Mother Baby
A nurse is caring for a newborn who was transferred to the nursery 30 min after delivery. Which of the following actions should the nurse take first? Confirm the newborn's Apgar score. Verify the newborn's identification. Administer vitamin K IM to the newborn. Determine obstetrical risk factors.
Verify the newborn's identification. Facilities vary in their newborn security practices; however, it is mandatory to continue ongoing identification of the newborn whenever the newborn is removed from the mother's direct presence and care.
A nurse is assessing a client during a weekly prenatal visit who is at 38 weeks of gestation. Which of the following client findings should the nurse report to the provider? Blood pressure 136/88 mm Hg Report of insomnia Weight gain of 2.2 kg (4.8 lb) Report of Braxton-Hicks contractions
Weight gain of 2.2 kg (4.8 lb) A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications; therefore, it should be reported to the provider.
A nurse is providing education about car seat safety to the parents of a newborn. Which of the following should the nurse include in the teaching? a. Secure the car seat harness at the newborn's waist. b. Install the car seat facing forward in the car's back seat. c. Position the newborn in the car seat at a 45° angle. d. Obtain approval from hospital staff before purchasing the car seat.
c. Position the newborn in the car seat at a 45° angle. Positioning the infant at a 45° angle provides the greatest protection to the newborn.
A nurse is caring for a client and her newborn whose culture differs from the nurse's. Which of the following indicates a need for intervention by the nurse? Placing of a belly band lightly over the newborn's navel Delaying feeding until breast milk comes in Waiting to name the newborn Using a cradle board to support the newborn
delaying feeding until breast milk comes in If the client delays feeding until mature milk appears, the newborn will not receive any nourishment during the first 1 to 3 days of life. In addition, colostrum is comprised of fluid and immunoglobins that are beneficial to the newborn.
A nurse is providing dietary teaching with a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? "I should eat to taste instead of trying to balance my meals." "I will avoid having a snack at bedtime." "I will have 8 oz of hot tea with each meal." "I should pair my sweets with a starch instead of eating them alone."
"I should eat to taste instead of trying to balance my meals." Clients who have hyperemesis gravidarum should eat to taste to avoid nausea.
A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? "I will get injections of the medication once a day until my labor stops." "My blood sugar may be low while I'm on this medication." "I will have blood tests because my potassium might decrease." "My blood pressure may increase while I'm on this medication."
"I will have blood tests because my potassium might decrease." An adverse effect of terbutaline is hypokalemia.
A nurse is teaching a client about Rho(D) immunoglobulin (RhoGAM). Which of the following statements by the client indicates an understanding of the teaching? "I will receive this medication if my baby is Rh-negative." "I will receive this medication at time of delivery." "I will need a second dose of this medication when my baby is 6 weeks old." "I will need this medication if I have an amniocentesis."
"I will need this medication if I have an amniocentesis." RhoGAM is recommended following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation. "I will receive this medication if my baby is Rh-negative." RhoGAM is administered to a mother who is Rh- negative and gives birth to an Rh-positive infant; therefore, this statement does not indicate an understanding of the teaching. "I will receive this medication at time of delivery." RhoGAM is administered at 28 weeks of gestation; therefore, this statement does not indicate an understanding of the teaching. "I will need a second dose of this medication when my baby is 6 weeks old." RhoGAM is administered at 28 weeks of gestation to mothers who are Rh-negative and following the birth of an infant who is Rh-positive; therefore, this statement does not indicate an understanding of the teaching.
A nurse is providing discharge instructions to a client who had a vaginal delivery and is breastfeeding her newborn. Which of the following statements indicates an understanding of the teaching? "I will need to eat an additional 330 calories a day while I'm breastfeeding." "I will change my perineal pad at least twice a day." "I will massage my uterus daily for 7 days." "I will breastfeed my baby every 2 hours."
"I will need to eat an additional 330 calories a day while I'm breastfeeding." A postpartum client who is breastfeeding should increase her daily caloric intake by 330 calories per day. "I will change my perineal pad at least twice a day." A client should change her perineal pads after each voiding or defecation or at least four times a day. "I will massage my uterus daily for 7 days." Massaging the uterus on a daily basis is not necessary following delivery. "I will breastfeed my baby every 2 hours." A client should assess her newborn for feeding cues and allow the infant to determine feeding times.
