Maternity Final Study Guide

A pregnant client who was of normal prepregnancy weight is now 30 weeks pregnant. She asks the nurse what appropriate weight gain for her should be. What is the nurse's best response?

"25-35 pounds"

The nurse is preparing a class on breastfeeding for pregnant women in their first trimester. The women are from a variety of cultural backgrounds, and all speak English well. Which statement should the nurse include in this presentation?

"Although some cultures believe colostrum is not good for the baby, it provides protection from infections and helps the digestive system to function."

The nurse is supervising a student nurse who is working with a 14-year-old client who delivered her first child yesterday. Which statement indicates that the nursing student understands the particular needs of an adolescent client?

"Because of her age, this client will probably need extra teaching about the terminology for her anatomy."

A client at 16 weeks' gestation has a hematocrit of 35%. Her prepregnancy hematocrit was 40%. Which statement by the nurse best explains this change?

"Because your blood volume has increased, your hematocrit count is lower."

The nurse is preparing a prenatal class about infant feeding methods. The maternal nutritional requirements for breastfeeding and formula-feeding will be discussed. What statement should the nurse include?

"Breastfeeding requires a continued high intake of protein and calcium."

The postpartum client who delivered 2 days ago has developed endometritis. Which entry would the nurse expect to find in this client's chart?

"Cesarean birth after extended labor with ruptured membranes."

A new grandmother comments that when her children were born, they stayed in the nursery. The grandmother asks the nurse why her daughter's baby stays mostly in the room instead of the nursery. How should the nurse respond?

"Contact between parents and babies increases attachment."

The physician has prescribed the medication clomiphene citrate (Clomid) for a client with infertility. What should the nurse's instructions to the woman include?

"Contact the doctor if visual disturbances occur."

During the history, the client admits to being HIV-positive and says she knows that she is about 16 weeks pregnant. Which statements made by the client indicate an understanding of the plan of care both during the pregnancy and postpartally? (Select all that apply.)

"During labor and delivery, I can expect the zidovudine (ZDV) to be given in my IV." "My baby will be started on zidovudine (ZDV) for six weeks following the birth."

A client who delivered 2 hours ago tells the nurse that she is exhausted and feels guilty because her friends told her how euphoric they felt after giving birth. How should the nurse respond?

"Everyone is different, and both responses are normal."

The pregnant client states she does not want "to take all these supplements." What recommendations could the nurse make for the client? (Select all that apply.)

"Folic acid has been found to be essential for minimizing the risk of neural tube defects." "Most women do not have adequate intake of iron pre-pregnancy, and iron needs increase with pregnancy."

A client is at 12 weeks' gestation with her first baby. She has cardiac disease, class III. She states that she had been taking sodium warfarin (Coumadin), but her physician changed her to heparin. She asks the nurse why this was done. What should the nurse's response be?

"Heparin is safer because it does not cross the placenta."

The nurse is caring for a pregnant client. The client's husband has come to the prenatal visit. Which question is the best for the nurse to use to assess the father's adaptation to the pregnancy?

"How are you feeling about becoming a father?"

The nurse is providing education to the new family. Which question by the nurse is best?

"How have your breastfeedings been going?"

After teaching a pregnant client about the effects of smoking on pregnancy, the nurse knows that the client needs further education when she makes which statement?

"I am at increased risk for preeclampsia."

At 32 weeks' gestation, a woman is scheduled for a second non-stress test (following one she had at 28 weeks' gestation). Which statement by the client would indicate an adequate understanding of this procedure?

"I can't get up and walk around during the test."

The nurse is providing follow-up education to a client just diagnosed with vaginal herpes. What statement by the client verifies correct knowledge about vaginal herpes?

"I could have another breakout during my period."

Which statement, if made by a pregnant client, would indicate that she understands health promotion during pregnancy?

"I elevate my legs while sitting at my desk."

A postpartum client has just received a rubella vaccination. The client demonstrates understanding of the teaching associated with administration of this vaccine when she states which of the following?

"I must avoid getting pregnant for 1 month."

The client with blood type A, Rh-negative, delivered yesterday. Her infant is blood type AB, Rh-positive. Which statement indicates that teaching has been effective?

"I need to get RhoGAM so I don't have problems with my next pregnancy."

Which statement made by the pregnant adolescent would indicate to the nurse that she understood her increased risk of physiologic complications during pregnancy?

"I need to take good care of myself so my baby doesn't come early."

A client presents to the antepartum clinic with a history of a 20-pound weight loss. Her pregnancy test is positive. She is concerned about gaining the weight back, and asks the nurse if she can remain on her diet. What is the nurse's best response?

"I understand that gaining weight after such an accomplishment might not look attractive, but weight gain during pregnancy is important for proper fetal growth."

The nursing instructor is conducting a class about attachment behaviors. Which statement by a student indicates the need for further instruction?

"Ideally, initial skin-to-skin contact occurs after the baby has been assessed and bathed."

The mother of a 16-week-old infant calls the clinic concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate?

"It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth."

Which statement by a new mother 1 week postpartum indicates maternal role attainment?

"It works better for me to undress the baby and to nurse in the chair rather than the bed."

The breastfeeding client asks the nurse about appropriate contraception. What is the nurse's best response?

"It's possible to get pregnant before your menstrual period returns. Let's talk about some different options for contraception."

The partner of a client at 16 weeks' gestation accompanies her to the clinic. The partner tells the nurse that the baby just doesn't seem real to him, and he is having a hard time relating to his partner's fatigue and food aversions. Which statement would be best for the nurse to make?

"Many men feel this way. Feeling the baby move in a few weeks will help make it real to you."

The mother of a premature newborn questions why a gavage feeding catheter is placed in the mouth of the newborn and not in the nose. What is the nurse's best response?

"Most newborns are nose breathers."

The client at 9 weeks' gestation has been told that her HIV test was positive. The client is very upset, and tells the nurse, "I didn't know I had HIV! What will this do to my baby?" The nurse knows teaching has been effective when the client makes which statement?

"My baby can get HIV during the pregnancy and through my breast milk."

A client at 20 weeks' gestation has not decided on a feeding method for her infant. She asks the nurse for advice. The nurse presents information about the advantages and disadvantages of formula-feeding and breastfeeding. Which statements by the client indicate that the teaching was successful?

"My baby will have a lower risk of food allergies if I breastfeed."

The community nurse is meeting a new mother for the first time. The client delivered her first child 5 days ago after a 12-hour labor. Neither the mother nor the infant had any complications during the birth or postpartum period. Which statement by the client would indicate to the nurse that the client is experiencing postpartum blues?

