Maternity HESI Questions

A newborn infant who is 24-hours-old is on a 4-hour feeding schedule of formula. To meet daily caloric needs, how many ounces are recommended at each feeding?

3.5 oz A newborn requires approximately 19 to 21 ounces of formula each day (six feedings per 24-hour period x 3.5 = 21). One-and-a-half to two ounces (A and C) may be insufficient to meet the newborn's calorie needs. (B) may cause the infant to spit-up due to over-feeding.

A client at 39-weeks gestation is admitted to the labor and delivery unit. Her obstetrical history includes 3 live births at 39-weeks, 34-weeks, and 35-weeks gestation. Using the GTPAL system, which designation is the most accurate summary of this client's obstetrical history?

4-1-2-0-3 The client with 3 previous gravid experiences and this current pregnancy totals 4 gravid experiences, and 1 term delivery (37-weeks or greater), 2 preterm deliveries (20 to 37 weeks, whether viable or not viable), no spontaneous abortions and 3 living children. (B) best designates this client's obstetrical history. (A, C, and D) are inaccurate for this client's history using the TPAL system.

Which cardiovascular findings should the nurse assess further in a client who is at 20-weeks gestation?

A decrease in pulse rate. Between 14 and 20 weeks gestation, the pulse increases about 10 to 15 beats/minute, which persists to term, so a decrease (A) should be assessed further. During the second trimester, both systolic and diastolic pressures decrease by about 5 to 10 mm Hg (B), a more audible splitting of S1 and S2 occurs (C), and there is an accelerated production of red blood cells (D).

Which procedure evaluates the effect of fetal movement on fetal heart activity?

A non-stress stress test (NST). A non-stress test (NST) (D) evaluates the ability of the fetal heart to accelerate either spontaneously or in association with fetal movement. Sonographic examinations visualize the fetus (A) and are done for various reasons. A contraction test evaluates the fetal reaction to contractions (B). The biophysical profile evaluates fetal status using many variables (C).

A client at 28-weeks gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client?

Acceptable weight gain. The normal pattern of weight gain is 2 to 4 pounds in the first trimester (by 13-weeks) and 1 pound per week after that. At 28-weeks gestation, a weight gain between 17 and 20 pounds is acceptable (D). (A, B and C) do not provide accurate information.

What nursing action should be implemented when intermittently gavage-feeding a preterm infant?

Allow formula to flow by gravity. Gavage feeding is commonly used to feed preterm infants who are born at less than 32-weeks gestation, infants who weigh less than 1500 grams, or infants who are unable to tolerate oral feedings. The feeding should flow by gravity (A) to avoid over-distention and a sudden sensation of fullness that may cause vomiting. Allowing the infant to suck on the tube, not (B), permits observation of the sucking response. The feeding tube should be inserted orally, since nasal insertion (C) impedes obligatory nose breathing and may irritate delicate nasal mucosa. (D) can result in vomiting if the rate of administration is too fast.

A 31-year-old woman uses an over-the-counter (OTC) pregnancy test that is positive one week after a missed period. At the clinic, the client tells the nurse she takes phenytoin (Dilantin) for epilepsy, has a history of irregular periods, is under stress at work, and has not been sleeping well. The client's physical examination and ultrasound do not indicate that she is pregnant. How should the nurse explain the most likely cause for obtaining false-positive pregnancy test results?

Anticonvulsants may yield false-positive pregnancy test results (B). Although over-the-counter pregnancy tests can yield positive results as soon as 4 days after implantation, the client's menstrual cycle dates indicate she is 3 weeks late, so implantation, which occurs 6 to 10 days after conception, has not occurred (C). Normal hormonal and menstrual cycles (A) may be influenced by stress (D), but hCG levels and positive pregnancy results are not affected.

A woman who is bottle-feeding her newborn infant calls the clinic 72 hours after delivery and tells the nurse that both of her breasts are swollen, warm, and tender. What instructions should the nurse give?

