CAT 7

A postpartum client tells the nurse they are constipated. Which response by the nurse is best?

"Add more fruits, vegetables and fluid to each meal"

A client wants to avoid methods of birth control that contain estrogen. Which method would be the nurse recommend?

"Although it varies, a gain of 25 to 35 lb (11.4 to 14.5 kg) is about average."

A client has just given birth to a stillborn baby at 39 weeks gestation. What is the most appropriate response to the client the nurse would make at this time?

"I am sorry for your loss."

A client has a cerclage placed at 16 weeks' gestation. The client has had no contractions and their cervix is dilated 2 cm. The nurse is preparing the client for discharge. Which statement by the client should indicate to the nurse that the client needs further instruction?

"I can have sex again in about 2 weeks."

A client just experienced spontaneous bleeding at 11 weeks gestation, which resulted in the loss of the fetus. The couple wonders if the bleeding could have been caused from the client working long hours in a stressful work environment. What is the most appropriate response from the nurse?

"I can understand your need to find an answer to what caused this. Let's talk about this further."

After the nurse instructs a primigravid client at 8 weeks' gestation about measures to overcome early morning nausea and vomiting, which client statement indicates the need for additional teaching?

"I will eat two large meals daily with frequent protein snacks."

A client who tells the nurse that they would like to use the basal body temperature method for family planning receives instructions about the method. Which client statement indicates to the nurse that the teaching has been successful?

"It's important to take my temperature at about the same time every morning before arising."

A primigravid client at 28 weeks' gestation tells the nurse that they and their spouse wish to drive to visit relatives who live several hours away. Which recommendation by the nurse would be best?

"Taking the trip is okay if you stop every 1 to 2 hours and walk."

While changing the newborn's diaper, a client states: "there is some bleeding from the vagina." Which is the nurse's appropriate response?

"This is in response to your hormones and will stop within a week."

A 15-year-old primipara who gave birth to a term neonate vaginally tells the nurse, "My parent started feeding me rice cereal when I was only 2 weeks old." What would be the most appropriate response to the client?

"Wait until the infant is at least 4 months of age before using cereal."

A certified nurse-midwife places a neonate under the radiant heat unit for the nurse's initial assessment. The initial assessment includes a heart rate of 110 beats/minute and an irregular respiratory effort. The neonate is moving all extremities and the body is pink. The neonate responds to gentle stimulation by withdrawing. The nurse notes copious amounts of clear mucus present both orally and nasally. Based on these assessment findings, what should the nurse do next?

Assign an Apgar score of 9, place the neonate in modified Trendelenburg position, and suction the neonate's nose and oropharynx.

When planning a class for primigravid clients about the common physiologic changes of pregnancy, the nurse should include which information in the teaching plan?

Cardiac output increases by 25% to 50% during pregnancy.

Which instruction should a nurse give to a client who's 26 weeks pregnant and reports of constipation?

Encourage the client to increase the intake of roughage and to drink at least six glasses of water per day.

During a home visit 4 days after birth, the breastfeeding primiparous client tells the nurse that their breasts are hard and tender. The nurse determines the client has breast engorgement and should instruct the client to perform which measure?

Express a small amount of breast milk before breastfeeding.

The nurse is caring for a laboring client fluent in English, but the client defers to a family member when asked to sign the hospital consent forms. Which of the following factors contributes to the challenges the nurse faces in obtaining consent?

Influence of the extended family

While preparing to provide neonatal care instructions to a primiparous client who gave birth to a term neonate 24 hours ago, what should the nurse include in the client's teaching plan?

Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks.

During the assessment, the nurse observes a gray-pigmented nevus on the neonate's buttocks. The nurse documents this as which finding?

Mongolian spots

When assessing a neonate, the nurse observes a vaguely outlined area of scalp edema that is most likely caput succedaneum. What is the most appropriate nursing action based on this finding?

Note the finding on the assessment record.

The nurse assesses a 15-hour-old infant and finds jaundice. What is the priority action the nurse needs to take?

Notify the health care provider of the finding.

While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and puts on clean gloves. What should the nurse do next?

Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.

Which action by the nurse would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched?

Request that the health care provider evaluate the neonate's neurologic status.

A nurse is assisting with a circumcision. After the health care provider has started the procedure, the nurse reviews the neonate's medical record and notices that an informed consent form hasn't been signed. What should the nurse do?

Tell the health care provider to stop the procedure immediately because an informed consent form hasn't been signed.

A client who is Rh-factor negative has given birth to a healthy infant who is Rh-factor positive. What teaching will the nurse provide to the client?

The client will need Rh immunoglobulin injection within 72 hours.

A nurse is teaching a group of clients about birth control methods. When providing instruction about subdermal contraceptive implants, the nurse should cite which feature as the main advantage of this method?

