maternity

A client with diabetes who just gave birth plans to breastfeed. The nurse determines that the client's understanding of breastfeeding instructions is sufficient when the client makes which statement?

"Breastfeeding will assist in lowering maternal blood glucose."

During a postpartum parenting class, a client tells the nurse that to save on the cost of formula, the client has switched their 6-month infant from formula to cow's milk. Which one of the following statements made by the nurse would be the best?

"Cow's milk can be safely given to an infant older than one year of age."

2/6 The nurse considers the client's cues and determines more information is needed. Which two (2) follow-up questions would be appropriate for the nurse to ask the client?

"Do you understand English?" "What language do you speak and understand?"

The nurse is teaching a new parent about the feeding patterns of a newborn infant. Which of the following statements by the parent would the nurse recognize as the correct description of a feeding pattern for a formula-fed infant?

"Formula-fed infants usually feed every 3 to 4 hours."

The parent of a premature infant asks the nurse how to do the paced bottle feeding technique. Which of the following would be the most appropriate response from the nurse?

"Hold the bottle nearly horizontally and take frequent breaks as the baby pauses between sucks."

A student nurse and their preceptor are providing care for postpartum families in the home. Which statements would indicate to the nurse that the student understands the benefits of community health?

"Home provides more access for families to services within their own community."

5/6 The interpreter has arrived and the nurse is able to begin a cultural assessment on the client and partner. The client and partner appear relieved to have someone who speaks their language. The nurse would like to learn more about the client's views on childbirth. Which four (4) questions should the nurse ask to learn more about the client's belief system?

"How do you view childbirth?" "Do you have a treatment plan?" "Do you have any concerns about being in the hospital and/or childbirth?" "Is there anything we can do to make you more comfortable during childbirth?"

A nurse is caring for a client in the 34th week of pregnancy who wears an external monitor. Which statement by the client indicates an understanding of the nurse's teaching?

"I can lie in any comfortable position, but I should stay off my back."

After the nurse instructs a pregnant client about swimming and bathing during pregnancy, which client statement indicates the need for additional teaching?

"I can relax in a hot tub for about 20 minutes."

A client just experienced spontaneous bleeding at 11 weeks gestation, which resulted in the loss of the fetus. The couple wonders if the bleeding could have been caused from the client working long hours in a stressful work environment. What is the most appropriate response from the nurse?

"I can understand your need to find an answer to what caused this. Let's talk about this further."

An obstetric ultrasound reveals that the client's fetus has spina bifida. The parent is concerned about raising a child with a congenital abnormality and starts to cry. Which response by the nurse is best?

"I know this must be overwhelming. I'm here to sit with you and support you."

6/6 The nurse is giving the client self-care instructions. Which statement(s) indicate client understanding? Select all that apply.

"I should use warm water in the peri bottle and make a sweeping motion from side to side." "I should pat the area with warm washcloths, front to back." "I should monitor for swelling and redness at the site of the sutures." "I should wash my hands before and after performing self care."

6/6 The nurse is speaking to the client and partner using the hospital interpreter. Complete the following sentence(s) by choosing from the lists of options. The nurse knows the client is now able to understand when they make the statement

"I would like to have more privacy during the birthing process."

A client who has been treated for infertility is now pregnant. During a routine ultrasound at 8 weeks' gestation, the client learns that five fetuses are visualized. The client's spouse is concerned that five infants will not survive and that the client may not be able to handle the stress of the pregnancy, so they ask the nurse about selective reduction. What is the nurse's best response?

"It has been used to decrease the possibility of complications."

A primiparous client who is bottle-feeding their neonate at 12 hours after birth asks the nurse, "When will my menstrual cycle return?" Which response by the nurse would be most appropriate?

"It will probably be 6 to 10 weeks before it starts again."

During a home visit to a primiparous client 1 week postpartum who is bottle-feeding the neonate, the client tells the nurse that their parent has suggested that they feed the neonate cereal so the neonate will sleep through the night. What would be the nurse's best response?

"It's better to continue feeding only formula until about 4 to 6 months of age."

A client who tells the nurse that they would like to use the basal body temperature method for family planning receives instructions about the method. Which client statement indicates to the nurse that the teaching has been successful?

"It's important to take my temperature at about the same time every morning before arising."

A client hospitalized for preterm labor tells the nurse a family member blames them for "overdoing it" and causing the preterm labor. Which of the following is the most appropriate response from the nurse?

"Let's talk about how preterm labor occurs to help you understand what causes it."

When the nurse instructs a pregnant client with a history of varicose veins about strategies to promote comfort, which client statement indicates that the teaching has been successful?

"Lying down with my feet elevated should help."

While the nurse is caring for a neonate at 32 weeks gestation in an isolette with continuous oxygen administration, the neonate's parent asks why the baby's oxygen is humidified. What should the nurse should tell the parent?

"Oxygen is drying to the mucous membranes unless it is humidified."

The nurse instructs the client about the procedures that will be performed on the neonate immediately after birth to prevent meconium aspiration. The nurse determines that the instructions have been effective when the client states that which procedure will be done to the baby?

"Suctioning will be needed if the baby is floppy."

While the nurse is assessing the fundus of a multiparous client who gave birth 24 hours ago, the client asks, "What can I do to get rid of these stretch marks?" Which response would be most appropriate?

"They usually fade to a silvery-white color over a period of time"

Which statement by the nurse would be most appropriate when responding to a primigravid client who asks, "What should I do about this brown discoloration across my nose and cheeks?"

"This usually disappears after birth."

The prenatal client wants to know why the nurse is asking about their use of herbal supplements. What is the nurse's best response?