"One minute I'm laughing and the next I'm crying."

A couple is at the clinic for preconceptual counseling. Both parents are 40 years old. The nurse knows that the education session has been successful when the wife makes which statement? (Select all that apply.)

"Our children are more likely to have genetic defects." "The tests for genetic defects can be done early in pregnancy."

The nurse is presenting a community education session on female hormones. Which statement from a participant indicates the need for further information?

"Prostaglandin is responsible for achieving conception."

During the initial visit with the nurse at the fertility clinic, the client asks what effect cigarette smoking has on the ability to conceive. What is the nurse's best response?

"Smoking can affect the quantity of sperm."

A postpartum client calls the nursery to report that her newborn's umbilical cord stump is draining, and has a foul odor. What is the nurse's best response?

"Take your newborn to the pediatrician."

The nurse is presenting a class to pregnant clients. The nurse asks, "The fetal brain is developing rapidly, and the nervous system is complete enough to provide some regulation of body function on its own, at which fetal development stage?" It is clear that education has been effective when a participant makes which response?

"The 25th-28th week"

The client at 34 weeks' gestation has been stabbed in the low abdomen by her boyfriend. She is brought to the emergency department for treatment. Which statements indicate that the client understands the treatment being administered? (Select all that apply.)

"The baby needs to be monitored to check the heart rate." "I might need an ultrasound to look at the baby."

A client and her husband have contacted their physician about fertility problems. At the initial visit, the nurse instructs them about the infertility workup. Which statement by the client would indicate that the instructions have been successful?

"The first test that we need to schedule is a semen analysis."

At her first prenatal visit, a woman is discussing fetal development with the nurse. The client asks, "When will my baby actually have a heartbeat?" The nurse should say the heartbeat of an embryo is distinguishable by what time?

"The fourth week"

The home care nurse is examining a 3-day-old infant. The child's skin on the sternum is yellow when blanched with a finger. The parents ask the nurse why jaundice occurs. What is the best response from the nurse?

"The liver of an infant is not fully mature, and doesn't conjugate the bilirubin for excretion."

A woman in labor asks the nurse to explain the electronic fetal heart rate monitor strip. The fetal heart rate baseline is 150 with accelerations to 165, variable decelerations to 140, and moderate long-term variability. Which statement indicates that the client understands the nurse's teaching?

"The most important part of fetal heart monitoring is the presence of variability."

During a prenatal examination, an adolescent client asks, "How does my baby get air?" What correct information would the nurse give?

"The placenta assumes the function of the fetal lungs by supplying oxygen and allowing the excretion of carbon dioxide into your bloodstream."

The nurse is teaching a class on infant care to new parents. Which statement by a parent indicates that additional teaching is needed?

"The red spots with a white center on my baby are abnormal acne."

The client with an abnormal quadruple screen is scheduled for an ultrasound. Which statement indicates that the client understands the need for this additional antepartal fetal surveillance?

"The ultrasound will show whether there are abnormalities with the baby's spine."

A woman is experiencing preterm labor. The client asks why she is on betamethasone. Which is the nurse's best response?

"This medication is effective in stimulating lung development in the preterm infant."

The client at 24 weeks' gestation is experiencing painless vaginal bleeding after intercourse. The physician has ordered a transvaginal ultrasound examination. Which statements by the client indicate an understanding of why this exam has been requested? (Select all that apply.)

"This ultrasound can determine the location of my placenta." "This ultrasound might detect whether the placenta is detaching prematurely."

The parents of a preterm newborn wish to visit their baby in the NICU. A statement by the nurse that would not support the parents as they visit their newborn is which of the following?

"Visits must be scheduled between feedings."

The nurse is working with an adolescent parent. The adolescent tells the nurse, "I'm really scared that I won't take care of my baby correctly. My mother says I'll probably hurt the baby because I'm too young to be a mother." What is the best response by the nurse?

"We can give the baby's bath together. I'll help you learn how to do it."

The nurse is admitting a Mexican woman scheduled for a cholecystectomy. The nurse uses a cultural assessment tool during the admission. Which question would be most important for the nurse to ask?

"What other treatments have you used for your abdominal pain?"

The client at 20 weeks' gestation has had an ultrasound that revealed a neural tube defect in her fetus. The client's hemoglobin level is 8.5. The nurse should include which statement when discussing these findings with the client?

"You haven't had enough folic acid in your diet. You should take a supplement."

The client is recovering from a delivery that included a midline episiotomy. Her perineum is swollen and sore. Ten minutes after an ice pack is applied, the client asks for another. What is the best response from the nurse?

"You need to leave it off for at least 20 minutes and then reapply."

The client having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The client states, "I'm wondering what will be different this time compared with my first birth, which was vaginal." What response is best?

"You'll be wearing a sequential compression device until you start walking."

A woman at 28 weeks' gestation is asked to keep a fetal activity record and to bring the results with her to her next clinic visit. One week later, she calls the clinic and anxiously tells the nurse that she has not felt the baby move for more than 30 minutes. Which of the following would be the nurse's most appropriate initial comment?

"Your baby might be asleep."

The nurse is working with a client who has experienced a fetal death in utero at 20 weeks. The client asks what her baby will look like when it is delivered. Which statement by the nurse is best?

"Your baby will be covered in fine hair called lanugo."

A newly diagnosed insulin-dependent type 1 diabetic with good blood sugar control is at 20 weeks' gestation. She asks the nurse how her diabetes will affect her baby. What would the best explanation include?

"Your baby will probably be larger than average at birth."

The nurse is interviewing an adolescent client. The client reports a weight loss of 50 pounds over the last 4 months, and reports running at least 5 miles per day. The client asserts that her menarche was 5 years ago. Her menses are usually every 28 days, but her last menstrual period was 4 months ago. The client denies any sexual activity. Which is the best statement for the nurse to make?

"Your lack of menses might be related to your rapid weight loss."

The prenatal client in her third trimester tells the clinic nurse that she works 8 hours a day as a cashier and stands when at work. What response by the nurse is best?

"Your risk of preterm labor is higher."

A postpartum patient weighing 165 lbs. is prescribed a subcutaneous injection of Enoxaparin 1 mg/kg twice daily. The medication available is 50 mg/mL. How many mL of medication should the nurse provide for each injection? (Calculate to the nearest tenth decimal point.)

1.5 mL

The order reads 7,500 units of heparin subcutaneous b.i.d. How many ml of heparin will you administer per dose? (picture)

1.5 mL

A patient in preterm labor is prescribed magnesium sulfate 6 grams intravenous infusion now followed by 5 grams per hour. The pharmacy prepares an infusion of 500 mL Lactated Ringer's with 100 grams of magnesium sulfate. If the patient receives the loading dose and 3 hours of the medication, how many total mL of the infusion did the patient receive?

