ATI RN Maternal Newborn Test A

A nurse is preparing to administer hep B immune globulin to a newborn. The prescription states, administer 5 mcg IM once today. Available is 5 mL vial with 10 mcg/mL. How many mL should the nurse administer?

0.5 mL

A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT) ? A) just above the umbilicus B) just above the symphysis pubis C) the right lower quadrant D) the left lower quadrant

B) just above the symphysis

A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching? A) you should replace the diaphragm every 5 years B) you should leave the diaphragm in place for at least 6 hrs after intercourse C) you should use an oil based lubricant when inserting the diaphragm D) you should use the diaphragm when your bladder is full

B) you should leave the diaphragm in place for at least 6 hrs after intercourse Rationale: The client should replace the diaphragm every 2 yr. The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy. The client should avoid using oil-based products because they can weaken the rubber. The client should have an empty bladder prior to inserting the diaphragm.

A nurse is providing teaching about comfort measures to a client who is breastfeeding and is experiencing engorgement. Which of the following nonpharm measures should the nurse include in the teaching? A) you may use a breast binder to relieve discomfort B) you should use cold compresses after each feeding C) you should apply a few drops of colostrum to the nipple following the feeding D) you may place breast shells inside your bra

B) you should use cold compresses after each feeding

A nurse is assessing a client who is in labor and notes early decelerations on the fetal monito. Which of the following findings should the nurse identify as a possible cause of the early decelerations? A) prolapsed umbilical cord B) placenta previa C) fetal head compression D) maternal hypotension

C) fetal head compression Rationale: The nurse should identify fetal head compression as a likely cause of the early decelerations on the fetal monitor. Early decelerations are an expected fetal pattern caused by fetal head compression due to uterine contractions, fundal pressure, and vaginal examinations. A prolapsed umbilical cord would cause variable decelerations, rather than early, because of the compression on the umbilical cord. Placenta previa would cause late decelerations, rather than early, because of the disruption of oxygen to the fetus. Maternal hypotension would cause late decelerations, rather than early, because of the disruption of oxygen to the fetus.

A nurse is teaching a client about RHo(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching? A) I will receive this medication if my baby is Rh-negative B) I will receive this medication when I am in labor C) I will need a second dose of this medication when my baby id 6wks old D) I will need this medication if I have an amniocentesis

D) I will need this medication if I have an amniocentesis Rationale: Rho(D) immune globulin is administered to a mother who is Rh-negative and gives birth to an Rh-positive newborn. Therefore, this statement does not indicate an understanding of the teaching. Rho(D) immune globulin is administered at 28 weeks of gestation or after birth if the newborn is Rh-positive. Therefore, this statement does not indicate an understanding of the teaching. Rho(D) immune globulin is administered at 28 weeks of gestation to mothers who are Rh-negative and following the birth of a newborn who is Rh-positive. Therefore, this statement does not indicate an understanding of the teaching. Rho(D) immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.

A nurse is teaching a client who is pregnant about managing nausea and vomiting. Which of the following instructions should the nurse include in the teaching? A) Brush your teeth immediately after eating B) Eat foods served at a warm temp C) Drink a glass of water with each meal D) Eat high carb foods

D) eat high carb foods

A nurse is teaching a client who is at 8 wks gestation about exercise. Which of the following instructions should the nurse include in the teaching? A) you should increase weight bearing exercises as your pregnancy progresses B) you should lie on your back to rest for 5 mins after exercising C) you should take your pulse every 20 mins while your are exercising D) you should exercise for 30 mins every day

D) you should exercise for 30 mins every day Rationale: The nurse should instruct the client to engage in 30 min of moderate exercise every day to improve muscle tone throughout her pregnancy. The nurse should instruct to client to decrease, rather than increase, weight-bearing exercises as the pregnancy progresses. The nurse should instruct the client to take her pulse every 10 to 15 min during exercise, rather than every 20 min. The nurse should instruct the client to rest in a lateral position for 10 min following exercise.

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 25mg/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 Rationale: The nurse should report an elevated BUN to the provider since it can indicate dehydration. A serum creatinine level of 0.8 mg/dL is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. Testing the urine for ketones is the most important laboratory test for a client who has hyperemesis gravidarum. Dehydration causes the catabolism of fat, which produces ketones that will be present in urine. Dehydration increases the risk of preterm labor. Therefore, the nurse does not need to report this finding to the provider.