"Understanding the full picture of what herbal supplements you use to manage your health will help us better provide coordinated and safe care."

The nurse is caring for a client who has decided to bottle-feed their newborn after meeting with the lactation consultant. The client asks how to best reduce breast engorgement. What is the nurse's best response?

"Use ice packs, and avoid stimulating the breasts at all. It should resolve in a few days."

The nurse is caring for a client who is gravida 2 para 1 and in active labor. The client asks the nurse if this labor is expected to be different from the first. What response by the nurse is most accurate?

"Usually it takes about half as long as your first labor."

A 15-year-old primipara who gave birth to a term neonate vaginally tells the nurse, "My parent started feeding me rice cereal when I was only 2 weeks old." What would be the most appropriate response to the client?

"Wait until the infant is at least 4 months of age before using cereal."

The nurse has completed discharge teaching with new parents who will be bottle-feeding their term newborn. Which statement by the parents reflects the need for more teaching?

"We should weigh our baby daily to make sure they are gaining weight."

Which response would be most appropriate for the nurse when comforting a primiparous client whose critically ill neonate born at 25 weeks dies while the birth parent is present?

"You can stay with your baby as long as you want and say anything you want."

A nurse is performing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible asphyxia in utero? Select all that apply.

-The neonate's toes do not fan out when soles of the feet are stroked. -The neonate doesn't respond when the nurse claps her hands above him. -The neonate displays weak, ineffective sucking.

A nurse in a prenatal clinic is assessing a client who is 28 weeks' pregnant. Which findings lead the nurse to suspect that the client has mild preeclampsia?

1+ protein, blood pressure 142/92 mmHg

A new parent asks, "When will the soft spot near the front of my baby's head close?" When should the nurse tell the parent the soft spot will close?

12 to 18 months

A laboring client with preeclampsia is prescribed magnesium sulfate 2g per hour intravenous (IV) piggyback. The pharmacy sends the IV to the unit labeled magnesium sulfate 20 g/500 mL normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour? Record your answer using one decimal place.

50 ml/hr

A primiparous client who is bottle-feeding their neonate asks, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age?

6 months

A labor and birth nurse is assessing the fetal heart rate of a client who is at term. Which rate would cause the nurse to intervene?

60-79 beats per minute

The nurse is caring for a neonate who has a suspected neonatal sepsis. The health care provider's order is for ampicillin 100 mg/kg/day to be given in four divided doses. The client weighs 7 lb, 8 oz (3.4 kg). How many milligrams would the nurse give with each dose? Record the answer using a whole number.

85

While the nurse is caring for a neonate born at 32 weeks' gestation, which finding would most suggest the infant is developing necrotizing enterocolitis (NEC)?

Abdominal distention

The nurse is caring for an adult female client who arrived at the emergency department with left sided abdominal and back pain. Today, 1400 Client is tearful. States that they have had abdominal discomfort on the left side of the umbilicus and back for 24 hours. Pain level reported as 5 out of 10. Client is diaphoretic, nauseated, abdomen soft, positive bowel sounds. Last bowel movement was 2 days ago.Vital signs: 98.8°F (37.1°C), heart rate 120 beats/min, respiration 24 breaths/min, blood pressure 162/88 mm HgLast menstrual period 6 weeks ago. Client denies pregnancy stating that they have an intrauterine device implanted to prevent pregnancy.

Actions to Take Administer methotrexate. Begin intravenous therapy. Possible Conditions Ectopic pregnancy Parameters to monitor Abdominal pain Serum hCG level

A nurse in a telemetry unit is providing care to a 36-year-old female client who is at 28 weeks' gestation. Client was admitted to the telemetry unit after experiencing increasing shortness of breath and fatigue over the past 2 days. Client reports that shortness of breath occurs especially when trying to lie flat or with exertion. Client thought it was related to their pregnancy; client is at 28 weeks' gestation with their first child. Today the client experienced palpitations, dizziness, and some chest discomfort. Then, they passed out for a few seconds. Their spouse drove them to the emergency department (ED). Client's chest pain had subsided by the time they arrived at the ED. A 12-lead electrocardiogram (ECG) and cardiac enzymes were obtained and a myocardial infarction was ruled out but some abnormalities of the left ventricle were noted on the ECG. Client was admitted to the telemetry unit for further observat

Actions to Take Request a prescription for a beta blocker medication. Prepare the client for echocardiography. Potential Conditions hypertrophic cardiomyopathy Parameters to Monitor lung sounds vital signs

A client gives birth to a neonate prematurely at 28 weeks' gestation. The neonate's Apgar score is 5 at 1 minute. What is the nurse's most important intervention for this premature neonate?

Administer oxygen.

On the second postpartum day after a cesarean birth, the client reports having gas pains. What should the nurse should instruct the client to do?

Ambulate more often.

A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from the episiotomy. What should the nurse instruct the client to do?

Apply an ice pack to the perineum.

An adolescent client in labor is dilated 4 cm and asks for an epidural. For cultural reasons, the client's parent states that the adolescent child "has to bite the bullet, just like I did." What should the nurse do to make sure the client's request is honored?

Ask the client in a nonthreatening way if they wish to have an epidural, and then speak with the health care provider.

Client's vital signs stable at present. Perineal pad changed for moderate amount of red drainage. Uterus palpated at the level of the umbilicus and to the left side of the abdomen. The nurse is assessing a client who is 4 hours postpartum. Based on the findings documented by the nurse, which action is most appropriate at this time?

Ask the client to empty their bladder.