105 mL The solution is 100 grams/500 mL or 1 gram in every 5 mL of solution. If the loading dose is 6 grams, then the patient received 6 grams × 5 mL =30 mL. For each hourly dose of 5 grams, the patient received 5 grams × 5 mL = 25 mL. Since the patient received the dose of 5 grams for 3 hours, then the patient received 25 mL × 3 = 75 mL. With the loading dose of 30 mL plus the three hours of infusion equaling 75 mL, the patient received 105 mL of the infusion.

The nurse is seeing prenatal clients in the clinic. Which client is exhibiting expected findings?

12 weeks' gestation, with fetal heart tones heard by Doppler fetoscope

A patient is labor is prescribed to receive nalbuphine 10 mg/70 kg intravenously now. The patient weighs 198 lbs. How many mg of medication should the nurse provide this patient? (Round to the nearest tenth decimal point.)

12.9 mg

Calculate the infusion time for an IV of 1000 mL running at 75 mL/h.

13 hours, 20 minutes

At birth a newborn weighs 8 lbs. 4 ounces. When discussing the infant's weight over the next week, what is the maximum amount of weight the mother should expect that the infant will lose? (Calculate to the first decimal point.)

13.2 ounces

An IV of NS 1000 mL is to infuse over 12 hours. The drop factor is 10 gtt/mL. Calculate the flow rate in gtt/min.

14 gtt/min

Which client would the nurse document as exhibiting signs and symptoms of primary dysmenorrhea?

14-year-old, irregular menses for 1 year, experiences cramping every cycle

The nurse seeing a client just diagnosed with Chlamydia trachomatis knows that which client is at greatest risk for the infection?

16-year-old sexually active girl, using no contraceptive

Several adolescent female students are waiting to be seen by the school sexual health clinic nurse. Which student should the nurse see first?

16-year-old who had chlamydia treated 2 weeks ago

The nurse has assessed four newborns' respiratory rates immediately following birth. Which respiratory rate would require further assessment by the nurse?

20 breaths per minute

Which client in the gynecology clinic should the nurse see first?

22-year-old with fever, hypotensive, using tampons

A breastfeeding mother is instructed to increase her daily caloric intake an additional 500 calories each day. If her daily intake of protein is 65 grams at 4 calories per gram, how many calories will this patient need to ingest to reach the recommended daily intake?

240 calories

The nurse is measuring the fundal height of a patient who is at 28 weeks gestation using the following method. What would be considered a normal finding? (picture)

28 cm

Order: Ampicillin 165 mg. IV q.8h. The directions on the package state: "Reconstitution of the single-use vial with 4.8 mL yields 250 mg/5 mL." How many milliliters will you administer per dose?

3.3 mL

Each of the following pregnant women is scheduled for a 14-week antepartal visit. In planning care, the nurse would give priority teaching on amniotic fluid alpha-fetoprotein (AFP) screening to which client?

35-year-old with a child with spina bifida

A new parent reports to the nurse that the baby looks cross-eyed several times a day. The nurse teaches the parents that this finding should resolve in how long?

4 months

When counseling a newly pregnant client at 8 weeks' gestation of twins, the nurse teaches the woman about the need for increased caloric intake. What would the nurse tell the woman that the minimum recommended intake should be?

4000 kcal and 135 grams protein

How many ml of medication are in the syringe below? (picture)

5.4 mL

If an IV starts at 1800 hours and lasts for 12 hours, at what time will it finish? (Express in standard time.)

6 a.m.

The nurse admits into the labor area a client who is in preterm labor. What assessment finding would constitute a diagnosis of preterm labor?

8 contractions in 1 hour

The nurse is providing care to a pregnant client during the first trimester of the pregnancy. When will the nurse attempt to auscultate the fetal heart rate by Doppler?

8 to 12 weeks' gestation

Order: 2000 mL D5W IV infused in six hours. The drop factor is 15 gtt/mL. Calculate the flow rate in gtt/min.

83 gtt/min

The nurse manager is planning a presentation on ethical issues in caring for childbearing families. Which example should the nurse manager include to illustrate maternal-fetal conflict?

A cesarean delivery of a breech fetus is court ordered after the client refuses.

The clinic nurse is compiling data for a yearly report. Which client would be classified as a primigravida?

A client at 15 weeks' gestation who has never been pregnant before

The nurse is responding to phone calls. Whose call should the nurse return first?

A client at 37 weeks' gestation reports no fetal movement for 24 hours.

A nurse is performing an assessment on a family with a father and mother who both work. What type of family does she record this family as being?

A dual-career/dual-earner family

Why is it important for the nurse to assess the bladder regularly and encourage the laboring client to void frequently?

A full bladder can impede fetal descent.

The nurse knows that in some cases, breastfeeding is not advisable. Which mother should be counseled against breastfeeding?

A mother who is HIV positive

The client tells the nurse that she has come to the hospital so that her baby's position can be changed. The nurse would begin to organize the supplies needed to perform which procedure?

A version

The nurse is conducting an initial prenatal assessment for a pregnant client. Which screenings should the nurse prepare the client for during this visit? (Select all that apply.)

ABO and Rh typing HIV screening Complete blood count (CBC) Urinalysis

An older person contacts the emergency medical service at 11 PM to report that she has been left sitting in her wheelchair all day after the caregiver left in the morning to buy groceries. What type of elder abuse is this person experiencing?

Abandonment

A Chinese woman who is 12 weeks pregnant reports to the nurse that ginseng and bamboo leaves help reduce her anxiety. How should the nurse respond to this client?

Advise the client to give up all herbal remedies.

The multiparous client at term has arrived to the labor and delivery unit in active labor with intact membranes. Leopold maneuvers indicate the fetus is in a transverse lie with a shoulder presentation. Which physician order is most important?

Alert surgical team of urgent cesarean.

The nurse provides the following diagram to a patient in the 3rd trimester of pregnancy. For which diagnostic test is the nurse preparing this patient? (picture)

Amniocentesis

Before the nurse begins to dry off the newborn after birth, which assessment finding should the nurse document to ensure an accurate gestational rating on the Ballard gestational assessment tool?

Amount and area of vernix coverage

The nurse is assessing a client who reports seeing an acupuncturist on a weekly basis to treat back pain. The nurse understands that acupuncture is an example of what?

An alternative therapy A complementary therapy

On assessment, a labor client is noted to have cardiovascular and respiratory collapse and is unresponsive. What should the nurse suspect?

