MATERNAL NEWBORN - PRACTICE QUESTIONS (DRAFT)

A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make?

*"This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor."* A caput succedaneum is an area of edema on the newborn's occiput, often seen where the cup of the vacuum was applied. It resolves within 3 to 4 days and requires no treatment.

A nurse is reinforcing teaching with a newly licensed nurse about the purpose of an indirect Coombs test. Which of the following statements should the nurse include in the teaching?

*"This test detects Rh-positive antibodies in the mother's blood."* An indirect Coombs test is performed on the mother's blood to determine if she has developed antibodies to the Rh antigen

A nurse is caring for a client who is postpartum. The client states, "I am concerned about my baby's hearing because my mother was born deaf." Which of the following statements should the nurse make?

*"We do routine hearing screenings on newborns. You'll know the results before you leave the hospital."* Most states mandate hearing screening for all newborns. The two tests in use do not diagnose hearing loss, but determine whether a newborn requires further evaluation.

A nurse in the antepartum unit is assisting with the care of a client who is at 36 weeks of gestation and reports continuous abdominal pain and vaginal bleeding. The nurse should identify that the client is likely experiencing which of the following complications?

*Abruptio placentae* The nurse should identify that a client experiencing an abruptio placentae will experience abdominal pain, uterine tenderness upon palpation, and vaginal bleeding that can be profuse.

A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication for the use of this medication?

*Active genital herpes* The use of oxytocin is contraindicated for clients who have an active genital herpes infection. The newborn can acquire the infection as they pass through the birth canal. Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection

A nurse is collecting data from a client who is at 35 weeks of gestation. Which of the following findings should the nurse report to the provider?

*Blurred vision* The nurse should report blurred vision to the provider, as this can indicate possible preeclampsia and requires further assessment.

A nurse is assisting in the care of a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

*Check the fetal heart rate pattern* The nurse's priority action is to check the fetal heart rate pattern before and immediately after the amniotomy to detect any changes in fetal status.

A nurse is collecting data from an infant who has hydrocephalus. Which of the following findings should the nurse expect?

*Dilated scalp veins* Manifestations of hydrocephalus in a newborn include dilated scalp veins, separated sutures, and bulging fontanels.

A nurse is collecting data from a newborn. Which of the following anatomical landmarks should the nurse use to measure chest circumference?

*Nipple line* The nurse should measure the chest circumference at the nipple line.

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions?

*Placenta Previa* Painless, bright red vaginal bleeding is a manifestation of placenta previa.

A nurse is reinforcing teaching with a client who is breastfeeding. Which of the following instructions should the nurse include in the teaching?

*Reduce your intake of iron* Recommendations for some nutrients, such as iron and folic acid, are less during lactation than during pregnancy. Because maternal blood volume decreases after childbirth, the client's need for these nutrients also diminishes.

A nurse is reinforcing discharge teaching with a client who is 2 days postpartum and has a history of postpartum depression. Which of the following instructions should the nurse include?

*Sleep as much as possible* The nurse should encourage the client to sleep as much as she can during the next few weeks. Sleep deprivation can increase the risk for postpartum depression.

A nurse is caring for a client who tells the nurse that she thinks she might be pregnant because she is able to feel the baby move. Which of the following statements should the nurse make?

*This is a presumptive sign of pregnancy* Changes that are felt by the client are presumptive signs of pregnancy such as quickening, breast changes, and fatigue.

A nurse is assisting in the care of a client who is in active labor. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following as a cause of variable decelerations?

*Umbilical cord compression* The nurse should identify that variable decelerations are caused by compression of the umbilical cord.

A nurse is caring for several newborn clients. For which of the following findings should the nurse notify the charge nurse?

A blood glucose fingerstick of 40 mg/dL for an infant who is 1-hr old Acrocyanosis in an infant who is 2-hr old *Jaundice in an infant who is 4-hr old* A hematocrit of 60% in an infant who is 8-hr old *Rationale* Jaundice occurring within the first 24 hr of life is related to some type of hemolytic pathology and requires notifying the charge nurse immediately

A nurse is reinforcing teaching with a client about how to reduce the risk of giving birth to a newborn who has a neural tube defect. Which of the following instructions should the nurse include in the teaching?

*Eat foods fortified with folic acid* An increased consumption of folic acid in the 3 months prior to pregnancy, as well as throughout the pregnancy, is associated with a decreased risk of the development of neural tube defects.

A nurse is reinforcing teaching with a client who is pregnant and has a new prescription for ferrous sulfate due to iron-deficiency anemia. The nurse should instruct the client to take this medication with which of the following?

*orange juice* Orange juice and other vitamin C-rich foods and beverages enhance iron absorption.

A nurse is collecting data from a newborn who has respiratory distress syndrome and is experiencing respiratory acidosis. Which of the following risk factors predisposes the newborn to respiratory difficulties?

*Small for gestational age* Newborns who are small for gestational age, have a low birth weight, are postterm, have a maternal history of diabetes, and have cord prolapse are at increased risk for respiratory difficulties.

A nurse is reinforcing teaching with a client who is at 6 weeks of gestation. The client tells the nurse that she smokes one pack of cigarettes per day. The nurse should instruct the client that her newborn is at increased risk for which of the following clinical manifestations?

*low birth weight* Women who smoke are at risk for many complications, including placental abruption, placenta previa, preterm delivery, fetal death, and newborns who have low birth weight.

A nurse in a provider's office is reinforcing teaching about home care with a client who has mild preeclampsia. Which of the following information should the nurse include in the teaching?

*perform daily fetal movements/kick counts* The client should count the number of fetal movements felt in one hour, preferably after a meal. Fetal movements are a reassuring sign of fetal oxygenation. The client should notify the provider if less than 3 movements per hour are noted, as this warrants further evaluation.

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

*precipitous birth* A client who has a precipitous birth is at an increased risk for postpartum hemorrhage.

