Maternal ATI Practice Exam

A nurse in a prenatal care clinic answers a phone call from a client who is at 37 weeks gestation and reports, "I became very dizzy while lying in bed this morning, but the feeling went away when I turned onto my side." Which of the following actions should the nurse take? A. Instruct the client about vena cava syndrome and measures to prevent it B. Arrange for the client to come to the clinic for an assessment C. Check the client's chart for gestational diabetes mellitus D. Schedule a nonstress test for the client

a

A nurse is assessing a client at 27 weeks of gestation. The client has placenta previa and reports vaginal bleeding. Which of the following additional manifestations should the nurse expect? A. The fundal height measures greater than gestational age. B. A rigid abdomen is noted on palpation. C. The client reports a pain level of 8 on a 0-to-10 pain scale. D. A urine drug screen is positive for cocaine.

a

A nurse is assessing a newborn who was born at 39 weeks gestation. Which of the following findings should the nurse expect? A. Symmetric rib cage B. Dry, wrinkled skin C. Vernix over the entire body D. Abundant lanugo on the back

a

A nurse is caring for a client at 32 weeks gestation who is experiencing preterm labor. Which of the following medications should the nurse plan to administer? A. Betamethasone B. Misoprostol C. Methylergonovine D. Poractant alfa

a

A nurse is caring for a client at 39 weeks gestation who is in the active phase of labor. The nurse observes late decelerations in the fetal heart rate (FHR). Which of the following findings should the nurse identify as the cause of late decelerations? A. Uteroplacental insufficiency B. Fetal head compression C. Fetal ventricular septal defect D. Umbilical cord compression

a

A nurse is caring for a client in the first trimester of pregnancy and asks how to manage heartburn. Which of the following responses should the nurse make? A. "Reduce the amount of food you eat during meals." B. "Sip carbonated beverages between meals." C. "Lie down and rest immediately after meals." D. "Drink iced tea with meals."

a

A nurse is caring for a client who is 32 hours postpartum. The client reports nipple soreness and breast engorgement. Which of the following recommendations should the nurse provide? A. "Call me to check your baby's latch the next time you breastfeed." B. "You should reduce the frequency of breastfeeding." C. "Apply expressed breast milk to sore nipples and cover them with nursing pads and a bra." D. "You should apply warm packs to the breasts between nursing sessions."

a

A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the following findings should the nurse expect? A. Abundant lanugo B. Good flexion C. Heel creases covering the bottom of the feet D. Dry, parchment-like skin

a

A nurse is planning care for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following interventions should the nurse include in the plan? A. Reposition the newborn every 3 hours B. Apply lotion to the newborn's exposed skin twice daily C. Feed the newborn 1 oz of glucose water every 2 hours D. Dress the newborn in a diaper and a thin cotton t-shirt

a

A nurse is providing discharge teaching to the parent of a newborn. Which of the following statements should the nurse include in the teaching? A. "Your baby should be rear-facing in a car seat until 2 years of age." B. "Cover your baby with a light blanket during naps." C. "Set your hot water heater to no more than 140 degrees Fahrenheit." D. "Ensure your baby's crib has side rails that can be lowered."

a

A nurse is providing nutritional counseling for a client who is pregnant. Which nutrients should the nurse instruct the client to increase her daily diet? A. Iron B. Calcium C. Vitamin E D. Vitamin K

a

A nurse is providing teaching about weight gain during pregnancy for a client who is a primigravida of normal pre-pregnancy weight. Which of the following statements should the nurse include? A. "You should plan to gain 25 to 35 pounds during pregnancy." B. "You should plan to gain 11 to 20 pounds during pregnancy." C. "Because you started pregnancy at a normal BMI and weight, your weight gain is not limited as long as you follow a healthy, balanced diet." D. "Because you are of normal weight before pregnancy, you are encouraged to gain 28 to 40 pounds during pregnancy."

a

A nurse is reviewing risk factors for postpartum depression with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Gestational diabetes B. Planned pregnancy C. Being married D. Post-term birth

a

A nurse is talking with a client during her initial prenatal visit. The client reports a history of trisomy 13 syndrome in her family and is concerned that her fetus might be at risk. Which of the following statements should the nurse provide? A. "If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder." B. "If the genetic screening shows that your baby has this disorder, I can provide you with information about an abortion clinic." C. "Screening for trisomy 13 syndrome and other chromosomal disorders is done automatically for clients at increased risk." D. "I can provide you with information about sterilization so that the disorder is not passed to your future children."

a

A nurse is teaching a client who has active genital herpes simplex virus, type 2. Which of the following statements should the nurse include in the teaching? A. "You will have a cesarean birth prior to the onset of labor." B. "Your baby will receive erythromycin eye ointment after birth to treat the infection." C. "You should take oral metronidazole for 7 days prior to 37 weeks gestation." D. "You should schedule a cesarean birth after your water breaks."

a

Which medications should the nurse prepare to administer to reverse the effects of heparin? A. Protamine sulfate B. Naloxone C. Calcium gluconate D. Flumazenil

a

A nurse is teaching a client who is pregnant about toxoplasmosis. Which of the following instructions should the nurse include? A. "To prevent toxoplasmosis, you will need to receive a measles, mumps, and rubella vaccination during your pregnancy." B. "You should avoid gardening during your pregnancy to decrease your risk of contracting toxoplasmosis." C. "You will get a body rash if you are infected with toxoplasmosis." D. "Toxoplasmosis is transmitted through a bite from an infected mosquito."

b; Toxoplasmosis infection is potentially teratogenic to the fetus. It can be transmitted through contact with cat feces, which can be found in garden areas. It can also be transmitted through contact with uncooked meat.

A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk of uterine atony? (Select all that apply.) A. Magnesium sulfate infusion B. Distended bladder C. Oxytocin infusion D. Prolonged labor E. Small for gestational age newborn

a, b, d; Magnesium sulfate is a smooth muscle relaxant and can prevent adequate contraction of the uterus. After birth, clients can experience a decreased urge to void due to birth-induced trauma, increased bladder capacity, and anesthetics, which can result in a distended bladder. A distended bladder displaces the uterus and can prevent adequate contraction of the uterus. Also, prolonged labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus from contracting.

A nurse is physically assessing a full-term newborn and eliciting the Moro reflex. Which of the following movements are expected responses to this reflex? (Select all that apply.) A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward C. Arms and legs adducting D. Arms falling backward after startling E. Head turning to the right

a, b; A "C" formation of the thumb and forefinger and an extension of the legs before pulling upward are expected components of the Moro reflex. This response is present at birth and absent by 6 months of age in neurologically intact infants.

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.) A. Massage the fundus B. Give oxygen at 2 L/min via nasal cannula C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30°

a, c, d, e; 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 providing education to a client who is 4 weeks postpartum and is breastfeeding. The client asks about expected weight loss. Which of the following responses should the nurse make? A. "Losing 2.2 pounds each month would be acceptable." B. "Losing 4.4 pounds each month would be acceptable." C. "Losing 5.5 pounds each month would be acceptable." D. "Losing 6.6 pounds each month would be acceptable."

a;

A nurse is caring for a client who is in labor. Which of the following assessment findings should the nurse report to the provider? A. Fetal heart rate baseline of 90 bpm B. Maternal temperature of 37.8°C (100°F) C. Uterine relaxation for 1 min between contractions D. Uterine contractions increasing in intensity

a; A fetal heart rate baseline of 90 bpm is considered bradycardia and should be reported to the provider. Fetal bradycardia is associated with fetal cardiac defects, maternal hypoglycemia, and fetal viral infections.

A nurse is assessing a client who is at 34 weeks gestation and has a cardiac disorder. The nurse should notify the provider about which of the following assessment findings? A. The client reports a frequent cough. B. The client reports that none of her shoes fit anymore. C. The client reports a weight gain of 2 lb in a 2-week period. D. The client reports leg cramps in the evening.

a; A frequent cough could be an indication of cardiac decompensation and should be reported to the provider.

A nurse is assisting with fetal heart monitoring during labor for a client who is at 40 weeks of gestation. The nurse should identify which of the following findings on the fetal monitoring tracing requires intervention. A. A fetal heart rate of 180/min for 15 minutes B. A deceleration that returns to baseline at the end of the contraction C. An acceleration of 20/min for 18 seconds during a contraction D. An occasional variable deceleration in fetal heart rate

a; A heart rate of more than 160/min for 10 minutes or longer is considered fetal tachycardia, which can indicate fetal hypoxemia; therefore, this finding requires intervention by the nurse

A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend? A. Copper intrauterine device B. Combination pill C. Vaginal ring D Medroxyprogesterone injection

a; A history of thrombophlebitis is a contraindication for the use of hormonal contraceptive methods such as oral combinations of estrogen and progesterone in pill form, vaginal inserts that release hormones continuously, and injectable progestins. A copper intrauterine device that does not contain hormones is a safer choice for this client. Other options for this client include barrier methods and spermicides.

A nurse on the antepartum unit is caring for a client who is at 28 weeks gestation and reports dizziness when lying on her back. Into which of the following positions should the nurse assist the client? A. Lateral B. Lithotomy C. Trendelenburg D. Prone

a; A lateral or side-lying position promotes uteroplacental blood flow and helps relieve the symptoms of supine hypotension, including faintness, dizziness, and breathlessness.

A nurse in the labor and delivery suite is planning care for a group of 4 clients. Which of the following clients should the nurse see first? A. A client who is in active labor and has late decelerations on the fetal heart monitor strip B. A client who is in transition and screaming and disturbing other clients C. A client who has epidural analgesia and is reporting breakthrough pain D. A client who has received an oxytocin infusion and is experiencing contractions every 2 minutes lasting 60 sec

a; Late decelerations are nonreassuring patterns that reflect impaired placental exchange or placental insufficiency. Because late decelerations indicate fetal hypoxia, the nurse should assess and intervene immediately by changing the client's position, administering oxygen, increasing IV fluids, and preparing for the possibility of an immediate cesarean birth.

A nurse is caring for a pregnant client who reports nausea and vomiting. Which of the following instructions should the nurse share with the client? A. "You should eat some crackers before rising from bed in the morning." B. "You should eat foods served at warm temperatures." C. "You should sip whole milk with breakfast." D. "You should brush your teeth immediately after meals."

a; Morning sickness is caused by the buildup of human chorionic gonadotropin (hCG) in the mother's system. Dry foods eaten before rising in the morning tend to reduce the risk of nausea in clients who are pregnant.

A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication? A. IV narcotics administered to the mother during labor B. Maternal drug use C. Hyaline membrane disease D. Meconium aspiration

a; The nurse should administer naloxone to reverse respiratory depression due to acute narcotic toxicity, which can result from IV narcotics administration during labor.

A nurse is caring for a client who is scheduled to undergo an amniocentesis to assess fetal lung maturity. The client is G2P1 and at 36 weeks of gestation, and she has an O-positive blood type. Which of the following interventions should the nurse perform? A. Apply an external fetal monitor to the client B. Instruct the client to drink fluids and not to void prior to the procedure C. Administer Rho(D) immunoglobin after the procedure D. Instruct the client to take a deep breath and hold it during the entry of the needle

a; The nurse should assess fetal heart tones and uterine tone prior to and throughout the procedure to establish a baseline and monitor for changes.

A nurse is assisting with an amniotomy for a client who is in active labor. Which of the following actions should the nurse take? A. Assess the fetal heart rate before and after the procedure B. Monitor the client's temperature every 4 hr after the procedure C. Medicate the client for pain 30 min prior to the procedure D. Perform cervical assessments every 2 hr after the procedure

a; The nurse should assess the fetal heart rate for the presence of variable decelerations or bradycardia, which can occur after rupturing of the membranes if the umbilical cord has prolapsed.

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 A. Ask the client to drink a glass of orange juice B. Prepare the client for a vaginal examination C. Request a serum hemoglobin level D. Obtain a clean-catch urine specimen

a; The nurse should give the client orange juice or a glucose preparation prior to this test. This should raise the client's blood glucose level and help promote fetal movement.

A nurse is reviewing the laboratory report of a newborn who has a blood type of B-negative. The mother's blood type is O-positive. The laboratory results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse anticipate? A. Hyperbilirubinemia B. Central cyanosis C. Intracranial hemorrhage D. Cardiomyopathy

a; The nurse should identify that some infants of mothers with type O blood are at an increased risk for developing hyperbilirubinemia because these mothers possess naturally occurring A and B antibodies, which are transferred across the placenta to the fetus.

A nurse is caring for a client who is scheduled to receive a spinal anesthetic. Which of the following actions should the nurse plan to perform? A. Infuse a 500 mL bolus of 0.9% sodium chloride immediately prior to the procedure B. Assess the fetal heart rate pattern for 10 min prior to the procedure C. Position the client upright and erect on the edge of the bed prior to the procedure D. Monitor vital signs every 15 min after the anesthetic is placed

a; The nurse should infuse a fluid bolus of 500 to 1,000 mL of 0.9% sodium chloride or lactated Ringer's 15 to 30 minutes before the procedure to offset the potential complication of hypotension.

A nurse is providing care for a client in the second labor stage. The fetal heart tracing indicates multiple variable decelerations. Which of the following actions should the nurse take? A. Prepare an amnioinfusion B. Place the client in a supine position C. Administer oxygen 2 L/min via nasal cannula D. Give a glucocorticoid

a; The nurse should prepare an amnioinfusion to decrease cord compression.

A nurse is reviewing the laboratory findings of a 24-hour-old newborn. Which of the following findings should the nurse report to the provider? A. Hemoglobin 12 g/dL B. Platelet count 200,000/mm^3 C. Total bilirubin 4 mg/dL D. Glucose 50 mg/dL

a; The nurse should report a hemoglobin level of 12 g/dL to the provider because it is below the expected reference range of 14 to 24 g/dL.

A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which of the following findings should the nurse report to the provider? A. Frequent headaches B. Leukorrhea C. Epistaxis D. Periodic numbness of fingers

a; The nurse should report frequent headaches to the provider. Frequent headaches, swelling of the face and fingers, visual disturbances, and epigastric pain are associated with preeclampsia.