A nursery nurse performs an assessment on a 1-day-old neonate. During the assessment, the nurse notes discharge from both of the neonate's eyes. The nurse should take which step to help determine whether the neonate has ophthalmia neonatorum?

Ask the physician for an order to obtain cultures of both of the neonate's eyes.

A laboring client is experiencing increased pain and asks the nurse when they can have an epidural. Which would be a priority intervention by the nurse to establish whether the client can have an epidural?

Assess cervical dilation.

The clinic nurse is assessing a postpartum client's fundus at the umbilicus 2 weeks after giving birth. Which of the following would the nurse include in the client's plan of care?

Assess the client's bleeding flow and color.

Two hours ago, a multigravid client was admitted in active labor with the cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on their lips, and extreme irritability. What should the nurse do first?

Assess the client's cervical dilation and station.

The health care provider (HCP) plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, what should the nurse do first?

Assess the fetal heart rate (FHR) for 1 full minute.

A couple arrives at the hospital stating that the client's contractions started 3 hours ago. As they are walking into the room, the client tells the nurse that this is their fifth baby. What is the nurse's first priority while performing the admission?

Assess the imminence of birth.

A primigravid client has just completed a difficult, forceps-assisted birth of a 9-Ib (4.08-Kg) neonate. Labor was unusually long and required oxytocin augmentation. The nurse who's caring for the client should stay alert for uterine

Atony

A 26-year-old primigravida visiting the prenatal clinic for their regular visit at 34 weeks' gestation tells the nurse that they take mineral oil for occasional constipation. What should the nurse should instruct the client to do?

Avoid taking mineral oil because it interferes with the absorption of fat-soluble vitamins.

A 6-hour-old neonate born at 38 weeks' gestation by cesarean birth after prolonged rupture of the membranes and a maternal oral temperature of 102°F (38.8°C) is being observed for signs and symptoms of infection. Which sign would alert the nurse to notify the health care provider (HCP)?

Behavioral changes

A nurse uses Nitrazine paper to determine whether a pregnant client's membranes have ruptured. If the membranes have ruptured, the paper will turn which color?

Blue

A nurse has been teaching a new birth parent how to feed the infant who was born with a cleft lip and palate. Which action by the client indicates that the teaching has been successful?

Burping the baby frequently

A postpartum client gave birth 6 hours ago without anesthesia and just voided 100 mL. The nurse palpates the fundus two fingerbreadths above the umbilicus and off to the right side. What should the nurse do first?

Catheterize the client.

While assessing a multigravid client at 10 weeks' gestation, the nurse notes a purplish color to the vagina and cervix. The nurse documents this as what finding?

Chadwick's sign

A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?

Change the client's position

A nurse is caring for a client who gave birth to a baby 2 hours ago. The nurse notes the client's perineal pad contains some small clots and a moderate amount of lochia has accumulated under the buttocks. What is the first action the nurse should take at this time?

Check the fundus for position and consistency.

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm?

Close all of the doors on the unit.

A new parent in the obstetrical unit notifies the nurse that their newborn is missing from the bassinet in the room. What should the nurse do? Select all that apply.

Close the unit and prevent anyone from entering or exiting. Search the entire unit for the infant. Alert the hospital security department of the abduction.

An alarm signals, indicating that a neonate's security identification band requires attention. The nurse responds immediately and finds that the parents removed the identification bands from the neonate. Which action should the nurse take next?

Compare the information on the neonate's identification bands with that of the birth parent's, then reattach the identification bands to one of the neonate's extremities.

The nurse is facilitating a childbirth education class with a group of parents. On the first day of class, the nurse finds that none of the clients is a first-time parent. Which of the following would be a teaching strategy to best assist the clients?

Complete a needs assessment about what the parents are interested in learning.

On examination of a newborn client, the nurse notes a macular, blue-black area of pigmentation near the buttocks. Which nursing action is appropriate?

Consider the finding as normal.

The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3912 g (3.91 kg) at birth. Today the neonate, who is being bottle-fed, weighs 3572 g (3.57 kg). Which instruction should the nurse give the parent?

Continue feeding every 3 to 4 hours since the weight loss is normal.

A client who had a Papanicolaou (Pap) test 2 months ago and is now beginning oral contraceptives tells the nurse that their menstrual flow has decreased since taking the oral contraceptives. What should the nurse tell the client to do?

Continue to take the oral contraceptives because decreased menstrual flow is normal.

The health care provider prescribes a tocolytic for a pregnant client with premature rupture of the membranes who begins to have contractions every 10 minutes. The drug has had expected effects when the nurse observes which finding?

Contractions cease

The nurse has administered promethazine intravenously to a client in active labor. The drug has had the desired effect when the nurse notes which finding?

Decreased nausea and vomiting

On the second postpartum day, the nurse enters the room and notices that the client is holding a crying baby and lightly rubbing the infant's back. The client states, "I don't know why my baby won't stop crying all the time." Which of the following is the most appropriate nursing intervention?

Demonstrate ways that the client can comfort the baby.

A nurse is caring for a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when the client says that they want to breast-feed the neonate?

Discourage breast-feeding because HIV can be transmitted through breast milk.

While assessing a 2-hour-old neonate, a nurse observes that the neonate has acrocyanosis. Which nursing action should the nurse perform at this time?

Do nothing — acrocyanosis is normal in the neonate.

The nurse notes a client has produced 1700 mL of dilute urine in the 12-hour period following cesarean birth. What action would the nurse take based on this finding?

Document the finding, and complete routine postpartum assessment.

While assisting a multiparous client to the bathroom for the first time 1 hour after a vaginal birth, the nurse notes that the client's urine has two small blood clots in the measuring container. What should the nurse do next?