A nurse is caring for a newborn who is at 34 weeks of gestation, weighs 1,550 g, and has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator for which of the following reasons?

*the newborn's temperature control mechanism is immature* Preterm newborns have poor body control of temperature and need immediate attention to keep from losing heat. Reasons for heat loss include little subcutaneous fat and poor insulation, large body surface for weight, immaturity of temperature control, and lack of activity. They require an external heat source that regulates their immediate environment via a sensor attached to the skin.

A nurse is reinforcing teaching about Kegel exercises with a client who is in the third trimester of pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"These exercises will help prevent bladder infections." *"These exercises will help my pelvic muscles stretch when I give birth."* "These exercises will help lessen my back aches." "These exercises will prevent further stretch marks." *Rationale* Kegel exercises help strengthen perineal muscles, facilitating stretching and contracting during childbirth.

A nurse is collecting data from a newborn immediately after delivery by a client who was at 42 weeks of gestation. Which of the following findings should the nurse expect?

*Dry, cracked skin* Newborns who are postmature have dry, cracked skin that feels like parchment paper.

A nurse is assisting with the care of a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

*Massaging the client's back* The gate control theory is based on the concept of preventing the transmission of pain signals to the brain by using distraction techniques. Massaging the client's back is a distraction technique.

A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

*The client is Rh negative and the newborn is Rh positive* Rho(D) immune globulin contains antibodies to Rho(D). Administering it prevents antibody formation in clients who are Rh-negative following exposure to Rh-positive blood, such as in a fetus who is Rh-positive.

A nurse is reinforcing teaching with a client who is pregnant and has a prescription for Rho(D) immune globulin. Which of the following information should the nurse include?

*This medication prevents the formation of Rh antibodies by a woman who is Rh-negative* Giving Rho(D) immune globulin prevents the client's immune system from forming antibodies secondary to exposure to fetal blood during pregnancy or delivery.

A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant?

*maintain integrity of the sac* The greatest risk to this client is injury from damage to the exposed spinal cord and fluid filled sac; therefore, the priority intervention is to maintain the integrity of the sac.

A nurse is caring for a client who is at 36 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse identify as the priority?

*non-reactive stress test* The nurse should apply the urgent versus nonurgent priority-setting framework when answering this item. Using this framework, the nurse should consider urgent needs to be the priority need because they pose more of a threat to the client. Using the urgent vs nonurgent approach to client care, the nurse determines that the priority finding is a nonreactive nonstress test. A nonstress test measures fetal heart rate (FHR) accelerations with normal movement. A fetal acceleration is a positive sign present when the FHR increases 15/min and lasts 15 seconds. In a nonreactive nonstress test, there are no accelerations. Absence of FHR accelerations suggests that the fetus might be going into distress. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent.

A nurse is caring for a client in the immediate postoperative period following removal of an ectopic pregnancy via salpingostomy. For which of the following indications should the nurse administer Rho(D) immune globulin?

*the client is Rh-negative* Administering Rho(d) immune globulin to the client prevents the formation of antibodies to Rh-positive blood. Exposure can occur following delivery, spontaneous or induced abortion, or amniocentesis involving an Rh-positive fetus.

A nurse is reinforcing teaching with a client who is scheduled for a nonstress test. Which of the following information should the nurse include?

*An external fetal monitor will be used to monitor the FHR* During a nonstress test, the client is seated in a semi-reclining position. An external fetal monitor is applied to detect the FHR and uterine contractions. The FHR is monitored for 20 to 30 min. A reactive, or reassuring, FHR is determined to be the presence of two accelerations in a 20-min period, each lasting at least 15 seconds and peaking at least 15 beats/min above the FHR baseline.

A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

*clear the respiratory tract* Using the airway, breathing, circulation (ABC) priority-setting framework, the first action the nurse should take is to open the airway of a newborn who was just delivered.

A nurse is reinforcing teaching about fetal development with a group of women who are pregnant. Which of the following statements should the nurse include in the teaching?

*"The baby's heartbeat is audible by a Doppler stethoscope at 12 weeks of pregnancy."* The fetal heartbeat is audible by Doppler stethoscope at 12 weeks of gestation.

A nurse is reinforcing teaching about bottle-feeding with a client who is postpartum. Which of the following statements by the client indicates a need for further teaching?

"I will keep my baby's head slightly elevated during the feeding." "I will hold my baby close to me while feeding." *"Each feeding should last about 15 minutes."* "Propping a bottle can cause otitis media." *Rationale* Newborns will suck vigorously for the first 5 min of a feeding. However, newborns should be allowed to continue to suck for at least 30 min.

A nurse is collecting data from a client who gave birth 12 hr ago. The nurse notes the fundus is deviated to the right, boggy, and 2 cm above the umbilicus. Which of the following actions should the nurse take first?

*Assist the client to void* A full bladder causes the fundus to become displaced, rise up above the level of the umbilicus, and leads to uterine atony. Uterine atony can cause postpartum hemorrhage. Therefore, assisting the client to void is the priority nursing action.

A nurse is caring for a client who is at 38 weeks of gestation and has a score of 10 on her biophysical profile. Which of the following actions should the nurse take?

*Assure the client that the score is within the expected range* The biophysical profile yields a score based on fetal breathing, movement, tone, amniotic fluid volume, and fetal heart rate reactivity. A score of 2 is assigned to each expected finding. A score of 10 indicates expected findings in all five areas.

A nurse is preparing to palpate the uterine fundus of a client who is at 22 weeks of gestation to measure fundal height. At which of the following locations should the nurse expect to find the fundus?

*At the umbilicus* At 22 weeks of gestation, the fundal height should be around the level of the umbilicus. The distance in centimeters from the symphysis pubis to the top of the fundus is a rough estimate of gestational age.

A nurse is caring for a client following a cesarean birth. The client tells the nurse that she is hungry. Which of the following actions should the nurse take first?