A nurse is teaching a postpartum client how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the teaching? A. "I should stop swaddling my baby once she is able to roll over by herself." B. "My baby's legs should be extended straight out when I swaddle her." C. "I should be able to slide just 1 finger between my baby's chest and the swaddled blanket." D. "After swaddling, I should place my baby on her side in her crib or bassinet."

a; The parent should discontinue swaddling the baby once the baby is able to roll over, which occurs around 2 months of age. Rolling over can tighten the swaddle and keep the baby from breathing properly.

A nurse is caring for a client who is at 38 weeks gestation and reports no fetal movement for the past 24 hr. Which of the following actions should the nurse take? A. Auscultate for a fetal heart rate B. Have the client drink orange juice C. Reassure the client that a term fetus is less active D. Palpate the uterus for fetal movement

a; The presence of a fetal heart rate is a reassuring manifestation of fetal wellbeing. The nurse should auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action.

A postpartum nurse is providing care for a client who is breastfeeding and has a perineal hematoma. The nurse should recommend that the client use the following breastfeeding positions? A. Side-lying B. Clutch hold C.Across-the-lap D. Cross-cradle

a; The side-lying position allows the client to access her baby, facilitates latching, and reduces pressure on the hematoma. The client will be more comfortable while breastfeeding in this position.

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? A. Uterine tone B. Fetal heart rate C. Blood pressure D. Amount of bleeding

a; 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 performing an initial physical assessment of a newborn following a vaginal birth. Which of the following findings should the nurse report to the provider? A. Small, pinpoint, reddish-purple spots on the chest B. Bluish coloring of the feet C. Overlapping suture lines D. White, cheese-like substance covering the skin

a; These marks are petechiae, commonly found above the neck if the umbilical cord was around the newborn's neck at birth. Petechiae in any other circumstance should be reported because this finding can indicate infection or a low platelet count.

A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following information should the nurse provide to the mother when she asks about this finding? A. "This will resolve in 3 to 6 weeks without treatment." B. "This will resolve on its own within 3 to 4 days." C. "The provider might drain this area with a syringe." D. "This appearance is expected at birth, so you don't need to worry."

a; This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum. It will resolve within 2 to 6 weeks.

A nurse is caring for a client at 39 weeks gestation who is in the active phase of labor. The nurse observes early decelerations in the fetal heart rate (FHR). Which of the following findings should the nurse identify as the cause of late decelerations? A. Uteroplacental insufficiency B. Fetal head compression C. Fetal ventricular septal defect D. Umbilical cord compression

b

A nurse is caring for a client who experienced a fetal loss. When initiating communication with this client, what statements should the nurse make? A. "I understand how you feel." B. "I'm here for you if you would like to talk." C. "It is better that the loss happened now before you got to know your baby." D. "You are young and can have other children."

b

A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which instructions should the nurse provide to the client about the treatment plan? A. "Your partner needs to be cultured and be treated with metronidazole only if his cultures are positive." B. "You and your partner need to take the medication and use a condom during intercourse until cultures are negative." C. "If both you and your partner are treated simultaneously, you may continue to engage in sexual intercourse." D. "Only you will need to take the metronidazole, but you should not have intercourse until your culture is negative."

b

A nurse is caring for a client who is at 20 weeks gestation. The client asks the nurse what the baby looks like at this point. Which of the following answers by the nurse provides an accurate response? A. "Lanugo has disappeared." B. "The fetus resembles a human." C. "The arm and leg buds are noticeable." D."Subcutaneous fat gives the body a wrinkled appearance."

b

A nurse is caring for a client who is at 26 weeks gestation and reports constipation. Which of the following responses by the nurse is appropriate? A. "You should drink 1 oz of mineral oil every morning." B. "You should walk for at least 30 min daily." C. "You should eat at least 3 oz of red meat daily." D. "You should stop taking your prenatal vitamin."

b

A nurse is caring for a client who is in labor and received meperidine for pain 1 hr prior to entering the second stage of labor. Which of the following actions should the nurse take? A. Assess the client's reflexes B. Assess the newborn for respiratory depression C. Assess the client for bradycardia D. Assess the newborn for signs of opiate withdrawal

b

A nurse is caring for a recently delivered newborn whose mother had gestational diabetes. What action should the nurse take within 1 hr after birth? A. Administer the hepatitis B (HBV) vaccine B. Assess the newborn's blood glucose level C. Bathe the newborn D. Perform a screening for congenital heart disease

b

A nurse is discussing potential complications of newborn hypothermia with a newly licensed nurse. Which of the following complications should the nurse include? A. Tachycardia B. Hypoglycemia C. Flushed skin D. Generalized petechiae

b

A nurse is performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks what the purpose of the test is. Which of the following responses should the nurse provide? A. "This test will determine if you will likely deliver within the next week." B. "This test will help determine if your baby is healthy." C. "This test can see how your baby responds when you have contractions." D. "This test will determine if your baby's lungs are mature."

b

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? A. Ensure the client has a full bladder B. Stand at the client's right side of the nurse is right-handed C. Assist the client onto her back with knees extended. D. Palpate the outline of the fetus's head with the palms of the hands

b

A nurse is providing education for a pregnant client about symptoms that should be reported immediately to the provider. Which of the following client responses indicates an understanding of the teaching? A. "I should call my provider if I develop melasma." B. "If I notice my eyes are puffy, I should call my provider." C. "I should call my provider if my feet and ankles are swollen." D. "If I notice periodic numbness and tingling in my fingers, I should call my provider."

b

A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse make? A. "Has your wife sensed your anger toward her and the baby?" B. "These feelings are common for expectant fathers in early pregnancy." C. "I'm sure that accepting this situation is challenging when it's your baby, too." D. "You should speak to a therapist about these feelings."

b

A nurse is teaching a client at 10 weeks gestation about an abdominal ultrasound in the first trimester. Which of the following pieces of information should the nurse include in the teaching? A. "You will have a nonstress test before the ultrasound." B. "You must have a full bladder during the ultrasound." C. "The ultrasound will determine the length of your cervix." D. "You will experience uterine cramping during the ultrasound."

b

A nurse is teaching a client who is pregnant about nonstress testing. Which of the following pieces of information should the nurse include? A. "This test is an invasive procedure that presents minimal risk to the fetus." B. "If the test is reactive, that means your baby's heart rate is healthy." C. "When your baby moves, the test should record the baby's heart rate decreasing by about 15 beats per minute." D. "The test results will be recorded as positive if no fetal movement occurs during the 20-minute testing period."

b

A nurse is teaching a newborn's parent how to care for the newborn's umbilical cord stump. Which of the following instructions should the nurse include? A. "Cover the cord with the edge of the diaper." B. "Clean the cord stump with tap water." C. "Apply a damp cloth over the cord stump once daily." D. "You should gently tug on the cord stump in 5 days if it has not yet fallen off."

b

A nurse is teaching a parent how to care for his newborn's circumcision site. Which of the following client statements indicates an understanding of the teaching? A. "I should clean the circumcision site with half-strength hydrogen peroxide twice a day." B. "I should apply the diaper loosely until the circumcision site is healed." C. "I should notify the doctor if yellow discharge forms on the head of the penis." D. "Newborns typically do not experience any pain from this procedure."

b

A nurse is teaching the guardians of a newborn about the facility's safety measures. Which of the following pieces of information should the nurse include? A. Expect staff to identify the newborn by verifying the information on the bassinet card B. Check for a photo identification badge before allowing a nurse to remove the newborn from the room C. Place the newborn in the bassinet when using the bathroom D. Hold the newborn securely when walking in the hallway

b

A nurse teaches a client about using the Lamaze method to manage pain during labor. Which of the following pieces of information should the nurse include? A. "Learning about childbirth will reduce any fear you might have, which will help you focus more on abdominal breathing during contractions." B. "You will learn how to prevent pain during labor by focusing your mind to control your breathing." C. "During labor, you will be encouraged to disassociate by using an internal focal point." D. "During labor, you will use conscious relaxation and levels of progressive breathing."

b

A nurse is caring for several clients. Which of the following clients should the nurse identify as a candidate for oral contraceptives? A. A client who smokes 2 packs of cigarettes per week B. A client who is breastfeeding a 7-month-old infant C. A client who is taking an anticonvulsant medication D. A client who is taking anti-HIV protease inhibitors

b; A client can begin using oral contraceptives 4 weeks after childbirth; therefore, this client is a candidate for oral contraceptive therapy.

A nurse in a clinic is teaching a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. Which of the following statements should the nurse make? A. "Your provider will insert a hand into your uterus and turn your baby around." B. "You will receive medication to relax your uterus prior to the procedure." C. "This procedure will be performed in the clinic at your next visit." D. "Your baby's heartbeat will be monitored occasionally throughout the procedure."

b; A client who is scheduled to undergo an external cephalic version often receives a tocolytic prior to the procedure to allow the uterus to relax. A relaxed uterus allows the provider to provide an easier version.

A nurse receives a report from a client who is in labor and is experiencing contractions that are 4 min apart. Which patterns should the nurse expect on the fetal monitor tracing? A. Contractions that last for 60 sec each with a 4 min rest between contractions B. Contractions that last for 60 sec each with a 3 min rest between contractions C. A contraction that lasts for 4 min followed by a period of relaxation D. Contractions that last for 45 sec each with a 3 min rest between contractions

b; A contraction interval indicates how often a uterine contraction occurs. The nurse will measure the interval from the beginning of one contraction to the beginning of the next contraction. A contraction lasting 60 seconds with a relaxation period of 3 minutes is equivalent to contractions every 4 minutes.

A nurse is assessing a client at 12 weeks gestation with a hydatidiform mole. Which of the following findings should the nurse expect? A. Hypothermia B. Dark brown vaginal discharge C. Decreased urinary output D. Fetal heart tones

b; A hydatidiform mole (a molar pregnancy) is a benign proliferative growth of the chorionic villi that gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grape-like clusters.

A nurse is caring for a client who requests an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for this device? A. Hypertension B. Menorrhagia C. History of multiple gestations D. History of thromboembolic disease

b; An IUD is a small plastic or copper device placed inside the uterus that changes the uterine environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia, severe dysmenorrhea, or a history of ectopic pregnancy.

A nurse is monitoring a newborn who is receiving phototherapy. The nurse should identify which of the following findings as requiring intervention? A. Bilirubin level 5 mg/dL B. Weight loss 12% of birth weight C. Loose, green stools D. Axillary temperature of 36.6°C (97.9°F)

b; An acceptable weight loss over the first 3 to 5 days is 10%. The nurse should report this finding to the provider.

A nurse is planning care for a client in active labor whose fetus is in an occipital brow presentation. Which of the following complications should the nurse anticipate as a result of this fetal presentation? A. Precipitous labor B. Prolonged labor C. Hypertonic uterine dysfunction D. Umbilical cord prolapse

b; An occipital brow presentation increases the diameter of the presenting part, which may prevent the fetal head from descending into the pelvis. This can result in prolonged labor, forceps- or vacuum-assisted birth, or a cesarean delivery.

A nurse is reviewing recent laboratory values during a prenatal visit for a pregnant client. The nurse notes a hemoglobin level of 10 g/dL. Which of the following actions should the nurse take? A. Review the medical record for a history of gastric bypass surgery B. Advise the client to start iron and vitamin C supplementation C. Review the medication list to determine if the client is taking an anticonvulsant D. Request an order for sickle cell anemia screening

b; Anemia during pregnancy is defined by hemoglobin levels less than 10.5 to 11 g/dL, depending on the client's gestational age. Iron-deficiency anemia is characteristically microcytic. It is treated with iron supplementation with added vitamin C to aid in iron absorption.

A nurse administers betamethasone to a client who is at 33 weeks gestation to stimulate fetal lung maturity. When planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? A. Hyperthermia B. Decreased blood glucose C. Rapid pulse rate D. Irritability

b; Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery. The nurse must assess the newborn's blood glucose level within the first hour following birth and frequently thereafter until blood glucose levels are stable.

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Anterior fontanel of 5 cm B. Central cyanosis C. Edematous scrotum D. Capillary refill of under 2 seconds

b; Central cyanosis is an indication of compromised cardiorespiratory status. Other manifestations include tachypnea, nasal flaring, retractions, and grunting.

A nurse is caring for a client who is in labor. The nurse decides to switch from intermittent auscultation to continuous fetal monitoring. Which of the following data can only be obtained from continuous electronic fetal monitoring? A. Determination of a baseline B. Determination of variability C.Presence of accelerations D. Presence of decelerations

b; Continuous electronic fetal monitoring is required to determine variability since the nurse needs a monitor tracing to quantify variability.

A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? A. Gently retract the foreskin to wash the glans with soap and water B. Sponge bathes the newborn every other day C. Use an antimicrobial soap for bathing D. Bathe the newborn with water between 46° and 49°C (115° and 120°F)

b; Daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The parents should sponge bathe the infant until the cord stump has detached and the area has healed.

A nurse is monitoring a newborn for indications of septic shock. Which of the following findings should the nurse expect if the newborn develops this complication? A.Slow respirations B. Decreased blood pressure C. Bradycardia D. Flushed skin

b; Decreased blood pressure

A nurse is caring for a client who had a vaginal delivery 24 hours ago. Which of the following findings should the nurse report to the provider? A. 2,000 mL urine since delivery B. 3+ deep tendon reflexes C. Fundus at umbilicus D. Soft breasts

b; Deep tendon reflexes of 3+ or greater can indicate preeclampsia and should be reported to the provider.

A nurse is assessing a client who is at 36 weeks of gestation. Which manifestations should the nurse recognize as a potential prenatal complication and report to the provider? A. Varicose veins B.Double vision C. Leukorrhea D. Flatulence

b; Double vision, blurred vision, or visual disturbances are signs of potential complications associated with preeclampsia. The nurse should report this finding to the provider.

A nurse is teaching a prenatal class about nonpharmacological comfort measures during labor. Which of the following statements should the nurse identify as indicating that the instructions have been understood? A. "I can have my partner apply counterpressure to my upper abdomen." B. "My baby will be monitored with a Doppler device during hydrotherapy." C. "I can have the nurse apply acupressure to my lower abdomen." D. "My TENS unit will not help with lower back pain during early labor."

b; During hydrotherapy, the nurse should monitor the fetal heart rate with a fetoscope, a Doppler device, or a wireless external fetal monitor.