Document this observation as a normal finding.

Which instruction should a nurse give to a client who's 26 weeks pregnant and reports of constipation?

Encourage the client to increase the intake of roughage and to drink at least six glasses of water per day.

3/6 The nurse recognizes that care needs to be prioritized. Select the four (4) most important care tasks.

Episiotomy wound care with site culture. Notify the provider of abnormal findings. Administer pain medication as ordered. Draw labs

While a birth parent is feeding a full-term neonate 1 hour after birth, the birth parent asks the nurse, "What are these white dots in my baby's mouth? I tried to wash them out, but they're still there." After assessing the neonate's mouth, the nurse explains that these spots indicate which condition?

Epstein's pearls

A client had a complicated pregnancy and childbirth and has just experienced the loss of the infant. The postpartum nurse assigned to care for the client is preparing for the client's care. What is the nurse's most appropriate initial action?

Gather pertinent information and enter the room, asking the client and the family how the staff can be most helpful.

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's birth parent tells the nurse that they were planning to breastfeed the neonate. Which instructions about breastfeeding would be most appropriate?

Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

1/6 A 21-year-old female has given birth in the hospital. Which vital(s) and assessment(s) does the nurse identify as concerning? Select all that apply.

Heart rate of 112 beats per minute Respiratory rate of 35 breaths per minute Temperature of 101.0°F (38.4°C) Edema, redness and yellow drainage present at the episiotomy site

What site should the nurse use to obtain a blood sample to screen a neonate for phenylketonuria (PKU)?

Heel

While assessing a neonate weighing 3175 g (3.2 kg) who was born at 39 weeks' gestation to a primiparous client who reports opiate use during pregnancy, the nurse understands that which finding would indicate possible opiate withdrawal?

High-pitched cry

After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when they say they will need to do which action?

Hold their breath throughout the length of the contraction.

A neonate born by cesarean birth at 42 weeks' gestation, weighing 4100 g (4.1 kg), with Apgar scores of 8 at 1 minute after birth and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours after birth. What is the priority problem for this neonate?

Hypoglycemia

The nurse is caring for a primiparous client and their neonate immediately after birth. The neonate was born at 41 weeks' gestation and weighs 4082 g (4.1 kg). Assessing for signs and symptoms of which condition should be a priority in this neonate?

Hypoglycemia

The nurse should be especially alert for what problem when caring for a term neonate, who weighed 10 lb (4500 g) at birth, 1 hour after a vaginal birth?

Hypoglycemia

6/6 The nurse reassesses the client after the postpartum hemorrhage protocol was initiated. Complete the following sentence by choosing from the list of options. The nurse reports that the clients condition has ____ with next step being to ____

Improved Continue to monitor peripads and fundus

A nurse is caring for a client who gave birth vaginally and is experiencing heavy vaginal bleeding. Which priority nursing action(s) should the nurse perform? Select all that apply

Insert straight catheter per protocol Perform fundal massage Administer uterotonics per protocol Monitor vital signs

A nurse is caring for laboring G2P1 client who is at 39 weeks gestation. Based on the most current findings, the nurse should take which four (4) nursing actions?

Instruct the client to stop pushing. Call for help. Push client's thighs to the abdomen to flex and abduct the hips. Apply suprapubic pressure.

A neonate is experiencing respiratory distress and is using a neonatal oxygen mask. An unlicensed assistive personnel (UAP) has positioned the oxygen mask (view the figure). What does the nurse assessing the infant determine about the UAP's mask selection?

It is appropriate for the neonate

After a long labor process, a primigravid client gives birth to a healthy newborn with a moderate amount of skull molding. What information would the nurse include when explaining to the client about this condition?

It usually lasts a day or two before resolving.

When caring for the neonate of a birth parent with gestational diabetes, which finding is most indicative of a hypoglycemic episode?

Jitteriness

5/6 The nurse is initiating the postpartum hemorrhage protocol. Which two (2) orders would the nurse complete immediately?

Massage fundus. Administer misoprostol.

A nurse is caring for a multiparous client in the fourth stage of labor. Assessment reveals a boggy uterus. Which nursing intervention has the highest priority?

Massage the uterus

While preparing to provide neonatal care instructions to a primiparous client who gave birth to a term neonate 24 hours ago, what should the nurse include in the client's teaching plan?

Milia are white papules from plugged sebaceous ducts that disappear by age 2 to 4 weeks.

When assessing a neonate, the nurse observes a vaguely outlined area of scalp edema that is most likely caput succedaneum. What is the most appropriate nursing action based on this finding?

Note the finding on the assessment record.

A client who gave birth to a healthy baby 6 hours ago is having cramps in their legs. Upon further assessment, the nurse identifies leg pain on dorsiflexion. What action should the nurse take?

Notify the health care provider (HCP).

The nurse assesses a 15-hour-old infant and finds jaundice. What is the priority action the nurse needs to take?

Notify the health care provider of the finding.

4/6 Select the orders that the nurse should include in the plan of care.

Nursing orders Intake and output Massage fundus Weigh peripads Oxygen to keep 02 saturation over 92% Laboratory orders Type and cross match blood Hemoglobin and hematocrit Medication orders Misoprostol Colloid fluids

A nurse is caring for a newborn who has developed sepsis. The health care provider has given the following orders. Which order will the nurse implement first?

Obtain blood cultures

1/6 The client is a gravida 3, now para 3. Transferred from the labor and delivery unit following a vaginal birth. Client required stitches for a 2nd degree perineal tear. Edema noted around perineal area. Fundus boggy, midline, 2 cm above umbilicus. Client has saturated 1 pad/hour since delivery. An orange sized blood clot is also on the pad. States, "I feel funny, somewhat tingly." Select four (4) assessment findings which need immediate follow-up by the nurse.