A nurse is providing discharge instructions to a client whose infant was circumcised using the clamp technique. Which of the following responses by the client indicates an understanding of the teaching? "I will apply the diaper loosely if bleeding occurs." "I will put petroleum jelly around the glans during each diaper change." "I will wipe off any yellow exudate that forms on the glans." "I will remove the plastic ring after 7 days."
"I will put petroleum jelly around the glans during each diaper change." When the clamp method is used, petroleum jelly should be applied around the glans during each diaper change.
A nurse is teaching a prenatal class about infant safety. Which of the following statements made by a parent indicates a need for further teaching? "I will set my hot water heater no higher than 130° F." "I will make sure the crib slats are no more than 2 3/8 inches apart." "I will refrain from using a comforter in the crib." "I will place the infant carrier on the floor when my baby is inside it."
"I will set my hot water heater no higher than 130° F." To avoid burns to the infant, the hot water heater should be set no higher than 49° C (120° F).
A nurse is providing teaching to a client of normal weight who is at 10 weeks of gestation. Which of the following client statements should indicate to the nurse that the client is accepting expected body image changes related to pregnancy? "I will not gain more than 10 to 15 pounds during pregnancy." "I will use new positions during intercourse." "I hope I do not get a dark line up my abdomen." "I will not be able to wear my bikini if I get stretch marks."
"I will use new positions during intercourse." The weight gain of pregnancy will likely require different positions for sexual intercourse. This statement indicates that the client is willing to accept the necessary weight gain for a healthy pregnancy.
A nurse is caring for a client who has had a perinatal death. Which of the following statements is an appropriate response by the nurse? "This happens for a reason." "This must be hard for you." "I understand how you feel." "You're young and will be able to have other children."
"This must be hard for you." This statement is therapeutic because it reflects on the feelings of the mother.
A nurse is providing discharge teaching to a client who is postpartum about resuming sexual activity. Which of the following instructions should the nurse include in the teaching? "You should use a water soluble gel for lubrication." "You can resume sexual activity in 10 days." "Your physical reaction to sexual stimulation will not be altered." "You will not ovulate for 3 months after delivery."
"You should use a water soluble gel for lubrication." The client should use a water soluble gel for lubrication to prevent discomfort.
A nurse is preparing to initiate IV oxytocin for a client who is admitted for induction of labor. Oxytocin 30 units is available in 500 mL. At what rate should the nurse set the infusion pump to deliver 2 mU/min? (Round the answer to the nearest whole number).
2mL/hr
A nurse is assessing a newborn who has a weak cry and is grimacing. The nurse notes the newborn has a heart rate of 102/min, blueish extremities, and a flaccid muscle tone. Which of the following reflects the appropriate APGAR score? 4 5 6 7
5 APGAR score is an evaluation made by the nurse at 1 and 5 min after birth to assist the nurse in the assessment of how well the infant is transitioning to extrauterine life. Heart rate, respiratory effort, reflex irritability, muscle tone, and color are components of the assessment. This is the correct APGAR score.
A nurse on the newborn unit is planning discharge for four clients. Which of the following newborns will require care beyond that of a standard follow-up visit with the provider after delivery? A newborn being sent home 22 hr after birth A newborn at 38 weeks of gestational age A newborn who is bottle feeding
A newborn being sent home 22 hr after birth This newborn requires additional actions at the follow-up visit. Screening tests must be repeated if they were performed before the newborn was 24 hr old.
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The fetal monitor shows uterine contractions every 6 min, lasting 20 to 25 seconds, and an FHR of 150/min. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect? Decreased uterine contractions An increase in the client's hemoglobin levels A reduction in respiratory distress in the newborn Increased production of antibodies in the newborn
A reduction in respiratory distress in the newborn Betamethasone is given to stimulate fetal lung maturity and prevent respiratory distress.
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? Abruptio placenta Placenta previa Preeclampsia Maternal bradycardia
Abruptio placenta Cocaine use increases the risk for vasoconstriction and possible abruptio placenta.
