Health Promotion of Newborn to One year chapter 21
A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? "I should not remove the yellow exudate on the end of the penis." "I will clean his penis with each diaper change." "The circumcision will heal completely within a couple of weeks." "I can give him a tub bath in two days."
"I can give him a tub bath in two days."
A nurse is assessing a client in the immediate postpartum period. The fundus is boggy and deviated to the left of the umbilicus. Which of the following is the most appropriate intervention? Reassess client in 30 minutes Begin an oxytocin infusion Assist client to void Assess lochia
Assist client to void
A nurse is caring for a neonate who exhibits abstinence syndrome and demonstrates clinical manifestations of the condition. Which assessment finding is associate with this condition? a. Negative Startle reflex b. Hypothermia c. Increased drowiness d. Diminished tendon reflexes
Hypothermia
The client asks the nurse to explain the difference between true and false labor. Which of the following is an example of true labor? In true labor the cervix will dilate and efface In true labor walking will cause contractions to slow down In true labor the presenting part is engaged In true labor contractions are felt in the abdomen above the umbilicus
In true labor the cervix will dilate and efface
A client in her first trimester is encouraged to increase intake of proteins and folic acid as essential nutrients for basic fetal growth. Which foods would the nurse identify as high in folic acid? Avocados Fish Tomatoes Lentils
Lentils
The nurse is observing sibling adaptation behaviors to the newborn infant during a family visit. To facilitate sibling acceptance, which action by the parents can assist with bonding? Provide the sibling a stuffed animal that they care for while the parents nurture the newborn. Discuss with the sibling the importance of being more independent. Encourage the sibling to spend time primarily with the babysitter. Create new traditions and routines.
Provide the sibling a stuffed animal that they care for while the parents nurture the newborn.
A nurse is assessing a client during her first prenatal visit. The client reports that her last normal period began on April 22. Use Nagele's rule to calculate this client's expected date of birth (EDB). Use the MMDD format to enter exactly four numerals, with no spaces or punctuation between the numbers. 0729 0129 0122 0722
0129
A nurse is caring for a client who is 11 weeks pregnant. Which of the following is an appropriate psychological task for the client? Verbalize concerns about the health care facility Accept the fact that she is pregnant Begin to think about names for the baby View morning sickness as tolerable
Accept the fact that she is pregnant
A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching? "My partner will put the condom on while his penis is erect." "I will remove the condom 30 minutes after intercourse." "My partner should leave an empty space at the tip." "I can use spermicidal gels or creams to increase effectiveness."
"I will remove the condom 30 minutes after intercourse."
A nurse is educating a parent of a newborn about safety measures. Which of the following statements made by the client would indicate a need for further teaching? Select one: "My baby's car seat should be in the back seat facing backwards." . "I should always support my baby's head when I pick him up." "Once my baby begins to roll over it is okay to use a small pillow in the crib."
"Once my baby begins to roll over it is okay to use a small pillow in the crib."
A nurse is providing a tour of the labor and delivery unit to expectant parents. Which statement made by the mother indicates a need for further education? "When the baby is born, my thumb print will be taken along with the baby's footprint." "We will need to remove the baby's ankle identification band during diaper changes." "We will request to see picture identification badges for all facility staff who care for our baby." "When the baby is returned to us from the nursery, we should check the baby's identification band."
"We will need to remove the baby's ankle identification band during diaper changes."
A client who is 32 weeks pregnant presents to the emergency room with bright red vaginal bleeding for the last 3 hours. The client reports feeling fetal movement since the bleeding started. Which of the following is the nurse's priority action? Assess maternal vital signs Assess fetal heart tones Perform a vaginal exam Administer a 500 mL fluid bolus
Assess maternal vital signs
A postpartum client is reporting heavy vaginal blood flow. The nurse correctly understands which of the following assessments has the highest priority? Assess the client's last voiding Assessing vital signs both lying and sitting Assess the fundus for tone and position Assess episiotomy for bleeding
Assess the fundus for tone and position
A nurse is caring for a client diagnosed with pre-eclampsia. The client is receiving Magnesium Sulfate IV. Which of the following assessment findings is the first sign of Magnesium toxicity? Respiratory depression Nausea and vomiting Decreased deep tendon reflexes Visual blurring
Decreased deep tendon reflexes
A client at 35 weeks gestation is admitted to the birthing unit with preterm labor. Which of the following assessments would require the nurse to immediately notify the provider? B/P 110/60mmHg, trace protein, contractions every 3-4 minutes FHR 140 b/min: good variability, contractions every 3-4 minutes B/P 138/80mmHg, contractions every 3-4 minutes FHR 120 b/min with late decelerations, contractions- every 1-2 minutes
FHR 120 b/min with late decelerations, contractions- every 1-2 minutes
A breastfeeding mother develops engorgement on her second postpartum day. Which of the following statements by the client indicates a need for further teaching? I will apply warm packs to each breast prior to feeding. I will offer my baby a bottle following each feeding. I will feed my baby every 2 hours. I will use a breast pump if my breasts do not soften.