*Auscultate the client's abdomen* Using the nursing process framework for client care, the nurse should first auscultate the client's abdomen for bowel sounds. During a cesarean birth, the bowel is manipulated, taking 24 to 48 hr before full peristaltic function is restored.

A nurse is reinforcing teaching with a new mother about the purpose of administering vitamin K to her newborn following delivery. The nurse should explain that the purpose of administering vitamin K is to prevent which of the following complications?

*Bleeding* A newborn is unable to manufacture vitamin K, which is necessary for blood clotting, without intestinal flora. Vitamin K also promotes production of clotting factors II, VII, IX, and X in the liver. Vitamin K is usually produced by day 8; therefore, it is routinely given to newborns to prevent bleeding problems.

A nurse is reinforcing teaching about management of constipation during pregnancy with a group of pregnant clients who are pregnant. Which of the following statements should the nurse include in the teaching?

*Eat an apple to help with constipation* Constipation is a common discomfort occurring during pregnancy that results from relaxation of gastrointestinal muscle tone and motility related to increased progesterone levels, increased pressure on the GI tract by the fetus, and the use of iron supplements. The nurse should teach the clients to increase dietary roughage, such as fruits, vegetables, and legumes, which are excellent sources of fiber.

A nurse is collecting data from a client who is 3 days postpartum and is breastfeeding. Her fundus is three fingerbreadths below the umbilicus, and her lochia rubra is moderate. Her breasts feel hard and warm. Which of the following recommendations should the nurse give the client?

*Express milk from both breasts* For this postpartum day, the client's fundal location and lochia characteristics are within the expected reference range. The client's manifestations indicate that she is experiencing breast engorgement, an expected finding, as this is the time when the milk "comes in." Frequent breastfeeding and expressing milk from the breasts can help relieve engorgement.

A nurse is reinforcing teaching with the parents of a newborn about caring for the umbilical cord stump. Which of the following instructions should the nurse include?

*Give the newborn a sponge bath until the cord stump falls off* The nurse should instruct the parents to give the newborn a sponge bath until the stump falls off.Immersing the umbilical cord stump in water might delay the process of drying, separation, and healing.

A nurse is caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client's plan of care?

*Have the client ambulate frequently in the hallway* Venous stasis is a major cause of thrombophlebitis. To help prevent it, the nurse should plan to have the client get out of bed and walk as soon as possible after delivery and as often as she can.

A nurse is collecting data from a newborn who weighs 5,160 g (11 lb, 6 oz) and whose mother has diabetes mellitus. For which of the following data should the nurse monitor?

*Hypoglycemia* Newborns of clients who have diabetes are at high risk for hypoglycemia as the constant supply of glucose creates fetal hyperinsulinemia. It can take several days for the newborn to adjust to secreting appropriate amounts of insulin for the new, lesser supply of glucose. Because severe hypoglycemia can lead to cyanosis and seizures, which pose the greatest risk to the newborn at this time, this is the nurse's highest priority.

A nurse is reinforcing teaching about nutritional needs with a client who is pregnant. Which of the following nutrients should the nurse instruct the client to increase during pregnancy?

*Iron* During pregnancy, the need for iron increases to allow transfer of the appropriate amounts to the fetus and to support expansion of the client's red blood cell volume.

A nurse is reinforcing teaching with a newly licensed nurse about the complications associated with maternal gestational diabetes. Which of the following complications should the nurse include?

*Newborn hypoglycemia* The nurse should identify that hypoglycemia is a common complication for newborns whose mothers have gestational diabetes.

A client is concerned that her newborn has "crossed eyes." Which of the following statements is a therapeutic response by the nurse?

*Newborns lack the necessary muscle control to regulate eye movement* Transient strabismus or nystagmus are common until the third or fourth month of life; therefore, the nurse should reassure the client that this is an expected finding.

A nurse is collecting data from a client who gave birth one week ago. Which of the following findings should the nurse identify as a manifestation of endometritis?

*Pelvic pain* Manifestations of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain.

A nurse is assisting with the care of a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?

*Place the client in a knee-chest or Trendelenburg position* Placing the client in the knee-chest or Trendelenburg position takes pressure off the umbilical cord to allow oxygen transport to the fetus. This is the priority nursing action until the baby can be delivered either vaginally or by cesarean birth.

A nurse is reinforcing teaching with the mother of a newborn who is small for gestational age. Which of the following should the nurse include as a cause of this condition?

*Placental insufficiency* Placental insufficiency is a cause of a newborn being born small for gestational age. Placental insufficiency can result from maternal infections, embryonic placental deficiency, teratogens, or chromosomal abnormalities.

A nurse is reinforcing teaching about quickening with a client who is at 6 weeks of gestation. Which of the following information should the nurse include?

*Quickening occurs between the fourth and fifth months of pregnancy* Quickening is defined as the first time the client is able to feel the fetus move. It usually occurs between 14 and 18 weeks of gestation.

A nurse is assisting in the plan of care for a client who is pregnant and has phenylketonuria (PKU). Which of the following actions should the nurse include in the plan of care?

*Reinforce teaching about a protein-free diet* PKU is managed by eliminating phenylalanine from the diet. All-natural food proteins contain phenylalanine. Therefore, initiating a controlled diet eliminating protein is the appropriate action for the nurse to take.

A nurse is assisting with the care of a newborn immediately following a cesarean delivery. The nurse's highest priority is to monitor the newborn for which of the following?

*Respiratory distress* The priority observation when using the airway, breathing, circulation (ABC) approach to client care is to monitor the newborn for respiratory distress. During a vaginal delivery, pressure on the chest from passage through the birth canal helps rid the newborn of amniotic fluid in the lungs and stimulates respiration. With a cesarean delivery, the newborn does not go through the birth canal and, therefore, is at risk for respiratory problems.

A nurse is assisting with the care of a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

*Respiratory rate of 16 breaths/min* The client's respiratory rate should be at least 12/min as a precaution against excessive depression of impulses at the myoneural junction. Based on this finding, the nurse can continue the infusion.