A nurse is assessing a client who is pregnant, and reports increased nasal stuffiness. The nurse should inform the client which of the following hormones is responsible for this discomfort? A. Relaxin B. Estrogen C. Progesterone D. Human chorionic somatomammotropin (HCS)

b; Estrogen increases vascularity and connective tissue growth. Nasal stuffiness, a common discomfort in pregnancy, results from the increased vascularity of the mucus membranes within the nasal passages.

A nurse is providing discharge instructions for a client who had a cesarean birth 4 days ago. The client's hemoglobin level is 9.2 g/dL, and the provider has prescribed an iron supplement. Which foods should the nurse recommend to help increase the client's iron intake? A. Spinach B. Citrus fruit C. Milk D. Whole-grain bread

b; Foods with a high vitamin C content help increase iron absorption. These foods include citrus fruits, strawberries, melons, and tomatoes.

A nurse is caring for a client who is pregnant with a male child and expresses concern to the nurse about the possibility of the child having hemophilia. The client is a carrier of the gene mutation for this condition. Which of the following percentages represents the child's chance of having this disorder? A. 25% B. 50% C. 75% D. 100%

b; Hemophilia A is an X-linked recessive inheritance disorder, which means that female clients who are carriers have a 50% chance of passing the gene mutation to their children. If the child is female, she will be a carrier. If the child is male, he will have the disorder. This is because male children inherit an X chromosome from their biological mothers and a Y chromosome from their biological fathers. If the male child has the gene mutation on 1 of his X chromosomes, it will cause the disorder even though it is on a copy of the gene.

A nurse is teaching about formula feeding to the guardian of a newborn. Which of the following pieces of information should the nurse include? A. Boil bottles and nipples for 20 minutes after each use B. Mix 1 scoop of powdered formula with 2 oz of water C. Store prepared bottles in the refrigerator for up to 4 days D. Warm formula by heating bottles in the microwave on the lowest setting

b; The guardian should use sterile water or water that has been boiled for 2 minutes when mixing powdered formula. The guardian should mix 1 scoop in 2 oz of water.

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? A. Respirations 16/min B. Urinary output 40 mL in 2 hr C. Reflexes +2 D. Fetal heart rate 158/min

b; Using the urgent versus nonurgent priority-setting framework, the nurse should consider urgent needs to be the priority since they pose more of a threat to the client. As a result, the nurse should report the client's urinary output immediately. Urinary output is critical to the excretion of magnesium from the body. The nurse should discontinue the magnesium sulfate if the hourly output is <30 mL/hr. The nurse may also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent.

A nurse is teaching a client who is at 8 weeks gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. Which of the following pieces of information should the nurse include? A. "The fibroid will shrink during the pregnancy." B. "The fibroid can increase the risk of postpartum hemorrhage." C. "You will receive an injection of medroxyprogesterone acetate to shrink the fibroid." D. "You will have to undergo a cesarean birth because of the fibroid."

b; Uterine fibroids can increase the risk of postpartum hemorrhage due to the increased blood supply to the uterus, which supports the fibroid.

A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take? A. Encourage the client to ambulate B. Provide a sitz bath with warm water for the client C. Instruct the client to perform Kegel exercises D. Apply anesthetic cream topically each hour while the client is awake

b; the nurse should provide a client who is postpartum with a sitz bath to decrease episiotomy discomfort. The use of a sitz bath provides warm, moist, direct heat to the incision area, which helps relieve the pulling and stinging associated with the healing incision. The warm water increases blood flow to the area through vasodilatation, which also promotes healing and comfort.

A nurse at a prenatal clinic is assessing an adult client who had genital cutting performed as a child as part of her cultural practices. The nurse notes that the client's clitoris and labia minora were removed, and she has scarring in the vaginal area. Which of the following actions should the nurse take? A. Report the findings to the local authorities B. Ask the client who performed the cutting C. Inform the client that giving birth vaginally might not be possible D. Prepare the client for the increased risk of spontaneous abortion

c

A nurse is caring for a client at 35 weeks gestation who has severe pre-eclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status? A. Blood pressure B. Intake and output C. Daily weight D. Severity of edema

c

A nurse is caring for a client at 36 weeks gestation who has pre-eclampsia. Which of the following findings should the nurse identify as the priority? A. 1+ proteinuria B. Blood pressure 140/98 mmHg C. Nonreactive nonstress test D. Fundal height 33 cm

c

A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse perform? A. Prepare the client for an ultrasound examination B. Prepare the client for an emergency cesarean birth. C. Prepare equipment needed for newborn resuscitation. D. Perform endotracheal suctioning as soon as the fetal head is delivered

c

A nurse is caring for a client in active labor who is experiencing hypotension following epidural placement. Which of the following actions should the nurse take? A. Decrease IV fluids B. Give oxygen at 2 L/min via nasal cannula C. Place the client in a lateral position D. Administer indomethacin

c

A nurse is caring for a client in active labor whose fetus is in a persistent occiput posterior position. Which of the following actions should the nurse take to promote rotation of the fetal head? A. Apply counterpressure to the client's back B. Place heat on the client's lower back C. Instruct the client to squat during contractions D. Encourage the client to ambulate in the hall

c

A nurse is caring for a client labor who has an epidural for pain relief. Which of the following is a complication of the epidural block? A. Nausea and vomiting B. Tachycardia C.Hypotension D. Respiratory depression

c

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? A. Uterine rupture B. Placental abruption C. Prolapsed umbilical cord D. Amniotic fluid embolus

c

A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer? A. Protamine sulfate B. Naloxone C. Calcium gluconate D. Flumazenil

c

A nurse is caring for a client with pelvic measurements recorded by the provider. The client asks, "Since my pelvis is gynecoid, will I be able to deliver vaginally?" Which of the following responses should the nurse make? A. "The shape of your pelvis will make vaginal childbirth difficult, but it is still possible." B. "The shape of your pelvis will require a cesarean delivery." C. "The shape of your pelvis is ideal for vaginal childbirth." D. "The shape of your pelvis will change as you near delivery, and the provider will determine if vaginal delivery is possible."

c

A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 sec. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? A. Administer oxygen B. Place the newborn in an isolette C. Continue to monitor the newborn routinely D. Assess the newborn's blood glucose

c

A nurse is planning care for a client at 35 weeks gestation. Which of the following laboratory tests should the nurse obtain? A. Rubella titer B. Blood type C. Group B streptococcus ß-hemolytic D. 1-hour glucose tolerance test

c

A nurse is providing education about continuous heparin therapy for a client who is 18 hours postpartum and has developed a deep vein thrombosis (DVT). Which of the following statements should the nurse include in the teaching? A. "An adverse effect of this medication is drowsiness." B. "This medication will require frequent monitoring of WBC levels." C. "Use a soft toothbrush to brush your teeth gently." D. "Avoid taking acetaminophen while receiving this medication."

c

A nurse is providing teaching for a client who is pregnant and has type 1 diabetes mellitus. Which of the following statements should the nurse include in the teaching? A. "You should expect to increase your insulin dosage during the first trimester of pregnancy." B. "You should expect to decrease your insulin dosage during the second and third trimesters of pregnancy." C. "You should expect to decrease your insulin dosage immediately after you deliver your baby." D. "You must increase your insulin dosage if breastfeeding."

c

A nurse is reviewing laboratory results for a client who is at 37 weeks gestation. The nurse notes that the client is rubella non-immune, is positive for group A beta-hemolytic streptococcus, and has a blood type of O negative. Which of the following actions should the nurse take? A. Administer a dose of Rho(D) immune globulin B. Request a prescription for an antibiotic until delivery C. Instruct the client to obtain a rubella immunization after delivery D. Inform the client that she will need to deliver via cesarean birth.

c

A nurse is teaching a client during the client's first prenatal visit. Which of the following instructions should the nurse include? A. "A fetal stethoscope can first detect your baby's heart rate at 22 weeks." B. "After week 16, we can see if your baby is a boy or a girl." C. "A Doppler device can detect your baby's heart rate at 12 weeks." D. "You will first feel the baby move at about 8 weeks."

c

A nurse is teaching a client who is in the third trimester of pregnancy and has herpes genitalis. Which of the following instructions should the nurse include? A. "Clean the lesions twice a day with hydrogen peroxide." B. "Apply a hot compress to the affected areas." C. "Talk with your doctor about a prescription for acyclovir to treat your symptoms." D. "Expect to receive penicillin prior to delivery."

c

A nurse is teaching a parent of a newborn about circumcision care. Which of the following instructions should the nurse include? A. Wash the site with soap and warm water once daily B. Gently remove the yellow exudate that forms around the site C. Avoid using diaper wipes on the site during diaper changes D. Apply the diaper tightly to apply pressure to the site

c

A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take? A. Prepare to initiate a warm water sitz bath for the client's perineum. B. Encourage the client to sit on a soft pillow C. Apply ice packs to the client's perineum D. Administer an acetaminophen suppository rectally

c

The parents of a child with phenylketonuria (PKU) ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns responsible for PKU? A. X-linked recessive B. X-linked dominant C. Autosomal recessive D. Autosomal dominant

c

A nurse is caring for a client who is receiving IV oxytocin for the induction of labor and notes repetitive early decelerations on the electronic fetal heart rate (FHR) tracing. Which of the following actions should the nurse take? A. Increase the rate of intravenous fluid infusion B. Discontinue the infusion of oxytocin C. Re-evaluate the FHR tracing in 15 minutes D. Request a prescription for an amnioinfusion

c; Early decelerations are a result of the compression of the fetal head during contractions. They are benign and require no specific intervention. The nurse should reassess the FHR and contraction pattern in 15 minutes due to the infusion of oxytocin.

A nurse is assessing a postpartum client and observes a steady trickle of bright red blood from the client's vagina. The uterus is palpated as firm, midline, and 1 cm below the umbilicus. Which of the following actions should the nurse take? A. Massage the fundus B. Instruct the client to empty her bladder C. Notify the provider D. Teach the client to perform a sitz bath

c; Excessive vaginal bleeding in the presence of a contracted uterus is a sign of a vaginal or cervical laceration. The provider must be notified so the laceration can be repaired.

A nurse cares for a client who states, "I think I am pregnant." Which of the following findings should the nurse identify as a positive sign of pregnancy? A. Positive serum pregnancy test B. Amenorrhea C. Fetal heart tones auscultated by Doppler D. Chadwick sign

c; Fetal heart tones heard by Doppler are a positive sign of pregnancy. The only possible explanation for hearing fetal heart tones is the presence of a fetus.

A nurse in an outpatient setting is providing education for a client who is pregnant. Which of the following statements should the nurse include in the teaching? A. "During the last trimester, you should sleep mainly on your back." B. "During the second trimester, you will notice increased urinary frequency and urgency." C. "You will probably first notice your baby moving when you are around 20 weeks gestation." D. "You should plan to gain 40 to 45 pounds during your pregnancy."

c; Fetal movement is typically noted by a pregnant client at 18 to 20 weeks gestation. Multiparous clients might notice the movement earlier.

A nurse is assessing a newborn. Which of the following findings should the nurse identify as an indication of recent maternal heroin use? A. Large for gestational age B. Hypotonicity C. Incessant crying D. Craniofacial anomalies

c; Manifestations of neonatal abstinence syndrome due to maternal heroin use include incessant crying, jitteriness, hyperactivity, poor feeding, tachycardia, and frequent yawning and sneezing. a - Heroin use during pregnancy can result in intrauterine growth retardation; therefore, the newborn would not be large for gestational age. b - Manifestations of neonatal abstinence syndrome due to maternal heroin use include hyperreflexia and hyperactivity, not hypotonicity. d - Craniofacial anomalies are a manifestation of fetal alcohol syndrome, not neonatal abstinence syndrome due to maternal heroin use.,

A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should the charge nurse include in the teaching? A. Newborn respiratory depression at birth B. Impaired ability of the neonate to maintain body temperature C. Impaired placental perfusion D. Decreased fetal heart rate (FHR) variability

c; Maternal hypotension can occur in 10% to 30% of women who receive epidural or spinal anesthesia. This can result in decreased blood flow to the placenta and impair the delivery of oxygen to the fetus.

A nurse is planning care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care? A. Swaddle the newborn in a receiving blanket during the treatment B. Maintain NPO status until the newborn's bilirubin is within the expected reference range C. Ensure the newborn's eyes are closed before applying the eye shield D. Apply lotion to the newborn's skin twice per day

c; Overexposure to the lights during treatment can cause damage to the newborn's corneas. Therefore, the nurse should gently close the newborn's eyes prior to applying the eye shield.

A nurse is caring for a client who is scheduled to receive a continuous IV infusion of oxytocin following a vaginal birth. Which of the following assessment findings should the nurse monitor to evaluate the effectiveness of the medication? A. Urinary output B. Blood pressure C. Fundal consistency D. Pulse rate

c; Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective.

A nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects? A. Diarrhea B. Thromboembolism C. Fetal asphyxia D. Oliguria

c; Oxytocin may cause tachysystole, which can lead to uteroplacental insufficiency. Inadequate oxygen transfer to the placenta will result in fetal asphyxia.

A nurse is providing teaching for a client about hormonal changes during pregnancy. The nurse identifies which of the following hormones plays a key role in preventing miscarriage? A. Oxytocin B. Prolactin C. Progesterone D. Estrogen

c; Progesterone maintains the endometrium and has a relaxant effect on the uterus so that the fetus is not expelled.

A nurse is caring for a client who is in labor. A vaginal examination reveals the following findings: 2 cm, 50%, +1, right occiput anterior (ROA). Based on this information, which of the following fetal positions should the nurse document in the medical record? A. Transverse B. Breech C. Vertex D. Mentum

c; ROA describes the relationship of the presenting part of the fetus to the client's pelvis. In this case, the occipital bone is the presenting part and is located anteriorly on the client's right side. Based on the presentation of the fetus, the position is vertex.