An amniotic fluid embolus

The postpartum client who is being discharged from the hospital experienced severe postpartum depression after her last birth. What should the nurse include in the plan of follow-up care for this client?

An appointment with a mental health counselor

Which of the following symptoms would be an indication of postpartum blues? (Select all that apply.)

Anger Crying Mood swings

On the 3rd day postpartum, a client who is not breastfeeding experiences engorgement. To relieve her discomfort, the nurse should encourage the client to do which of the following?

Apply cold packs to the breasts

The nurse teaches the parents of an infant who recently was circumcised to observe for bleeding. What should the parents be taught to do if bleeding does occur?

Apply gentle pressure to the site with gauze.

The nurse who is taking a sexual history from a client should do which of the following?

Ask mostly open-ended questions.

The nurse is preparing to receive a newly delivered client. The client is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important?

Ask the client how much contact she would like with the baby, and whether she wants to feed it.

The client with limited English language skills has a black eye, and bruises across her face and arms. The client's husband has been acting as an interpreter for her, and answers all of the questions the nurse asks, often without talking to his wife first. The nurse suspects the client has been a victim of domestic abuse. What should the nurse do next?

Ask the husband to step out of the room, and obtain an interpreter.

The nurse assesses the postpartum client to have moderate lochia rubra with clots. Which nursing intervention would be appropriate?

Assess fundus and bladder status.

A newborn is receiving phototherapy. Which intervention by the nurse would be most important?

Assessment of hydration status

The client delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight tingling sensation in both lower extremities, but normal movement. She sustained a second-degree perineal laceration. Her perineum is edematous and ecchymotic. What should the nurse include in the plan of care for this client?

Assist the client to the bathroom in 2 hours to void.

If the physician indicates a shoulder dystocia during the delivery of a macrosomic fetus, how would the nurse assist?

Assist the woman into McRoberts maneuver.

When assisting with a transabdominal sampling, which of the following would the nurse do?

Assist the woman into a supine position on the examining table.

The nurse is reviewing the process of fertilization with a group of high school students. Which structure should the nurse identify as the location where fertilization of the ovum occurs? (picture)

B.

A mother who is HIV-positive has given birth to a term female. What plan of care is most appropriate for this infant?

Begin prophylactic AZT (Zidovudine) administration.

A woman asks her nurse what she can do before she begins trying to get pregnant to help her baby, as she is prone to anemia. What would the nurse correctly advise her to do?

Begin taking folic acid supplements daily.

When blood pressure and other signs indicate that the preeclampsia is worsening, hospitalization is necessary to monitor the woman's condition closely. At that time, which of the following should be assessed? (Select all that apply.)

Blood pressure Pulse and respirations Temperature Fetal heart rate

During an assessment, the nurse determines that a female patient is at risk for developing osteoporosis. Which information did the nurse use to make this clinical determination? (Select all that apply.)

Body weight of 120 lbs. Smokes 2 ppd of cigarettes Ingests 2 to 3 cocktails every day Mother diagnosed with osteoporosis

During an intraparum vaginal examination the following is palpated. In which type of presentation is this fetus? (picture)

Breech

The nurse is supervising care in the emergency department. Which situation most requires an intervention?

Bright red bleeding with clots at 32 weeks' gestation; pulse = 110, blood pressure 90/50, respirations = 20

The nurse is reviewing educational material on newborn care with a patient in the 3rd trimester of pregnancy. Which area on the following diagram should the nurse point out as being the anterior fontanelle? (picture)

C in diamond type thing

The nurse is preparing to provide a newborn with a prescribed intramuscular injection. Which area should the nurse use for this injection?

C-picture at the vastus lateralis

Which of the following drugs and drug categories can cause multiple fetal central nervous system (CNS), facial, and cardiovascular anomalies?

Category X: Isotretinoin

The nurse assesses four newborns. Which of the following assessment findings would place a newborn at risk for developing physiologic jaundice?

Cephalohematoma

During the initial intrapartal assessment of a client in early labor, the nurse performs a vaginal examination. The client's partner asks why this pelvic exam needs to be done. The nurse should explain that the purpose of the vaginal exam is to obtain information about which of the following? (Select all that apply.)

Cervical dilation and effacement Presenting part

The labor nurse would not encourage a mother to bear down until the cervix is completely dilated, to prevent which of the following? (Select all that apply.)

Cervical edema Tearing and bruising of the cervix Maternal exhaustion

A patient pregnant with twins late in the 3rd trimester has an ultrasound that shows the position of the fetuses as follows. What should the nurse expect will be planned for this patient? (picture)

Cesarean birth

The laboring client presses the call light and reports that her water has just broken. What would the nurse's first action be?

Check fetal heart tones.

The nurse at the prenatal clinic has four calls to return. Which phone call should the nurse return first?

Client at 32 weeks, reports headache and blurred vision.

During the fourth stage of labor, the client's assessment includes a BP of 110/60, pulse 90, and the fundus is firm midline and halfway between the symphysis pubis and the umbilicus. What is the priority action of the nurse?

Continue to monitor.

What is required for any women receiving oxytocin (Pitocin)?

Continuous electronic fetal monitoring

A laboring client's obstetrician has suggested amniotomy as a method for creating stronger contractions and facilitating birth. The client asks, "What are the advantages of doing this?" What should the nurse cite in response?

Contractions elicited are similar to those of spontaneous labor.

A client who is having false labor most likely would have which of the following? (Select all that apply.)

Contractions that lessen with rest and warm tub baths Contractions that do not intensify while walking Pain in the abdomen that does not radiate

The 22-year-old client is scheduled for her first gynecologic examination. What can the nurse do to make the client more comfortable during this exam? (Select all that apply.)

Create a trusting atmosphere. Show the client what the speculum looks like. Provide a mirror for the client.

During a pelvic examination, a patient is diagnosed with a Bartholin gland cyst. For which treatment should the nurse prepare this patient? (Select all that apply.)

Culture and sensitivity of the discharge Incision and drainage of the cyst Antibiotic therapy

A patient schedules an appointment to be seen in the community clinic for dysuria, urgency, frequency, blood in the urine, and low back pain. For which health problem should the nurse provide care for this patient?

Cystitis

Which of the following is a sign of dehydration in the newborn?

Depressed fontanelles

The nurse is observed performing the following with a patient: (picture) What information will this assessment technique provide to the nurse?

Determines the height of the fundus

A 16-year-old is making her first prenatal visit to the clinic in her fourth month of pregnancy. What is the nurse's first responsibility?

Develop a trusting relationship.