A nurse is assisting in the care of a newborn immediately following birth. The nurse notes mucus bubbling out of the newborn's mouth and nose. Which of the following actions should the nurse take first?

*Suction the newborn's mouth with a bulb syringe* The nurse should first suction the newborn's mouth with a bulb syringe, followed by the nares. Suctioning the mouth first helps prevent aspiration of mucus into the newborn's airway.

A nurse is assisting with the care of a client who is in labor and has the urge to push. Which of the following instructions should the nurse give the client?

*Take a deep, cleansing breath before and after each contraction* It is important that the client ventilates her lungs to provide for adequate oxygenation to the fetus during the delivery process. Therefore, the nurse should remind the client to take deep breaths before and after each contraction.

A nurse is reinforcing teaching about umbilical cord care with a client who is postpartum. Which of the following instructions should the nurse include?

*The stump will fall off in 10-14 days* Cord separation will vary by the type of cord care, type of birth, and other prenatal events, but usually the cord will fall off in 10 to 14 days.

A nurse is reinforcing teaching about common discomforts of pregnancy during the first trimester with a client who is pregnant. Which of the following manifestations should the nurse include in the teaching?

*Urinary urgency* Urinary urgency and frequency are common discomforts occurring during the first trimester. Hormones cause vascular engorgement and altered bladder function. Education should also include regular emptying of the bladder, performing Kegel exercises, and limiting fluid intake prior to bedtime.

A nurse is assisting in the care of a client who is in the second stage of labor. Which of the following findings should the nurse report to the provider?

*Uterine contraction lasting 2 minutes* A uterine contraction lasting for more than 90 seconds is a sign of uterine tachysystole, which can lead to uterine rupture. The nurse should report this finding to the provider.

A nurse reinforcing teaching about vitamin K with a client who is postpartum. Which of the following statements should the nurse include?

*Vitamin K decreases the newborn's risk of hemorrhagic disorders* Newborns cannot produce vitamin K until about 8 days after birth. It is administered in the delivery suite to prevent hemorrhagic disorders.

A nurse is reinforcing nutritional teaching with a client who is at 8 weeks of gestation. Which of the following statements should the nurse include?

*You should increase your folic acid intake during your pregnancy* The nurse should reinforce teaching with the client about increasing her folic acid intake throughout pregnancy. Adequate intake of folic acid protects the fetus against neural tube defects.

A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?

*a large amount of bright red vaginal bleeding without pain* With placenta previa, the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os, or outlet to the vagina. Clients who have placenta previa have sudden, painless vaginal bleeding, typically in the third trimester.

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88./min, respiratory rate 18/min. Which of the following actions should the nurse perform?

*ask the client to empty her bladder* Whenever the fundus is deviated from the midline, a full bladder should be considered as a potential cause. A full bladder could result in complications such as uterine atony or infection.

A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

*check for blood under the client's buttocks* The nurse should check for blood under the client's buttock to evaluate the amount of lochia flow and to check for pooling of blood that would otherwise be missed.

A nurse is caring for a client who is experiencing shaking chills during the immediate postpartum period. Which of the following actions should the nurse take?

*cover the client with warm blankets* Shaking chills often occur immediately postpartum due to the cool birthing room, excess epinephrine production during the birth, and the sudden release of pressure on the pelvic nerves. The nurse should cover the client with a warm blanket following delivery.

A nurse is caring for a newborn immediately following delivery. After assuring a patent airway, which of the following actions should be the nurse's priority?

*dry the newborn* Drying the newborn is the priority action the nurse should take. Failure to dry the newborn can result in cold stress, which poses the greatest risk to the infant's safety. Cold stress increases oxygen demand and can result in respiratory distress and hypoglycemia.

A nurse is reinforcing teaching with a client about checking her basal temperature to identify when ovulation occurs. The nurse should instruct the client to check her temperature at which of the following times?

*every morning before arising* The nurse should instruct the client to measure her temperature every morning throughout her menstrual cycle, upon waking, before getting out of bed. Activity or movement can raise body temperature slightly and provide inaccurate results. The client should use a special thermometer that is accurate to the tenth of a degree.

A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not initiated until a good labor pattern has been established. Which of the following explanations should the nurse include?

*given too soon, epidural anesthesia can prolong labor* Progress in labor slows when clients are given anesthesia before the active phase of labor. The medication depresses the central nervous system, thus it will take longer for the cervix to dilate and efface.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and has heavy, red vaginal bleeding, without contractions, that started spontaneously. She is in no distress and states that she can "feel the baby moving." The client should undergo an ultrasound to determine which of the following findings?

*location of the placenta* Painless, spontaneous vaginal bleeding might be an indication of placenta previa. With the ultrasound, the provider can identify the location of the placenta and urgency of the delivery.

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?

*At 28 weeks gestation* The nurse should administer Rh(D) Immune Globulin to a client who is pregnant and has Rh-negative blood at 28 weeks of 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 is reinforcing teaching with a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse recognizes that which of the following is the most common risk factor for a placental abruption?

*Maternal hypertension* Maternal hypertension is the most common risk factor for placental abruption

A nurse is assisting with the care of a client who is experiencing preterm labor and is scheduled to undergo amniocentesis. The client needs an amniocentesis to determine which of the following findings?

*Maturity of lungs* Amniocentesis is the best means for determining fetal lung maturity The lecithin/sphingomyelin ratio (L/S) helps measure the amount of lung enzyme surfactant A ratio of 2:1 or greater means the lungs are mature enough to withstand extrauterine life

A nurse is preparing to administer vitamin K IM to a newborn. Into which of the following muscles should the nurse inject the medication?

*Vastus lateralis* The nurse should administer vitamin K, or phytonadione (AquaMEPHYTON), into the vastus lateralis muscle in the thigh. This medication prevents and treats hemorrhagic disease of the newborn, as newborns are born with vitamin K deficiency.