A nurse is caring for a client in the latent stage of labor who is reporting a pain level of 4 on a scale of 1 to 10. Which of the following actions should the nurse take? A. Encourage the client to use hydrotherapy B. Teach the client biofeedback to control labor pain C. Lead the client in relaxation breathing techniques D. Administer a benzodiazepine medication

c; Relaxation breathing techniques in the first stage of labor promote relaxation of the abdominal muscles. This decreases discomfort and allows fetal descent. a - Hydrotherapy should not be implemented for pain relief until the client has entered the active stage of labor. Early introduction of hydrotherapy is associated with a prolonged labor. b - While biofeedback can be an effective method of relaxation, the technique must be introduced and practiced during the prenatal period to be effective during labor. d - Benzodiazepines are not recommended for laboring clients because they have a significant maternal amnesic effect and can disrupt thermoregulation in the newborn.

A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Post-term birth B. Macrosomia C. Respiratory distress syndrome D. Maternal gestational diabetes

c; Respiratory distress syndrome is a risk factor for NEC. Respiratory distress causes intestinal ischemia secondary to hypoxia.

A nurse is performing a physical assessment of a newborn. Which of the following actions should the nurse take? A. Measure the newborn's length from the anterior fontanel to the heel B. Measure the newborn's weight while he is wearing a clean diaper C. Measure the circumference of the newborn's head with a tape measure just above the eyebrows D. Measure the circumference of the newborn's chest with a tape measure 2 cm (0.79 in) below the nipple line

c; Shortly after birth, the nurse should measure the circumference of the newborn's head at its largest diameter, which is around the occipitofrontal area.

A nurse is planning educational sessions for clients in a childbirth class. Which of the following findings should the nurse plan to instruct the clients to report immediately? A. Vaginal leukorrhea B. Shortness of breath C. Swelling of the face and fingers D. Lower back pain

c; Swelling of the face, fingers, or area over the sacrum is an indication of hypertensive disorders such as eclampsia. The nurse should ensure these educational sessions include instructing clients about reporting such indications to their provider immediately.

A nurse is caring for a client who is scheduled to receive intravenous oxytocin for the induction of labor. The client has a Bishop score of 10. Which of the following findings should the nurse expect? A. The client will require a dinoprostone for the ripening of the cervix. B. The client will experience lower back pain during labor. C. The client will experience a successful induction of labor. D. The client will require a vacuum- or forceps-assisted delivery.

c; The Bishop score indicates cervical favorability for labor inducibility by assessing cervical dilation, effacement, station, consistency, and position. A score of 8 or more favors a successful induction.

A nurse is assessing a 7-month-old infant during a well-child visit and notes the presence of a full Moro reflex. For which of the following conditions should the nurse screen the infant? A. Congenital heart disease B. Hearing loss C. Neurological disorder D. Amblyopia

c; The Moro reflex, also known as the startle reflex, is elicited by striking the surface next to the newborn to startle him/her. A classic pattern of abduction and extension of the arms is expected. This reflex should be gone by 4 months of age; its presence after 4 months of age is associated with a neurological disorder.

A nurse is teaching a client about breastfeeding. Which of the following client statements indicates an understanding of the teaching? A. "I should consume about 700 extra calories a day while breastfeeding." B. "I will introduce bottle feeding of pumped breast milk when my baby is 2 weeks old." C. "I may notice increased cramping when I am feeding my baby." D. "I will place my baby on a strict feeding schedule to help establish a good feeding pattern."

c; The client may notice an increase in uterine cramping while breastfeeding due to the release of oxytocin, which causes uterine muscle contraction.

A nurse is planning care for a client who is scheduled to have prostaglandin E2 gel inserted for cervical ripening. Which of the following actions should the nurse take? A. Assess fetal heart rate and contraction pattern every 15 min after insertion B. Thaw the frozen gel in a warm water bath prior to insertion C. Maintain the client in a side-lying position for 30 min after insertion D. Initiate an oxytocin infusion for induction 1 hr after gel insertion

c; The client should maintain a side-lying or supine position with a lateral tilt for 30 to 40 minutes after the insertion of the medication to allow the gel to stay in contact with the cervix.

A nurse is assessing a client who is 2 days postpartum. In which locations should the nurse expect to locate the client's fundus? A. 3 cm above the umbilicus B. 1 cm above the umbilicus C. 3 cm below the umbilicus D. 1 cm below the umbilicus

c; The client's fundus should descend about 1 to 2 cm every 24 hours; therefore, at 2 days postpartum, the client's fundus should be located 3 cm below the umbilicus.

A nurse is teaching a client who is in labor about the use of nitrous oxide analgesia for pain control. Which of the following statements by the client indicates an understanding of the teaching? A. "Nitrous oxide could make my baby sleepy when he is born." B. "I should inhale the nitrous oxide between contractions." C. "I will feel the effects of the nitrous oxide almost immediately." D. "Nitrous oxide can make me feel disoriented."

c; The effects of nitrous oxide are felt within 1 minute of inhalation. a - Nitrous oxide does not appear to cause neonatal sedation or a difference in Apgar scores. b - The client should inhale nitrous oxide through a face mask as the contraction begins and use it during the contraction. d - Nitrous oxide induces a feeling of relaxation and decreases the client's perception of pain. It does not cause feelings of disorientation.

A nurse is caring for a client who just had a spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and a prolapsed umbilical cord. Which of the following actions should the nurse take first? A. Place the client in an extreme Trendelenburg position B. Increase the IV fluid infusion rate C. Manually apply upward pressure intravaginally on the presenting part D. Administer 8 to 10 L/min of oxygen via a nonrebreather face mask

c; The greatest risk to this client is fetal CNS injury or death from fetal hypoxia due to cord compression. Therefore, the first action the nurse should take is to insert a gloved hand into the vagina and apply upward pressure to the presenting part to move it away from the cord. The nurse should place the client in an extreme Trendelenburg position, a knee-chest position, or a modified Sims' position to use gravity to keep the pressure of the presenting part off the cord; however, another action is the priority.

A nurse teaches a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include? A. Urinary hesitancy B. Hematuria C. Stress incontinence D. Increased vaginal moisture

c; The nurse should teach the client that stress incontinence can occur due to the shrinking of the uterus, vulva, and distal portion of the urethra. Urinary incontinence and uterine displacement can occur because of common age-related changes but are not necessarily a result of menopause-related changes.

A nurse is planning care for a client who is postpartum and has cardiac disease. For which of the following prescriptions should the nurse seek clarification? A. Monitor the client's intake and output B. Initiate a high-fiber diet for the client C. Monitor the client's weight weekly D. Initiate bedrest with the head of the bed elevated

c; The nurse should weigh the client daily to monitor for fluid overload.

A nurse is teaching new parents about newborn reflexes. Which of the following reflexes facilitates infant feeding? A. Stepping B. Moro C. Rooting D. Babinski

c; The rooting reflex is elicited when the cheek is stroked and the newborn turns the head while making sucking motions with the mouth. This reflex supports effective sucking.

A nurse is caring for a client who is nulliparous and experiencing hypertonic uterine dysfunction. An assessment indicates 3 cm dilation. Which of the following actions should the nurse take? A. Encourage the client to bear down with contractions B. Request a prescription to initiate oxytocin C. Offer the client hydrotherapy D. Assist the client with ambulation

c; Therapeutic rest measures should be initiated for a client who has hypertonic uterine dysfunction. Therapeutic rest can include hydrotherapy and analgesia to relieve pain. Decreasing uterine contractions and helping the client relax and sleep will help prevent early exhaustion.

A nurse is testing the reflexes of a newborn to assess neurological maturity. Which of the following reflexes is the nurse assessing by quickly and gently turning the newborn's head to one side? A. Rooting B. Moro C. Tonic neck D. Babinski

c; To elicit the tonic neck reflex, the nurse should quickly and gently turn the newborn's head to one side when the newborn is sleeping or falling asleep. The newborn's arm and leg should extend outward to the same side that the nurse turned the head while the opposite arm and leg flex. This reflex persists for about 3 to 4 months.

A nurse is providing teaching about rubella immunization to a client who is 24 hours postpartum. Which of the following client statements indicates an understanding of the teaching? A. "I should not breastfeed for at least 3 days after receiving this immunization." B. "I will need a second rubella booster when I see my midwife at 6 weeks postpartum." C. "I should be careful to avoid becoming pregnant within the next month." D. "This vaccine will be given into my arm muscle."

c; While the chances of fertility in the first 4 weeks postpartum are low, clients who receive a rubella immunization must be additionally careful to avoid pregnancy either through maintaining abstinence or through using an effective contraceptive. The rubella vaccine is a live virus vaccine and can cause birth defects.

A charge nurse teaches newly licensed nurses about teratogens that affect fetal development. The nurses should recognize which of the following is an example of a teratogen? A. Consuming caffeine during pregnancy B. A family history of a genetic disorder C. Gum disease in a pregnant client D. Drinking alcohol during pregnancy

d

A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect? A. Increased platelet count B. Fetal distress C.Decreased urinary output D. Dark red vaginal bleeding

d

A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump following a cesarean birth. Which of the following findings should the nurse report to the provider? A. Respiratory rate 14/min B. Temperature 37.8°C (100°F) C. Dizziness upon rising D. Urine output 20 mL/hr

d

A nurse is assessing a client who missed 2 menstrual cycles and reports that she might be pregnant. Which of the following findings is a positive sign of pregnancy? A. Quickening B. Breast tenderness C. Uterine enlargement D. Auscultation of a fetal heart rate

d

A nurse is assessing a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements? A. "Prolactin is increasing the blood supply to your uterus, and you are feeling blood vessel engorgement." B. "You probably have a small blood clot in your uterus, which is causing the uterus to contract in order to expel it." C. "Your breasts are secreting a hormone that enters the bloodstream and causes your abdominal muscles to contract." D. "The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract."

d

A nurse is assessing the Moro response of a newborn. Which of the following findings should the nurse expect? A. Abduction and extension of the arms are asymmetric. B. The opposite leg flexes while a leg is extended and the sole of the foot is stimulated. C. Toes hyperextend with dorsiflexion of the great toe. D. The legs move in a similar pattern of response to the arms.

d

A nurse is assisting with monitoring the fetal heart rate tracings of a client who is in labor. Which of the following findings should the nurse report to the provider? A. Baseline fetal heart rate of 110 to 130/min B. Moderate baseline variability C. Accelerations in response to fetal stimulation D. Late decelerations with fetal bradycardia

d

A nurse is caring for a client at 39 weeks gestation who is in the active phase of labor. The nurse observes variable decelerations in the fetal heart rate (FHR). Which of the following findings should the nurse identify as the cause of late decelerations? A. Uteroplacental insufficiency B. Fetal head compression C. Fetal ventricular septal defect D. Umbilical cord compression

d

A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? A. Anemia B. Frequent urinary tract infections C. Previous cesarean birth D. Pelvic inflammatory disease (PID)

d

A nurse is caring for a client who is at 34 weeks gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority? A. "My ankles are swollen at the end of the day." B. "I can feel the baby kicking my ribs, and it is very uncomfortable." C. "I'm growing more and more worried every day." D. "My heart feels like it is racing."

d

A nurse is caring for a client who is at 35 weeks of gestation and is scheduled to undergo an amniocentesis. Which of the following statements should the nurse make? A. "You will have to drink 3 to 5 8-oz glasses of water to fill your bladder." B. "This procedure will not rupture your membranes or cause premature labor." C. "You might feel light pressure while collecting a blood sample from the baby." D. "You will feel some mild discomfort during the procedure."

d

A nurse is caring for a client who is in labor. Which of the following methods will determine the frequency of the client's contractions? A. Palpating the firmness of the uterus during a contraction B. Calculating the time from the end of each contraction to the beginning of the next C. Measuring the time from the beginning of a contraction to the end of that same contraction D. Evaluating the time from the beginning of a contraction to the beginning of the next contraction

d

A nurse is caring for a newborn who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect and report to the provider? A. Weak cry B. Absent Moro reflex C. Constipation D. Tremors

d

A nurse is caring for a postpartum client who is having difficulty voiding. Which of the following actions should the nurse take first? A. Place the client's hands in warm water B. Administer an analgesic to the client C. Pour water from a squeeze bottle over the client's perineum D. Assist the client to the bathroom

d

A nurse is caring for a preterm infant in the NICU. Which of the following actions by the nurse will promote the infant's optimal development? A. Avoiding swaddling B. Placing the infant in the supine position C. Providing physical care at short, frequent intervals D. Reducing ambient noise and lighting

d

A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include in the plan? A. Discontinue therapy if a fine rash appears B. Place moisturizing lotion on the newborn's skin C. Supplement feedings with 1 oz of glucose water every 4 hours D. Change the newborn's position every 2 to 3 hours

d

A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse include in the teaching? A. "You should eat foods served at warm temperatures." B. "You should brush your teeth right after you eat." C. "You should try to eat sweet foods when you feel nauseated." D. "You should eat dry foods high in carbohydrates when you wake up."

d

A nurse is preparing a client who is in labor for the insertion of an intrauterine pressure catheter. The client asks why this type of monitoring is needed. Which of the following responses should the nurse make? A. "This type of monitoring is necessary for timing the frequency of your contractions." B. "This type of monitoring is noninvasive, so it is the best way to monitor your labor contractions." C. "This type of monitor allows us to evaluate your baby's heart rate while you are in labor." D. "This type of monitoring will allow us to measure the intensity of your contractions."

d

A nurse is providing education for the parent of a premature infant on interventions to promote optimal development. Which of the following actions should the nurse instruct the parent to perform? A. Maintain bright lighting to enable close observation of the infant at all times B. Place the infant in a prone position with arms and legs extended C. Rouse the infant every 1-2 hr to provide auditory and visual stimulation D. Provide kangaroo care for the infant

d

A nurse is providing teaching for a client at 7 weeks of gestation who is experiencing nausea and vomiting. Which of the following client statements indicates an understanding of the teaching to the nurse? A. "I should eat fatty foods to increase my caloric intake." B. "I should brush my teeth right after eating." C. "Acupressure bands on my elbows might help me feel better." D. "I should have a small snack before bedtime."

d

A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I must drink milk every day in order to ensure good-quality breast milk." B. "Drinking lots of fluids will increase my breast milk production." C. "After the first few weeks, my nipples will toughen, and breastfeeding won't hurt anymore." D. "My baby may sometimes feed every hour for several hours in a row."