The nurse is teaching the pregnant client symptoms of preeclampsia. Which clinical manifestations will the nurse include in the teaching session? (Select all that apply.)

Dizziness Blurred vision Severe headache

The nurse is planning care for a newborn. Which nursing intervention would best protect the newborn from the most common form of heat loss?

Drying the newborn thoroughly

The nurse is planning an educational session for pregnant vegans. What information should the nurse include?

Eating beans and rice provides complete protein needs.

Which relief measure would be most appropriate for a postpartum client with superficial thrombophlebitis?

Elevate the affected limb

A postpartum client has inflamed hemorrhoids. Which nursing intervention would be appropriate?

Encourage sitz baths.

The nurse is caring for a client who had a cesarean birth 4 hours ago. Which interventions would the nurse implement at this time? (Select all that apply.)

Encourage the use of breathing, relaxation, and distraction. Encourage leg exercises every 2 hours. Encourage the client to cough and deep-breathe every 2 to 4 hours. Administer analgesics as needed.

The client vaginally delivers an infant that weighs 4750 g. Moderate shoulder dystocia occurred during the birth. During the initial assessment of this infant, what should the nurse look for?

Erb palsy

The student nurse encounters a 15-year-old girl who reports that she has no pubic or axillary hair and has not yet experienced growth of her breasts. The student asks the nurse about the physiology of this occurrence. The nurse explains that the client probably lacks which hormone?

Estrogen

A 38 year old female is scheduled for a laparoscopic-assisted vaginal hysterectomy (LAVH) for severe endometriosis with the removal of both ovaries. What should the nurse expect to be prescribed for this patient postoperatively?

Estrogen replacement therapy

In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn?

Eye prophylaxis medication

A cesarean section is ordered for a pregnant client. Because the client is to receive general anesthesia, what is the primary danger with which the nurse is concerned?

Fetal depression

A laboring client's obstetrician has suggested amniotomy as a method for inducing labor. Which assessment(s) must be made just before the amniotomy is performed?

Fetal presentation, position, and station

Clinical features of posttraumatic stress disorder (PTSD) include which of the following? (Select all that apply.)

Flashbacks Difficulty sleeping Irritability

A woman at 7 weeks' gestation is diagnosed with hyperemesis gravidarum. Which nursing diagnosis would receive priority?

Fluid Volume: Deficient

The postpartum client is concerned about mastitis because she experienced it with her last baby. Preventive measures the nurse can teach include which of the following?

Frequent breastfeedings

A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included? (Select all that apply.)

Gently massage the site after injection. Cleanse the site with alcohol prior to injection. Inject in the vastus lateralis muscle.

What is the increased vascularization causing the softening of the cervix known as?

Goodell sign

The nurse is performing Leopold maneuvers with a patient in the 3rd trimester of pregnancy. Which maneuver should the nurse perform first? (picture)

Hands from below on each side

The clinic nurse is assisting with an initial prenatal assessment. The following findings are present: spider nevi present on lower legs; dark pink, edematous nasal mucosa; mild enlargement of the thyroid gland; mottled skin and pallor on palms and nail beds; heart rate 88 with murmur present. What is the best action for the nurse to take based on these findings?

Have the physician see the client today.

The nurse seeks to involve the adolescent father in the prenatal care of his girlfriend. What is the rationale for this nursing strategy?

Having the father more involved with the birth

Before the newborn and mother are discharged from the birthing unit, the nurse teaches the parents about newborn screening tests that includes which of the following?

Hearing screening

Which of the following symptoms, if progressive, are indicative of CHF, the heart's signal of its decreased ability to meet the demands of pregnancy? (Select all that apply.)

Heart murmurs Rales Dyspnea Palpitations

While assisting a female client into the lithotomy position for a pelvic examination the nurse observes the following on the patient's perineum. For which health problem should the nurse expect orders to be written by the healthcare provider? (picture)

Human papillomavirus

The nurse is admitting a client with possible hydramnios. When is hydramnios most likely suspected?

Hydramnios is most likely suspected when the fundal height increases disproportionately to the gestation.

A laboring client has received an order for epidural anesthesia. In order to prevent the most common complication associated with this procedure, what would the nurse expect to do?

Hydrate the vascular system with 500-1000 mL of intravenous fluids

The nurse is explaining induction of labor to a client. The client asks what the indications for labor induction are. Which of the following should the nurse include when answering the client?

Hypertension

A 38-year-old patient is concerned that a month after becoming a widow, her menstrual cycles stopped. What should the nurse suspect as being the cause for this patient's secondary amenorrhea?

Hypothalamic dysfunction

When teaching a culturally diverse group of childbearing families about hospital birthing options, the culturally competent nurse does which of the following?

Incorporates the specific beliefs of the cultural groups that are attending the class

Lesbian and bisexual women are greater risk for health and social disparities, including which of the following? (Select all that apply.)

Increased risk of homelessness Lack of screening for female-related cancers Increased suicide risk

Which of the following would be considered a clinical sign of hemorrhage?

Increasing pulse

The nurse auscultates the FHR and determines a rate of 112 beats/min. Which action is appropriate?

Inform the maternal client that the rate is normal.

The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require which of the following?

Initial resuscitation

The client with insulin-dependent type 2 diabetes and an HbA1c of 5.0% is planning to become pregnant soon. What anticipatory guidance should the nurse provide this client?

Insulin needs decrease in the first trimester and usually begin to rise late in the first trimester as glucose use and glycogen storage by the woman and fetus increase.

A nurse examining a prenatal client recognizes that a lag in progression of measurements of fundal height from week to week and month to month could signal what condition?

Intrauterine growth restriction

During labor, the client at 4 cm suddenly becomes short of breath, cyanotic, and hypoxic. The nurse must prepare or arrange immediately for which of the following? (Select all that apply.)

Intravenous access A crash cart Cesarean delivery

A pregnant client confides to the nurse that she is eating laundry starch daily. The nurse should assess the client for which of the following?

Iron deficiency anemia

Mild or chronic anemia in an infant may be treated adequately which of the following?

Iron supplements or iron-fortified formulas

The nurse manager in a hospital with a large immigrant population is planning an in-service. Aware of how ethnocentrism affects nursing care, the nurse manager asks, "The belief that one's own values and beliefs are the only or the best values has which of the following results?"

It can create barriers to communication through misunderstanding.

A newborn has the following applied to the umbilical cord.

It is removed in 24 hours if the cord has dried

The nurse receives a phone call from a client who claims she is pregnant. The client reports that she has regular menses that occur every 28 days and last 5 days. The first day of her last menses was April 10. What would the client's estimated date of delivery (EDD) be if she is pregnant?