Apply ice to the breasts. Since the baby is receiving bottled formula, suppression of breast milk production is desired. Ice applications to the breast cause vasoconstriction which reduces engorgement and provides topical pain relief. A well-fitted support bra or breast binder , not (B), should be recommended to reduce stimulation of the nipples and breast tissue, which often stimulates breast milk production and engorgement. Applying heat to the breast causes vasodilation and increased engorgement (C). Expressing milk from the breast will stimulate additional milk production (D) and contribute to engorgement.

The nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics. The infant expels a bloody stool. What nursing action should the nurse implement?

Assess for abdominal distention. Etiological factors playing an important role in the development of necrotizing enterocolitis (NEC), a complication common in premature infants, include intestinal ischemia, colonization by pathogenic bacteria, and substrate (formula feeding) in the intestinal lumen. Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of NEC. Nursing responsibilities include measuring the abdomen (C) and listening for bowel sounds. Contact precautions (A) are necessary if a contagious gastrointestinal infection is suspected. Rectal temperatures are contraindicated (B) because of the risk for perforation of the bowel. Oral or gavage feeding is stopped, not (D), until necrotizing enterocolitis is ruled out.

Which nursing intervention is the priority during the fourth stage of labor?

Assess for hemorrhage. The fourth stage of labor starts after delivery of the placenta which leaves open uterine wall sinuses subject to bleeding. The main focus of the fourth stage is to monitor vital signs and assess for vaginal hemorrhage (B). Although promoting bonding (A) and providing comfort measures (C) are important, assessing for bleeding during the first hours after delivery is the highest priority. Although "after-pains" can occur after delivery, regular uterine contractions have ceased during the fourth stage (D).

A multiparous client has been in labor for 8 hours when her membranes rupture. What action should the nurse implement first?

Assess the fetal heart rate and pattern. The fetal heart rate and pattern should be assessed (B) to determine compromise of fetal well-being caused by compression or prolapse of the umbilical cord. The intensity and frequency of the uterine contractions often trigger spontaneous rupture of the membranes (SROM), which does not indicate that birth is imminent (A). The healthcare provider should be notified of the client and fetal well-being after evaluation of SROM. Although the characteristics of the amniotic fluid should be documented (C), assessment of fetal response to the SROM is the priority.

A newborn infant is jaundiced due to Rh incompatibility. Which finding is most important for the nurse to report to the healthcare provider?

Bilirubin Neonatal erythrolysis due to Rh incompatibility causes rapid release of unconjugated bilirubin (D), which results in serum levels (hyperbilirubinemia) that place the infant at risk for neurological damage (kernicterus). (A, B, and C) may influence the serum bilirubin level, but the most significant finding is the serial bilirubin levels that determines the need for early intervention.

A primigravida at 12-weeks gestation tells the nurse that she does not like diary products. Which food should the nurse recommend to increase the client's calcium intake?

Canned sardines. A 3 ounce can of sardines (with bones) provides about the same amount of calcium as 1 cup of milk (C). (A, B, and D) are not good sources for dietary calcium.

While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross the suture lines. How should the nurse document this finding?

Caput succedaneum Caput succedaneum (D) is characterized by swelling of the soft tissues of the scalp that extends across suture lines. Molding (A) of the head results from adjustment of the infant's skull structure, which allows for the passage of the infant's head through the birth canal and is a common occurence in vaginal deliveries. Hemangioma (B) is a collection of blood vessels close to the skin. Cephalohematoma (C) is an edematous area caused by extravasation of blood between the skull bone and periosteum and does not cross the suture lines, which differentiates it from caput succedaneum.

While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document?

Cephalohematoma A cephalohematoma (B) should be documented because it is a collection of blood beneath the periosteum of the cranial bone causing scalp swelling that does not cross the suture line. Molding (A) is overlapping of cranial bones that occurs as the fetal head accommodates for the descent through the vaginal vault. Caput succedaneum (C) is differentiated from a cephalohematoma by generalized edematous swelling of the presenting part of the head. Fontanel tension should feel slightly concave and well defined against the edges of the cranial bones, whereas a bulging anterior fontanel (D) is tense and distends from an increased intracranial pressure, such as seen in congenital hydrocephalus.