A nurse is caring for a client during a nonstress test (NST). The nurse observes two decelerations of 15/min in the fetal heart rate during a period of fetal movement. Each deceleration lasts 20 seconds. Which of the following results are indicated by these findings?

*a non-reactive test* A nonreactive test is indicated by the absence of at least 2 qualifying accelerations within a 20-minute period. These findings indicate a nonreactive NST.

A nurse is caring for a client who has just learned that she is pregnant. The nurse should reinforce with the client to call her provider if she experiences which of the following manifestations?

*facial edema* Facial edema is an indication of pregnancy-induced hypertension, which should be reported to the client's provider.

A nurse is assisting with the care of a client who is at 32 weeks of gestation and in labor. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse make?

*you must be feeling very scared* This response illustrates the therapeutic communication technique of restatement. The nurse shows empathy for the client by focusing on the client's feelings and recognizing that the client is scared about the safety of her newborn. This open-ended statement encourages further communication by the client.

A nurse in the newborn nursery is receiving report on four newborns. Which of the following newborns should the nurse see first?

A newborn who is 18 hr old and has not voided. A newborn who is 8 hr old and has acrocyanosis. A newborn who is 24 hr old and has not passed meconium. *A newborn who is 12 hr old and has an axillary temperature of 37.8° C (100° F)* *Rationale* An axillary temperature of 37.8°C (100°F) indicates hyperthermia in the newborn and requires immediate intervention. Left untreated, hyperthermia can cause seizures, heat stroke, and death.

A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as a possible indication of inhibition of parental attachment?

"He's got my husband's nose, that's for sure." "I don't need the bath demonstration. I know how to do it." *"I just wish he had more hair. I'm going to have to keep a hat on his head till he grows some."* "Do you think you could keep him in the nursery for the next feeding so I can get some sleep?" *Rationale* This comment conveys disappointment in the newborn's appearance and a need to hide what the client perceives as an undesirable feature. This is a possible indication of inhibited attachment.

A nurse is assisting with a community program to educate adolescents about contraception. After the class, a 15-year-old girl asks the nurse which method is best for her to use. Which of the following statements is an appropriate nursing response?

*"Before I can help you with that question, I need to know more about your sexual activity"* Effective consultation with a client about the best form of birth control for her requires further data collection about the frequency of intercourse, number of partners, and her own motivation and reliability.

A nurse is reinforcing teaching about diaphragms with a client. Which of the following statements by the client indicates an understanding of the teaching?

*"I will leave the diaphram in for at least 6 hours after vaginal intercourse."* The diaphragm must be left in place for 6 to 8 hours following after vaginal intercourse to be effective. For subsequent vaginal intercourse during this 6 to 8-hr time period, additional spermicidal jelly must be added without disturbing the placement of the diaphragm.

A nurse is caring for a client who is at 32 weeks of gestation and is in labor. Which of the following medications is contraindicated for this client?

Folic acid Nifedipine *Misoprostol* Terbutaline sulfate *Rationale* Misoprostol can cause abortion, premature labor, and birth defects. This prescription should be clarified with the provider.

A nurse is assisting with the care of a client who is in labor. The client's labor is difficult and prolonged and she reports a severe backache. Which of the following factors is a contributing cause of difficult, prolonged labor?

*Fetal position is persistent occiput posterior.* The persistent occiput posterior position of the fetus is a common cause of prolonged, difficult labor with severe back pain.

A nurse is caring for a client who is postpartum and asks, "When will my breast milk come in?" Which of the following responses should the nurse make?

*In 3 to 5 days after delivery* By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milk.

A nurse is caring for a client who is receiving oxytocin for induction of labor. Which of the following actions should the nurse take?

*Perform continuous fetal heart rate monitoring* When oxytocin is administered to an antepartum client, the fetal monitor must be used to continuously monitor the fetal heart rate and maternal contractions.

A nurse is preparing to administer methylergonovine IM for a client who had a vaginal delivery earlier that day. The nurse should explain to the client that this medication will help prevent which of the following?

*Postpartum hemorrhage* Methylergonovine is an oxytocic. It causes uterine contractions to help control postpartum bleeding.

A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

*Prepare for cesarean birth* The nurse should begin preparing for a cesarean birth for a client who is full term and has heavy vaginal bleeding. A client who has heavy vaginal bleeding is at risk for hemorrhage and subsequent fetal compromise. Therefore, immediate delivery via cesarean section will likely be advised.

A nurse is assisting a client with breastfeeding her newborn. The nurse should explain that which of the following reflexes will initiate sucking?

*Rooting* The nurse elicits the rooting reflex by stroking the newborn's cheek. The newborn will turn his head while making sucking motions with his mouth.

A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?

*The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines.* Dilation of the cervix is measured from closed to 10 cm; effacement, or thinning and shortening of the cervix, is measured from 0% to 100% station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is -1, then the presenting part is 1 cm above the ischial spine.

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?

*These feelings are common to expectant fathers in early pregnancy* The father needs reassurance that these feelings are expected. The nurse should reassure him that when the pregnancy becomes obvious he will feel more involved. This therapeutic response addresses the client's feelings by providing information.

A nurse is caring for a client who is at 16 week of 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?

*Use a 20-gauage needle, and administer the medication using the Z-track method* 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 four newborns. Which of the following newborns is at greatest risk for Hypoglycemia?

*a newborn who is large for gestational age* Large for gestational age (LGA) newborns are those newborns whose weight is at or above the 90th percentile. One of the most common etiologies of LGA newborns is a mother who is diabetic. LGA newborns, especially those born to mothers who have diabetes, are at increased risk for hypoglycemia. Other newborns at risk for hypoglycemia are small for gestational age (SGA) newborns (those below the 10th percentile), premature newborns, and newborns who have perinatal hypoxia.

A nurse is caring for a client who desires an Intrauterine device for contraception. Which of the following findings is a contraindication of the use of this device?

*menorrhagia* 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 history of ectopic pregnancy.

