Maternity

A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?

FHR 152/min

A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess?

Abruption placenta. - Cocaine use increases the risk for vasoconstriction and possible abruption placenta.

A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate if the client develops magnesium toxicity?

Calcium gluconate

A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior?

Lays the newborn across her lap and gently sways

A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse indicate in the teaching?

"Ensure that the newborn has been receiving feeding for 24 hours prior to obtaining the specimen."

A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for miosprostol. Which of the following instructions should the nurse include in the teaching?

"I can administer oxytocin 4 hours after the insertion of the medication." - Oxytocin can not be administered sooner than 4 hours. It can be administered for clients who have cervical ripening and have not begun labor.

A nurse is teaching client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"I should take 600 micrograms of folic acid each day."

A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching?

"I will likely need to use alternative positions for sexual intercourse."

A nurse is providing teaching for a client who gave birth 2 hr ago about the facility for newborn safety. Which of the following client statements indicates an understanding of the teaching?

"The person who comes to take my baby's pictures will be wearing a photo identification badge."

A nurse is teaching a client who is at 37 weeks of gestation and has prescription for a non stress test. Which of the following instructions should the nurse include?

"You should press the handheld button when you feel your baby move"

A nurse is assessing a prenatal clinic in assessing a group of clients. Which if the following clients should the nurse see first?

A client who is at 11 weeks of gestation and reports abdominal cramping

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?

A newborn who is 18 hours old and has an axillary temperature of 37.7 degrees celsius

A nurse is caring for client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect?

A reduction in respiratory distress in the newborn

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect?

Acrocyanosis, positive babinski reflex, two umbilical arteries visible

A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure?

Administer oxygen via a non rebreather mask

A nurse caring for a client who has hyperemesis gravidarum is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?

BUN 25 mg/dL

A nurse is admitting a client to the labor and delivery unit when the client states, "My rate just broke." Which of the following interventions is the nurse's priority?

Begin FHR monitoring. - greatest risk due to potential cord prolapse

A nurse is caring for a client who is at 36 weeks gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests?

Biophysical profile - provide a real time ultrasound of the fetus

A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect?

Blurred vision. - The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasm and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, or dark spots in the visual field.

A nurse is providing teaching about non pharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following?

Cold cabbage leaves

A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?

Depression. - Depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness.

A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a non stress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take?

Have the client change position. - relive umbilical cord compression

A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect?

Heart rate 154/min, RR 58, weight of 5 lbs 12 oz

A nurse is reviewing the prenatal lab results for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following lab findings should the nurse report to the provider?

Hemoglobin 10 g/dL

A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication?

Hypertension - carboprost is a vasodilator

A nurse is preforming a vaginal exam on a client who is in labor and observes the umbilical coed protruding from the vagina. After calling for assistance, which of the following actions should the nurse take?

Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. - This will relieve umbilical cord compression and increase oxygenation to the fetus.

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?

Jaundice - within first 24 hrs is can be associated with ABO incompatibility, hemolysis, or Rh-isoimmunization

A nurse is caring for a client who is at 24 weeks gestation and has a suspected placental abruption. Which of the following lab tests should the nurse expect the provider to prescribe?

Kleihaurer-Betke test. - This is used to determine is fetal blood is in maternal circulation. This test is useful to determine if the Rh0-(D) immune globulin therapy should be administered to a client who is Rh-negative.

A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindications the initiation of the oxytocin infusion and should be reported to the provider?

Late decelerations

A nurse is caring for a postpartum client who is receiving heparin via continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take?

Maintain the client on bed rest. - decrease the risk of dislodging the clot which could cause a pulmonary embolism

A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority?

Massage the clients funds. - minimize the about of blood lost

A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard scale. Which of the following findings should the nurse expect?

Minimal arm recoil

A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following intervention is the nurse's priority following the procedure?

Monitor the FHR

A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following interventions should the nurse include in the plan?

Monitor the FHR continuously

A nurse is assessing a client who is receiving morphine via IV bolus for pain following a c-section. The nurse notes a respiratory rate of 8/min. Which of the following medications should the nurse administer?

Naloxone - morphine is a common opioid analgesic used for postoperative pain management that can cause CNS depression and respiratory distress.

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member?

Obtain a gift from the newborn to present to the sibling

A nurse is caring for a Clint who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?

Perform Leopold maneuvers - used to determine best placement for the monitor

A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect?

Petechiae over the head

A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn?

Place the newborn skin to skin on the mother's chest. - This is an effective technique to significantly decrease the newborn's pain and anxiety level. The nurse should implement this technique before, during, and after the procedure.

A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia?

Pregestational diabetes mellitus

A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications?

Premature rupture of membranes

A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include on the plan of care?

Protect the client's head and feet from cold air

A nurse is caring for a client who is at 30 weeks of gestation and has prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects?

RR. of 10/min

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?

Remove all clothing from the newborn expect the diaper

A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider?

Report of decreased fetal movement

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider?

Report of visual disturbances - potential prenatal complication associated with hypertension

A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?

Report the client's condition to the local health department. - HIV is one of the conditions on the list of Nationally Notifiable Infectious Conditions that it required to be reported.

A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect?

Reports of increased urinary output. - Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain, constipation, drowsiness, and headaches are manifestations of hyperglycemia. Pt can have weak rapid pulse, fruity breath odor, urine positive for sugar and acetone, and blood glucose greater than 200 mg/dL.

A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?

Respiratory distress

A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?

Schedule an ultrasound examination. - The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth.

A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?

Substernal retractions

A nurse is caring for a client who is at 36 weeks of gestation and has prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound?

To locate a pocket of fluid

A nurse is assessing a client who is 1 day postpartum and has vaginal hematoma. Which of the following manifestations should the nurse expect?

Vaginal pressure

A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take?

Verify that the parent's identification brand matches the newborn's identification band

A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider?

Weight gain of 4.8 lbs

A nurse is providing discharge teaching to a client who had a c-section 3 days ago. Which of the following instructions should the nurse include?

You can still become pregnant if you are breastfeeding