A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage?

Change in fetal heart rate pattern. Hypoperfusion of the fetus may be present before the onset of clinical signs of maternal compromise or shock in a pregnant woman, so the external fetal monitor tracings should be assessed first to determine signs of fetal hypoxia due to internal bleeding in the mother. (A, B, and D) are not the first findings of internal hemorrhage in the pregnant client.

When assessing a newborn infant's heart rate, which technique is most important for the nurse to use?

Count the heart rate for one full minute. It is most important for the nurse to count the heart rate for at least one full minute (C) so that irregularities or murmurs can be detected. (A) is not necessary for the heart rate to be correctly auscultated. The heart rate can be heard clearly over any point of an infant's chest, not just (B). Immediately after delivery, (D) will allow the nurse to assess the rate, but (B) is the most accurate method of obtaining a newborn's heart rate.

A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to 70 mm Hg at the peak of a contraction and the resting tone is 6 to 10 mm Hg. Based on this information, what action should the nurse implement?

Document the findings in the client's record. This labor pattern indicates that the client is in the active phase of the first stage of labor and has a normal labor pattern, so the findings should be documented in the client's medical record (D). There is no indication to notify the healthcare provider (A) or bring the delivery table into the room (B) at this time. Oxytocin augmentation (C) is not needed for this labor pattern.

When assessing the integument of a 24-hour-old newborn, the nurse notes a pink papular rash with superimposed vesicles on the thorax, back, and abdomen. What action should the nurse implement next?

Document the findings. Erythema toxicum, or newborn rash, is a normal, transient rash that is found in term neonates during the first 3 weeks of age. No treatment is required, so (C) should be implemented. (A, B, and D) are not indicated since this is a normal finding.

The nurse is teaching a primigravida at 10-weeks gestation about the need to increase her intake of folic acid. Which explanation should the nurse provide that supports preventative perinatal care?

Folic acid can significantly reduce neural tube defects (C) if taken during early pregnancy. (A, B, or D) are not valid explanations.

A preterm infant with an apnea monitor experiences an apneic episode. Which action should the nurse implement first?

Gently rub the infant's back and feet for 10-15 seconds. Gentle stimulation of the infant's feet and back (D) can cause an infant to resume spontaneous respirations. If the infant does not respond to manual stimulation, resuscitative measures should be implemented using Ambu bag ventilation (A), suctioning (B), and the administration of oxygen (C).

The nurse notes a pattern of the fetal heart rate decreasing after each contraction. What action should the nurse implement?

Give 10 L of oxygen via the face mask. Late decelerations occur when there is reduced placental and fetal perfusion. Administering oxygen (A) increases the oxygen saturation in the blood thus increasing oxygen to the fetus. (B, C, and D) are inaccurate.

What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta?

Hard, board-like abdomen Abruptio placenta causes concealed intrauterine hemorrhage when the placenta separates and its edges do not. The formation of a hematoma behind the placenta and subsequent infiltration of the blood manifests as a firm, board-like abdomen (B), which should be reported immediately to the healthcare provider. As bleeding occurs, fetal oxygenation and maternal stability are compromised leading to fetal and maternal tachycardia, not (A). With abruptio placenta, fundal height and abdominal pain increase, not (C and D).

During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide?

Make sure to include adequate folic acid in the diet. A healthy diet before conception is the best way to ensure that adequate nutrients are available for the developing fetus. Folate or folic acid intake in the periconception period (B) reduces the risk of neural tube defects. Recommendations to stop or continue medications (A and D) during pregnancy should be evaluated on an individual basis. Losing weight so more can be gained during pregnancy (C) is not indicated as a generalization and may place the client at risk for nutritional deficiencies.