A nurse is caring for a client who is at 36 weeks of 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 stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with 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 the maternal circulation when there is a risk of Rh-isoimmunization.

A nurse in a prenatal clinic who reports that her menstrual period is 2 wks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make? A) You can miss your period for several other reasons, describe your typical menstrual cycle. B) If you have been sexually active and havent used protection, it is likely that you are pregnant. C) Lets check to see if you have any other signs of pregnancy, have you noticed any abdominal enlargement yet? D) Because you have missed your period, you should try taking a home pregnancy test before you start worrying.

A) You can miss your period for several other reasons, describe your typical menstrual cycle.

A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client dilated to 8cm and reports back pain. Which of the following actions should the nurse take? A) Apply sacral counterpressure B) Perform transcutaneous electrical nerve stimulation (TENS) C) initiate slow-paced breathing D) assist with biofeedback

A) apply sacral counterpressure Rationale: The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position. The nurse should perform TENS during the first stage of labor. The nurse should transition a client to pattern-paced breathing during this stage of labor. The nurse should teach the client about biofeedback during the prenatal period for it to be effective during labor.

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 resp function B) increase the IV fluid rate C) access emergency medications from cart D) collect a maternal blood sample for coagulopathy studies

A) determine resp function Rationale: 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. The nurse should increase the IV fluid rate to maintain circulation. However, this is not the first action the nurse should take. The nurse should access emergency medication to assist in resuscitative efforts. However, this is not the first action the nurse should take. The nurse should collect a maternal blood sample in preparation for a blood transfusion. However, this is not the first action the nurse should take.

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next? a) massage the clients fundus B) insert an indwelling urinary catheter C) administer oxygen at 10 L/ min D) Elevate the clients right hip

A) massage the clients fundus Rationale: The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions. The nurse should insert an indwelling urinary catheter to monitor perfusion of the kidneys. However, this is not the next action the nurse should take. The nurse should administer oxygen at 10 L/min to enhance perfusion. However, this is not the next action the nurse should take. The nurse should elevate the client's right hip to enhance perfusion. However, this is not the next action the nurse should take.

A nurse is assessing a newborn who was born at 26 wks 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 sole D) raised areolas with 3-4 mm buds

A) minimal arm recoil Rationale: The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil. A popliteal angle of 90° is an indicator of physical maturity with increasing gestational age after 26 weeks. Creases over the entire sole of a newborn's foot are an indicator of physical maturity with increasing gestational age after 26 weeks.Raised areolas with 3 to 4 mm buds is an indicator of physical maturity with increasing gestational age after 26 weeks.

A nurse is calculating a clients expected DOB using Naegele's rule. The client tells the nurse her last menstrual cycle started November 27th. Which of the following dates is the clients expected DOB? A) Sept 3rd b) Sept 20th c) august 3rd D) august 20th

A) sept 3rd Rationale: Just add 9 months and add 7 days lol

A nurse is assessing a client who is at 30 wks 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

A) swelling of the face

A nurse is providing discharge teaching to a client who is postpartum and was taking insulin for gestational diabetes mellitus. Which of the following instructions should the nurse include in the teaching? A) you should get a 2 hour oral gluscose tolerance test in 6-12 wks B) you should avoid using low dose oral contraceptives for birth control C) you will need to monitor your blood glucose levels daily at home for 2-3 wks D) you will need to take a lower dose of insulin than you took during your pregnancy

A) you should get a 2 hour oral glucose tolerance test in 6-12 wks

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 temp

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

A nurse an 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 wks gestation and reports epigastric pain C) a client who is at 28 wks gestation and has a Hgb of 10.4 g/dl D) A client who is at 39 wks of gestation and reports urinary frequency and dysuria

B) A client who is at 34 wks gestation and reports epigastric pain Rationale: Epigastric pain is a clinical manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority. A fasting blood glucose of 120 mg/dL is above the expected reference range for a client who has gestational diabetes. However, this is a nonurgent finding, which means that another client is the nurse's priority. This finding is a clinical manifestation of anemia in a client who is pregnant, which is a nonurgent condition. Therefore, another client is the nurse's priority. Dysuria can indicate a urinary tract infection, which can cause preterm labor. Dysuria in a client who is at 39 weeks of gestation is a nonurgent condition. Therefore, another client is the nurse's priority.