d

A nurse is teaching a sibling class for a group of expectant parents and their older children. Which of the following statements should the nurse include to facilitate sibling adaptation? A. "Move the siblings out of their cribs and into beds 2 weeks prior to the baby's delivery." B. "Consider having siblings play in another room when feeding your newborn." C. "Have the sibling present during the discharge of your newborn from the hospital." D. "Involve the siblings in decorating your newborn's room."

d

A nurse is using Naegele's rule to determine the estimated date of birth (EDB) for a client whose first day of her last menstrual period was February 2, 2018. The nurse should identify which of the following as the client's EDB? A. November 16, 2018 B. October 19, 2018 C. October 26, 2018 D. November 9, 2018

d

A nurse prepares to provide umbilical cord care for a newborn 12 hours after delivery. Upon inspection, the nurse noted moderate bleeding from a blood vessel. Which of the following actions should the nurse take? A. Check the newborn's heart rate B. Place a pressure dressing on the cord stump. C. Administer vitamin K D. Check the integrity of the cord clamp

d

A postpartum nurse cares for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make? A. "This is an attempt by your body to retain the fluid gained during pregnancy." B. "This is caused by an increase in your estrogen hormonal levels." C. "This is caused by the increased pressure on your veins in your lower legs." D. "This is a source of your fluid loss after delivery."

d

Which medications should the nurse prepare to administer to reverse the effects of benzodiazepines? A. Protamine sulfate B. Naloxone C. Calcium gluconate D. Flumazenil

d

While assessing a client in the fourth stage of labor, the nurse suspects bladder distention. Which of the following findings should the nurse anticipate with bladder distention? A. The fundus is at midline. B. The fundus is below the umbilicus. C. The bladder is resonant with percussion. D. The bladder fluctuates with palpation.

d

A nurse is performing a physical assessment of a male newborn. Which of the following findings should the nurse report to the provider? A. Superficial cracking and peeling are evident on the skin of the hands and feet. B. The palmar grasp occurs spontaneously when a newborn is sucking. C. The bulge of the testes is palpable in the inguinal canal. D. There is decreased abdominal movement with breathing.

d;

A nurse is caring for a client who is in active labor and receiving an oxytocin infusion. The nurse notes tachysystole with a Category 1 fetal heart rate tracing. Which of the following actions should the nurse take? A.Discontinue oxytocin infusion and apply oxygen B. Increase oxytocin infusion rate by 2 mu/min C. Administer terbutaline 0.25 mg subcutaneously D. Reposition the client in a side-lying position and continue to monitor

d; A Category 1 fetal heart rate tracing is an expected finding and does not represent fetal distress. The nurse should reposition the client in a side-lying position to optimize uteroplacental perfusion and continue to monitor the tracing for another 10 minutes to determine if tachysystole resolves.

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? A. Extended periods of sleep B. Poor muscle tone C. Respiratory rate 50/min D. Exaggerated reflexes

d; A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the central nervous system (CNS). Exaggerated reflexes are indicative of CNS irritability.

A nurse is caring for a client who is attempting a trial of labor (TOL) after several cesarean births. The client reports a sudden onset of constant abdominal pain, and the nurse observes a prolonged deceleration in the fetal heart rate tracing. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Place the client in a knee-chest position C. Plan to administer calcium gluconate D. Prepare the client for an emergency cesarean delivery

d; A sudden onset of abdominal pain in a laboring client who previously delivered by cesarean section, accompanied by a prolonged fetal deceleration, is a manifestation of a uterine rupture, which requires an emergency cesarean delivery.

A nurse is teaching a client who had a vacuum-assisted vaginal delivery. Which statements should the nurse identify as indicating that the client understands the information? A. "My baby's head will be cone-shaped for about 2 months." B. "My doctor performed this procedure because I did not dilate past 6 centimeters." C. "The doctor performed this procedure because my hemoglobin was low." D. "My baby has a higher risk of developing jaundice."

d; A vacuum-assisted birth increases the risk of jaundice as the bruises caused by the device dissipate.

A nurse is counseling a female client who expresses a desire to conceive in the near future. Which dietary recommendations should the nurse make to prevent neural tube defects? A. Take a multivitamin every day B. Decrease consumption of mercury-containing fish C. Increase consumption of dairy products D. Begin taking a folic acid supplement

d; Adequate amounts of folic acid are necessary for fetal neural tube development. All women of child-bearing age and intention should take a folic acid supplement of 0.4 mg.

A nurse is providing care for a pregnant adolescent who is at 12 weeks gestation and verbalizes a fear of gaining weight during pregnancy. Which of the following actions should the nurse take? A. Have the client watch a fetal growth and development video during pregnancy. B. Supply pamphlets that discuss the importance of nutrition during pregnancy. C. Explain how poor nutrition can prevent the baby from growing properly. D. Provide examples of how eating well will help maintain a healthy weight during pregnancy.

d; Adolescents are typically preoccupied with self and lack the ability to understand outcomes that will occur in the future. Effective teaching for this age group should mainly focus on benefits to the client and positive outcomes that will occur in the near future.

A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching? A. Apply the diaper tightly over the circumcision area B. Remove the yellow exudate with each diaper change C. Use prepackaged commercial wipes to clean the circumcision site D. Encourage non-nutritive sucking for pain relief

d; Allowing the newborn to suck on a pacifier is an effective form of nonpharmacological pain management.

A nurse is creating a plan of care for a client who is in the active stage of labor and expresses a desire to use nonpharmacological methods of pain relief. Which of the following interventions should the nurse include? A. Encourage the client to listen to music B. Instruct the client on how to use informational biofeedback C. Ask the client to reconsider using a regional anesthetic D. Assist the client into a warm shower

d; Assisting the client into a warm shower is a nonpharmacological method used to decrease labor pain. This method stimulates the release of endorphins and increases circulation. Research supports the use of hydrotherapy as an effective method of labor pain management.

A nurse cares for a client at 39 weeks gestation and in active labor. Which of the following actions should the nurse include in the plan of care? A. Keep all 4 side rails up while the client is in bed B. Monitor the fetal heart rate every hour C. Insert an indwelling urinary catheter D. Check the cervix prior to analgesic administration

d; Before administering an analgesic during active labor, the nurse must know how many centimeters the cervix is dilated. If administered too close to the time of delivery, the analgesic could cause respiratory depression in the newborn.

A nurse is discussing epidural anesthesia with a client who is receiving oxytocin to induce labor. Which of the following statements should the nurse make? A. "An epidural given too early during labor can cause maternal hypertension." B. "An epidural given too early during labor will not be effective in active labor." C. "An epidural given too early can cause fetal depression." D. "An epidural given too early can prolong labor."

d; Clients who receive anesthesia before the active phase of labor usually find the progression of their labor slows. The medication depresses the central nervous system, extending the time needed for the cervix to dilate and efface.

A nurse is providing nutritional teaching for a pregnant client who had a prepregnancy body mass index (BMI) of 38. Which of the following statements by the client demonstrate an understanding of the teaching about her recommended weight gain during pregnancy? A. "I should plan to gain 12.7 to 18.1 kg during my pregnancy." B. "I should plan to gain 11.3 to 15.9 kg during my pregnancy." C. "I should plan to gain 6.8 to 11.3 kg during my pregnancy." D. "I should plan to gain 5 to 9.1 kg during my pregnancy."

d; Clients with a prepregnancy BMI of greater than 30 are considered to be obese and should plan to limit their weight gain to 5 to 9.1 kg (11 to 20 lb) during pregnancy.

A nurse is caring for a pregnant client who is at 37 weeks of gestation and who has a biophysical profile with a total score of 4. Which of the following actions should the nurse anticipate taking? A. Discharge the client to home B. Administer betamethasone C. Perform an amnioinfusion D. Prepare for delivery of the infant

d; Delivery is considered when a biophysical profile score of 6 or lower is obtained at or after 36 weeks of gestation or with a score of 4 or lower at any gestational age.

A nurse is performing an admission assessment of a client who has just arrived at the labor and delivery unit. Which of the following findings should the nurse identify as the priority? A. The client reports a pain level of 8 on a scale from 0 to 10 during contractions. B. The client's blood pressure is 148/92 mmHg. C. The client's temperature is 38.3°C (101°F). D. The fetal heart rate is 90/min.

d; Fetal bradycardia indicates that this client is at greatest risk for fetal consequences due to a cardiac disorder or infection, leading to hypoxia and asphyxiation; therefore, this is the priority finding.

A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department? A. Bacterial vaginosis B. Trichomoniasis C. Candidiasis D. Gonorrhea

d; Gonorrhea is often asymptomatic. The client might have purulent endocervical discharge. Gonorrhea is one of the infectious conditions on the Nationally Notifiable Infections list and should be reported by the nurse to the community health department, which will report the infection to the CDC.

A nurse is caring for a client who is 24 years old and at 13 weeks of gestation. The client's history includes a BMI of 31 prior to pregnancy, a prior post-term delivery, and a newborn birth weight of 4,167.38 g (9 lb 3 oz). Which of the following laboratory values should the nurse expect to collect? A. Maternal serum alpha-fetoprotein B. Pregnancy-associated plasma protein A C. Chorionic villus sampling D. HbA1c

d; HbA1c measures average plasma glucose concentration over the 12 weeks preceding the test. A female client whose BMI is >30 and who has a history of delivering a baby weighing over 4,082.33 grams (9 lb) is at risk for impaired glucose metabolism and should be screened at the end of the first trimester.

A nurse is reviewing the plan of care before assuming the care of a newborn who is prescribed a hepatitis B vaccine, vitamin K, and an antiretroviral regimen. The plan of care indicates the newborn's mother is HIV-positive and plans to breastfeed. Which findings should the nurse address with the newborn's interdisciplinary team? A. Hepatitis B vaccine B. Antiretroviral regimen C. Vitamin K D. Breastfeeding

d; In areas with access to nutritious infant formula and clean water, breastfeeding by mothers who are HIV-positive is not recommended because HIV can be transmitted through breast milk. HIV is a contraindication to breastfeeding and requires discussion with the newborn's interdisciplinary team.

A postpartum nurse is caring for a client who reports abdominal cramping. Which of the following actions should the nurse take? A. Teach the client to lie on her side B. Request a prescription for an opioid analgesic C. Offer a sitz bath to the client D. Encourage the client to interact with the newborn

d; Interacting with the baby can help provide a distraction and decrease the discomfort of uterine contractions. While it is important to let the parent know that afterpains are more intense during and after breastfeeding, it is also necessary to encourage the planning of methods that provide the most effective and timely relief. Other nonpharmacological interventions can include distraction, therapeutic touch, imagery, hydrotherapy, acupressure, aromatherapy, music therapy, massage therapy, and transcutaneous electrical nerve stimulation (TENS).

A nurse is providing teaching about exercise to a client who is pregnant. Which of the following pieces of information should the nurse include? A. "You can continue participating in whatever sports or activities you did before becoming pregnant." B. "Intermittent exercise is a great way to stay healthy during pregnancy." C. "You should limit your exercise to walking if you did not exercise prior to becoming pregnant." D. "Vigorous exercises should be limited and should not be performed in hot, humid weather."

d; vigorous or strenuous activities should be limited to no longer than 20 minutes. Hot, humid weather and vigorous exercise can prompt dehydration or cause the fetus to develop hyperthermia.

A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take? A. Administer vitamin K subcutaneously. B. Administer erythromycin eye ointment within 12 hours C. Administer erythromycin eye ointment from the outer canthus toward the inner canthus D. Administer vitamin K in the newborn's thigh

d; The nurse should administer vitamin K in the vastus lateralis muscle in the newborn's thigh. a - The nurse should administer the newborn vitamin K 1 mg intramuscularly. b - The nurse should administer erythromycin eye ointment bilaterally within 1 to 2 hours after birth. The nurse can administer the medication after the initial breastfeeding. c - The nurse should administer a thin ribbon of eye ointment starting at the inner canthus and instill it toward the outer canthus.

A nurse is assessing a newborn who has a congenital diaphragmatic hernia. Which of the following findings should the nurse expect? A. Distended abdomen B. Increased blood pressure C. Generalized petechiae D. Barrel-shaped chest

d; The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit a barrel-shaped chest as the abdominal organs have shifted into the chest cavity.

A nurse is teaching a client who is at 12 weeks gestation and has a human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? A. "Breastfeed your newborn to provide passive immunity." B. "Abstain from sexual intercourse throughout the pregnancy." C. "You will be in isolation after delivery." D. "You should continue to take zidovudine throughout the pregnancy."

d; The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmitting HIV to her newborn.

A nurse is explaining lactation suppression to a client whose newborn will be bottle-fed. Which of the following client statements indicates an understanding of the teaching? A. "I should lightly massage my breasts when I feel discomfort." B. "I should express a small amount of milk if my breasts feel tight." C. "I should take a warm shower twice a day." D. "I should wear a support bra for a few days."

d; The nurse should instruct the client to wear a support bra that fits securely. Wearing this bra continuously for the first 3 days postpartum helps promote suppression of lactation.

A nurse is preparing to perform a heel stick on a newborn. Which of the following actions should the nurse take? A. Don sterile gloves prior to puncturing the newborn's heel B. Puncture the center aspect of the newborn's heel C. Elevate the newborn's heel prior to the procedure. D. Warm the heel with a warm washcloth prior to the procedure.

d; The nurse should warm the heel with a warm washcloth for 5 to 10 minutes prior to the procedure to enhance blood flow to the heel.

A nurse is planning care for a client with a prescription for oxytocin. Which of the following is a contraindication to the use of this medication? A. Prolonged rupture of membranes at 38 weeks gestation B. Intrauterine growth restriction C. Post-term pregnancy D. Active genital herpes

d; The use of oxytocin is contraindicated for clients who have an active genital herpes infection. The newborn can acquire the infection while passing through the birth canal. Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection.