The nurse notes an irregular bluish hue on the sacral area of a 1-day old Hispanic infant. How should the nurse document this finding?

Mongolian spots Mongolian spots (usually in the sacral, lumbar, and gluteal regions) are a common skin variation in newborns of African, Asian, Native American, and Hispanic descent (B). (A) refers to cyanosis of the hands and feet, a normal finding in newborns soon after birth. (C) is a pink, papular rash that may appear on the thorax, back, buttocks, and abdomen within 24 to 48 hours after birth. (D) is visible when an infant lies on the side and the lower half of the body is pink or red and the upper half is pale.

An infant with hyperbilirubinaemia is receiving phototherapy. What intervention should the nurse implement?

Monitor temperature. Minor side effects of phototherapy include loose, green stools, transient rashes, hyperthermia, increased metabolic rate, dehydration, electrolyte disturbances, and priapism. Regular monitoring of the infant's temperature (B) allows evaluation of hyperthermia and dehydration. Extra oral fluids are provided to reduce the risk of dehydration, so NPO status is not necessary (A). Skin lotion is contraindicated (C) to prevent increased tanning or an increase in heat or skin "frying" effect. Clothing reduces the area of exposed skin to the lights, so T-shirts (D) should not be worn during phototherapy.

The nurse administers meperidine (Demerol) 25 mg IV push to a laboring client, who delivers the infant 90 minutes later. What medication should the nurse anticipate administering to the infant?

Naloxone (Narcan) Demerol is a CNS depressant, which moves across the placenta and can cause respiratory depression in the infant, so Narcan (A), a narcotic antagonist, is administered to the infant to reverse CNS effects. Nubain (B), Fentanyl (C), and Phenergan (D) are analgesics and not indicated for the infant.

Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate?

Oral sucrose and nonnutritive sucking. Studies of nonpharmacologic interventions for pain in the newborn most frequently indicate that the administration of oral sucrose and nonnutritive sucking (D), such as the provision of a pacifier, are effective in reducing objective indicators of pain after an invasive procedure. Other interventions, such as tactile stimulation (A) during apnea and bradycardic episodes and warm packs (B) for thermoregulation, have not been shown to reduce pain responses. Skin-to-skin contact (C) fosters neurobehavioral development and supporting parent-infant intimacy and attachment, but sucking behaviors provide the most effective pain-comfort responses.

The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at 32-weeks gestation who has severe preeclampsia with pulmonary edema. As the PAC enters the right ventricle, what is the priority nursing assessment?

Observe for premature ventricular contractions. During and following the insertion of a pulmonary artery catheter (PAC), ECG activity should be monitored for the occurrence of any ventricular ectopy (C). Although fetal well-being (A) is important, the primary nursing assessment at this time is monitoring for immediate cardiac changes in the mother. Adverse cardiac responses to PAC insertion should first identify changes in the client's heart rhythm before the client complains of chest pain (B). Manual blood pressures (D) evaluate systemic perfusion, but the primary purpose in monitoring pulmonary artery pressures is to detect early cardiac changes due to left ventricular failure.

A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the priority nursing action?

Obtain serum blood glucose levels and assess frequently for hypoglycemia. The infant's birth weight falls within the parameter (4000 grams or greater) for a large-for-gestational-age (LGA) infant and should be assessed for hypoglycemia (C) and trauma. Early recognition of hypoglycemia requires immediate intervention and takes precedence over assessing newborn reflexes (A). Although the infant may remain in the room with the mother (B), frequent assessments of the newborn should be performed. Additional assessment tools (D) can be used after serum glucose levels are determined (C).

A gravid client develops maternal hypotension following regional anesthesia. What intervention(s) should the nurse implement? (Select all that apply.)

Oxygen Fluids Lateral position Evaluate fetal response Correct selections are (A, B, E, and F). Oxygen (A), fluids (B), lateral position (E), and evaluating fetal response (F) effectively manage maternal hypotension following regional anesthesia. Placing the client in a sitting position (D) does not facilitate venous return to the heart and limits perfusion of the fetus. A sterile vaginal examination (C) does not increase blood flow and oxygenation to the placenta and fetus.