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 mvmnt b) leakage of fluid from the vagina c) upper abdominal discomfort d) urinary frequency

B) leakage of fluid from the vagina Rationale: Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider. Upper abdominal discomfort is not a potential complication associated with an amniocentesis.

A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her 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 every 12hr D) apply cold compresses to the affected calf

B) maintain the client on bed rest

A nurse is caring for a client who is at 38 wks 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 specimen exam d) prep a Nitrazine paper test

B) perform leopold maneuvers Rationale: 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. The nurse should determine the client's dilation and effacement prior to applying an internal monitor. This action is not required prior to applying an external transducer for fetal monitoring. A Nitrazine paper test is performed to assess the components (pH level) of vaginal fluid to determine if the membranes have ruptured. This action is not required prior to applying an external transducer for fetal monitoring.

A nurse is caring for a client who is 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound? A) to estimate fetal weight B) to locate a pocket of fluid C) to determine multiparity D) to pre-screen for fetal anomalies

B) to locate a pocket of fluid

A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching? A) Obtain an informed consent prior to obtaining the specimen B) Collect at least milliliter of the urine for the test C) Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen. D) Premature newborns may have false negative tests due to immature development of liver enzymes.

C) Ensure that the newborn has been receiving feedings for 24 hrs prior to obtaining the specimen.

A nurse is caring for a client who is at 35 wks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? A) give the client orange juice B) Elevate the clients legs C) Have the client change position D) Establish IV access

C) Have the client change position

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? A) I will get injections of the medication once daily until my labor stops b) my blood sugar may be low while I'm on this medication c) I will have blood tests because my potassium might decrease d) my bp may increase while I'm on this medication

C) I will have blood tests because my potassium might decrease Rationale: Terbutaline is a medication used to delay preterm labor. It is in a class of drugs called betamimetics, which help prevent and slow contractions of the uterus. Terbutaline is primarily used when doctors need to delay birth for several hours or days in order to allow the child to mature more before being born. Adverse effects of terbutaline include hyperglycemia, hypokalemia, and hypotension. Terbutaline is administered subcutaneously q4 hr for no longer than 24 hours.

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 Rationale: 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. The nurse should not feed the newborn any water or glucose water. Hydration can be maintained through regular breastfeeding or formula feeding. Water and glucose water do not increase the excretion rate of bilirubin or provide nutritional value. The nurse should not apply lotion or creams to a newborn who is undergoing phototherapy. Lotions and creams can absorb heat and lead to burns. The nurse should not discontinue phototherapy if the newborn develops a rash. A temporary, fine rash can occur during therapy. This rash requires no treatment.

A nurse is caring for a client who is anemic at 32 wks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect? A) decreased uterine contractions B) an increase in the clients hemoglobin levels C) a reduction in respiratory distress in the newborn D) increased production of antibodies in the newborn

C) a reduction in respiratory distress in the newborn

A nurse is caring for a client who is 26 wks of gestation and has epilepsy. She enters the room and observes the client is having a seizure. After turning the clients head to one side , which action should the nurse take? A) Monitor the FHR B) assess uterine activity C) administer oxygen via a nonrebreather mask D) start a bolus of IV fluids

C) administer oxygen via nonrebreather mask Rationale: When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask to ensure adequate oxygenation to the fetus. The nurse should monitor the FHR to assess fetal well-being. However, this is not the action the nurse should take next. The nurse should assess uterine activity for potential complications of the seizure. However, this is not the action the nurse should take next. The nurse should start IV fluids following the seizure to ensure adequate hydration. However, this is not the action the nurse should take next.