A nurse is caring for a client who is in premature labor at 32 weeks of gestation and is receiving magnesium sulfate 2 g IV for tocolytic therapy. The nurse should report which of the following findings to the provider? Respiratory rate of 12/min Absent deep tendon reflexes Client report of hot flashes Serum calcium level of 9.5 mg/dL
Absent deep tendon reflexes This is a sign of an adverse reaction to magnesium sulfate and should be reported to the provider.
A nurse is caring for a client in labor who is reporting excessive pain. Which of the following interventions requires the nurse to hold an additional certification or licensure?
Acupuncture Acupuncture, a pain-control technique that involves the insertion of fine needles into specific body areas, should be performed only by a trained, certified therapist. In some states, additional licensure is required.
A nurse is caring for a client who is pregnant and has epilepsy. The nurse observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take next? Monitor fetal heart rate Assess uterine activity Administer oxygen via a nonrebreather mask Start a bolus of IV fluids
Administer oxygen via a nonrebreather mask The priority action the nurse should take using the airway, breathing, and circulation priority framework is to keep the client oxygenated; therefore, administering oxygen via a nonrebreather mask is the next action the nurse should take.
A nurse is providing education for a client who is in her third trimester and is scheduled for a biophysical profile. The nurse should tell the client that which of the following variables is included in the test? Gestational age L/S ratio Amniotic fluid index Doppler flow analysis
Amniotic fluid index Amniotic fluid index (AFI) is one of the variables included in the biophysical profile. AFI measures the amount of amniotic fluid present in the uterus. Adequate amniotic fluid is important for the maintenance of placental perfusion.
A nurse is caring for a client newly admitted to the PACU following a cesarean birth. Which of the following is the priority nursing assessment? Parent-child attachment Amount of postpartum lochia Patency of the IV catheter Quality and quantity of urine output
Amount of postpartum lochia During the immediate postpartum period, the greatest risk to the client is bleeding. The amount of lochia can assist the nurse in determining if excessive bleeding is occurring. Using the Airway, Breathing, Circulation (ABC) priority-setting framework, the nurse should observe the client for postpartum hemorrhage.
A nurse is caring for a client who is using jet hydrotherapy during labor. The nurse is aware that which of the following methods of monitoring the fetal heart rate is contraindicated for this client? A Doppler device A fetoscope A wireless external monitor device An internal electrode
An internal electrode The use of an internal electrode is contraindicated for a client who is using jet hydrotherapy.
A nurse is caring for a client who is in labor and has ruptured membranes and one inch of the umbilical cord protruding into the vagina. After calling for assistance, which of the following is a priority nursing action? Place a rolled towel beneath one of the client's hips. Apply internal upward pressure to the presenting part. Administer oxygen at 10 L/min. Increase the IV infusion rate.
Apply internal upward pressure to the presenting part. This action relieves cord compression; therefore, it is the priority action.
A nurse is caring for a client who is in labor with right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following is an appropriate action for the nurse to take? Apply sacral counterpressure Perform transcutaneous electrical nerve stimulation (TENS) Initiate slow-paced breathing Assist with biofeedback
Apply sacral counterpressure The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.
A nurse is caring for a client whose labor is not progressing due to shoulder dystocia of the infant. Which of the following actions should the nurse take? Apply fundal pressure. Apply suprapubic pressure. Place the client in the Trendelenburg position. Place the client in Fowler's position.
Apply suprapubic pressure. Suprapubic pressure can be used to attempt to push the shoulder to go under the symphysis pubis and thus pass through the birth canal.
A nurse is caring for a client who is 1 day post-vaginal delivery. The nurse determines the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first? Insert an indwelling urinary catheter. Notify the provider. Assist the client to empty her bladder. Encourage the client to ambulate.
Assist the client to empty her bladder. The greatest risk to this client is subinvolution of the uterus due to a distended bladder. Therefore, the first action the nurse should take is to assist the client to empty her bladder.
A nurse is caring for a client who is in active labor and reports back pain. The nurse performs a vaginal exam and determines the client is 8 cm dilated, 100% effaced, and -2 station. The fetus is in the occiput posterior position. Which of the following is an appropriate nursing intervention? Perform effleurage during contractions. Place the client in lithotomy position. Assist the client to the hands and knees position. Apply a fetal scalp electrode.
