. amnioinfusion c. biophysical profile (BPP) d. Chorionic villus sampling (CVS)

c. biophysical profile (BPP) The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli.

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? a. acrocyanosis b. transient strabismus c. jaundice d. caput succedaneum

c. jaundice Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider.

A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include? a. "The test should take 10 to 15 minutes to complete." b. "You will lay in a supine position throughout the test." c. You should not eat or drink for 2 hours before the test." d. "You should press the handheld button when you feel your baby move."

d. "You should press the handheld button when you feel your baby move." The nurse should instruct the client to press the handheld button when the fetus moves. This action will mark the fetal monitor tracing with the client's reports of fetal movement. This will assist in the interpretation of the nonstress test to determine if it is reactive or nonreactive.

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 The greatest risk to the client and their fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take.

A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? a. deep tendon reflexes 4+ b. fundal height 14 cm c. urine protein 2+ d. FHR 152/min

d. FHR 152/min The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse.

A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take? a. Administer penicillin G 2.4 million units IM to the client b. Instruct the client to schedule an annual pelvic examination c. Tell the client they will start medication for HIV immediately after delivery d. Report the client's condition to the local health department

d. Report the client's condition to the local health department HIV is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is required to be reported.

The nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? a. Hypertonia b. Increased feeding c. Hyperthermia d. Respiratory distress

d. Respiratory distress Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.

A nurse is assessing the newborn of a client who took selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? a. Large for gestational age b. Hyperglycemia c. Bradypnea d. Vomiting

d. Vomiting Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? a. a newborn who is 26 hr old and has erythema toxicum on their face b. a newborn who is 32 hr old and has not passes a meconium stool c. a newborn who is 12 hr old and has pink-tinged urine d. a newborn who is 18 hr old and has an axillary temperature of 37.7 degrees Celsius

d. a newborn who is 18 hr old and has an axillary temperature of 37.7 degrees Celsius An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider.

The nurse should first implement (blank) and (blank)

1. providing education on medications is correct. 2. administering ceftriaxone Providing education on medications is correct. The nurse should first educate the adolescent regarding medications because clients have the right to know the purpose and potential adverse reactions of all prescribed medications before receiving them. An understanding of the prescribed medications will increase the likelihood that the adolescent will adhere to the prescribed therapy. Administering ceftriaxone is correct. Ceftriaxone is designated as a NOW prescription, which means it should be given within 90 min of the provider writing the prescription. The nurse should administer ceftriaxone after educating the adolescent about the purpose and potential adverse reactions of the medication.

A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1g orally now." Available are 250 mg tablets. How many tablets should the nurse administer?

4 tablets

A nurse in a clinic is caring for a 16-year-old adolescent. Exhibit 1: VS 1300: Blood pressure 118/72 mm Hg, Heart rate 100/min, Respiratory rate 20/min, Temperature 38.3° C (101° F) Exhibit 3: Hx and Physical Adolescent is sexually active with two current partners. IUD in place. Reports not using condoms during sexual activity. History of type 1 diabetes mellitus Exhibit 4: RN Notes 1300: Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours. Reports painful urination and pain during sexual intercourse with minimal vaginal itching. Tenderness with palpation to lower abdomen, guarding abdomen observed. Greenish vaginal discharge observed. Reports last menstrual period was 3 weeks ago as normal period lasted 4 days.

Abdominal assessment Vaginal discharge Temperature Dyspareunia

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply) a. Cholecystitis b. Hypertension c. Human papillomavirus d. Migraine headaches e. Anxiety disorder

Cholecystitis, hypertension, and migraine headaches is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is a contraindication for the use of oral contraceptives. A history of migraine headaches is a contraindication for the use of oral contraceptives. HPV and anxiety disorder is incorrect. The presence of human papillomavirus is not a contraindication for the use of oral contraceptives. The presence of an anxiety disorder is not a contraindication for the use of oral contraceptives.

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.) a. Flaccid uterus b. Cervical laceration c. Excess vaginal bleeding d. Increased afterbirth cramping e. Increased maternal temperature

Flaccid uterus is correct. Oxytocin increases the contractility of the uterus. Cervical laceration is incorrect. Bleeding resulting from a cervical laceration continues even when the uterus is contracted and firm. It will require repair by the provider. Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding. Increased afterbirth cramping is incorrect. The use of oxytocin will increase, rather than decrease, afterbirth cramping. Increased maternal temperature is incorrect. The use of oxytocin will have no effect on maternal temperature.

The nurse is reviewing laboratory results in the adolescent's medical record. Exhibit 1: VS 1300: Blood pressure 118/72 mm Hg, Heart rate 100/min, Respiratory rate 20/min, Temperature 38.3° C (101° F) Exhibit 2: Provider Prescription Provider Prescriptions1300:Standing prescriptions for clients who present with abdominal pain: Obtain laboratory tests: Urinalysis, Cervical culture, C-reactive protein, Beta hCG Exhibit 3: Hx and physical Adolescent is sexually active with two current partners.IUD in placeReports not using condoms during sexual activity.History of type 1 diabetes mellitus

Pelvic inflammatory disease is correct. Pelvic inflammatory disease (PID) is an infection that involves the pelvic reproductive organs. There are several causative agents that lead to infection, including Neisseria gonorrhoeae and C. trachomatis. PID occurs as a result from untreated infections ascending from the vagina. Manifestations include fever, increased C-reactive protein, nausea, and vomiting; therefore, the nurse should suspect the adolescent is developing PID. C-reactive protein is correct. The adolescent's C-reactive protein is elevated, which is a manifestation of PID.