A nurse is collecting data about reflexes from a newborn. Which of the following actions should the nurse take to elicit the newborn's Moro reflex?

*perform a sharp hand clap near the infant* To elicit the Moro reflex, the nurse should perform a sharp hand clap near the newborn. The newborn should exhibit symmetric abduction and extension of the arms, fanning of the fingers with the thumb and forefinger forming a C shape, followed by the arm and hand's return to a relaxed flexion position.

A nurse is assisting with the monitoring of a client who is in the first stage of labor, with an external fetal monitor in place and IV fluids infusing. Which of the following factors will cause variable decelerations in the fetal heart rate?

*umbilical cord compression* Variable decelerations are drops in the fetal heart rate with an abrupt onset followed by a return to baseline. Variable decelerations coincide with cord compression.

A nurse is working with an assistive personnel (AP) who is pregnant. The nurse is unsure of the AP's immune status. Which of the following clients should the nurse safely assign to the AP?

A preschool-age child who has varicella. *A toddler who has impetigo* A school-age child who has rubella. A school-age child who has fifth disease with aplastic crisis. *Rationale* Impetigo contagiosa has minimal systemic effects. Therefore, it should be safe for the nurse to assign the AP care of this client.

A nurse is reinforcing teaching with a client who is being fitted for a contraceptive diaphragm. Which of the following information should the nurse include?

*Replace the device after a 20% weight loss* It is important for the device to fit appropriately in the vaginal vault in order to provide adequate contraceptive protection. The client should replace the diaphragm after a 20% weight loss or gain.

A nurse is reinforcing teaching with a client who is at 17 weeks of gestation and is scheduled to have a maternal serum alpha-fetoprotein (MSAFP) determination. Which of the following information should the nurse include?

*this test will screen for neural tube defects.* MSAFP measures blood levels of alpha-fetoprotein in the client's blood. Abnormal levels can indicate a neural tube defect, such as spina bifida, as well as multifetal pregnancies and fetal abdominal wall defects.

A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborn's umbilical cord?

*two arteries and one vein* The vein carries oxygenated blood to the fetus, and the two arteries carries unoxygenated blood back to the placenta.

A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching?

*your baby can lose 5% of body weight during the first few days of life* The nurse should instruct the mother that the baby can have a weight loss between 5% and 10% of their birth weight during the first 3 days of life. Breastfed infants usually regain birth weight by their second or third week of life.

A nurse is caring for a client who might have a hydatidiform mole. The nurse should monitor the client for which of the following findings?

*Excessive uterine enlargement* A hydatidiform mole is a rare tumor that arises from placental tissue and results in a rapidly enlarging uterus.

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?

*Encourage the newborn to breastfeed every 2 hours* The newborn should be encouraged to eat frequently, at least every 2 hr, while receiving phototherapy. The therapy can cause fluid loss and dehydration. Feeding of plain water or glucose water is not recommended, as these have no nutritional value.

A nurse is caring for a client who is pregnant and reports constipation. Which of the following recommendations should the nurse make?

*Increased cellulose and fluid in the diet* Increasing fiber and fluid and getting regular exercise are simple and effective ways to deal with constipation during pregnancy.

A nurse is reinforcing teaching about immunizations with a woman in her first trimester of pregnancy whose diagnostic testing indicates she does not have an immunity to rubella. The nurse should recommend that the client receive a measles, mumps, rubella (MMR) vaccine at which of the following times?

*prior to discharge from the hospital AFTER giving birth* The nurse should recommend the client receive the MMR vaccine following delivery, so she is protected from contracting rubella then and during any subsequent pregnancies.

A nurse is collecting data from a newborn 1 hr after delivery. Which of the following respiratory rates is within the expected reference range for a newborn?

22 breaths/minute *48 breaths/minute* 100 breaths/min 110 breaths/min *Rationale* the expected reference range for a newborn's resting respiratory rate is 30-60 breaths/minute

A nurse is reinforcing teaching with a parent about using an iron fortified formula to feed her newborn. Which of the following information should the nurse include in the teaching?

*the newborn's iron source will start to deplete* Iron sources deplete and need to be supplemented in newborns.

A nurse is reinforcing teaching with a client who is pregnant and has a body mass index (BMI) of 26.5. She asks the nurse how much weight she should gain over the course of her pregnancy. Which of the following statements is an appropriate response by the nurse?

"You should gain 11 to 20 pounds." *"The recommendation for you is about 15 to 25 pounds."* "A gain of about 25 to 35 pounds is best for you and for your baby." "It really doesn't matter exactly how much weight you gain, as long as your diet is healthy." *Rationale* The client's BMI indicates that she is overweight. Overweight clients should gain 7 to 11.5 kg (15 to 25 lb). The nurse should also reinforce that the pattern of weight gain is important, with minimal gain in the first trimester.

A nurse is caring for a client in the prenatal clinic who is at 7 weeks of gestation. The client reports urinary frequency and asks the nurse if this will continue throughout her pregnancy. Which of the following responses by the nurse is appropriate?

*"No, it should only last until about your 12th week, but it will return near the end of the pregnancy."* Urinary frequency usually disappears at about 12 weeks of gestation but returns near term as the enlarging uterus presses on the bladder. It can also worsen following fetal descent.

A nurse is caring for a female client who is scheduled to have a pelvic examination. The client tells the nurse, "I'm really nervous because I've never had a pelvic exam before." Which of the following is an appropriate therapeutic response by the nurse?

*"Tell me more about your concerns."* This therapeutic response is an open-ended statement and encourages the client to tell the nurse more about her concerns.

A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min. Which of the following actions should the nurse take first?

*Place the client in a lateral position* The nurse should first turn the client laterally to relieve the pressure on the inferior vena cava and improve the blood pressure.

A nurse is collecting data from a newborn who is 12 hrs old. His respiration rate is 44/min, shallow, with periods of apnea lasting up to 5 seconds. Which of the following actions should the nurse take?