Assist the client to the hands and knees position. This may help relieve back pain and help the fetus rotate. INCORRECT Perform effleurage during contractions. Effleurage is not indicated to facilitate internal rotation of the fetus. Place the client in lithotomy position. This will not facilitate rotation of the fetal head. Apply a fetal scalp electrode. This is an invasive procedure done to monitor fetal heart rate. There is no indication of a need for internal monitoring at this time.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following assessment findings by the nurse should be reported to the provider? BUN 25 mg/dL Serum creatinine 0.8 mg/dL Urine output of 280 mL in 8 hr Weight gain of 0.9 kg (2 lb) in 24 hr
BUN 25 mg/dL An elevated BUN can indicate dehydration and should be reported to the provider.
A nurse is providing family planning education to a client who has decided to use a diaphragm. Which of the following should the nurse include in the plan of care? "You should replace the diaphragm every 3 years." "You should leave the diaphragm in place for at least 6 hours after intercourse." "You should use an oil based product as a lubricant when inserting the diaphragm." "You should insert the diaphragm when your bladder is full."
CORRECT: "You should leave the diaphragm in place for at least 6 hours after intercourse." The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy. INCORRECT You should replace the diaphragm every 3 years." The client should replace the diaphragm every 2 yr. "You should use an oil based product as a lubricant when inserting the diaphragm." The client should avoid using oil-based products because they can weaken the rubber. "You should insert the diaphragm when your bladder is full." The client should have an empty bladder prior to inserting the diaphragm.
A nurse on an antepartum unit is reviewing the assessment findings of four clients who are in the third trimester of pregnancy. Which of the following assessment findings is the highest priority? A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL A client who is reporting epigastric pain A client who has a Hgb of 10 g/dL A client who reports urinary frequency and burning upon urination
CORRECT: A client who is reporting epigastric pain Epigastric pain is an indicator of hepatic involvement and is a clinical manifestation of severe preeclampsia. This should be reported to the provider immediately. If left untreated, the condition can be life-threatening for the mother and the fetus. INCORRECT: A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL This finding is above the expected reference range of a fasting level equal to or less than 105 mg/dL; however, it is not the highest priority finding. A client who has a Hgb of 10 g/dL This finding is a clinical manifestation of anemia in the client who is pregnant; however, this is not the highest priority finding. A client who reports urinary frequency and burning upon urination While urinary frequency is an expected finding in the third trimester, burning upon urination is indicative of a urinary tract infection; however, this is not the highest priority finding.
A nurse in a clinic is caring for a client who is at 32 weeks of gestation. Which of the following clinical findings should alert the nurse to a potential complication? Fundal height is 34 cm Client reports diarrhea for 3 days Client reports ankle edema Blood pressure is 130/80
Client reports diarrhea for 3 days A client experiencing diarrhea could indicate an illness or infection.
A nurse is providing teaching about nonpharmacological pain management for a postpartum client who is breastfeeding and has engorgement. Which of the following methods should the nurse recommend? Cold cabbage leaves Modified lanolin cream A breast binder Breast shells
Cold cabbage leaves The application of cold cabbage leaves is an effective nonpharmacological method to relieve pain associated with engorgement.
A nurse on the postpartum unit is caring for a client who has idiopathic thrombocytopenia purpura (ITP). Which of the following assessment findings should the nurse expect to find? Decreased platelet count Increased ESR Decreased megakaryocytes Increased WBC
Decreased platelet count A client who has ITP will have an autoimmune response resulting in a decreased platelet count.
A nurse is assessing a fetal heart monitor tracing of a client receiving oxytocin at 10 milliunits/min. Uterine contractions are noted every 60 to 90 seconds. After turning the client to a side-lying position, which of the following actions should the nurse take next? Discontinue the medication infusion. Prepare to administer terbutaline 0.25 mg subcutaneously. Administer oxygen at 8 to 10 L/min by face mask. Increase the maintenance IV fluid rate.
Discontinue the medication infusion. Prolonged contractions reduce the blood flow to the placenta and result in FHR decelerations; therefore, oxytocin should be discontinued.