A client with asthma who is 8 hours post-delivery is experiencing postpartum hemorrhage. Which prescription should the nurse administer?

Oxytocin (Pitocin) Oxytocin is the drug of choice, and it will not exacerbate symptoms of asthma (A). Nonsteroidal antiinflammatory drugs (NSAIDs) (B) are not used to treat bleeding. Fentanyl (C) is used to treat pain, not bleeding. Prostaglandin derivatives (D) may exacerbate asthma symptoms.

Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routine standing order for methylergonovine maleate (Methergine)?

PIH - Pregnancy Induced Hypertension Methergine is used for post-partum bleeding. A client's history of pregnancy-induced hypertension (A) is a contraindication for Methergine which causes vasoconstriction and increases blood pressure, so the routine standing order should be withheld and reported to the healthcare provider. (B, C, and D) are not contraindications for the use of Methergine.

A client in active labor at 39-weeks gestation tells the nurse she feels a wet sensation on the perineum. The nurse notices pale, straw-colored fluid with small white particles. After reviewing the fetal monitor strip for fetal distress, what action should the nurse implement?

Perform a nitrazine test. The normal characteristic of amniotic fluid is pale, straw-colored fluid, which may contain white flecks of vernix, with an alkaline pH, so (C) should be done to confirm the pH of the fluid. (A or B) may be indicated if the fluid is urine. (D) should be done after determining the type of fluid expelled.

During an assessment of a multiparous client who delivered an 8-lb 7-oz infant 4 hours ago, the nurse notes the client's perineal pad is completely saturated within 15 minutes. What action should the nurse implement next?

Perform fundal massage. Perineal pad saturation within 15 minutes during the early post partum period is indicative of bleeding, which is commonly due to uterine atony and can lead to post-partum hemorrhage. Fundal assessment and massage should be performed (A) first to control bleeding. (B, C, and D) are actions implemented after manually stimulating the fundus to contract. (Assess blood pressure, notify provider, encourage client to void.)

Which gastrointestinal findings should the nurse be concerned about in a client at 28-weeks gestation?

Pica. Pica is the practice of craving substances with little or no nutritional value. Most pregnancy and pica related cravings involve non-food substances such as dirt or chalk. The word pica is Latin for magpie which is a bird notorious for eating almost anything.

What action should the nurse implement when caring for a newborn receiving phototherapy?

Place an eyesheild over the eyes. Phototherapy converts unconjugated bilirubin, which is deposited in the skin, to a water-soluble form that is more easily excreted by the liver. Exposure to the light source can increase the risk for ocular damage, so an eyeshield (B) is placed while the infant is under the light source. To ensure all body surfaces are exposed to the lights, the newborn should be reposition every 2 to 4 hours, not every 6 hours (A). Phototherapy can increase insensible water loss, and to prevent dehydration, fluid intake should be encouraged, not restricted (C). Lotions (D) absorb heat and can potentially cause burns and should not be used on the skin while phototherapy is in progress.

A primigravida at 37-weeks gestation tells the nurse that her "bag-of-water" has broken. While inspecting the client's perineum, the nurse notes the umbilical cord protruding from the vagina. What action should the nurse implement first?

Place the client in a knee-chest position. Until an emergency delivery is accomplished, the client should be placed in a knee-chest position (C) to relieve compression of the presenting part on the umbilical cord, which can compromise fetal oxygenation. (A, B, and C) are implemented after the client is positioned to relieve pressure on the umbilical cord.

The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart rate occurring with the peak of each contraction. What action should the nurse implement?

Place the client in a side lying position. Variable decelerations are caused by compression of the umbilical cord and are evidenced by V shape appearance,characterized by a rapid descent and ascent to and from the depth of the deceleration. To alleviate the pressure on the umbilical cord, the nurse should reposition the client into a side-lying position (C). Once the client is repositioned and evaluated, then (A, B, and D) should be implemented. (Notify the healthcare provider, give 10Loxygen

What action should the nurse implement to prevent conductive heat loss in a newborn?