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.

The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.

A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? a. "I will eat foods that taste good instead of balancing my meals." b. "I will avoid having a snack before I go to bed each night." c. "I will have a cup of hot tea with each meal." d. "I will eliminate products that contain dairy from my diet."

a. "I will eat foods that taste good instead of balancing my meals." Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet.

The nurse is reviewing laboratory results in the adolescent's medical record. Exhibit 1: Hx and physical Adolescent is sexually active with two current partners. IUD in place. Reports not using condoms during sexual activity. History of type 1 diabetes mellitus Exhibit 2: RN Notes: 1300:Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours. Reports painful urination and pain during sexual intercourse with minimal vaginal itching. Tenderness with palpation to lower abdomen, guarding abdomen observed. Greenish vaginal discharge observed. Reports last menstrual period was 3 weeks ago as normal period lasted 4 days. Exhibit 3: VS 1300: Blood pressure 118/72 mm Hg, Heart rate 100/min, Respiratory rate 20/min, Temperature 38.3° C (101° F)

The nurse should anticipate a provider's prescription for: what and what acyclovir, ceftriaxone, doxycycline, fluconazole, imiquimod Ceftriaxone and doxycycline are correct. The nurse suspects that the adolescent is experiencing pelvic inflammatory disease (PID); Therefore, the nurse should anticipate a provider's prescription for ceftriaxone and doxycycline. The recommended treatment for PID in an outpatient setting is ceftriaxone administered as a single dose intramuscularly, along with doxycycline administered orally 2x/day for 14 days. The treatment regimen may change following the results of the cervical culture.

A nurse is caring for a client who is pregnant in an antepartum clinic. Which of the following findings should the nurse report to the provider? Select the 3 findings that should be reported?

Uterine contractions is correct. The client is experiencing regular uterine contractions and cervical change, which are indicators of preterm labor; therefore, the nurse should notify the provider about this finding. Fetal heart rate is incorrect. The fetal heart rate is within the expected reference range; therefore, the nurse should not report this finding to the provider. Gestational age is correct. The client is at 32 weeks of gestation and is experiencing regular uterine contractions and cervical dilation, which indicates that the client is in preterm labor; therefore, the nurse should notify the provider about this finding. Vaginal examination is correct. The client's cervix is dilated to 2 cm and is 50% effaced, which indicate the client is in preterm labor; therefore, the nurse should notify the provider about this finding. Maternal blood pressure is incorrect. The client's blood pressure is within the expected reference range; therefore, the nurse should not report this finding to the provider.

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching? a. "You should take the medication within 72 hours following unprotected sexual intercourse." b. "You should avoid taking this medication if you are on an oral contraceptive." c. "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test." d. "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it."

a. "You should take the medication within 72 hours following unprotected sexual intercourse." Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse.

A nurse is reviewing the laboratory results for a client who is at 10 weeks gestation. Which of the following laboratory findings should the nurse report to the provider? a. Hemoglobin 10 g/dL b. WBC count 15,000/mm^3 c. RBC count 5.8 million/mm^3 d. Hematocrit 34%

a. Hemoglobin 10 g/dL A hemoglobin level of 10g/dL is below the expected reference range of greater than 11g/dL for a client who is pregnant. The nurse should report this laboratory finding to the provider.

A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider? a. Late decelerations b. Moderate variability of the FHR c. Cessation of uterine dilation d. Prolonged active phase of labor

a. Late decelerations Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider.

A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior? a. Lays the newborn across their lap an gently sways b. Places the newborn in the crib in a prone position c. Offers the newborn a pacifier dipped in formula d. Prepares a bottle of formula mixed with rice cereal

a. Lays the newborn across their lap an gently sways This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn.

A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? a. Minimal arm recoil b. Popliteal angle of 90 degrees c. Creases over the entire foot side d. Raised areolas with 3 to 4 mm buds

a. Minimal arm recoil The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil.

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring? a. Oligohydramnios b. Hyperemesis gravidarum c. Leukorrhea d. Periodic tingling of the fingers

a. Oligohydramnios The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.

A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider? a. Substernal retractions b. Acrocyanosis c. Overlapping suture lines d. Head circumference 33 (13 in)

a. Substernal retractions The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection or respiratory distress in the newborn. The nurse should report these findings to the provider for immediate intervention.

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? a. Swelling of the face b. Varicose veins in the calves c. Nonpitting 1+ ankle edema d. Hyperpigmentation of the cheeks

a. Swelling of the face Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.

A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? a. depression b. polyuria c. hypotension d. urticaria

a. depression The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness.