Jan. 17

Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn?

Jitteriness

The nurse is assessing a drug-dependent newborn. Which symptom would require further assessment by the nurse?

Jitteriness and irritability

The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation? (Select all that apply.)

Kernicterus causes irreversible neurological damage. Physiologic jaundice occurs after 24 hours of age.

During an intrapartum vaginal examination the following is assessed. In which position should the patient be placed at this time? (picture)

Knee-chest

When a woman seeks care for an injury, the nurse should be alert to which clues of abuse? (Select all that apply.)

Lack of eye contact Defensive injuries Vague complaints without accompanying pathology

What is the primary carbohydrate in mammalian milk that plays a crucial role in the nourishment of the newborn?

Lactose

The labor and delivery nurse is assigned to four clients in early labor. Which electronic fetal monitoring finding would require immediate intervention?

Late decelerations with minimal variability

A client arrives in the labor and delivery unit and describes her contractions as occurring every 10-12 minutes, lasting 30 seconds. She is smiling and very excited about the possibility of being in labor. On exam, her cervix is dilated 2 cm, 100% effaced, and -2 station. What best describes this labor?

Latent phase

The pregnant client employed at a factory asks the nurse whether exposure to chemicals can cause harm to her fetus. The nurse should advise that exposure to which substance can lead to neurological damage?

Lead

A 38-week newborn is found to be small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn?

Maintain a warm environment.

The nurse provides a postpartum patient with the following diagram. For which procedure is the nurse preparing this patient? picture

Manual compression of the uterus

The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do?

Massage the uterine fundus until it is firm.

What is the major adverse side effect of epidural anesthesia?

Maternal hypotension

What is one of the most common initial signs of nonreassuring fetal status?

Meconium-stained amniotic fluid

The newborn's cry should have which of the following characteristics? (Select all that apply.)

Medium pitch Lusty Strength

The nurse would expect a physician to prescribe which medication to a postpartum client with heavy bleeding and a boggy uterus?

Methylergonovine maleate (Methergine)

A nonpregnant client is diagnosed with bacterial vaginosis (BV). What does the nurse expect to administer?

Metronidazole 500 mg p.o. b.i.d. for a week

The nurse is preparing a class on reproduction. What is the cell division process that results in two identical cells, each with the same number of chromosomes as the original cell called?

Mitosis

The nurse is providing care to a pregnant client who is experiencing an increase in white, thick, and "cottage-cheese-like" vaginal discharge. Based on this data, which diagnosis does the nurse anticipate for this client?

Moniliasis

A client at 32 weeks' gestation is admitted with painless vaginal bleeding. Placenta previa has been confirmed by ultrasound. What should be included in the nursing plan? (Select all that apply.)

Monitoring blood loss, pain, and uterine contractility No vaginal exams Evaluating fetal heart rate with an external monitor

The nurse is answering phone calls at the pediatric clinic. Which call should the nurse return first?

Mother of a 2-week-old infant who doesn't make eye contact when talked to

After nalbuphine hydrochloride (Nubain) is administered, labor progresses rapidly, and the baby is born less than 1 hour later. The baby shows signs of respiratory depression. Which medication should the nurse be prepared to administer to the newborn?

Naloxone (Narcan)

During a routine health visit the nurse notes that a patient who is 10 weeks pregnant is wearing the following item. On what should the nurse focus when assessing the patient? (picture)

Nausea and vomiting

The nurse manager is preparing an educational in-service for staff nurses about elder abuse. The nurse manager develops a hypothetical situation: A wheelchair-bound client who lives with her daughter has experienced hunger because she cannot reach the cupboards to make lunch. Which category of elder abuse does this example describe?

Neglect

The nurse is caring for a client with hydramnios. What will the nurse watch for?

Newborn congenital anomalies

A postpartum mother questions whether the environmental temperature should be warmer in the baby's room at home. The nurse responds that the environmental temperature should be warmer for the newborn. This response is based on which newborn characteristics that affect the establishment of thermal stability? (Select all that apply.)

Newborns have a large body surface to weight ratio. Infants have increased total body water. Newborns have less subcutaneous fat than do adults.

Which of the following tests has become a widely accepted method of evaluating fetal status?

Non-stress test (NST)

A client is having contractions that last 20-30 seconds and that are occurring every 8-20 minutes. The client is requesting something to help relieve the discomfort of contractions. What should the nurse suggest?

Nonpharmacologic methods of pain relief

A variety of drugs are used either alone or in combination to provide relief of postpartum pain. Which of the following would be an option for pain relief?

Nonsteroidal anti-inflammatory agents

The true moment of fertilization occurs when what happens?

Nuclei unite

The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure?

Observe for urine output.

The nurse assesses the postpartum client who has not had a bowel movement by the third postpartum day. Which nursing intervention would be appropriate?

Obtain an order for a stool softener.

The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 mg/dL. What should the nurse include in the plan of care for this newborn?

Offer early feedings with formula or breast milk.

An expectant father has been at the bedside of his laboring partner for more than 12 hours. An appropriate nursing intervention would be to do which of the following?

Offer to remain with his partner while he takes a break.

Recommendations for parents to help their teens avoid pregnancy include which of the following?

Parents should be clear about their own sexual attitudes and values.

A woman is being treated for preterm labor with magnesium sulfate. The nurse is concerned that the client is experiencing early drug toxicity. What assessment finding by the nurse indicates early magnesium sulfate toxicity?

Patella reflexes weak or absent

Remedies for back pain in pregnancy that are supported by research evidence and may safely be taught to any pregnant woman by the nurse include which of the following? (Select all that apply.)

Pelvic tilt Proper body mechanics Maintaining good posture Water aerobics

The nurse is preparing to assess the fetus of a laboring client. Which assessment should the nurse perform first?

Perform Leopold maneuvers to determine fetal position.

A woman is admitted to the birth setting in early labor. She is 3 cm dilated, -2 station, with intact membranes and FHR of 150 beats/min. Her membranes rupture spontaneously, and the FHR drops to 90 beats/min with variable decelerations. What would the initial response from the nurse be?

Perform a vaginal exam.

The nurse sees the following patient in the neonatal intensive care unit and realizes that additional care will need to be provided for which health problem?

Picture of baby with eye mask- hyperbilirubinemia

The nurse is explaining the processes of infant heat loss with a new mother. Which diagram should the nurse use to describe the process of convection?

Picture-convection baby with air current

A client is preparing to take a sitz bath for the first time. What will the nurse do?

Place a call bell well within reach and check on the client frequently.

The student nurse attempts to take a newborn's vital signs, but the newborn is crying. What nursing action would be appropriate?