A nurse is reviewing the medical record of a client who is one day postpartum. The client had a vaginal birth with a fourth degree perineal laceration. The nurse should contact the provider regarding which of the following prescriptions? A) docusate sodium 100 mg capsule po by mouth 3x daily B) sitz bath 2-3 x a day prn for pain C) bisacodyl rectal suppository daily prn for constipation d) ibuprofen 600 mg by mouth every 6 hr prn for pain

C) bisacodyl rectal suppository daily prn for constipation Rationale: The nurse should not administer a rectal suppository or enema to a client who has a fourth-degree perineal laceration. These can cause separation of the suture line, bleeding, or infection. Ibuprofen is a nonsteroidal, anti-inflammatory medication that is used to decrease pain and swelling. The client who has a fourth-degree perineal laceration will likely receive scheduled ibuprofen as well as an opioid analgesic as needed for breakthrough pain. A sitz bath filled with warm water is soothing to the perineum. The warm water also increases blood flow to the tissues, promoting healing. The nurse should encourage the client to use a sitz bath two to three times per day, or as often as needed, to decrease perineal pain. Docusate sodium is a stool softener that is often prescribed following birth. The client should take a stool softener until the perineum is healed. Hard stool can separate the suture line between the vagina and rectum, leading to bleeding and infection.

A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make? A) Let me help you into a comfortable pushing position so you can begin bearing down. B) I am going to call the doctor to get a prescription for medication to ripen your cervix. C) I will give you some IV pain medicine to strengthen your contractions. D) Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions.

D) Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions.

A nurse is observing a new mother caring for her crying newborn who is bottle feeding. Which of the following actions by the mother should the nurse recognize as a positive parenting behavior? a) lays the newborn across her lap and 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 her lap and gently sways Rationale: This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn. The mother should place the infant in the supine position, not a prone position, in the bassinet or crib because of the risk of sudden infant death syndrome. Pacifiers may be used for a newborn who needs extra sucking for self-soothing. However, formula should not be placed on the tip of the pacifier because the newborn may become accustomed to it and refuse to take the pacifier in the future without added supplement. Rice cereal should not be added to the bottle of a newborn because solids should not be introduced until 4 to 6 months of age.

A nurse on the postpartum unit is caring for a client following a cesarean birth.Which of the following assessments is the nurses priority? a) parent child attachement b) amount of lochia C) patency of the IV catheter D) quality and quantity of urine output

b) amount of lochia Rationale: When using the airway, breathing, circulation approach to client care, the nurse should place the priority in the immediate postpartum period on assessing the amount of postpartum lochia. The greatest risk to the client is bleeding and postpartum hemorrhage. Parent-child attachment is an important assessment following a cesarean birth. However, another assessment is the nurse's priority. Patency of the IV catheter is an important assessment following a cesarean birth. However, another assessment is the nurse's priority. Assessing the quality and quantity of urine output is important following a cesarean birth. However, another assessment is the nurse's priority.

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: There are no antiviral medications available to treat this disease. The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Hydrops fetalis (fetal hydrops) is a serious fetal condition defined as abnormal accumulation of fluid in two or more fetal compartments, including ascites, pleural effusion, pericardial effusion, and skin edema. In some patients, it may also be associated with polyhydramnios and placental edema. An indirect Coombs' is inaccurate because the test determines whether the client has antibodies to the Rh antigen. The titer determines the mother's sensitization and if there is Rh incompatibility. The Haemophilus influenzae type b vaccine is given to prevent the flu, not fifth disease

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) temp c) bp d) urinary output

b) temp Rationale: The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature. Assessing the client's O2 saturation is important during labor. However, another assessment is the nurse's priority. Assessing the client's blood pressure is important. However, another assessment is the nurse's priority. Assessing the client's urinary output is important during labor. However, another assessment is the nurse's priority.

A nurse in an antepartum clinic providing care for a client who is at 26 weeks of gestation. Which of the following findings should the nurse report to the provider? a) 1-hr glucose tolerance test = 120 mg/dL B) hematocrit = 34% C) fundal height measurement = 30 cm d) fetal heart rate = 110/min

c) fundal height measurement Rationale: 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 glucose tolerance test result of 120 mg/dL is within the expected reference range for this client. A value of 130 to 140 mg/dL or greater for a 1-hr glucose tolerance test indicates a positive test result and should be reported to the provider. A hematocrit of 34% is within the expected reference range for this client. The level should be greater than 33%. The FHR is within the range of 110-160 BPM at 26 weeks

A nurse is teaching a client who is at 35wks gestation about clinical 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 Rationale: A headache that is unrelieved by analgesia may indicate preeclampsia and should be reported to the provider. Shortness of breath is related to the enlarging uterus interfering with the expansion of the diaphragm and is an expected clinical manifestation at 35 weeks of gestation. Swelling of feet and ankles is due to the enlarging uterus interfering with blood return to the heart and is an expected clinical manifestation at 35 weeks of gestation. Braxton Hicks contractions are an indication that the uterus is preparing for labor and is an expected clinical manifestation at 35 weeks of gestation.