Put a blanket on the scale when weighing the infant. Placing a blanket on the scale (B) provides a barrier to prevent conductive heat loss when the infant's body comes in contact with a cooler solid surface. (A) prevents convection heat loss from the infant's body to the surrounding air. (C) prevents heat loss by evaporation when the infant's body cools as moisture present on the skin evaporates. (D) prevents radiant heat loss when the body loses heat to solid items that are not in contact with the body but are in close proximity.

The nurse assesses a high-risk neonate under a radiant warmer who has an umbilical catheter and identifies that the neonate's feet are blanched. What nursing action should be implemented?

Report findings to the healthcare provider. Vasoconstriction of peripheral vessels, which can seriously impair circulation, is triggered by arterial vasospasm caused by the presence of the catheter, the infusion of fluids, or the injection of medication. Blanching of the buttocks, genitalia, or the legs or feet is an indication of vasospasm and should be reported immediately to the healthcare provider (D). (A, B, and C) do not provide effective resolution of this potentially serious complications.

The nurse is providing discharge teaching for a gravid client who is being released from the hospital after placement of cerclage. Which instruction is the most important for the client to understand?

Report uterine cramping and low back ache. Uterine cramping and low back pain (D) are symptoms of preterm labor and should be reported to the healthcare provider immediately because the cerclage may need to be removed. A cesarean birth can be planned (A) or the cerclage can be removed at 37-weeks gestation to prepare for a vaginal birth. Home uterine activity monitoring (B) is used to limit the woman's need for visits and to safely monitor her status at home. Bed rest is an element of care so the client should make arrangements for care at home (C) and someone to do household chores. (A, B, and C) do not have the priority of (D).

A 36-week gestation client with pregnancy-induced hypertension (PIH) is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider?

Respiratory rate of 11 breaths per minute. A sign of magnesium toxicity is respiratory depression, so the client's respiration rate of 11 breaths/minute (D) should be reported to the healthcare provider. (A, B, and C) are expected findings for a 36-week gestation client with PIH.

A woman, whose pregnancy is confirmed, asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide?

Secretes both estrogen and progesterone. One of the early functions of the placenta as an endocrine gland is the production of four hormones, hCG, hPL, estrogen, and progesterone (C), necessary to maintain the pregnancy and support the embryo and fetus. The placenta does not excrete prolactin and insulin (A). The placenta functions as a means of metabolic exchange between the maternal and fetal blood supplies, but it does not produce nutrients (B), and is not impenetrable (D) because many bacteria and viruses can cross the placental membrane.

A client delivers her first infant and asks the nurse if her skin changes from pregancy are permanent. Which change should the nurse tell the client will remain after pregnancy?

Striae gravidarum. Striae gravidarum (D), or "stretch marks," occur on the lower abdomen of pregnant women during the second half of pregnancy fade after delivery but do not disappear entirely because they reflect separation within the underlying connective (collagen) tissue of the skin. Pruritis (A) is a temporary skin condition most commonly caused by cholestasis. Chloasma (B), or "mask of pregnancy," is a temporary, blotchy, brownish hyperpigmentation caused by hormonal levels of pregnancy. Vascular spiders (C), or "angiomas," are small, pulsating end arterioles, found on the upper body, that occur as a result of increased circulating estrogen, which usually disappear soon after delivery.

What nursing action should be included in the plan of care for a newborn experiencing symptoms of drug withdrawal ?

Swaddle the infant and hold tightly. An infant experiencing drug withdrawal should be swaddled, wrapped snugly, or placed in a "kangaroo pouch" to reduce self-stimulation behaviors and protect skin from abrasions that may occur due to muscular irritability (D). Music or talking to the infant is more likely to stimulate the infant and increase CNS irritability and should be minimized (A). Phenobarbital or diazepam are used to decrease central nervous system (CNS) irritability, not (B). To diminish aspiration and maintain hydration, the infant should be given small, frequent feedings followed by successful burping or bubbling.