Place a gloved finger in the newborn's mouth

The nurse is observed conducting the following measurement. For what reason will this measurement be used?

Placement of gavage tube- picture

The nurse knows that a contraindication to the induction of labor is which of the following?

Placenta previa

Upon delivery of the newborn, what nursing intervention most promotes parental attachment?

Placing the newborn on the mother's abdomen.

The nurse is assessing a client who has severe preeclampsia. What assessment finding should be reported to the physician?

Platelet count of less than 100,000/mm3

A nurse is teaching a class on the different types of uterine bleeding. The nurse explains that which of the following is one of the causes of abnormal uterine bleeding?

Polyps

The postpartum client states that she doesn't understand why she can't enjoy being with her baby. What would the nurse be concerned about?

Postpartum depression

The postpartum nurse is caring for a client who gave birth to full-term twins earlier today. The nurse will know to assess for symptoms of which of the following?

Postpartum hemorrhage

Which of the following is the most prevalent medical complication of pregnant adolescents?

Preeclampsia-eclampsia

The nurse in a prenatal clinic finds that four clients have called with complaints related to their pregnancies. Which call should the nurse return first?

Pregnant woman at 15 weeks' gestation with nausea and vomiting and a 15-pound weight loss

The prenatal clinic nurse has received four phone calls. Which client should the nurse call back first?

Pregnant woman at 28 weeks with history of asthma who is reporting difficulty breathing and shortness of breath

What is the most significant cause of neonatal morbidity and mortality?

Prematurity

The nurse at an elementary school is performing TB screenings on all of the students. Permission slips were returned for all but the children of one family. When the nurse phones to obtain permission, the parent states in clearly understandable English that permission cannot be given because the grandmother is out of town for 2 more weeks. Which cultural element is contributing to the dilemma that faces the nurse?

Presence and influence of the extended family

The community nurse is preparing to visit the home of an adolescent who is 18 weeks pregnant. For which health problems should the nurse focus when assessing this patient? (Select all that apply.)

Preterm birth Low-birth-weight Iron deficiency anemia Preeclampsia

The nurse is preparing a brochure for couples considering pregnancy after the age of 35. Which statements should be included? (Select all that apply.)

Preterm births are more common. Amniocentesis can be performed to detect genetic anomalies. Preexisting medical conditions can complicate pregnancy.

Women with pyelonephritis during pregnancy are at significantly increased risk for which condition?

Preterm labor

A pregnant patient is scheduled to have the procedure, as depicted in the diagram, performed. What should the nurse explain as the purpose for this procedure? (picture)

Prevent preterm cervical dilatation and pregnancy loss

What is the most significant maternal risk factor for preterm birth?

Previous preterm birth

The nurse is reviewing the insertion of a diaphragm with a female patient. At which step in the process is the following diagram to be used? (picture)

Prior to inserting

A woman is hospitalized with severe preeclampsia. The nurse is meal-planning with the client and encourages a diet that is high in what?

Protein

What are the three functions of the fallopian tubes? (Select all that apply.)

Provide transport for the ovum from the ovary to the uterus Provide a site for fertilization to occur Serve as a warm, moist, nourishing environment for the ovum or zygote

Which findings would indicate the presence of a perineal wound infection? (Select all that apply.)

Purulent drainage Hardened tissue Redness Tender at the margins

The nurse understands that the classic symptom of endometritis in a postpartum client is which of the following?

Purulent, foul-smelling lochia

A patient is having the following anesthesia provided. What is the purpose for this type of anesthesia? (picture)

Repair of an episiotomy

The nurse knows that a baby born to a mother who had oligohydramnios could show signs of which of the following?

Respiratory difficulty

The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. What is the nurse most concerned about?

Respiratory distress

Which of the following behaviors noted in the postpartum client would require the nurse to assess further?

Responds hesitantly to infant cries.

Narcotic analgesia is administered to a laboring client at 10:00 a.m. The infant is delivered at 12:30 p.m. What would the nurse anticipate that the narcotic analgesia could do?

Result in neonatal respiratory depression

Premonitory signs of labor include which of the following? (Select all that apply.)

Rupture of membranes Cervical softening and effacement Braxton Hicks contractions

Usually, the family is advised to arrive at the birth setting at the beginning of the active phase of labor or when which of the following occur? (Select all that apply.)

Rupture of membranes (ROM) Any vaginal bleeding Decreased fetal movement Regular, frequent uterine contractions (UCs)

The nurse has received a phone call from a multigravida who is 21 weeks pregnant and has not felt fetal movement yet. What is the best action for the nurse to take?

Schedule an appointment for her with her physician for that same day.

A female client with an intrauterine device calls the clinic because she is unable to locate the strings after her last menstrual period. What should the nurse counsel this client?

Schedule an appointment immediately

The nurse is providing care to a client in labor who admits to using heroin throughout the pregnancy. Which will the neonate be at risk for following birth?

Seizure activity

A patient in the first trimester of pregnancy recently emigrated from a foreign country and is diagnosed with rubella. What can occur to the developing fetus because of this infection? (Select all that apply.)

Sensorineural deafness Congenital cataracts Congenital heart defects

A telephone triage nurse gets a call from a postpartum client who is concerned about jaundice. The client's newborn is 37 hours old. What data point should the nurse gather first?

Skin color

A nurse is checking the postpartum orders. The doctor has prescribed bed rest for 6-12 hours. The nurse knows this is an appropriate order if the client had which type of anesthesia?

Spinal

To identify the duration of a contraction, the nurse would do which of the following?

Start timing from the beginning of one contraction to the completion of the same contraction.

A client's labor has progressed so rapidly that a precipitous birth is occurring. What should the nurse do?

Stay with the client and ask auxiliary personnel for assistance.

During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the following assessment findings are noted: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood from the vagina. What is the assessment finding that would necessitate follow-up?

Steady trickle of blood

A patient who is postmenopausal is encouraged to take calcium 1500 mg every day. How should the nurse instruct the patient to take this supplement?

Take calcium 500 mg three times a day with meals

A client was admitted to the labor area at 5 cm with ruptured membranes about 14 hours ago. What assessment data would be most beneficial for the nurse to collect?

Temperature

The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains that the newborn must remain in the radiant warmer. This is based on which assessment data?

Temperature 96.8°F

What indications would lead the nurse to suspect sepsis in a newborn?

Temperature of 97.0°F 2 hours after warming the infant from 97.4°F

The nurse suspects that a client has developed a perineal hematoma. What assessment findings would the nurse have detected to lead to this conclusion?

Tense tissues with severe pain

The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first?