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

A staff nurse on an obstetric unit is caring for a client who is scheduled for an induced abortion. The staff informs the nurse manager that she has a moral issue with the clients decision. Which of the following actions should the nurse manager take? A) inform the staff nurse that she is required to care for the client B) advise the staff nurse that she will likely receive disciplinary action C) reassign the client to another staff nurse D) advise the staff nurse to transfer to another unit

c) reassign the client to another staff nurse Rationale: The nurse manager should take into account the staff nurse's moral beliefs and recognize that she also has rights and responsibilities concerning the care of a client who is undergoing an induced abortion. Therefore, the nurse manager should reassign the care of the client to another staff nurse.

A nurse is performing a routine assessment on a client who is 18 wks 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 Rationale: 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 urine protein concentration of 2+ is an indication of preeclampsia and should be investigated further. Therefore, the nurse should expect the urine protein for this client to be less than 1+. From gestational weeks 18 to 32, the height of the fundus is approximately equal to the number of weeks of gestation plus or minus 2 cm. Therefore, the nurse should expect the fundal height for this client should be 16 to 20 cm. Deep tendon reflexes (DTRs) are an indication of the balance between the cerebral cortex and spinal cord. The nurse should expect the client's DTR to be 2+. Therefore, a DTR of 4+ indicates hyperreflexia.

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following lab results should the nurse report to the provider? A) Hct 39% b) serum albumin 4.5 g/dl c) WBC 9,000/mm^3 d) Platelets 50,000/mm^3

d) Platelets 50,000/mm^3 Rationale: A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. Disseminated intravascular coagulation is a condition in which small blood clots develop throughout the bloodstream, blocking small blood vessels. The increased clotting depletes the platelets and clotting factors needed to control bleeding, causing excessive bleeding. The nurse should report this result to the provider. Hct drop moderately for 3-4 days then begin to increase and reach nonpregnant levels by 8 weeks postpartum. WBC values between 20,000-25,000 are common 4-7 days after birth. Normal platelets: 146-~400

A nurse is caring for a full term newborn immediately following birth? Which of the following actions should the nurse take first? A) assign apgar scores to the newborn b) weigh the newborn C) place id bracelets on the newborn d) dry the newborn

d) dry the newborn Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take immediately after delivery is to dry the newborn. The nurse should obtain Apgar scores at 1 and 5 min after birth. Therefore, this is not the first action the nurse should take.

A nurse is teaching a mother about steps the nurse will take to promote the security and safety of the newborn. Which of the following statements should the nurse make? A) we will prevent unidentified visitors from entering the unit b) we will document the relationship of visitors in your medical record C) your baby will stay in the nursery while you are asleep D) staff members who take care of your baby will be wearing a photo identification badge

d) staff members will wear a photo id badge Rationale: The nurse should teach 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 her newborn's safety. The nurse should teach the client that visitors are allowed to enter the unit without identifying themselves. However, visitors must provide the name of the client they are visiting.

A client who is at 34 weeks of gestation asks the nurse how she will know when she is in labor and should go to the hospital. Which of the following responses should the nurse make? a) you will feel the contractions primarily in your upper abdomen b) you will feel extremely fatigued when your labor starts c) your breasts will begin to excrete colostrum d) you will notice blood-tinged discharge from your vagina

d) you will notice blood-tinged discharge from your vagina

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

A) A client who is at 11 wks of gestation and reports abdominal cramping Rationale: 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. The other clients should be seen but they are not who should be seen first.

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, ''happy one min 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

A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? A) protect the clients head and feet from cold air B) bathe the client within 12 hr following delivery C) ambulate the client within 24 hr following delivery D) offer the client a glass of cold milk with her meal

A) Protect the clients head and feet from cold air Rationale: Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period. Bathing the client within 12 hr following delivery should not be included in the plan of care because traditional Hispanic practices include delaying bathing for 14 days following delivery. Ambulating the client within 24 hr following delivery should not be included in the plan of care because traditional Hispanic practices include bed rest for 3 days following delivery. Offering the client a glass of cold milk with her first meal should not be included in the plan of care because traditional Hispanic practices include drinking warm beverages following birth.