A nurse is caring for a client who is 3 days postpartum and has chosen to formula-feed her newborn. During an examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take? A. Encourage the client to pump the breasts B. Instruct the client to take a warm shower twice per day C. Tell the client to massage the breasts D. Instruct the client to apply cold compresses

d; To help relieve breast engorgement, the client should apply cold compresses for about 15 minutes every hour. The client can also try applying fresh, cold cabbage leaves to the breasts.apply

An adolescent reports abdominal cramping due to dysmenorrhea. Which of the following analgesics should the nurse expect the provider to prescribe? A. Fentanyl B. Acetaminophen and oxycodone C. Acetaminophen and hydrocodone D. Ibuprofen

d; To treat dysmenorrhea, providers prescribe NSAIDs such as ibuprofen and naproxen. Providers also recommend exercise and dietary changes such as reducing salt and sugar intake and following a low-fat, vegetarian diet.

A nurse is caring for a client who is in labor and has fetal heart tracings of variable decelerations. Which of the following actions should the nurse take? A. Request a prescription for oxytocin B. Administer oxygen at 2 L/min via nasal cannula C. Prepare for the insertion of an intrauterine balloon D. Reposition the client from side to side

d; Variable decelerations are caused by cord compression. Changing the client from side to side or assisting her into a knee-chest position might relieve cord compression and improve the variable decelerations.

A nurse is assessing a client who is at 30 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse identify indicating that the client needs a biophysical profile? A. Fundal height 30 cm B. Fetal movement count 12 kicks in 12 hours C. Fetal heart rate 136/min D. Nonreactive non-stress test

d; When a non-stress test is nonreactive, the examiner will extend the duration of the test and use techniques such as vibroacoustic stimulation to try to elicit a response from the fetus. If the test is still nonreactive, the client should undergo a biophysical profile.

A nurse at a prenatal clinic is assessing an adolescent who is pregnant and is visiting the clinic for the first time. Which of the following factors is the nurse's priority to evaluate? A. Psychological readiness B. Partner support C. Socioeconomic status D. Nutritional status

d; When using Maslow's hierarchy of needs, the nurse should determine that the priority factor to evaluate is the adolescent's nutritional status. According to Maslow's hierarchy of needs, the most basic needs that take priority over all others are physiological needs, which include nutrition.

A nurse is assessing a client who is suspected of having hyperemesis gravidarum. Which of the following laboratory tests should the nurse check first? A. Complete blood count B. Liver enzymes C. Bilirubin level D. Urine ketones

d; 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 cares for a newly admitted newborn who is large for gestational age. After 30 min, the newborn becomes jittery and lethargic with hypotonic muscles and a cry that is different from the time of admission. Which of the following actions should the nurse take? A. Perform a heel stick to check the newborn's glucose level B. Obtain a prescription for serum substance screening C. Provide a feeding of sterile water D. Screen the newborn for phenylketonuria (PKU)

a; A newborn who is large for gestational age is at risk of hypoglycemia. The nurse should monitor the newborn for manifestations of this condition such as jitteriness, lethargy, hypotonia, an unusual cry, respiratory distress, poor feeding, and an unstable body temperature. Based on these manifestations, the nurse should perform a heel stick to check the newborn's serum glucose level and then implement interventions to correct hypoglycemia if present.

A nurse is caring for a client who is in labor and is receiving IV oxytocin. The nurse notes contractions lasting 3 min each. What action should the nurse take? A. Stop the oxytocin infusion B. Apply oxygen at 2 L/min via nasal cannula C. Administer methylergonovine intramuscularly D. Prepare for an emergent cesarean birth prior to the test?

a; A pattern of contractions lasting longer than 2 minutes or of more than 5 contractions in a 10-minute period is considered tachysystole. This pattern can decrease the placental perfusion of oxygen. The appropriate action is to discontinue the oxytocin infusion.

A nurse is caring for a client who is at 38 weeks of gestation and is receiving an oxytocin IV for labor augmentation. The nurse notes variable decelerations on the FHR tracing. Which of the following actions should the nurse take first? A. Place the client in a side-lying position B. Discontinue the oxytocin infusion C. Apply oxygen to the client via a face mask D. Check for umbilical cord prolapse

a; According to evidence-based practice, the nurse should act quickly to restore the oxygen supply to the fetus. Variable decelerations reflect an umbilical cord prolapse; therefore, the nurse should act immediately to help shift the pressure of the presenting part off the cord.

A labor and delivery unit nurse is caring for a client in the second stage of labor. Which of the following actions should the nurse take? A. Encourage the client to change positions frequently. B. Instruct the client to take breaths and hold them for 10 seconds while pushing C. Assess maternal vital signs every 1 hour D. Assist the client to the restroom

a; During the second stage, frequent position changes can promote the descent of the fetus through the birth canal. The nurse should assist the client in finding optimal positions of comfort which allow the client to rest between contractions but also enhances expulsive efforts.

A nurse is caring for a client who is in labor and asks her partner to perform effleurage. The client has a monitor belt for electronic fetal monitoring. Which instructions should the nurse provide to the client's partner? A. "Lightly stroke the upper thighs." B. "Steadily apply pressure to the sacrum." C. "Gently massage the mid-abdominal area." D. "Firmly squeeze both hips."

a; Effleurage involves lightly stroking or massaging the abdomen in rhythm with breathing to help relieve labor pain. However, when a monitor belt is in use, the sides of the abdomen, chest, or upper thighs are alternative locations for massage.

A nurse cares for a client who asks, "How will I know if I'm having true or false labor contractions?" Which of the following responses should the nurse make? A. "True contractions will begin irregularly and then become regular in timing." B. "True contractions will go away with ambulation." C. "False contractions increase in frequency and duration the closer you are to your due date." D. "False contractions are first felt in the pelvic area and then in the lower back and abdomen."

a; False contractions begin and remain irregular, but true contractions will begin irregularly and become regular and predictable.

A nurse is teaching a client who is pregnant and has pregestational diabetes about dietary changes. Which of the following statements should the nurse include in the teaching? A. "Carbohydrates should make up 55% of your diet." B. "Protein should make up 70% of your diet." C. "Fats should make up 45% of your diet." D. "Fiber should make up 10% of your diet."

a; For clients who have pregestational diabetes, intake of simple carbohydrates should be limited. The ideal diet is composed of 55% carbohydrates, 20% protein, 25% fat, and less than 10% saturated fat.

A nurse is teaching a prenatal class about pain management during labor. Which of the following statements should the nurse identify as indicating that the client understands the instructions? A. "I can apply a heating pad to my back to relieve pain." B. "I can have a low spinal block to help with labor pain." C. "I can have butorphanol every 2 hours during labor." D. "My time limit for staying in the hydrotherapy tub is 30 minutes."

a; Heat applications to the lower back can help promote relaxation and relieve pain because they reduce ischemia in the muscles and bring more blood flow to the area. The client should have 1 or 2 layers of cloth between her skin and the heating pad. b - Low spinal anesthesia is useful during a vaginal birth, but it is not an appropriate method for managing labor pain. c - If the provider prescribes it, the client can receive butorphanol every 3 to 4 hours. d - Although most clients stay in the hydrotherapy tub for 30 to 60 minutes, there is no time limit for how long they may stay in the tub.

A nurse is providing discharge teaching to a client after removing a hydatidiform mole. Which of the following statements should the nurse include in the teaching? A. "Do not become pregnant for at least 1 year." B. "Seek genetic counseling for yourself and your partner prior to getting pregnant again." C. "You should have an hCG level drawn in 6 weeks." D. "Have your blood pressure checked weekly for the next month."

a; Hydatidiform moles are uncontrolled growths in the uterus arising from placental or fetal tissue in early pregnancy. There is an increased incidence of choriocarcinoma associated with molar pregnancies. Pregnancy must be avoided for 1 year so the client can be closely monitored for manifestations of this condition.

A nurse is assessing a newborn 1 hr after birth. Which of the following findings should the nurse report to the provider? A. Jaundice of the sclera B. Respiratory rate 50/min C. Acrocyanosis D. Blood glucose 60 mg/dL

a; If the newborn has jaundice within the first 24 hours of life, this can indicate a potentially pathological process such as hemolytic disease. Pathological jaundice can result in high levels of bilirubin, which can damage the neonatal brain.

A nurse is assessing a client who reports that she might be pregnant. Which of the following findings should the nurse identify as a presumptive sign of pregnancy? A. Nausea in the morning B. Positive home pregnancy test C. Increased sensitivity of the cervix noted upon examination D. Gestational sac observed by transvaginal ultrasound

a; Nausea is a presumptive sign of pregnancy—that is, a subjective symptom reported by the mother that could have a cause other than pregnancy. b - A home pregnancy test assesses for the presence of human chorionic gonadotrophin in the client's urine. This test is an objective finding, but a positive test could have other causes such as the presence of a hydatiform mole or certain cancers. Therefore, a positive home pregnancy test is considered a probable sign of pregnancy. c - An increase in sensitivity of the cervix and vagina is an objective finding noted by the examiner and a probable sign of pregnancy. d - Visualization of the gestational sac is a positive sign that can only be attributed to pregnancy.

A nurse in a clinic educates a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide? A. "You should slightly increase your exposure to sunlight." B. "You will need extensive dermatological treatment for this condition after you deliver your baby." C. "Your provider will schedule weekly lab testing to monitor your liver function." D. "Your provider will prescribe isotretinoin cream."

a; Pruritus gravidarum is a condition of pregnancy that causes generalized itching without the presence of a rash. This occurs due to the stretching of the skin. Exposure to sunlight can reduce itching.

The guardian of a 3-day-old female newborn tells the nurse that he noticed a small amount of blood-tinged mucus discharge on the newborn's labia. Which of the following responses should the nurse make? A. "The blood-tinged mucus is a result of pseudomenstruation." B. "The blood-tinged mucus indicates a urinary tract infection." C. "The blood-tinged mucus is due to uric acid crystals." D. "The blood-tinged mucus is a result of the initial genital examination."

a; Pseudomenstruation is a result of the loss of maternal hormones at birth, resulting in vaginal discharge with withdrawal bleeding. It is an expected finding in female newborns.

A nurse is reviewing a client's medical record at 20 weeks of gestation. Which of the following findings should the nurse identify as a presumptive indication of pregnancy? A. Report of fetal movement by the client B. Auscultation of the fetal heart rate with Doppler ultrasound C. Presence of Chadwick's sign on pelvic examination D. Report of Braxton-Hicks contractions by the client

a; Quickening (the report of fetal movement felt by the client) begins around 18 to 20 weeks of gestation and is considered a presumptive indication of pregnancy.

A nurse is teaching a client about squatting exercises during pregnancy. Which of the following statements should the nurse include? A. "These exercises should be done for 15 minutes daily to strengthen the perineal muscles." B. "Squatting exercises can tone your abdomen, helping you lose weight faster following delivery." C. "Practicing squatting exercises during pregnancy will reduce lower back pain during labor." D. "Doing squatting exercises 3 times weekly will improve your overall fitness."

a; Squatting exercises help stretch the perineum, allowing stretching during delivery and improving functional efficiency after delivery.

A nurse enters a postpartum client's room and notices many visitors in the room, conversing loudly and taking turns holding the newborn. The newborn intermittently cries and attempts to suck on her hand. After a few minutes, the newborn quiets, stares, and turns her head away when someone talks to her. What teaching should the nurse provide for this family? A. The newborn would benefit from skin-to-skin contact in a quiet environment. B. The newborn's blanket should be removed so her movements will not be restricted. C. The newborn's hat should be removed to avoid overheating. D. The newborn should be discouraged from sucking on her hand since this habit can interfere with feeding.

a; Staring and gaze aversion indicate the newborn is overstimulated and is "switching off" in an attempt to cope with excess stimuli. When these phenomena are observed, stimulation should be decreased, and supportive measures such as skin-to-skin contact should be increased.

A nurse is providing discharge teaching about circumcision care to the parent of a newborn who has undergone a Gomco clamp procedure. Which of the following statements should the nurse identify as indicating that the client understands the instructions? A. "I will apply petroleum jelly to my baby's penis for the first few days." B. "I will use pre-moistened towelettes to clean my baby's penis." C. "I will remove any yellow crusts when I clean my baby's penis." D. "I will wrap my baby's penis in dry gauze until it heals."

a; The client should apply petrolatum to the penis with each diaper change to protect the incision from contact with urine and feces.

A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following statements should the nurse include? A. "Notify your provider if you notice cracking on your nipples." B. "Notify your provider if you have not had a bowel movement within 5 days." C. "Notify your provider if your breasts leak when you shower." D. "Notify your provider if your vaginal discharge is a brownish-red color."

a; The client should notify the provider of cracking, bleeding, or blistered nipples since this increases the client's risk of infection.

A nurse is caring for a client who is at 33 weeks of gestation and reports dark red vaginal bleeding and contractions that do not stop. Which of the following actions should the nurse take first? A. Check the fetal heart tones B. Assess the uterine contraction pattern C. Measure maternal vital signs D. Obtain a biophysical profile

a; The greatest risk to this client is fetal mortality from placental abruption; therefore, the priority assessment is immediate auscultation of fetal heart tones to determine the status of the fetus.

A nurse is caring for a client who is at 16 weeks gestation and has severe iron-deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication? A. Use a 20-gauge needle and administer the medication using the Z-track method B. Use a 22-gauge needle and administer the medication deep into the thigh C. Use a 25-gauge needle and administer the medication into the deltoid muscle D. Use an 18-gauge needle and administer the medication into the rectus femoris muscle

a; The nurse should administer iron using the Z-track method to prevent staining of tissue. A 20-gauge needle is the correct size.

A nurse is caring for a client in active labor whose membranes have ruptured. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first? A. Turn the client onto her left side B. Palpate the client's uterus C. Administer oxygen to the client D. Increase the client's IV fluids

a; Turning the client onto her left side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify the most urgent finding. b - The nurse should palpate the client's uterus to assess for tachysystole. However, another action is the priority. c - To enhance placental perfusion, the nurse should administer oxygen at 8 to 10 L/min by nonrebreather facemask. However, another action is the priority. d - The nurse should increase the client's IV fluids to boost circulating fluid volume. However, another action is the priority.

A nurse is caring for a client who reports intestinal gas pain following a cesarean section. Which of the following actions should the nurse take? A. Assist the client to ambulate in the hallway B. Instruct the client to splint the incision with a pillow C. Have the client drink fluids through a straw D. Encourage the client to drink carbonated beverages

a; Walking can help stimulate peristalsis, which will promote the expulsion of gas.