I will offer my baby a bottle following each feeding.
A nurse is teaching a client the correct use a diaphragm as a method of contraception. Which of the following statements is correct? Douche promptly after removing the diaphragm Do not use any cream or jelly with the diaphragm Insert diaphragm at least 8 hours prior to sexual intercourse Leave diaphragm in place for at least 6 hours post coitus
Leave diaphragm in place for at least 6 hours post coitus
A client diagnosed with pregnancy induced hypertension (PIH) has been receiving a Magnesium Sulfate infusion for three days. Serum drug levels have been between 8-10 mg/dl. Which of the following finding should the nurse expect to assess in the infant after delivery? Lethargy and respiratory depression Hypothermia and bradycardia Tachycardia and respiratory distress Hyperactivity and irritability
Lethargy and respiratory depression
A nurse is caring for a newborn diagnosed with a neonatal infection. Which of the following risk factors is most important to the care of this client? Increased size of neonate's heart. Maternal history of cytomegalovirus. A decreased number of functional alveoli. Documented birth trauma.
Maternal history of cytomegalovirus.
A client with gestational diabetes gave birth to a 9 pound neonate 12 hours ago. The neonate is presenting with a high pitched cry and jitteriness. Which of the following is the nurse's priority intervention? Offer the neonate breast milk or formula Place the neonate under a radiant warmer Administer subcutaneous insulin Provide oxygen via oxyhood
Offer the neonate breast milk or formula
Thirty minutes after admission to the nursery an infant appeared jittery and exhibits a weak, high pitched cry. Which of the following would be the nurse's priority action? Hold and comfort the infant to stop the crying. Feed the infant oral feeding. Perform a heel stick to check serum glucose. Obtain an order for a drug screening blood test.
Perform a heel stick to check serum glucose.
Thirty minutes following initiation of oxytocin infusion a client's contractions are lasting 95 seconds and coming one minute apart. Late decelerations are observed on the fetal monitor. Which of the following is the correct priority nursing intervention? Stop the oxytocin infusion and administer terbutaline 0.25 Stop oxytocin infusion and assess contractions and fetal heart rate. Notify provider and prepare for an emergency cesarean birth Assess vital signs and apply O2 via facemask.
Stop oxytocin infusion and assess contractions and fetal heart rate.
A nurse is positioning a client on the operating room table in preparation for a cesarean birth. Which of the following is the correct position? Lithotomy position with a foam wedge behind the shoulders. Supine position with foam wedge positioned under one hip. C Modified Trendelenburg position with a foam wedge under the legs. Left lateral position with a foam wedge between the legs.
Supine position with foam wedge positioned under one hip.
A nurse is caring for a client who has been prescribed magnesium sulfate for pregnancy induced hypertension. On admission the client's B/P is 160/90 mm Hg and urine output is 25mL/hr. Following initiation of magnesium sulfate, which of the following symptoms should be reported to the provider? The client is voiding 40 mL/hr The client reports feeling flushed and warm The client is drowsy and difficult to rouse The client's blood pressure is 130/70 mm Hg
The client is drowsy and difficult to rouse
A nurse is caring for a client who has been prescribed magnesium sulfate as tocolytic therapy. Several hours after the infusion was started, contractions ceased. Which of the following is the best analysis of this data? The drug is having a therapeutic effect The medication dose should be decreased The medication dose should be increased Deep tendon reflexes should be assessed
The drug is having a therapeutic effect
A nurse is performing a fundal assessment on the client's second postpartum day. Which of the following should the nurse expect if the client is experiencing normal involution? The fundus will be one centimeter above the umbilicus. The fundus will be two centimeters below the umbilicus. The fundus will be one centimeter below the umbilicus. The fundus will be at the level of the umbilicus.
The fundus will be one centimeter below the umbilicus.
The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response? The purpose of the NST is to assess the fetal CNS. The purpose of the NST helps to determine gestational age. The purpose of the NST is to determine fetal lie. The purpose of the NST is to determine fetal breathing.
The purpose of the NST is to assess the fetal CNS.
A client in the early postpartum period is talkative and enjoys recounting the details of her labor and birth. The nurse recognizes that the behaviors must likely indicate which of the following? The taking-hold phase of maternal psychosocial adaptation. The taking-in phase of maternal postpartum adjustment. Postpartum role transition. Positive mother-infant bonding.
The taking-in phase of maternal postpartum adjustment.
A nurse is caring for a client who is reporting lower abdominal pain. The client has a positive pregnancy test and is estimated to be 10 weeks pregnant. Which of the following best support a possible ectopic pregnancy? Unilateral stabbing abdominal lower abdominal pain. Absence of fetal heart tones and fetal movement. Steady bleeding with lower abdominal pain. Edematous face, hands, and ankles.
Unilateral stabbing abdominal lower abdominal pain.
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? "When did your contractions begin?" "Have you noticed any bloody show or fluid coming from your vagina?" "What happens to your contractions when you move about?" "Have you felt fetal movement over the last 24 hours?"
b. "Have you noticed any bloody show or fluid coming from your vagina?"
