Exam 2 Evolve Review
A nurse is caring for a primigravida during labor. At 7 cm of dilation a prescribed pain medication is administered. Which medication requires monitoring of the newborn for the side effect of respiratory depression?
Butorphanol (Stadol)
A preterm neonate is receiving oxygen by way of an overhead hood. What should the nurse do to protect the infant under the oxygen hood?
Put a hat on the infant's head to avoid hypothermia
A client in labor is admitted to the birthing room. The nurse's assessment reveals that the fetus is at −1 station. Where is the presenting part?
1 cm above the ischial spines
A client who is formula feeding her infant complains of discomfort from engorged breasts. What should the nurse recommend that the client do?
Apply cold packs and a snugly fitting bra.
A nurse is evaluating the effectiveness of fundal massage in a postpartum client 3 hours after giving birth. An intravenous infusion of 10 units of oxytocin (Pitocin) is infusing at a rate of 100 mL/hr. The client's blood pressure is 135/90 mm Hg, the uterus is boggy and 3 cm above the umbilicus and displaced to the right, and the perineal pad is saturated with lochia rubra. What should the nurse do next?
Assist the client to the bathroom
What is the best nursing action for a client in active labor whose cervix is dilated 4 cm and 100% effaced with the fetal head at 0 station?
Assist the client's coach in helping her with the use of breathing techniques.
A preterm infant is receiving oxygen from an overhead hood. What nursing care is required while the infant is under the hood?
Putting a hat on the infant's head
As part of the physical assessment, a nurse inspects a newborn for the presence of an umbilical hernia. What infant behavior helps the nurse identify this problem?
Crying
What should the nurse include in the plan of care for a neonate who is undergoing phototherapy?
Discontinuing therapy to hold the infant for feeding
A priority intervention for the infant undergoing phototherapy is:
Exposing as much skin as possible by turning the infant every 2 hours
Using the five-digit system, determine the obstetric history in this situation: The client is 38 weeks into her fourth pregnancy. Her third pregnancy, a twin gestation, ended at 32 weeks with a live birth, her second pregnancy ended at 38 weeks with a live birth, and her first pregnancy ended at 18 weeks
G4, T1, P1, A1, L3
What does the nurse do to elicit the Moro reflex during a newborn assessment?
Jars the infant's bassinet suddenly but gently
A newborn who is born at 36 weeks' gestation weighs 8 lb 13 oz (3997 g). How should the nurse document this finding?
LGA and preterm
A nurse who is assessing a full-term newborn elicits the magnet reflex. How is this reflex elicited?
Maintaining the supine position and applying pressure to the soles of the newborn's feet
Five minutes after being born, a newborn is given an Apgar score of 8. Twelve hours later the newborn becomes hyperactive and jittery, sneezes frequently, and has difficulty swallowing. What does the nurse suspect is the cause of these clinical findings?
Opioid drug withdrawal
A nurse is assessing a primigravida who was admitted in early labor after her membranes ruptured. She is at 41 weeks' gestation. Her contractions are irregular and her cervix is dilated 3 cm. The fetal head is at station 0 and the fetal heart rate tracing is reactive. How can the nurse help the client facilitate labor?
Take a walk around the unit with her
A nurse caring for a client who gave birth to a healthy neonate evaluates the client's uterine tone 8 hours later. How does the nurse determine that the uterus is demonstrating appropriate involution?
The amount of lochia rubra is moderate.
The nurse assures a breastfeeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested?
Voids six or more times a day
A client in active labor has requested epidural anesthesia for pain management. The anesthetist has completed an evaluation, and the nurse has initiated an intravenous fluid bolus. The client's partner asks why this is necessary. What is the best explanation?
There is a risk of hypotension, and the large amount of IV fluid reduces the risk.
During a newborn assessment the nurse counts the infant's cord vessels. What does the nurse expect to observe in a healthy newborn?
Three vessels: one vein and two arteries
A new mother asks a nurse why medicine is being put in her baby's eyes. What infection should the nurse tell the mother it is given to prevent?
Chlamydia
A client has chosen not to have her son circumcised. What instruction should be included in discharge teaching for the care of an uncircumcised neonate?
Clean the penis with warm water at each diaper change
Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. What nursing action is most beneficial at this time?
Helping the client change her position