*Continue routine monitoring* This observation indicates adaptation of the respiratory system to extrauterine life. Continued monitoring is indicated.

A nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take first?

*Position client on her side* Late decelerations are caused by uteroplacental insufficiency. A position change should increase perfusion to, or decrease compression of, the placenta, and is the first intervention the nurse should try.

A nurse is collecting data from a client who is at 18 weeks of gestation and tells the nurse that she felt light fluttering in her stomach the previous day. The nurse should use which of the following terms to document this finding?

*Quickening* Clients often describe quickening as a fluttering sensation they first perceive as early as the 14th week of gestation. It reflects fetal movement.

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

*Check the client's fundus.* The primary cause of excessive postpartum bleeding is uterine atony the priority action the nurse should take is to check the client's fundus. A boggy fundus requires massage by the nurse Failure of the uterus to contract with massage warrants further intervention by the nurse, such as having the client empty her bladder

A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn. Which of the following client statements indicates an understanding of the teaching?

"I will stop breastfeeding until I am done with the antibiotics." "I won't wear a bra during the daytime." "I'll apply cold compresses 20 min before each feeding." *"I'll feed my baby every 2 hours."* *Rationale* The primary therapy for relieving breast engorgement is emptying both breasts. The client might be able to accomplish this with more frequent feedings. She can also pump her breasts after she feeds her newborn to ensure optimal emptying.

A nurse is assisting a client out of bed for the first time since delivery. The client becomes frightened when she passes a large amount of lochia. Which of the following responses should the nurse make?

*"Lochia can pool in the vagina while you lie in bed."* The client needs to be reassured that this is expected following a period of rest in bed.

A nurse is caring for a client who has consented to an amniocentesis for genetic cell analysis. The client asks why she can't have the test before 14 weeks of gestation. Which of the following responses should the nurse make?

*"There is not enough amniotic fluid until this time."* Amniocentesis requires adequate amniotic fluid for testing, which is not available until about 14 weeks of gestation.

A nurse is reinforcing teaching with a newly licensed nurse about a biophysical profile. Which of the following information should the nurse include in the teaching?

*this test predicts fetal well-being in the third trimester* The biophysical profile is used to predict fetal well-being in the third trimester of pregnancy. A biophysical profile consists of a nonstress test combined with a detailed ultrasound. The ultrasound measures four markers: amniotic fluid volume, fetal breathing movements, gross fetal movement, and fetal tone.

A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate effectiveness of this medication?

*fundal consistency* Oxytocin is given to improve the quality of uterine contractions and is given following a delivery to prevent or treat uterine atony. If the oxytocin is effective, the fundus should be firm on palpation.

A nurse is caring for a newborn immediately after birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

*Drying the newborn's skin thoroughly* Drying the newborn's skin thoroughly prevents evaporative heat loss, which is the most significant heat loss in the first few days of life.

A nurse is teaching a client about a Non-stress test. Which of the following statements by the client indicated an understanding of the teaching?

*"I should press the button on the handheld marker when my baby moves"* The purpose of the test is to assess fetal well-being. The client should press the button on the handheld marker when she feels fetal movement.

A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and is scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following responses by the nurse is appropriate?

*"It assists in identifying the location of the placenta and fetus."* The location of the placenta or fetus is identified by ultrasound prior to amniocentesis to assist with correct placement of the needle.

A nurse is speaking to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?

*"This is an expected finding because of the way iron is broken down during digetsion."* Iron supplements turn a client's stools black. In the absence of cramping and abdominal pain, this is an expected finding. The client should be instructed to expect black stools.

A nurse is reinforcing teaching with a client who is pregnant and whose routine diagnostic testing reveals a negative rubella titer. Which of the following statements should the nurse tell the client?

*"You will need an immunization following delivery."* The negative rubella titer means that the client is susceptible to the rubella virus and needs to be immunized after delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following the rubella immunization, the client should be cautioned not to conceive for 3 months.

A nurse is assisting with the care of a client who is in labor. Immediately after delivery of a newborn, which of the following actions should the nurse take first?

*Dry the newborn* Using the urgent vs nonurgent framework for nursing care, the nurse should first dry the newborn. Failing to dry and keep the newborn warm can cause cold stress, which results in unnecessary use of oxygen by the newborn, resulting in respiratory distress and decreased PaO2.

A nurse in a prenatal clinic is reviewing the medical record of a client who is at 28 weeks of gestation. The client's history reveals one pregnancy terminated by elective abortion at 9 weeks; the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks of gestation. According to the GTPAL system, which of the following describes her present parity?

*2-0-1-2-2* This response correctly describes the client's present parity. She has had 2 pregnancies that have reached 20 weeks or more of gestation (G); she has had no term births (T); one pregnancy resulted in the preterm (P) birth of her twins; two pregnancies ended in abortion (A); and she has two living children (L).

A nurse is assisting with the care of a client who is using pattern-paced breathing during the first stage of labor. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?

*Assist the client to breathe into a paper bag* This client is experiencing respiratory alkalosis due to hyperventilation. She needs to rebreathe carbon dioxide to replace the bicarbonate ion by breathing into a paper bag or her cupped hands.

A nurse is collecting data from a client who is 12 hr postpartum following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client's abdomen?

*At the level of the umbilicus* Within 12 hours, the fundus should rise to the level of the umbilicus and then recede 1 to 2 cm each day.

A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings should the nurse expect?

*Blood glucose instability* Decreased glycogen storage and less gluconeogenesis put newborns who are SGA at high risk for hypoglycemia.

A nurse is caring for a newborn shortly after birth and places the newborn under a radiant warmer. Which of the following potential complications does this action help to prevent?

*Cold stress* Prevention of cold stress is important to decrease metabolic and physiologic demands on the newborn. Cold stress can lead to hypoglycemia and respiratory distress in the newborn.

A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 seconds. The newborn is pink with Acrocyanosis. Which of the following actions should the nurse take?