The implants provide effective, continuous contraception that isn't user dependent.

While the nurse is caring for a neonate born at 32 weeks' gestation, which finding would mostsuggest the infant is developing necrotizing enterocolitis (NEC)?

abdominal distention

A primigravid client visits the clinic for a routine examination at 35 weeks' gestation. The client's blood pressure is near the baseline of 120/74 mm Hg with no proteinuria or evidence of facial edema. The client asks the nurse, "What should I take if I get an occasional headache after looking at my computer at work all day?" Which over-the-counter medicine does the nurse consider to be safest for occasional use by a pregnant client with no known risks?

acetaminophen

A nurse is developing a teaching plan for a primigravid client who's 2 months pregnant. The nurse should tell the client that fetal movement can be felt beginning at which time?

between 18 and 20 weeks' gestation

The nurse develops a teaching plan for the parent of an infant about introducing solid foods into the diet. The nurse should expect to include which measure in the plan to help prevent obesity?

decreasing the amount of formula or breast milk intake as solid food intake increases

A nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus which sign will the nurse see in the neonate?

enlarged breast tissue

Which nursing intervention is most important when working with neonates who are suspected of having congenital hypothyroidism?

identifying the disorder early

A nurse is providing care for a pregnant client with gestational diabetes. The client asks the nurse if gestational diabetes will affect the birth. The nurse should know that:

labor may need to be induced early.

A nurse is performing a neurologic assessment on a neonate. Which assessment finding would be normal for a neonate?

positive Babinski's reflex

A pregnant parent who has brought their toddler to the clinic for a checkup asks the nurse how they can keep their next baby from becoming obese. The parent plans to bottle-feed the next child. Which information should the nurse include in the teaching plan to help the parent avoid over nourishing the infant?

recognizing clues indicating that the baby is full

Assessment of a term neonate at 2 hours after birth reveals a heart rate of less than 100 bpm, periods of apnea approximately 25 to 30 seconds in length, and mild cyanosis around the mouth. The nurse notifies the health care provider (HCP) based on the interpretation that these findings may lead to which condition?

respiratory arrest

A nurse is teaching the birth parent of an infant about the importance of immunizations. The nurse should teach that active immunity

results from exposure of an antigen through immunization or disease contact.

After circumcision with a Plastibell, the nurse should instruct the neonate's parent to cleanse the circumcision site with which agent?

warm water

Which finding is considered normal in the neonate during the first few days after birth?

weight loss then return to birth weight

The nurse assesses a postterm neonate. Which finding is considered normal for a postterm infant?

wrinkled, peeling skin

A client who has tested positive for the human immunodeficiency virus (HIV) gives birth. When the client asks whether the baby has acquired immunodeficiency syndrome (AIDS), how should the nurse respond?

"Your child may have acquired HIV in utero, but we won't know for sure until the child is older."

When teaching a primiparous client who used cocaine during pregnancy how to comfort their fussy neonate, the nurse can advise the client to use which intervention?

Tightly swaddle the neonate.

After a vaginal birth of a term neonate, the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse notifies the health care provider (HCP) based on the analysis that this may be indicative of which anomalies?

cardiovascular anomalies

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death?

chaplain, because their educational background includes strategies for handling grief

A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the right occiput posterior position. The nurse should place the client in which position for pain relief?

hands and knees

During the initial assessment of a laboring client, the nurse notes the following: blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, a nurse should expect the client to have which complaints?

headache, blurred vision, and facial and extremity swelling

A nurse is monitoring a premature neonate for development of neonatal sepsis. Which assessment finding is an early sign of neonatal sepsis?

temperature instability

After instructing a primigravid client about the functions of the placenta, the nurse determines that the client needs additional teaching when they say that which hormone is produced by the placenta?

testosterone

A client is concerned that their 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if:

the neonate latches onto the areola and swallows audibly.

A multigravid client visits the clinic because they suspect that they are pregnant. The client, however, is unable to tell the nurse when their last menstrual period began. The client has a history of preterm birth. The nurse instructs the client that the gestational age of the fetus can be estimated by which procedure?

ultrasonography

During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. What action should the nurse take first?

Clear the neonate's airway with suction or gravity.

During a visit to the clinic, a pregnant 25-year-old client who began prenatal care at 10 weeks' gestation and is now in the third trimester reports frequent constipation. Which suggestion by the nurse would be most helpful?

Eat at least four pieces of fruit daily.

Which instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy?

Keep the neonate's eyes completely covered.

A pregnant client states that they frequently ingest laundry starch. The nurse should assess the client for which condition?

anemia

During a prenatal visit, a pregnant client with cardiac disease and slight functional limitations reports increased fatigue. To help combat this problem, the nurse should advise the client to:

divide daily food intake into five or six meals.