A primigravida at 12-weeks gestation who just moved to the United States indicates she has not received any immunizations. Which immunization(s) should the nurse administer at this time? (Select all that apply.)

Tetanus Diphtheria Hepatitis B Correct selections are (A, C, and E). Vaccines composed of killed viruses may be administered during pregnancy. Rubella (B) and chickenpox (D) consist of live or attenuated live viruses which would be contraindicated during pregnancy due to potential teratogenicity.

A client at 8-weeks gestation ask the nurse about the risk for a congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur?

The heart develops in the 3-5th week after conception. The cardiovascular system is the first organ system to develop and function in the embryo. The blood vessel and blood formation begin in the third week, and the heart is developmentally complete in the fifth week (D). Regardless of the etiological factor, the heart is vulnerable during its period of development -- the third to fifth weeks. (A, B, and C) are inaccurate.

A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An intrauterine pressure catheter (IUPC) is in place when the client's membranes rupture after 5 hours of active labor. Which finding should require the nurse to implement further action?

The intensity of the contractions are 130 mm Hg. The goal of induction of labor with oxytocin is to produce an effective labor, which can be measured by an IUPC reading of 40 to 90 mm Hg for contractions when giving oxytocin, so (B) requires further intervention. (A, C, and D) are goals for induction of labor using oxytocin.

The nurse is giving discharge instructions for a client following a suction curettage for hydatidiform mole. The client asks why oral contraceptives are being recommended for the next 12 months. What information should the nurse provide?

The major risk after a molar pregnancy is the development of choriocarcinoma, which is detected by measuring the same hormone (hCG) that the body produces during pregnancy. Continued elevated hCG levels may be either from choriocarcinoma or a subsequent pregnancy making diagnosis and treatment difficult, so oral contraceptives are prescribed to prevent pregnancy for a year since it interferes with monitoring the return of hCG levels (C) to normal. (A, B, and D) are inaccurate.

The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first?

The nurse should first assess the infant's blood glucose level (C), because the infant is displaying signs of hypothermia (normal newborn axillary temperature is 96 to 98 F) and hypoglycemia may occur as glucose is metabolized in an effort to meet cellular energy demands. The infant's respiratory and heart rates are within normal limits, so (A) is not a priority. (B and D) would be implemented after information regarding the blood sugar level has been obtained.

An infant who weighs 3.8 kg is delivered vaginally at 39-weeks gestation with a nuchal cord after a 30-minute second stage. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide the parents about this finding?

The pinpoint spots are benign and disappear within 48 hours. Rapid delivery and a tight nuchal cord cause the presenting parts (head) to have bruising and pin point hemorrhages (petechiae), which are benign and usually disappear within two days after birth (D). (A) is not indicated. Birth injuries caused by forceps (B) present as linear configuration across both sides of the face and outline the placement of the forceps. (C) is inaccurate.

At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villi sampling (CVS) procedure. What assessment finding requires immediate intervention?

Uterine cramping. The client should be monitored for 1 to 2 hours following the procedure for the occurrence of uterine cramping (A) so that immediate intervention to decrease the risk of miscarriage can be initiated. This procedure (removal of a small piece of tissue from the fetal portion of the placenta) may cause initiation of labor. (B) may occur at the puncture site if the procedure was done transabdominally. (C and D) are normal findings during in the first trimester.

Which prescription should the nurse administer to a newborn to reduce complications related to birth trauma?

Vitamin K The normal neonate is vitamin K deficient, so to rapidly elevate prothrombin levels and reduce the risk of neonatal bleeding, newborns receive a single injection of vitamin K (AquaMEPHYTON) (D). (A and B) are prophylactic ophthalmic agents used to prevent neonatal ophthalmia. (C) is an antibiotic used to treat neonatal infections.