Pad saturation Client statement Boggy fundus Orange-sized blood clot

A primigravida states, "I think my water just broke." What should the nurse do? Select all that apply.

Perform a nitrazine test to confirm that the membranes are ruptured. Monitor the fetal heart rate and pattern. Assess maternal temperature.

The nurse is caring for a full-term, nonmedicated, primiparous client who is in the transition stage of labor. The client is writhing in pain and saying, "Help me, help me!" The client's last vaginal examination was 1 hour ago and showed the client was 8 cm dilated, +1 station, and in what appeared to be a comfortable position. What does the nurse anticipate as the highest priority intervention in caring for this client?

Perform a vaginal examination to determine if the client is fully dilated.

A nurse is assessing a full-term neonate and discovers a heart rate of 100 beats/minute and an axillary temperature of 97.3°F (36.3°C). What action should the nurse take?

Place a cap on the neonate's head, and offer the neonate to the birth parent for skin-to-skin contact.

A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Which action should the nurse take?

Place the client on their left side and start supplemental oxygen, as ordered.

The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn?

Places the infant horizontally and in a prone position with one hand

During a home visit to a breastfeeding primiparous client 1 week after birth, the client tells the nurse that their nipples have become sore and cracked from the feedings. Which instruction should the nurse give the client?

Position the baby with as much of the areola as possible in the baby's mouth.

The nurse is caring for a pregnant client. The nurse notes hypotension and a non-reassuring fetal heart tracing. Which action would the nurse include in the client's plan of care?

Position the client on their left side.

A nurse is assisting a grieving client and spouse to deal with the loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply.

Provide an early opportunity for the couple to see the child if desired. Offer to stay with the grieving parents. Answer the parents' questions accurately.

When preparing a multigravid client at 34 weeks' gestation experiencing preterm labor for the shake test performed on amniotic fluid, the nurse would instruct the client that this test is done to evaluate the maturity of which fetal system?

Pulmonary

A client at 22 weeks' gestation has right upper quadrant pain radiating to their back. The client rates the pain as 9 on a scale of 0 to 10 and says that it has occurred two times in the last week for about 4 hours at a time. The client does not associate the pain with food. Which nursing measure is the highest priority for this client?

Refer the client to their health care provider for evaluation and treatment of the pain.

A nurse notices repetitive late decelerations on the fetal heart monitor. What are the best initial actions by the nurse?

Reposition the client, apply oxygen, and increase IV fluids.

Which action by the nurse would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched?

Request that the health care provider evaluate the neonate's neurologic status.

A client received magnesium sulfate during labor. Which condition should the nurse anticipate as a potential problem in the neonate?

Respiratory depression

At birth, a neonate weighs 7 lb, 3 oz (3,267 g). When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb (3,182 g) and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should add which nursing diagnosis to the care plan?

Risk for injury related to hyperbilirubinemia

A nurse is working on a labor and delivery unit that requires all visitors to pass a screening protocol prior to entry. What is the nurse's priority action when a person gains access to the unit after bypassing the screening protocol?

Stop the visitor, and ask for identification.

A client's partner tells the nurse that they will remain in the waiting room while the client is in labor. The client's sibling has been chosen to be the birth companion. Which of the following responses from the nurse would be most appropriate?

Tell the partner that they will receive updates of the client's progress and be called as soon as the baby is born.

A client is seeking infertility treatment after attempting pregnancy for 2 years. Of the data from the client's history, which has the greatest impact on infertility?

The client is a gymnast weighing 105 lb (47.6 kg).

2/6 After analyzing the concerning assessment data, what conclusion can the nurse make regarding the client? Select the best answer.

The client is developing an infection at the episiotomy site.

While assessing a primiparous client 8 hours after birth, the nurse inspects the episiotomy site, finding it edematous and slightly reddened. Which interpretation by the nurse is most appropriate?

The client needs application of an ice pack

A client asks the nurse if they are at risk for developing postpartum depression. Which of the following assessment data would further assist the nurse to identify a postpartum depression risk? Select all that apply.

The client states they have a history of postpartum depression. The client states they have a history of depression. The client's partner has stated the couple has financial problems. The client's pregnancy has had multiple complications.

A primigravid client gave birth vaginally 2 hours ago with no complications, As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority?

The client will demonstrate self-care and infant care by the end of the shift

Following a cesarean birth for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other births were like this." Which factor is most important for the nurse to consider when responding to the client?

The client's feeling of grief is a normal reaction.

A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when they ambulated to the bathroom after sleeping for 4 hours, their dark red lochia seemed heavier. Which information would the nurse include when explaining to the client about the increased lochia on ambulation?

The increased lochia occurs from lochia pooling in the vaginal vault.

A client is experiencing contractions every 3 minutes, right occiput posterior (ROP) position, intact membranes, and a moderate amount of bloody show. The quality of the tracing on the external fetal monitor is poor, and the nurse would like to place an internal fetal scalp electrode (FSE) to assess the baby better. Which of these prevents the nurse from being able to complete this activity?

The intact membranes

The client and their partner are very distressed and state that they feel the nurse has been negligent in providing care during labor. What is the nurse's best defense against an accusation of negligence?

The national standards of practice were met when providing care.

The community nurse works with the family to answer their questions on infant care. The nurse would like to maintain therapeutic boundaries within the therapeutic relationship. Which of the following is the best way to maintain boundaries?

The nurse does not disclose their home address or accept the invitation to stay for lunch.