A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress?

nasal flaring

Which common characteristics should the nurse include in the teaching plan for a multiparous client after giving birth to a neonate diagnosed with Down Syndrome? Select all that apply

webbed neck, congenital heart defects, epicanthal folds, and hypotonia

A pregnant client arrives in the emergency department and states, "My baby is coming." The nurse sees a portion of the umbilical cord protruding from the vagina. What should the nurse do first?

Hold pressure on the fetal head.

A full-term neonate is suspected of having hydrocephalus. The nurse collects what assessment finding to best assist in confirming the diagnosis?

increasing occipital frontal circumference

A preterm infant born 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which procedure?

insertion of a chest tube into the neonate

The neonate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is

lethargy

Sick and preterm neonates who experience continuity of nursing care directly benefit from

nursing recognition of subtle changes in high-risk neonates' conditions.

A 32-year-old client visits the family planning clinic and requests an intrauterine device for contraception. When the nurse is assessing the client, a history of which problem would be mostimportant to determine?

pelvic inflammatory disease

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation?

thin, wasted appearance

While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's parent asks why the baby's oxygen is humidified. What should the nurse should tell the parent?

"Oxygen is drying to the mucous membranes unless it is humidified."

When teaching a primigravid client about the diagnostic tests used in pregnancy, the nurse should include which information?

A fetal biophysical profile involves assessments of breathing movements, body movements, tone, amniotic fluid volume, and fetal heart rate reactivity

On the second postpartum day, the nurse enters the room and notices that the client is holding a crying baby and lightly rubbing the infant's back. The client states, "I don't know why my baby won't stop crying all the time." Which of the following is the most appropriate nursing intervention?

Demonstrate ways that the client can comfort the baby.

A primiparous client who will be bottle-feeding their neonate asks, "What is the best position for the baby to nap after feeding?" What should the nurse recommend?

Hold the baby upright for 15 to 20 minutes before placing them down for a nap.

A full-term neonate is admitted to the newborn nursery. When lifting the baby out of the crib the nurse notes the baby's arms move sideways with the palms up and the thumbs flexed. What should the nurse do next?

Identify this reflex as a normal finding.

While assisting the health care provider with an amniocentesis on a multigravid client at 38 weeks' gestation, the nurse observes that the fluid is very cloudy and thick. The nurse interprets this finding as indicating which of the following?

Intrauterine infection.

While caring for a neonate 2 days after birth, the nurse observes a swelling on the neonate's head that does not cross the cranial suture line. What should the nurse tell the client about the swelling?

The swelling will resolve without treatment by 6 weeks of age.

At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. What is this neonate most likely experiencing?

a state of deep sleep

A newborn was discharged from the hospital before receiving the newborn metabolic screening (NMS) test. The community health nurse is scheduling the home visit for the infant. Which time would be the most critical time to perform the heel stick on this infant?

at least 24 hours after birth

During an assessment of a neonate born at 33 weeks' gestation, a nurse finds and reports a heart murmur. An echocardiogram reveals patent ductus arteriosis, for which the neonate received indomethacin. What is the expected outcome after the administration of indomethacin to a neonate with patent ductus arteriosis?

closure of a patent ductus arteriosus

A dilatation and curettage (D&C) is scheduled for a primigravid client admitted to the hospital at 10 weeks' gestation with abdominal cramping, bright red vaginal spotting, and passage of some of the products of conception. The nurse should assess the client further for the expression of which feeling?

guilt

A client gives birth to a neonate prematurely at 28 weeks' gestation. The neonate's Apgar score is 5 at 1 minute. What is the nurse's most important intervention for this premature neonate?

Administer oxygen.

A primigravid client at 16 weeks' gestation visits the clinic for a routine examination. The client tells the nurse that they knows someone whose baby was born with congenital toxoplasmosis. What should the nurse instruct the client to do to prevent transmission of the toxoplasmosis protozoan?

Cook all meats, such as beef and pork, thoroughly.

During an annual checkup, a client tells the nurse that they and their partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?

It should begin before conception and end 3 months after childbirth.

After a long labor process, a primigravid client gives birth to a healthy newborn with a moderate amount of skull molding. What information would the nurse include when explaining to the client about this condition?

It usually lasts a day or two before resolving.

A primigravid with severe gestational hypertension has been receiving magnesium sulfate IV for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next?

Stop the magnesium sulfate infusion.

Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after the nurse administers the medication, which finding should alert the nurse to the development of a possible side effect?

dizziness

A client at 42 weeks of gestation is 3 cm dilated and 30% effaced, with membranes intact and the fetus at 12 station. Fetal heart rate (FHR) is 140 beats/minute. After 2 hours, the nurse notes that, for the past 10 minutes, the external fetal monitor has been displaying an FHR of 190 beats/minute. The client states that the baby has been extremely active. Uterine contractions are strong, occurring every 3 to 4 minutes and lasting 40 to 60 seconds. Which piece of data would indicate fetal hypoxia?

excessive fetal activity and fetal tachycardia

A client who is breastfeeding tells the nurse that they plan to return to work in 6 months and will probably wean their baby then. The client asks the nurse, "How will I stop producing milk when I want to wean the baby?" What information should the nurse give the client?

gradual decrease in milk supply as the baby nurses less

A client makes a routine visit to the prenatal clinic. Although the client is 14 weeks pregnant, the size of their uterus approximates an 18- to 20-week pregnancy. The health care provider diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal:

grapelike clusters.

A 30-year-old multigravida client has missed three periods and now visits the prenatal clinic because they assume they are pregnant. The client is experiencing enlargement of the abdomen, a positive pregnancy test, and changes in the pigmentation on the face and abdomen. These assessment findings reflect this client is experiencing a cluster of which signs of pregnancy?

probable

A newborn baby has developed physiologic jaundice. The parents are concerned about the appearance of the newborn and ask the nurse about their concerns. Which of the following would be the most appropriate response by the nurse?

"I can tell you are worried about your baby. Let's talk about this change in your baby's skin color."

During a health-teaching session, a pregnant client asks the nurse how soon the fertilized ovum becomes implanted in the endometrium. Which answer should the nurse supply?

7 days after fertilization

A client is admitted for an amniocentesis. Initial assessment findings include 16 weeks' gestation, vital signs within normal limits, hemoglobin 12.2 g/dL (122 g/L), hematocrit 35% (0.35), and type O-negative blood. Which action would the nurse complete first after amniocentesis has been completed?

Assess fetal heart rate and compare to pre-procedure baseline.

Assessment of a client in active labor reveals the following: moderate discomfort; cervix dilated 3 cm, 0 station, and completely effaced; and fetal heart rate of 136 bpm. What should the nurse plan to do next?

Assist the client with comfort measures and breathing techniques.

A nurse has been providing care to a client in labor for the past 9 hours. The partner remains at the bedside while the laboring client is sleeping with the epidural block in situ. Which is the most appropriate nursing action?

Offer to remain with the client while the partner takes a short break.

The nurse is teaching the parent of a newborn to develop their baby's sensory system. To further improve the infant's most developed sense, the nurse should instruct the parent to perform which action?

Stroke the newborn's cheek with the nipple to direct the baby's mouth to the nipple.

The parent of a neonate diagnosed with gastroschisis tells the nurse that their spouse had planned on breastfeeding the neonate. Which information should the nurse include in the preoperative teaching plan about feeding the neonate?

The neonate will remain on nothing-by-mouth (NPO) status until after surgery.

A primigravid client at 8 weeks' gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, the client has noticed flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on their vagina. The nurse refers the client to a primary health care provider (HCP) because the nurse suspects which sexually transmitted infection?

herpes genitalis

The nurse is admitting a newborn to the nursery. Report reveals that the newborn was slow to crown and delivery of the head and chin was difficult. For which complication would the nurse need to assess?

shoulder dystocia

A nurse is teaching parents of a neonate the proper position for the neonate's sleep. The nurse stresses the importance of placing the neonate on their back to reduce the risk of which concern?

sudden unexplained infant death syndrome (SUIDS)

The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3912 g (3.91 kg) at birth. Today the neonate, who is being bottle-fed, weighs 3572 g (3.57 kg). Which instruction should the nurse give the parent?

Continue feeding every 3 to 4 hours since the weight loss is normal.

A client who is 14 weeks' pregnant mentions that they have been having difficulty moving their bowels since they became pregnant. Which hormone is responsible for this common discomfort during pregnancy?

progesterone

Parents who bring a 3-week-old neonate to the hospital report that the infant has been "throwing up after every feeding." A nurse notes projectile vomiting while assessing the neonate. X-rays confirm

pyloric stenosis.

The client who is breastfeeding asks the nurse if they should supplement breastfeeding with formula feeding. The nurse bases the response on which principle?

Formula feeding should be avoided to prevent interfering with the breast milk supply.

A client has obtained levonorgestrel as emergency contraception. After unprotected intercourse, the client calls the clinic to ask questions about taking this contraceptive. The nurse realizes the client needs further explanation when they make which statement?

"I can wait up to 4 days after intercourse to start taking these to prevent pregnancy."

A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why they needed RhoGAM. What is the most appropriate response by the nurse?

"RhoGAM suppresses antibody formation in clients with Rh negative blood after giving birth to an Rh positive baby."