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first? a. determine respiratory function b. increase the IV fluid rate c. access emergency medications from cart d. collect a maternal blood sample for coagulopathy studies

a. determine respiratory function The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation.

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that they are "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following? a. emotional lability b. focusing phase c. cognitive restructuring d. Couvade syndrome

a. emotional lability The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.

A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor? a. Passive descent b. Active c. Early d. Descent

b. Active The nurse should identify that the client is in the active phase of labor. This phase is characterized by a cervical dilatation of 6 to 10 cm and contractions every 1.5 to 5 min, each lasting 40 to 90 seconds.

A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take? a. restrict hourly intake to 150 mL/hr b. Have calcium gluconate readily available c. assess deep tendon reflexes every 6 hr d. monitor intake and output every 4 hr

b. Have calcium gluconate readily available The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity.

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority? a. O2 saturation b. Temperature c. Blood pressure d. Urinary output

b. Temperature The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.

A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority? a. a client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL b. a client who is at 34 weeks of gestation and reports epigastric pain c. a client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL d. a client who is at 39 weeks of gestation and reports urinary frequency and dysuria

b. a client who is at 34 weeks of gestation and reports epigastric pain When using the urgent vs. nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority.

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? a. decreased heart rate b. chin quivering c. pinpoint pupils d. slowed respirations

b. chin quivering Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow.

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication? a. increased fetal movement b. leakage of fluid from the vagina c. upper abdominal discomfort d. urinary frequency

b. leakage of fluid from the vagina Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider.

A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take? a. administer aspirin for pain b. maintain the client on bed rest c. massage the affected leg d. apply cold compresses to the affected calf

b. maintain the client on bed rest The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended.

A nurse is caring for a client who is at 38 weeks of 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 The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer.

A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first? a. confirm the newborn's Apgar score b. verify the newborn's identification c. administer vitamin K to the newborn d. determine obstetrical risk factors

b. verify the newborn's identification When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery.

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. "I should have a goal of maintaining my fasting blood glucose between 100 and 120." b. "I should engage in moderate exercise for 30 minutes if my blood glucose in 250 or greater." c. "I will continue taking my insulin if I experience nausea and vomiting." d. "I will ensure that my bedtime snack is high in refined sugar."

c. "I will continue taking my insulin if I experience nausea and vomiting." The nurse should teach the client to continue to take their insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes.

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care. a. Place the client in a supine position for 30 min following the first dose of anesthetic solution b. Administer 1000 mL of dextrose 5% in water prior to the first dose of anesthetic solution c. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution d. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution

c. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution.

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? a. Feed the newborn 1 oz of water every 4 hr b. Apply lotion to the newborn's skin three times per day c. Remove all clothing from the newborn except the diaper d. Discontinue therapy if the newborn develops a rash.

c. Remove all clothing from the newborn except the diaper The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin.

A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. "I should increase my protein intake to 60 grams each day." b. "I should drink 2 liters of water each day." c. "I should increase my overall daily caloric intake by 300 calories." d. "I should take 600 micrograms of folic acid each day."

d. "I should take 600 micrograms of folic acid each day." A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects.

A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make? a. "The nurse will carry your baby in their arms to the nursery for scheduled procedures." b. "We will document the relationship of visitors in your medical record." c. "It's okay for your baby to sleep in the bed with you while in the hospital." d. "Staff members who take care of your baby will be wearing a photo identification badge."

d. "Staff members who take care of your baby will be wearing a photo identification badge." The nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs.

A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Exhibit 1: Graphic Record ​Blood pressure 130/78 mm Hg, Respiratory rate 20/min, Heart rate 90/min Exhibit 2: Diagnostic Results​Hemoglobin 12 g/dL, Hematocrit 34%, 1-hr glucose tolerance test 120 mg/dL Exhibit 3: Progress Notes Fundal height 30 cm, Good fetal movement, Not experiencing headache, dizziness, blurred vision, or vaginal bleeding, Fetal heart rate 110/min a. 1-hr glucose tolerance test b. Hematocrit c. Fundal height measurement d. Fetal heart rate (FHR)

d. Fundal height measurement A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider.

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care? a. Maintain the client NPO throughout the procedure b. Place the client in a supine position c. Instruct the client to massage the abdomen to stimulate fetal movement d. Instruct the client to press the provided button each time fetal movement is detected

d. Instruct the client to press the provided button each time fetal movement is detected Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when they detect fetal movement will ensure that the fetal movement is noted.

A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had amniocentesis. Which of the following interventions is the nurse's priority following the procedure? a. check the client's temperature b. observe for uterine contractions c. administer Rh (D) immune globulin d. monitor the FHR

d. monitor the FHR The greatest risk to this client and their fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis.

"I should continue taking all my medications even if i dont show any symptoms" indicates understanding of teaching. "If i continue to get this type of infection, it can affect my ability to have kids in the future" indicates understanding of teaching" "I'm more likely to get a sunburn while taking these medications" indicates understanding of teaching 'I should go to the ED if my urine turns dark" indicates a need for further education' As long as I keep my IUD, i don't need to use condoms" indicates a need for further education

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