A nurse is reviewing the medical record of a client at 33 weeks gestation who has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider? A. Perform a vaginal examination B. Perform continuous external fetal monitoring C. Insert a large-bore IV catheter D. Obtain a blood sample for laboratory testing

a; When a client has a placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta and increased bleeding.

A nurse is planning care for a newborn who was born at 30 weeks gestation. The nurse should plan to assess the newborn for which of the following potential complications associated with prematurity? A. Intraventricular hemorrhage B. Hyperglycemia C. Hyperthermia D. Meconium aspiration syndrome

a; When an infant is born before 34 weeks gestation, the blood vessels in the brain are fragile. Additionally, premature infants have an impaired coagulation process and fluctuating blood pressure. Combined, these factors increase the risk of bleeding into the ventricles of the brain and subsequent neurological damage.

A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? A. Respiratory depression B. Hypothermia C. Hypoglycemia D. Jaundice

aMagnesium sulfate can cause respiratory and neuromuscular depression in the newborn. The nurse should monitor the newborn for clinical manifestations of respiratory depression.

A client at a routine prenatal care visit asks the nurse if developing vaginal yeast infections is common during pregnancy. Which of the following responses should the nurse make? A."Have you discussed this with your doctor yet?" B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common." C. "Women who are already prone to vaginal yeast infections get them during pregnancy." D. "Why are you concerned about yeast infections during pregnancy?"

b

A nurse in a prenatal clinic is reviewing the laboratory results of a client who is at 33 weeks of gestation. For which of the following results should the nurse notify the provider? A. Hgb 11.3 g/dL B. Platelet count 135,000/mm^3 C. WBC count 10,500/mm^3 D. Hct 38%

b

A nurse is assessing a pregnant client at 26 weeks of gestation who reports an episode of dizziness after lying on her back on the couch. Which of the following actions should the nurse take? A. Request a prescription for preeclampsia laboratory studies B. Advise the client to lie on her side C. Request an ultrasound to evaluate fetal wellbeing D. Advise the client to add a calcium supplement to her diet

b

A nurse is assessing the respiratory status of a newborn born 2 hours ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress? A. Acrocyanosis B. Expiratory grunting C. Respiratory rate 56/min D. Irregular respirations

b

A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client becomes frightened by a gush of dark red blood from her vagina. Which of the following statements should the nurse make in response? A. "You might have retained placental fragments in your uterus." B. "Blood pools in the vagina when you are lying in bed." C. "You might have a damaged blood vessel." D. "Your blood flow will increase during the first few days after giving birth."

b

A nurse is caring for a client at 38 weeks gestation and in the active phase of the first stage of labor. The nurse notes 2 late fetal heart rate decelerations during the last 5 contractions. Which of the following actions should the nurse take? A. Slow the IV infusion rate B. Assist the client to a lateral position C. Assess the bladder for urinary retention D. Initiate an oxytocin infusion

b

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? A. Platelet count 97,000/mm^3 B. Deep tendon reflexes 4+ C. Urine protein 1+ D. BUN 22 mg/dL

b; 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 -A client's platelet count is usually below 100,000/mm^3 with preeclampsia3. There is no need to report this finding. c - With preeclampsia, a client's proteinuria is usually above 1+ on a urine reagent strip. There is no need to report this finding. d - With preeclampsia, a client's BUN level is usually above 20 mg/dL. There is no need to report this finding.

A nurse is planning care for a client in labor who is positive for HIV. Which actions should the nurse take after the baby is born? A. Encourage the mother to breastfeed B. Administer the hepatitis B vaccine prior to discharge C. Implement contact and droplet precautions when providing care for the infant D. Collect a cord blood specimen to test for the presence of HIV

b; Infants who are exposed to HIV should receive all routine vaccinations. Infants who are infected with HIV can receive all inactivated vaccinations.

A nurse assesses a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform? A. Obtain a rectal temperature B. Assess the newborn's blood glucose level C. Bathe the newborn with warm water D. Position the infant's bassinet in front of a heater vent

b; Infants who become cold attempt to generate heat through increased muscular and metabolic activity. This process increases glucose consumption and puts the newborn at risk of hypoglycemia.

A nurse is caring for a client who is in labor and has received epidural analgesia. The client's blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Increase the rate of the primary IV infusion C. Position the client in a semi-Fowler's position D. Provide glucose via oral hydration or IV

b; Late decelerations can be caused by uteroplacental insufficiency. The fetal heart tracing shows a gradual decrease in fetal heart rate with a return to baseline on uterine contractions. This could be related to maternal hypotension, which can be corrected with increased IV fluids to increase maternal blood volume. This improves uterine and cardiac perfusion as well.

A nurse is caring for a client who is in labor. The client speaks a different language than the nurse and is grimacing. Which actions should the nurse take while waiting for an interpreter? A. Administer pain medication B. Change the client's position C. Insert an indwelling urinary catheter D. Prepare for an epidural insertion

b; Offering position changes and comfort measures such as drinks or ice, heat packs, and other tangible items will aid in relieving pain and developing trust. A stoic persona might not mean the client is not in need of pain management.

A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect? A. Atrial septal defect B. Renal agenesis C. Spina bifida D. Hydrocephalus

b; Oligohydramnios is a volume of amniotic fluid <300 mL during the third trimester of pregnancy. This occurs when there is a renal system dysfunction or obstructive uropathy. The absence of fetal kidneys will cause oligohydramnios.

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication of the oxygen therapy? A. Atelectasis B. Retinopathy C. Interstitial emphysema D. Necrotizing enterocolitis

b; Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. It is a disorder of retinal blood vessel development in premature newborns. In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fills the back of the eye. This condition can reduce vision or result in complete blindness.

A nurse is reviewing the laboratory values of a client who is pregnant and has a low progesterone level. Which of the following complications should the nurse expect? A. Gestational diabetes B. Preterm labor C. Inadequate milk supply D. Inadequate uterine growth

b; Progesterone maintains the lining of the uterus, which maintains the pregnancy. It also reduces uterine contractility. A client who has a low progesterone level is at risk for preterm labor.

A nurse in labor and delivery is teaching a newly licensed nurse about performing the McRoberts maneuver to relieve shoulder dystocia. Which of the following pieces of information should the nurse include? A. Position the client on her hands and knees while in bed B. Flex the client's legs apart and raise her knees to her abdomen C.Apply gentle pressure on the client's fundus while she is lying supine D. Push the fetus's anterior shoulder under the symphysis pubis externally

b; The McRoberts maneuver includes helping the client flex her knees apart, which rotates the pubic bone anteriorly. This movement releases the anterior shoulder, but the nurse should not apply pressure directly to the anterior shoulder during this maneuver. This maneuver can be used for clients with or without epidural anesthesia.

A nurse is admitting a client who is in post-term labor. Which of the following statements should the nurse identify as the priority? A. "I had blood-streaked discharge a few hours ago." B. "When my water broke, it was not clear." C. "I have not felt my baby move as much today." D. "I feel like I cannot breathe when I walk up the stairs."

b; The greatest risk to this client is an injury to the newborn from meconium aspiration; therefore, addressing this statement is the nurse's priority.

A nurse in a clinic is assessing a client who is at 13 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse identify as the priority? A. Blood pressure 90/52 mmHg B. Ketones 2+ C. Specific gravity 1.035 D. Sodium 130 mEq/L

b; The greatest risk to this client is malnutrition that poses a serious risk to the developing fetus. Ketonuria indicates that the client's body is breaking down fat and protein stores for energy and cannot provide the fetus with essential nutrients. Therefore, this is the priority finding, and the nurse should report it to the provider immediately.

A nurse is caring for a term newborn 90 minutes after a scheduled cesarean birth. The newborn's 1-minute Apgar score was 9. The newborn's heart rate is 120/min, and his respiratory rate is 70/min. There are no indications of retractions, grunting, or nasal flaring. Which of the following actions should the nurse take? A. Request a prescription for continuous positive airway pressure (CPAP) B. Initiate close observation of the newborn for indications of respiratory distress C. Consult a respiratory therapist for chest physiotherapy D. Request an order for nitric oxide therapy

b; The newborn has manifestations of transient tachypnea of the newborn (TTN). This condition is thought to be a result of an incomplete clearance of fluid from the lungs at birth. Newborns born by cesarean are more likely to have TTN because the thoracic cavity is not compressed as in a vaginal birth. It usually resolves spontaneously, and close observation of the newborn is indicated.

A community health nurse is planning care for 4 high-risk newborns discharged yesterday. Which of the following newborns should the nurse plan to care for first? A. A 1-week-old newborn who needs another phenylketonuria screening test B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy C. A 10-day-old newborn who is small for gestational age and requires daily weighing D. A 2-week-old newborn who was born at 35 weeks gestation and weighed 2,268 g (5 lb) at discharge

b; The nurse should apply the safety and risk-reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to the client's safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. An elevated bilirubin level can lead to kernicterus; therefore, it is imperative for the nurse to initiate phototherapy immediately to help prevent this dangerous outcome.

A nurse is assessing a client who is in the first stage of labor and has preeclampsia. Which of the following findings should the nurse expect? A. Severe hypotension B. Proteinuria C. Elevated platelet count D. Seizures

b; The nurse should expect a client with preeclampsia to have proteinuria and impaired kidney function.

A nurse is assessing a client at 37 weeks gestation who has a suspected pelvic fracture due to blunt abdominal trauma. Which of the following findings should the nurse expect? A. Bradycardia B. Uterine contractions C. Seizures D. Bradypnea

b; The nurse should expect the client to be experiencing uterine contractions due to abdominal trauma.

A nurse is caring for a client who is in labor. The nurse observes late decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Decrease the rate of the client's maintenance IV fluid B. Place the client in a left lateral position C. Apply oxygen at 2 L/min via nasal cannula D. Prepare the client for an amniocentesis

b; The nurse should identify that decelerations of the fetal heart rate with an onset beginning after a contraction has started that persist beyond the end of the contraction are considered late decelerations. Later decelerations indicate an interruption in fetal oxygenation. A lateral position improves blood flow to the uterus and intervillous spaces. Repositioning the client is a component of intrauterine resuscitation.

A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take? A. Perform a vaginal examination to determine cervical dilation B. Obtain blood samples for baseline laboratory values C. Place a spiral electrode on the fetal presenting part D. Prepare the client for a transvaginal ultrasound

b; The nurse should obtain samples of the client's blood for baseline testing of hemoglobin and hematocrit levels.

A labor and delivery unit nurse is preparing to teach a newly licensed nurse about intermittent auscultation of the fetal heart rate. Which of the following interventions should the nurse include? A. Count the fetal heart rate for 15 seconds after contractions B. Palpate and count the maternal radial pulse while listening to the fetal heart rate C.Place the listening device over the fetal chest to hear the fetal heart rate D. Percuss the maternal abdomen to verify the position of the fetus

b; The nurse should palpate and count the maternal pulse while listening to the fetal heart rate to validate findings and distinguish the maternal pulse from the fetal heart.

A nurse is preparing to administer an IV infusion of oxytocin for labor induction to a client who is at 41 weeks of gestation. Which of the following actions should the nurse plan to take? A. Administer the oxytocin with manual IV tubing B. Monitor the fetal heart rate every 15 minutes initially C. Begin the infusion at 10 milliunits/min D. Titrate the dosage until the client has 1 contraction every minute

b; The nurse should plan to monitor the fetal heart rate (FHR) every 15 minutes through the first stage of labor and then every 5 minutes during the second stage. Additionally, the nurse should document the FHR with every change of the oxytocin dosage.

A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? A. Overlapping suture lines B. Generalized petechiae C. Acrocyanosis D. Transient strabismus

b; The nurse should report generalized petechiae to the provider. This manifestation can be associated with an infection or a clotting-factor deficiency.

A nurse is teaching a client with pre-eclampsia who is scheduled to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching? A. Elevated blood pressure B. Feeling of warmth C. Hyperactivity D. Generalized pruritus

b; The nurse should tell the client to expect a feeling of warmth all over her body while the magnesium sulfate is infusing.

A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. Which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord? A. They can cause increased pain from the cord. B. They can cause delayed cord separation. C. They can cause swelling of the surrounding tissue. D. They can cause skin discoloration.

b; There is no evidence that antimicrobial preparations are of any benefit in the process of the drying and detachment of the umbilical cord stump. Keeping the cord moist with any kind of preparation prevents drying and separation and also increases the risk for infection.

A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching? A. "I should clean my diaphragm with alcohol each time I use it." B. "I should leave the diaphragm in place for 4 hours after intercourse." C. "I should replace my diaphragm every 2 years." D. "I should use a vaginal lubricant to insert my diaphragm."

c; A diaphragm is a flexible rubber cup that is filled with spermicide and inserted over the cervix prior to intercourse. The diaphragm is a prescribed device fitted by a provider and should be replaced every 2 years. a - A diaphragm should be cleaned with mild soap and water and dried gently. Alcohol can dry out the diaphragm and can weaken the rubber, which will reduce its effectiveness for birth control. b - A diaphragm should remain in place for at least 6 hours after intercourse. d - A diaphragm should be rinsed with water, and contraceptive jelly should be applied prior to placing the device into the vagina. Vaginal lubricants, mineral oil, and baby oil should not be used on the diaphragm because they can weaken the rubber.

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Respiratory rate 52/min B. Weight 2500 grams (5.5 lb) C. Head circumference 28 cm (11 in) D. Blood glucose 48 mg/dL

c; A head circumference of 28 cm (known as microcephaly) is below the expected reference range of 32 to 36.8 cm for a newborn. Microcephaly can indicate fused cranial sutures or prenatal infection with rubella, toxoplasmosis, or cytomegalovirus. The nurse should report this finding to the provider. a - A respiratory rate of 52/min is within the expected reference range of 30 to 60/min for a newborn. b - A weight of 2500 grams is within the expected reference range of 2500 to 4000 grams for a newborn. d - A blood glucose level of 48 mg/dL is within the expected reference range of greater than 45 mg/dL for a newborn.