While caring for a neonate 2 days after birth, the nurse observes a swelling on the neonate's head that does not cross the cranial suture line. What should the nurse tell the client about the swelling?

The swelling will resolve without treatment by 6 weeks of age.

When developing a teaching plan for the parents of a neonate who is to receive phototherapy, the nurse should give the parents which information? Select all that apply.

Their baby's eyes will be covered. The vital signs will need to be monitored frequently. They will be able to visit and care for their baby.

A nurse is conducting an assessment of a neonate born 3 hours ago. Which finding makes the nurse suspect a congenital hip dislocation?

Unequal gluteal folds

A nurse is assessing a neonate. Health history findings indicate that the birth parent drank 3 oz (90 mL) or more of alcohol per day throughout pregnancy. Which characteristic should the nurse expect to find?

Upturned nose

3/6 Complete the following sentence by choosing from the list of options. The client is most likely experiencing a postpartum hemorrhage caused by

Uterine atony

2/6 For each assessment finding, click to indicate if the finding is consistent with a postpartum hemorrhage related to uterine atony, a pelvic hematoma, or a laceration of the genital tract.

Uterine atony Boggy fundus Saturation of 1 pad/hr. pulse oximeter, 90-% decreasing blood pressure client statement of feeling tingly An orange size blood clot Pelvic hematoma pulse oximeter, 90-% decreasing blood pressure client statement of feeling tingly Laceration of the genital tract pulse oximeter, 90-% decreasing blood pressure client statement of feeling tingly

Four hours after the cesarean birth of a neonate weighing 4000 g (8 lb, 13 oz), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response about vaginal birth after cesarean (VBAC) on which standard of practice?

VBAC may be possible if the client has not had a classic uterine incision.

A nurse is providing care to a neonate. Place the following steps in the order that the nurse would implement them to properly perform ophthalmia neonatorum prophylaxis. All options must be used.

Wash hands and put on gloves. Shield the neonate's eyes from direct light, and tilt the head slightly to the side that will receive the treatment. Gently raise the neonate's upper eyelid with the index finger and gently pull the lower eyelid down with the thumb. Instill the ointment in the lower conjunctival sac. Close and manipulate the eyelids to spread the medication over the eye. Repeat the procedure for the other eye.

A nurse in the neonatal nursery is preparing to perform phenylketonuria (PKU) testing. Which neonate is ready for the nurse to test?

a 2-day-old neonate who has been breast-fed

The nurse is caring for four clients in labor. Which client is at most risk for a postpartum hemorrhage?

a client who is a gravida 4 para 3 with a history of polyhydramnios with this pregnancy

A client is admitted to the facility with a suspected ectopic pregnancy. When reviewing the client's health history for risk factors for this abnormal condition, what would the nurse most expect to find?

a history of pelvic inflammatory disease

While assessing a postterm neonate, the nurse explains to the birth parent that postterm neonates typically exhibit which characteristic?

a long, thin body

A primiparous client, who has just given birth to a healthy term neonate after 12 hours of labor, holds and looks at their neonate and begins to cry. The nurse interprets this behavior as a sign of which response?

a normal response to the birth

At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/min. What is this neonate most likely experiencing?

a state of deep sleep

While the nurse is caring for a neonate born at 32 weeks' gestation, which finding would most suggest the infant is developing necrotizing enterocolitis (NEC)?

abdominal distention

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate?

adduction and flexion of the extremities with gently rounded shoulders

A small-for-gestational-age infant is born with facial abnormalities and vision abnormalities. These abnormalities are likely caused by which maternal factor?

alcohol consumption

Which behavior should cause the nurse to suspect that a client's labor is moving quickly and that the health care provider should be notified?

an increased sense of rectal pressure

The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. The nurse should contact the health care provider to further assess the baby and request which prescription?

an x-ray for nasogastric tube placement

When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which point?

at about the level of the client's umbilicus

What interval should the nurse use when assessing the frequency of contractions of a multiparous client in active labor admitted to the birthing area?

beginning of one contraction to the beginning of the next contraction

A client is in the last trimester of pregnancy. The nurse should instruct the client to notify the primary health care provider immediately of:

blurred vision.

A primigravid client at 26 weeks' gestation visits the clinic and tells the nurse that their lower back aches when they arrive home from work. The nurse should suggest that the client perform which exercise?

blurred vision.

The fetus of a multigravid client at 38 weeks' gestation is determined to be in a frank breech presentation. The nurse describes this presentation to the client as which fetal part coming in contact with the cervix?

buttocks

The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean birth?

client at 38 weeks' gestation with active herpes lesions

A client is 37 weeks gestation and is experiencing preeclampsia. The health care provider has ordered magnesium sulfate, increased fetal surveillance, and increased nursing interventions. The nightshift charge nurse is preparing the client-nurse assignment before the morning shift begins. Which factors should be the primary factor in the decision surrounding who should care for this client?

complexity of care requirements

The nurse reviews the daily weights of a breastfeeding term newborn. The nurse's best action is to:

continue routine monitoring.