A nurse is teaching a new mother about newborn safety. Which of the following instructions should the nurse include in the teaching? A) you can share your room with your baby for the next few weeks B) cover your baby with light blanket while she is sleeping C) Check the temp of your baby's bath water with your hand D) your baby can nap in her car seat during the daytime

A) you can share your room with your baby for the next few weeks Rationale: Room-sharing is recommended during the first few weeks. This allows the parents to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parents to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome. The nurse should instruct the parents to check the temperature of the newborn's bath water with their elbow, which is more sensitive to temperature than the hand. The hot water heater should be set at or below 120° F to prevent burns. The nurse should instruct the parents to place the newborn in a sleep sack or a one-piece sleeper. Covering the newborn with a blanket or quilt increases the risk for sudden infant death syndrome. The nurse should instruct the parents to lay the newborn in a bassinet or crib on her back to sleep. Sleeping in a supine position on a firm mattress decreases the risk of sudden infant death syndrome.

A nurse is demonstrating to a client how to bathe her newborn. In which order should the nurse perform the following actions? ( Use all the steps and list them in order) A) Clean the newborn's diaper area B) Wash the newborn's neck by lifting the newborn's chin. C) Wipe the newborn's eyes from the inner canthus outward. D) Cleanse the skin around the newborn's umbilical cord stump. E) Wash the newborn's legs and feet.

C,B,D,E,A

A nurse is planning discharge for a client who is 3 days postpartum.Which of the following non pharmacological interventions should the nurse include in the plan of care for lactation suppression? A) Place warm, moist packs on the breast. B) Apply cabbage leaves to the breast. C) Wear a loose- fitting bra. D) Put green tea bags on the breasts.

B) Apply cabbage leaves to the breasts.

A nurse is assessing a newborn following a circumcision. Which of the following 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

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her 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 her bladder D) Instruct the client to lie on her right side

C) Assist the client to empty her bladder Rationale: The nurse should assist the client to empty her 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. The nurse should assess the client more frequently after birth to determine the position of the uterus and to intervene as soon as possible if necessary. The nurse should administer simethicone to reduce bloating, discomfort, or pain caused by excessive gas. Lying on her right side will not resolve the client's displaced uterus.

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old in accepting the new family member? A. Allow the sibling to hold the newborn during a bath B. Make sure the sibling kisses the newborn each night C. Obtain a gift from the newborn to present to the sibling D. Switch the sibling's room with the nursery

C. Obtain a gift from the newborn to present to the sibling Rationale: Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that they understand their role in the family. Allowing the sibling to hold the newborn during a bath may be a safety issue. Forcing a kiss between the siblings can cause anger from the older sibling. Switching rooms can cause the older sibling to become jealous.

A nurse is teaching a client who is at 10 wks 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 to 60 grams daily B) I should drink 2 L 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 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 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

A nurse is assessing the newborn of a client who took a 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

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. Therefore, this is the priority action the nurse should take. All other choices should be included in the assessment but are not the priority.

A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure? A. Check the client's temperature B. Observe the uterine contractions C. Administer Rho(D) immune globulin D. Monitor the FHR

D. Monitor the FHR Rationale: The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis. All other choices are correct but are not priority interventions.

A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? ( Select all that apply). Heart Rate 154/min Axillary temperature 96.8 F Respiratory rate 58/min Length 43 cm (16.9in) Weight 5lb 12 oz

Heart rate Respiratory Weight

A nurse is caring for a client and her partner who have experienced a fetal death. Which of the following actions should the nurse take? A) Take photos of the newborn to give to the parents. B) Tell the parents that they can consider organ donations. C) Encourage the parents to avoid allowing older children to visit them in the hospital. D) Explain to the parents the need to name the newborn.

Take photos of the newborn to give to the parents.

A nurse is reviewing the lab report of a client who is 24 hr postpartum following a vaginal delivery. Which of the following lab results should the nurse identify as an indication of a postpartum infection? a) Platelets 300,000/mmm^3 b) WBC 9,000/mm^3 c) Erythrocyte sedimentation rate (ESR) 26mm/hr d) C-reactive protein 0.8mg/dl

c) Erythrocyte sedimentation rate (ESR) 26mm/hr