A nurse is assessing a newborn who was circumcised 24 hours ago. Which of the following findings should the nurse report to the provider? A. A scant amount of serosanguineous drainage is noted in the newborn's diaper. B. The newborn's circumcision site is covered with yellow exudate. C. The newborn has urinated once since the circumcision. D. The newborn fusses during each diaper change.

c; A newborn should void 2 to 6 times a day the first 24 to 48 hours after birth and then 6 to 8 times per day starting on the third day. Therefore, the nurse should report 1 void in 24 hours following circumcision to the provider.

A postpartum nurse is caring for a client who has developed hemorrhagic shock. Which of the following manifestations should the nurse expect? A. Urinary output of 40 mL/hr B. Deep abdominal breathing C. Weak and irregular pulse D. Warm, dry hands with prompt capillary refill

c; A weak, irregular, and rapid pulse can indicate postpartum hemorrhagic shock due to decreased oxygenation and perfusion to the heart. The client will need fluid replacement and medical attention.

A nurse is assessing a client in the fourth stage of labor. Which of the following findings should the nurse expect? A. Breast engorgement B. Hypothermia C. Urinary retention D. Rupture of membranes

c; After delivery, many clients have a reduced urge to urinate. This can result from birth trauma, a larger bladder capacity after birth, analgesia, pelvic soreness, an episiotomy, and other factors.

A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving this vaccine? A. Shellfish B. Gelatin C. Baker's yeast D. Eggs

c; An allergy to baker's yeast is a contraindication to receiving the hepatitis B vaccine. The nurse should notify the client's provider.

A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching? A. "You should supplement your baby with formula until you notice that your breasts become firm and full." B. "You should adhere to a schedule when feeding your baby to ensure she is getting enough to eat." C. "Your milk supply will noticeably increase in volume around the third or fourth day after delivery." D. "It is typical for your nipples to hurt for the first few weeks while you are breastfeeding."

c; As the colostrum transitions to mature breast milk, the volume of milk produced will also increase. Typically, the postpartum client will notice that 72 to 96 hours after delivery her breasts feel fuller and firmer and that milk is leaking from her nipples.

A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure? A. Send a sample of amniotic fluid to the laboratory to screen the client for chlamydia B. Send a sample of amniotic fluid to the laboratory to test for an elevated Rh-negative titer C. Administer immune globulin to the client to prevent fetal isoimmunization D. Administer intravenous antibiotics to prevent an infection

c; Because the client is Rh-negative, Rh immune globulin is administered after the procedure to prevent fetal isoimmunization or help ensure maternal antibodies will not form against any placental red blood cells that might have accidentally been released into the maternal bloodstream during the procedure.

A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn? A. Placenta previa B. Multiple gestation C. Infection D. Anemia

c; Blood group incompatibilities, maternal infection, maternal diabetes, and the administration of oxytocin during labor are potential risk factors for the development of hyperbilirubinemia in newborns.

A nurse at a prenatal clinic is teaching a client how to perform a kick count. Which of the following statements should the nurse include in the teaching? A. "Drop by the clinic any day this week so we can count your baby's kicks." B. "Count fetal kicks once a day for a total of 30 minutes." C. "Before bedtime is a good time to start counting the kicks." D. "Wear loose clothing when performing the kick count."

c; Clients should be instructed to perform a kick count, which is the daily fetal movement count (DFMC), before bedtime or after meals for 2 hours, or until 10 movements are counted. Alternatively, the client can count all fetal movements in a 12-hour period each day until at least 10 movements are counted.

A nurse cares for a client in the first stage of labor. Which of the following findings should the nurse identify as a cause for concern? A. Pink, mucoid vaginal discharge B. Brownish vaginal discharge C. Contractions lasting 100 seconds D. Contractions occurring every 4 to 5 minutes

c; Contractions during the first stage of labor range from 45 to 80 seconds. They should not exceed 90 seconds.

A nurse is providing teaching about breastfeeding to a client who is 4 hours postpartum. Which of the following pieces of information should the nurse include? A. Feed the newborn for 5 minutes on each breast. B. Newborns are expected to lose up to 15% of their birth weight. C. Ensure the newborn's mouth covers the nipple and areola D. Provide a pacifier to the newborn between feedings starting 3 days after birth

c; The newborn's mouth should open wide prior to latching on to the breast. The client should ensure the newborn's mouth covers the nipple and areola to allow an adequate seal and prevent tissue damage. a - The nurse should instruct the client to feed the newborn for approximately 15 to 20 minutes per breast, or until the newborn shows signs of satiety. b - Newborns might lose 7% to 10% of their birth weight. The nurse should notify the provider if a breastfed newborn loses more than 7% of the birth weight or if a formula-fed newborn loses more than 10% of the birth weight. d - The client should not offer a pacifier to the newborn until breastfeeding is well established, which is generally 3 to 4 weeks after birth.

A nurse is caring for a client who had a precipitous delivery. Which of the following assessments is the priority during the fourth stage of labor? A. Obtaining the client's temperature B. Inspecting the client's perineum C. Palpating the client's fundus D. Checking the client for hemorrhoids

c; The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority.

A nurse is caring for an infant who begins displaying manifestations of neonatal abstinence syndrome (NAS). Which of the following actions should the nurse take? A. Swaddle the infant with arms and legs extended B. Administer naloxone IM C. Avoid eye contact during feedings D. Discourage the mother from handling the infant during the withdrawal phase

c; The nurse should avoid eye contact and talking during feedings. Infants with NAS have difficulty processing multiple forms of stimulation and can quickly become frustrated.

A nurse assesses a 12-hour-old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 sec. Which of the following actions should the nurse take? A. Perform chest percussion B. Place the newborn in a prone position C. Continue routine monitoring D. Request a prescription for supplemental oxygen

c; The nurse should continue routine monitoring because the newborn's assessment findings indicate adaptation to extrauterine life.

A nurse is caring for a client in the latent phase of labor who is receiving oxytocin via continuous IV infusion. The client has contractions every 2 min that last 100 to 110 sec, and the fetal heart rate (FHR) is reassuring. Which of the following actions should the nurse take? A. Decrease the infusion rate of the maintenance IV fluid B. Administer oxygen via a nonrebreather mask C. Decrease the dose of oxytocin by half. D. Administer terbutaline 0.25 mg subcutaneously

c; The nurse should decrease the dose of oxytocin by half because the client is experiencing uterine tachysystole.

A nurse is reviewing the laboratory report for a client with suspected HELLP syndrome. Which of the following findings should the nurse report to the provider as an indication of this disorder? A. Elevated hemoglobin B. Elevated creatinine clearance C. Elevated liver enzymes D. Elevated platelet count

c; The nurse should expect a client who has HELLP syndrome to have elevated liver enzymes. HELLP refers to hemolysis (H), elevated liver enzymes (EL), and low platelet count (LP). This syndrome is a severe form of preeclampsia.

A nurse is teaching about the selection of commercial formula to the guardian of a newborn. Which of the following pieces of information should the nurse include? A. Soy-based formula is recommended to decrease colic. B. Amino acid formula is recommended to increase the newborn's protein intake. C. Cow's milk-based formula is recommended for healthy newborns. D. Low-iron formula is recommended to prevent excess iron intake.

c; The nurse should identify that cow's milk-based formulas are similar to human breast milk and are recommended for newborns and infants unless prescribed otherwise by the provider. Certain conditions that might indicate a need to switch to an alternate formula include galactosemia, a congenital lactase deficiency, and immunoglobulin E allergies.

A nurse is teaching about calcium intake to a breastfeeding client. Which of the following is the recommended daily calcium intake for a client who is breastfeeding? A. 800 mg B. 400 mg C. 1,000 mg D. 2,000 mg

c; The nurse should instruct the client that 1,000 mg of calcium is recommended for women age 19 and older and those who are lactating. This amount of calcium is sufficient to meet the client's and the infant's needs because additional calcium is absorbed from the intestines during this time.

A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration? A. Continuous lochia flow and a flaccid uterus B. Report of increasing pain and pressure in the perineal area C. Slow trickle of bright vaginal bleeding and a firm fundus D. Gush of rubra lochia when the uterus is massaged

c; The nurse should monitor for bright red bleeding in the form of a slow trickle, oozing or outright bleeding, and a firm fundus to identify a cervical laceration.

A nurse is caring for a client who is 2 hours postpartum and is exhibiting signs of hypovolemic shock. Which of the following actions should the nurse take? A. Saline lock the IV catheter B. Provide oxygen via nasal cannula C. Elevate the client's legs to a 30° angle D. Place the client in a semi-Fowler's position

c; The nurse should position the client on her side with her right hip elevated by a pillow or in a supine position with her legs elevated to at least a 30° angle. This improves blood flow and reduces manifestations of hypotension.

A nurse reinforces teaching about nutritional requirements during lactation for a client who plans to breastfeed. Which of the following nutrients should the client increase during lactation? A. Calcium B. Iron C. Vitamin D D. Vitamin C

c; The nurse should recommend that the client increase her vitamin C intake during lactation to 115-120 mg per day.

A nurse at a clinic is preparing to teach the process of involution to a group of antenatal clients. Which of the following information should the nurse provide? A. The fundus is approximately 2 cm (0.79 in) above the level of the umbilicus at the end of the third stage of labor. B. The fundus is approximately 3 cm (1.18 in) above the umbilicus within 12 hours after delivery. C. The fundus is located halfway between the umbilicus and mons pubis on the sixth day postpartum. D. The fundus is not palpable abdominally at 2 weeks postpartum.

d; Involution is the return of the uterus to its normal pre-pregnancy state, which occurs after the delivery of the placenta. By the end of the third stage of labor, the fundus is 2 cm below the umbilicus. Within 12 hours after delivery, the fundus rises 1 cm above the umbilicus. The fundus descends 1 to 2 cm (0.39 to 0.79 in) every 24 hours. The fundus is not palpable after the sixth postpartum day.

A nurse is assessing an 18-hour-old newborn. Which of the following findings should be reported to the provider? A. Blood-tinged discharge from the vagina B. Overlapping sutures on the skull C. Subconjunctival hemorrhage D. Yellow-tinged skin

d; Jaundice in the first 24 hours of life is not an expected finding and should be reported to the provider. It can indicate the presence of a neonatal hemolytic disorder.

A nurse is caring for a client who is pregnant and has a rupture of membranes. The nurse notes the presence of meconium-stained fluid. Which of the following actions should the nurse take? A. Prepare for emergency cesarean delivery B. Discontinue oxytocin infusion C. Position the parent to facilitate the McRoberts maneuver. D. Gather equipment for neonatal resuscitation

d; Meconium-stained amniotic fluid can cause neonatal meconium aspiration syndrome. The nurse should gather equipment for neonatal resuscitation.

A nurse is preparing to administer meperidine hydrochloride to a client who is in labor. Which of the following statements should the nurse make to the client? A. "This medication can cause your blood pressure to rise." B. "This medication can cause dry mouth." C. "This medication can cause you to urinate excessively." D. "This medication can make you sleepy."

d; Meperidine hydrochloride is an opioid analgesic used for moderate to severe pain during labor. It binds to the brain's opioid receptors and alters the client's response to pain. The client should be informed of the possible adverse effects of this medication, such as hypotension, confusion, sedation, headaches, respiratory depression, constipation, and urinary retention.

A nurse is caring for a client who is in labor. The client asks the nurse, "Why are you pressing on my abdomen?" Which of the following responses should the nurse make? A. "I can determine your baby's heart rate." B. "I can confirm that you have sufficient fluid around your baby." C. "I can confirm that your baby moves with stimulation." D. "I can determine the position of your baby."

d; Palpation of the abdomen can determine which fetal part is in the uterine fundus and where the back of the fetus is. Palpating the lower abdomen will help determine whether the fetus's head is down or if another extremity is the presenting part.

A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect? A. Fundal height of 34 cm (13.4 in) B. Total pregnancy weight gain of 3.6 kg (8 lb) C. Gestational hypertension D. Fetal gastrointestinal anomaly

d; Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurological disorders are expected findings for a fetus experiencing the effects of polyhydramnios.

A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make? A. "You will not get pregnant while you are breastfeeding, so you will not need any birth control." B. "A birth control pill that contains only estrogen is available for use while you are breastfeeding." C. "Condoms are the only method of contraception that is appropriate while you are breastfeeding." D. "A progestin-only pill or injection is available for use while you are breastfeeding."

d; Progestin-only injections, implants, and birth control pills are acceptable options for clients who are breastfeeding, although some experts recommend waiting until 6 weeks postpartum to initiate the medication.

A nurse is teaching a client who is breastfeeding about strategies for preventing mastitis. Which of the following instructions should the nurse include? A. "Take an herbal galactagogue." B. "Gradually increase the time between feedings." C. "Wear an underwire bra." D. "Use your finger to release suction after feeding."

d; Releasing the newborn's grasp on the nipple with a finger before removing the newborn from the breast helps prevent injury to the nipples, which can lead to mastitis.

A nurse is providing education to a female client of child-bearing age. The nurse should state which of the following structures expels the mature ovum? A. Blastocyst B. Fallopian tube C. Corpus luteum D. Graafian follicle

d; The Graafian follicle expels the mature ovum.

A nurse is teaching about mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I will limit breastfeeding to 5 minutes per breast." B. "I will not breastfeed if I start to have flu-like symptoms." C. "I will shop for an underwire nursing bra today." D. "I will avoid any of my family members who are ill."

d; The client should avoid ill family members to decrease the risk of mastitis. While the causative organisms of mastitis tend to be bacterial, exposure to viral illnesses can compromise the immune system and leave the client vulnerable to mastitis.

A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) immune globulin? A. While the client is in labor B. Following an episode of influenza during pregnancy C. Prior to a blood transfusion D. At 28 weeks gestation

d; The nurse should administer Rh(D) immune globulin to a client who is pregnant and has Rh-negative blood at 28 weeks gestation. Rh(D) immune globulin consists of passive antibodies against the Rh factor, which will destroy any fetal RBCs in the maternal circulation and block maternal antibody production.

A nurse cares for a client with a soft uterus and increased lochial flow. Which medications should the nurse plan to administer to promote uterine contractions? A. Terbutaline B. Nifedipine C. Magnesium sulfate D. Methylergonovine

d; The nurse should administer methylergonovine, an ergot alkaloid, which promotes uterine contractions.