The nurse should assess a newborn with esophageal atresia and tracheoesophageal fistula (TEF) for which complications? Select all that apply.

copious frothy mucus episodes of cyanosis distended abdomen

A 24-year-old client admitted to the hospital is suspected of having an ectopic pregnancy. On admission, which factor would be most important to assess?

date of last menstrual period

A nurse is caring for a client on a labor and delivery unit. Complete the following sentences by choosing from the list of drop-down options. The nurse analyzes that due to the client's___, the infant has developed ___.

delivery method cephalohematoma

A 19-year-old unmarried college student who is approximately 8 weeks pregnant asks the nurse, "If I have an abortion in the next 2 or 3 weeks, how will it be done?" The nurse instructs the client that at this gestational age, an abortion is usually performed by which technique?

dilatation and curettage

A neonate weighing 3 lb, 5 oz (1,503 g) is born at 32 weeks' gestation. During an assessment 12 hours after birth, a nurse notices these signs and symptoms: hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness. These symptoms indicate

drug dependence

At which time should the nurse anticipate assisting a client to breastfeed their neonate?

during the neonate's first period of reactivity

A nurse is evaluating the external fetal monitoring strip of a client who is in labor. The nurse notes decreases in the fetal heart rate (FHR) that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding?

early decelerations

When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is most appropriate?

encouraging increased fluid intake

A client in labor asks the nurse about Reiki, an alternative therapy that they have heard may be useful during the intrapartum period. The nurse tells the client that Reiki is based on the principle of

energy from light touch.

The nurse returns the newborn to the new birth parent after obtaining assessment data and performing newborn interventions. The nurse recognizes the best evidence of positive bonding when the birth parent:

engages in direct eye contact with the infant.

A client whose blood type is A- gives birth to a neonate whose blood type is A+. The client is scheduled to have RhoD) immune globulin administered. Before administering the medication, which action by the nurse is most important?

ensuring that the client understands the procedure and signs a consent for the vaccination

5/6 Complete the following sentence(s) by choosing from the lists of options. The nurse should first perform from the providers orders.

episiotomy wound care with site culture

After the first breastfeeding, the client asks the nurse, "How often should I try to breastfeed?" What frequency should the nurse recommend?

every 2 to 3 hours for the first 48 hours

The nurse is working on a birthing unit that has several unlicensed assistive personnel (UAP). The nurse should instruct the UAP assigned to several clients in labor to notify the nurse if any of the clients have which finding?

evidence of spontaneous rupture of the membranes

While the nurse is performing a complete assessment of a term neonate, which finding would alert the nurse to notify the health care provider (HCP)?

expiratory grunt

Which action is the best precaution against transmission of infection?

eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection

A nurse recognizes that labor is divided into how many stages?

four

A nursery nurse just received the shift report. Which neonate should the nurse assess first?

four-hour-old term neonate with jaundice

When evaluating a pregnant client's fundal height, the nurse should measure in which way?

from the symphysis pubis notch to the highest level of the fundus

A client is at the end of the first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation?

fundus two fingerbreadths above the umbilicus

An antenatal primigravid client has just been informed they are carrying twins. The plan of care includes educating the client concerning factors that put the client at risk for problems during the pregnancy. The nurse realizes the client needs further instruction when they indicate carrying twins puts the client at risk for which complication?

group B streptococcus

While assessing a neonate weighing 3175 g (3.2 kg) who was born at 39 weeks gestation to a primiparous client who reports opiate use during pregnancy, the nurse understands that which finding would indicate possible opiate withdrawal?

high-pitched cry

A nurse is assessing a 1-hour-old neonate in the special care nursery. Which assessment finding indicates a metabolic response to cold stress?

hypoglycemia

After teaching a client about the neonate's positive Babinski reflex, the nurse determines that the birth parent understands the instructions when they say that a positive Babinski reflex indicates which condition?

immaturity of the central nervous system

A breastfeeding primiparous client with a midline episiotomy is prescribed ibuprofen orally. When does the nurse instruct the client to take the medication?

immediately after a feeding

A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which information should be part of this report? Select all that apply.

interpretation of the fetal monitor strip analgesia or anesthesia being used prior birth history support persons with the client

A client who used heroin during the pregnancy gives birth to a neonate. When assessing the neonate, the nurse expects to find

irritability and poor sucking.

3/6 0500The client is admitted from triage with rupture of membranes in early labor. The nurse is performing an admission assessment and going over the labor process. While doing so, the nurse notices that the client nods frequently and the responses are not always appropriate. The client also frequently looks to their partner before answering and has a heavy accent. 0515The nurse asks the client what their native language is and if they understand English. The client states "Chinese and only a little bit." The nurse asks the same of the partner and they just shake their head in a negative manner. The nurse needs to finish the admission assessment and make sure the client is comfortable and understands the labor process. Complete the following sentence(s) by choosing from the lists of options.

language barrier communicate appropriately with the client

The nurse is assessing a neonate born to a birth parent with type 1 diabetes. Which finding is expected?

large size

At a home visit, the nurse assesses a neonate born vaginally 5 days prior. The infant was born at 41 weeks gestation. Which finding warrants further assessment?

loose, watery stool in the diaper

During labor, a primigravid client receives an epidural anesthetic, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia?

maternal hypotension

A multigravid client is admitted to the hospital with a diagnosis of ectopic pregnancy. Because the client's fallopian tube has not yet ruptured, the nurse anticipates that which medication may be prescribed?

methotrexate

A nurse is caring for a 26-year-old G1P1 client who gave birth vaginally. Which four (4) findings indicate that this client is responding to medications?

most current trends in perineal pain most current temperature trends quality of wound discharge reported on 6/24 at 0900 wound approximation reported on 6/24 at 0900

A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress?

nasal flaring

The health care provider prescribes a maternal blood test for alpha-fetoprotein for a nulligravid client at 16 weeks' gestation. When developing the teaching plan, the nurse bases the explanations on the understanding that this test is used to detect which condition?

neural tube defects

A registered nurse on the neonatal unit appropriately uses the chain of command when

notifiing the unit manager of unresolved issues between the nursing unit and housekeeping personnel.