*Continue to routinely monitor the newborn* This newborn is exhibiting a normal respiratory rate and rhythm. No additional measures are needed at this time.

A nurse is collecting data from a client who is postpartum 2 hr following delivery of a healthy newborn. Which of the following findings indicates the client's bladder is distended?

*Elevated fundus level* If the bladder is distended, it will push the uterus up out of the pelvis above the umbilicus, thus elevating the level of the fundus.

A nurse in a prenatal clinic is determining a client's estimated date of delivery using Naegele's rule. The first day of her last menstrual period was May 4. Which of the following dates should the nurse tell the client is her estimated date of delivery?

*February 11* Using Naegele's rule to calculate the client's estimated date of delivery, the nurse should subtract 3 calendar months and add 7 days to the client's first day of her last menstrual period. The nurse should calculate February 11th as the estimated date of delivery for this client.

A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?

*Fetal heart rate 100 breaths/min for a 10-minute period* A fetal heart rate of 100/min for a 10-min period is bradycardia. Therefore, the nurse should notify the provider of this finding.

A nurse is assisting with the care of a client who is in active labor at 39 weeks of gestation. The nurse locates the fetal heart tones above the client's umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions?

*Frank breech* With a frank breech presentation, the fetal heart is generally above the level of the client's umbilicus.

A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following treatments should the infant receive?

*Hepatitis B immune globulin and the hepatitis B vaccine within 12 hr of birth* A newborn whose mother is positive for the hepatitis B surface antigen should receive both the hepatitis B vaccine and the hepatitis B immune globulin within 12 hr of birth.

A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate that the provider will order an amniotic fluid alpha-fetoprotein screening for which of the following clients?

*History of delivering a child with a neural tube defect* Screening for alpha-fetoprotein is indicated for the client who previously delivered a child with a neural tube defect.

A nurse is discussing a diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching?

*I should replace my diaphragm every 2 years* The diaphragm is a flexible rubber cup that is filled with spermicide and is inserted over the cervix prior to intercourse. The diaphragm is a prescribed device fitted by the provider. It should be replaced every 2 years.

A nurse in a prenatal clinic is caring for a client who is at 12 weeks of gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make?

*Increased progesterone production causes decreased motility of smooth muscle.* Increased progesterone production causes a relaxation of the cardiac sphincter and delayed gastric emptying, which can result in heartburn.

A nurse is assisting in the care of a client who is scheduled for a cesarean birth based on the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?

*Lecithin/sphingomyelin (L/S) ratio of 2:1* An L/S ratio of 2:1 is an indication of fetal lung maturity.

A nurse is assisting with the care of a client who is in labor and has an external electronic fetal monitor. The nurse observes that the fetal heart rate begins to decelerate after the contraction has started, with the lowest point of the deceleration occurring after the peak of the contraction. Which of the following actions should the nurse take first?

*Place the client in a lateral position* This is a late deceleration and is associated with insufficient placental perfusion. Placing the client in the lateral position is the first action the nurse should take.

A nurse is preparing to auscultate fetal heart tones for a client who is pregnant. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundal portion of the uterus and a long, smooth surface on the mother's right side. In which of the following maternal quadrants should the nurse auscultate fetal heart tones?

*Right upper quadrant* Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, is in the right upper quadrant.

A nurse is caring for a client who is at 34 weeks of gestation and has a suspected placenta previa. Which of the following actions should the nurse take?

*Apply an external fetal monitor* The nurse should immediately apply the fetal monitor to determine if the fetus is in distress.

A nurse is caring for a client who is pregnant and undergoing a nonstress test. The nurse records the FHR as 130 to 150/min, with no fetal movement for 15 min. Which of the following actions should the nurse take?

*Apply vibroacoustic stimulation to the woman's abdomen* This technique is sometimes used with a nonstress test to stimulate a fetal response. A sound source, typically a laryngeal stimulator, is applied to the client's abdomen over the fetal head for 3 seconds.

A nurse is reinforcing teaching about Rho(D) immunoglobulin to a client who is pregnant. Which of the following findings can an Rh incompatibility cause?

*Hydrops fetalis* Hydrops fetalis is a serious condition that occurs when fluid builds up in multiple body parts of the fetus is a result of an Rh incompatibility

A nurse is caring for a newborn who is small for gestational age. Which of the following findings is associated with this condition?

*Wide skull sutures* Newborns who are small for gestational age have wide skull sutures due to inadequate bone growth.

A nurse is assisting with the care of a client who is in early labor with intact membranes and a temperature of 38.9° C (102° F). After notifying the provider, which of the following actions should the nurse take?

*Administer acetaminophen orally* The nurse should administer acetaminophen to lower the client's temperature and encourage her to drink sips of water. Acetaminophen is a pregnancy risk category B medication, so it is likely that the provider will prescribe it.

A nurse is preparing to administer oxygen to a newborn who was born at 30 weeks of gestation. Which of the following actions should the nurse take?

*Administer warm, humidified oxygen to the newborn* The nurse should administer warm, humidified oxygen to the newborn to prevent cold stress during therapy.

A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect?

*pelvic pain* The client will experience a dull to colicky pain at the beginning, progressing to a sharp, stabbing pain as the tube stretches.

A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nursing observations is appropriate to use in evaluating the adequacy of the newborn's hydration?

*the number of wet diapers per day* The easiest and most reliable method to evaluate hydration is urinary output. Six to eight wet diapers per day is generally considered adequate.

A nurse is caring for a client who wants to know if it is possible to have a vaginal birth after a cesarean birth (VBAC). Which of the following statements by the nurse is appropriate?

*the primary consideration is what type of incision you had* A transverse incision (also known as a horizontal incision) cuts across the lower, thinner part of the uterus. It is used during most cesarean births and makes a VBAC possible. A vertical incision cuts up and down through the uterine muscles that strongly contract during labor and might cause uterine rupture during a VBAC.