Term male, nasal flaring

The nurse is preparing educational materials at a family planning clinic. The client who is an appropriate candidate for using emergency contraception would be one who reports which of the following?

That a condom broke yesterday in the middle of her cycle

A client had a cesarean birth 3 days ago. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, what would the nurse anticipate would be the next course of action?

That the client would be placed on bed rest

A laboring client asks the nurse, "Why does the physician want to use an intrauterine pressure catheter (IUPC) during my labor?" The nurse would accurately explain that the best rationale for using an IUPC is which of the following?

The IUPC provides more accurate data than does the tocodynamometer.

The nurse is planning care for three newly delivered adolescents and their babies. What should the nurse keep in mind when planning their care?

The baby's father should be encouraged to participate when the nurse is providing instruction.

The postpartum client has developed thrombophlebitis in her right leg. Which finding requires immediate intervention?

The client appears anxious, and describes pressure in her chest.

An analgesic medication has been administered intramuscularly to a client in labor. How would the nurse evaluate if the medication was effective?

The client dozes between contractions.

What is the advantage of a client using a patient-controlled analgesia (PCA) following a cesarean birth?

The client feels a greater sense of control, and is less dependent on the nursing staff.

A woman has come to the emergency department with multiple bruises over her body and a small laceration over her upper lip. She says she fell down the stairs while doing her housework. Which observation would most likely cause the nurse to suspect that she has been a victim of battering?

The client is hesitant to provide details about how the injuries occurred.

The charge nurse is assessing several postpartum clients. Which client has the greatest risk for postpartum hemorrhage?

The client who had oxytocin augmentation of labor

The nurse is calling clients at 4 weeks postpartum. Which of the following clients should be seen immediately?

The client who reports hearing voices talking about the baby

A 28-year-old woman has been an insulin-dependent diabetic for 10 years. At 36 weeks' gestation, she has an amniocentesis. A lecithin/sphingomyelin (L/S) ratio test is performed on the sample of her amniotic fluid. Because she is a diabetic, what would an obtained 2:1 ratio indicate for the fetus?

The fetus may or may not have immature lungs.

The nurse educator is presenting a program to college students about factors that can cause congenital malformations. What should the nurse tell them?

The growing embryo is considered most vulnerable to hazardous agents during the first months of pregnancy.

The nurse is caring for four newborns who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health?

The infant's mother has group B streptococcal (GBS) disease.

The client has been pushing for 2 hours and is exhausted. The physician is performing a vacuum extraction to assist the birth. Which finding is expected and normal?

The location of the vacuum is apparent on the fetal scalp after birth.

The nurse is caring for a 15-year-old client who gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parenting adolescent?

The nurse explains the characteristics and cues of the baby when assessing him.

A maternity client is in need of surgery. Which healthcare member is legally responsible for obtaining informed consent for an invasive procedure?

The physician

The nurse explains to the client that the obstetric conjugate measurement is important because of which reason?

The size of this diameter determines whether the fetus can move down into the birth canal so that engagement can occur.

On the first postpartum day, the nurse teaches the client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be related to which of the following?

The taking-in period

While conducting a home visit the nurse observe the father of a newborn hold the infant so that the following is observed. What should the nurse explain to the parents about this behavior?

This will disappear between 4 and 8 weeks of age

A client describes breast swelling and tenderness. What piece of data would be most important for the nurse to gather initially?

Timing of the symptoms

The client delivered her first child vaginally 7 hours ago. She has not voided since delivery. She has an IV of lactated Ringer's solution running at 100 mL/hr. Her fundus is firm and to the right of midline. What is the best nursing action?

To assist the client to the bathroom

The nurse administered oxytocin 20 units at the time of placental delivery. Why was this primarily done?

To contract the uterus and minimize bleeding

During the nursing assessment of a woman with ruptured membranes, the nurse suspects a prolapsed umbilical cord. What would the nurse's priority action be?

To use gravity and manipulation to relieve compression on the cord

The nurse is caring for the newborn of a drug-addicted mother. Which assessment findings would be typical for this newborn? (Select all that apply.)

Transient tachypnea Exaggerated reflexes Hyperirritability

A client is admitted to the labor unit with contractions 1-2 minutes apart lasting 60-90 seconds. The client is apprehensive and irritable. This client is most likely in what phase of labor?

Transition

A 58-year-old father and a 45-year-old mother gave birth to a baby boy 2 days ago. The nurse assesses a single palmar crease and low-set ears on the newborn. The nurse plans to counsel the couple about which chromosomal abnormality?

Trisomy 21

To assess the healing of the uterus at the placental site, what does the nurse assess?

Type, amount, and consistency of lochia

After several hours of labor, the electronic fetal monitor (EFM) shows repetitive variable decelerations in the fetal heart rate. The nurse would interpret the decelerations to be consistent with which of the following?

Umbilical cord compression

A pregnant patient is observed lying in bed in the following position. Which health problem is this patient prone to developing? (picture)

Vena caval syndrome

The nurse is analyzing assessment findings on four newborns. Which finding might suggest a congenital heart defect?

Visible, blue discoloration of the skin

A pregnant teenage client is diagnosed with iron-deficiency anemia. Which nutrient should the nurse encourage her to take to increase iron absorption?

Vitamin C

The nurse is preparing a teaching brochure for Spanish-speaking postpartum clients. Which topics are critical for this population?

When and how to contact their healthcare provider

The nurse is reviewing preconception questionnaires in charts. Which couple are the most likely candidates for preconceptual genetic counseling?

Wife's family has a history of hemophilia

At birth, an infant weighed 8 pounds 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds 15 ounces. The nurse explains that the change in the newborn's weight is which of the following?

Within normal limits

The nurse has received the end-of-shift report on the postpartum unit. Which client should the nurse see first?

Woman day of delivery, fundus firm 2 cm above umbilicus

A patient weighing 80 kg. with a body mass index of 29.8 is 6 weeks pregnant. What should be this patient's maximum weight at the time of delivery?

Women who are obese are advised to limit weight gain to 5 to 9 kg (11 to 20 lb). Since the patient weighs 80 kg. at 6 weeks pregnant, the maximum amount she should weigh would be 80 kg + 9 kg = 89 kg.

The fetus of a patient in labor is determined to be in the brow presentation. Which diagram should the nurse provide to the patient to explain this position? (picture)

brow is presenting

The nurse instructs a patient who is 16 weeks pregnant about the different types of pelvic structures. Which structure should the patient identify as being the most common?

mickey mouse

The nurse is determining a postpartum patient's amount of lochia. For which observation should the nurse document a moderate amount? picture

pad with moderate amount