The nurse enters a client's room in the obstetrical unit and notices that the bassinet is empty. The maternal parent does not know where the infant is located. The nurse should first ___ and ___.

notify hospital security with a description of the infant and search the entire unit for the missing infant

4/6 Drag words from the choices below to fill in each blank in the following sentence. The nurse knows to and, in order to continue proper care for the client.

notify the provider anticipate orders

A primigravida, currently about 8 weeks' gestation, and their spouse ask when they should begin the preparation for birth classes that discuss maternal nutrition during pregnancy. Which time would be most appropriate for the nurse to suggest that they begin the classes?

now during the first trimester of pregnancy

After completing discharge instructions for a primiparous client who is bottle-feeding their term neonate, the nurse determines that the parent understands the instructions when the parent says they should contact the health care provider (HCP) if the neonate exhibits which sign or symptom?

passage of a liquid stool with a watery ring

A primiparous client who is beginning to breastfeed their neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with which factor?

passive immunity from maternal antibodies

A primigravid client at 26 weeks' gestation visits the clinic and tells the nurse that their lower back aches when arriving home from work. The nurse should suggest that the client perform which exercise?

pelvic tilts

A nurse is providing care for a postpartum client. Which condition increases this client's risk for a postpartum hemorrhage?

placenta previa

A 25-year-old primiparous client who gave birth 2 hours ago has decided to breastfeed their neonate. Which instruction should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?

placing as much of the areola as possible into the baby's mouth

During the first formula feeding, a client has difficulty getting the neonate to take the artificial nipple into the mouth. In assessing the problem, the nurse should intervene if the parent

pushes only the tip of the nipple into the neonate's mouth.

Parents who bring a 3-week-old neonate to the hospital report that the infant has been "throwing up after every feeding." A nurse notes projectile vomiting while assessing the neonate. X-rays confirm

pyloric stenosis

A neonate born by elective cesarean birth weighs 7 lb, 3 oz (3,267 g). The nurse closely monitors for which assessment finding related to a complication from this type of birth?

respiratory distress

During a scheduled cesarean birth for a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean birth tend to have an increased incidence of which problem?

respiratory distress syndrome

A new nurse is asked to start an I.V. on an antepartum client. The new nurse has performed the procedure only once and isn't familiar with the I.V. pumps used in this facility. The new nurse should:

review the unit's procedure manual.

On a client's second postpartum visit, a health care provider reviews the chart. What's the best term for the lochia described?

rubra

1/6 Click to highlight the findings that will require follow up. The client is admitted from triage with rupture of membranes in early labor. The nurse is performing an admission assessment and going over the labor process. While doing so, the nurse notices that the client nods frequently and the responses are not always appropriate. The client also frequently looks to their partner before answering and has a heavy accent.

rupture of membranes client nods frequently and the responses are not always appropriate. client also frequently looks to their partner before answering

A client who has given birth to a healthy neonate is being discharged. As part of discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the health care provider (HCP) of which finding?

saturating a pad in less than an hour

Which assessment finding should a nurse interpret as abnormal for a 38-week gestation neonate who is 1 hour old?

slight yellowish hue to the skin

A primiparous client who gave birth 3 days ago is to be discharged on heparin therapy. After teaching the client about the possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when they state that the adverse effects include which symptom?

slow pulse

A client is 41 weeks gestation and is admitted to the hospital in true labor. The client has an external fetal monitor in place. What does the nurse recognize as a reassuring fetal heart rate (FHR) pattern?

spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15

Twenty-four hours after cesarean birth, a neonate at 30 weeks' gestation is diagnosed with respiratory distress syndrome (RDS). When explaining to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body's secretion of which substance?

surfactant

4/6 While waiting for the interpreter, the nurse notices, the client putting on clothes over the hospital gown and covering up with the blanket whenever someone knocks on the door to come in the room. Complete the following sentence(s) by choosing from the lists of options. The nurse should first contact the Select...the charge nurse the hospital interpreter the provider Select... in order to

the hospital interpreter communicate appropriately with the client

A client is concerned that their 2-day-old, breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if:

the neonate latches onto the areola and swallows audibly.

A client who is in the third trimester presents at the labor and delivery triage area with a history of a fall. The client has bruising on their back and arms. There is no vaginal bleeding and the fetal heart rate (FHR) shows accelerations. A completed Abuse Assessment Screen indicates the possibility of abuse. The nurse should refer this client to

the social worker on call.

A primigravid client is admitted to the labor and delivery area, where the nurse evaluates the client. Which assessment finding may indicate the need for cesarean birth?

umbilical cord prolapse

A client undergoes an amniotomy. Shortly afterward, the nurse detects large variable decelerations in the fetal heart rate (FHR) on the external electronic fetal monitor (EFM). These findings may signify:

umbilical cord prolapse.

During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a postterm neonate after an oxytocin induction. When the nurse is developing the client's plan of care, which problem should the nurse expect to assess for frequently?

uterine atony

A client at 36 weeks' gestation with type 1 diabetes has an abnormal biophysical profile and is scheduled for a contraction stress test. After explaining the purpose of the test, the nurse determines that the client understands the instruction when they state that the test is done to detect which problem?

uteroplacental sufficiency

After circumcision with a Plastibell, the nurse should instruct the neonate's parent to cleanse the circumcision site with which agent?

warm water

After teaching the client about lochia, the nurse determines that the client understands the instructions when they say that on the 10th or 11th postpartum day, the lochia should be which color?

white

The nurse assesses a postterm neonate. Which finding is considered normal for a postterm infant?

wrinkled, peeling skin