ATI shiz
A postpartum nurse is caring for a client who reports excessive sweating Question Feedback during the first night after delivery. Which of the following statements should the nurse make?
"This is a source of your fluid loss after delivery."
A nurse is caring for a client in the third trimester of pregnancy who is scheduled to undergo a non-stress test. Which of the following actions should the nurse take prior to the test?
Ask the client to drink a glass of orange juice
A nurse is assessing a client who is at 26 weeks of gestation and has mild preeclampsia. Which of the following findings should the nurse report to the provider? Deep tendon reflexes 4+ RATIONALE
Hyperactive deep tendon reflexes demonstrate a progression from mild preeclampsia to severe gestational hypertension or preeclampsia with severe features. This finding indicates the need for hospitalization and treatment with magnesium sulfate to prevent eclamptic seizures.
A nurse is assessing a newborn 1 hr after birth. Which of the following findings should the nurse report to the provider?
Jaundice of the sclera
A nurse is caring for a client who is 8 hr postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider? (Select all that apply.) Massage the fundus Give oxygen at 2 L/min via nasal cannula Administer oxytocin with IV fluids Insert an indwelling urinary catheter Place the client in a lateral position with her legs elevated 30°
Massage the fundus Administer oxytocin with IV fluids Insert an indwelling urinary catheter Place the client in a lateral position with her legs elevated 30°
A postpartum nurse is caring for a client who reports excessive sweating Question Feedback during the first night after delivery. Which of the following statements should the nurse make? "This is a source of your fluid loss after delivery." RATIONALE
Postpartum diuresis is the loss of the remaining pregnancy-induced increase in blood volume. The loss of excess tisue fluid begins within 12 hours after birth. Fluid loss by urination and perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum period.
A nurse is reviewing the laboratory values of a client who is pregnant and has a low progesterone level. I LTd. of the following complications should the nurse expect?
Preterm labor
A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect?
Prolapsed umbilical cord
A nurse is preparing to perform Leopold maneuvers on a client who is in labor. Which of the following actions should the nurse plan to take?
Stand at the client's right side if the nurse is right-handed
A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect? Prolapsed umbilical cord RATIONALE
The nurse should identify that prolonged deceleration during a uterine contraction is a sign of cord prolapse. This is an emergent condition that should be reported to the provider immediately.
A nurse is caring for a client who is 8 hr postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider? (Select all that apply.) Massage the fundus Administer oxytocin with IV fluids Insert an indwelling urinary catheter Place the client in a lateral position with her legs elevated 30° RATIONALE
The nurse should massage the fundus to expel clots and help the uterus contract. The nurse should add oxytocin to the intravenous drip and insert an indwelling urinary catheter to monitor urinary output and perfusion to the kidney. Finally, the nurse should place the client in a lateral position with her legs elevated 30°.
A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take? Use a photometer to monitor the lamp's energy RATIONALE
The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective.
A nurse is preparing to perform Leopold maneuvers on a client who is in labor. Which of the following actions should the nurse plan to take? Stand at the client's right side if the nurse is right-handed RATIONALE
The nurse should stand facing the client on the side that correlates with the nurse's dominant hand; therefore, if the nurse is right-handed, the nurse should stand at the client's right side.
A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or an abruptio placenta? Uterine tone. RATIONALE
The uterus will be relaxed, soft, and painless if the bleeding is caused by placenta previa. With abruptio placenta, the uterus will be firm and board-like, and the client will complain of pain.
A nurse is assessing a client who is receiving magnesium sulfate as a treatment for pre-eclampsia. Which of the following clinical findings is the nurse's priority?
Urinary output 40 mL in 2 hr
A nurse is assessing a client who is suspected of having hyperemesis gravidarum. Which of the following laboratory tests should the nurse check first?
Urine ketones
A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take?
Use a photometer to monitor the lamp's energy
A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or an abruptio placenta?
Uterine tone.
A nurse is assessing a client who is suspected of having hyperemesis gravidarum. Which of the following laboratory tests should the nurse check first? Urine ketones RATIONALE
When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority laboratory test to check is urine ketones. Excessive ketones in the urine indicate the body is not using carbohydrates from food as fuel and is inadequately trying to break down fat. The presence of ketones in the urine supports the diagnosis of hyperemesis gravidarum.
A nurse is assessing a client who is at 26 weeks of gestation and has mild preeclampsia. Which of the following findings should the nurse report to the provider?
Deep tendon reflexes 4+