A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to enable the family's 7-year-old child to accept the new family member? Allow the sibling to hold the newborn during the bath. Make sure the sibling kisses the newborn each night. Encourage the sibling to sing to help soothe the newborn. Switch the sibling's room with the nursery.
Encourage the sibling to sing to help soothe the newborn. Singing a song is an example of interacting with the newborn. Interaction will assist the sibling in connecting to the new family member.
A nurse is caring for a client who has a history of rheumatic heart disease, but no physical symptoms prior to pregnancy. The client begins to experience dyspnea, orthopnea, and pulmonary edema. Which of the following physiological alterations explains this change? Increased maternal weight Increased blood volume Change in hematocrit levels Change in heart size
Increased blood volume The increase in blood volume during pregnancy increases the workload on the heart, which causes the symptoms. While increased maternal weight during pregnancy will put more pressure on the heart, this condition does not precipitate these symptoms. Decreased hematocrit levels are expected during pregnancy and do not cause the described symptoms. While the heart does enlarge slightly during pregnancy, it does not increase the workload on the heart.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following should the nurse include in the plan of care? Maintain the client NPO throughout the procedure. Place the client in a supine position. Instruct the client to massage the abdomen to stimulate fetal movement. Instruct the client to press the provided button each time fetal movement is detected
Instruct the client to press the provided button each time fetal movement is detected. Fetal movement may not be evident on the fetal monitor and tracing. So, instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.
A nurse is teaching the mother of a newborn about erythromycin ophthalmic ointment 0.5%. Which of the following should be included in the teaching? We will need you to sign a consent form prior to administration. It is required by law that newborns receive this treatment. We will administer this medication 3 hr after birth of the newborn. We administer this medication for HPV prophylaxis.
It is required by law that newborns receive this treatment. The nurse should inform the client that eye prophylaxis is required by all states in the United States to prevent ophthalmia neonatorum.
A nurse is performing an admission assessment on a newborn who is large for gestational age (LGA). Which of the following findings indicates a need for further assessment? Heel-stick blood glucose of 50 mg/dL Respirations 50/min Acrocyanosis Jitteriness
Jitteriness This is a symptom of hypoglycemia for which this infant is at increased risk due to glucose requirements during the first hour of life, particularly for an LGA or macrosomic infant.
A client who is pregnant presents to a prenatal clinic for her first visit. She tells the nurse that her last normal menstrual period began Oct 13. Using Nägele's rule, the nurse should determine the client's estimated date of delivery as which of the following? July 6 July 13 July 20 July 27
July 20 Nägele's rule can be used to calculate the estimated date of birth (EDB). If the client's last menstrual period was Oct 13, by subtracting 3 months and adding 7 days and 1 year, her EDB is July 20.
A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and requires notification of the provider? Late decelerations Baseline variability Cessation of uterine dilation Prolonged active phase of labor
Late decelerations Oxytocin is contraindicated based on late decelerations noted on fetal assessment findings. Late decelerations are indicative of uteroplacental insufficiency.
A nurse is observing a mother caring for her newborn who is crying. Which of the following actions by the mother should the nurse recognize as a positive parenting behavior? Lays the newborn across her lap and gently sways Places the newborn in the crib in a prone position Offers the newborn a pacifier dipped in milk Prepares a bottle of milk mixed with rice cereal
Lays the newborn across her lap and gently sways This is a correct technique for quieting a newborn.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? Assessment of dilatation and effacement Leopold maneuvers Sterile speculum exam Nitrazine test
Leopold maneuvers Leopold maneuvers help the nurse assess the position of the fetus to best determine the optimal placement for the fetal monitoring transducer; therefore, this is the correct nursing action.
A nurse is assessing a young adult client in a women's health clinic who asks for a contraceptive. The client reports to the nurse a familial history of osteoporosis. Which of the following contraceptive methods is contraindicated for this client? Combined estrogen-progestin oral contraceptives An intrauterine device Medroxyprogesterone Norelgestromin/ethinyl estradiol
Medroxyprogesterone Use of medroxyprogesterone causes a decrease in bone mineral density and places the client at risk for the development of osteoporosis.
A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following is the priority intervention for the nurse to take? Perform Nitrazine testing. Assess the amniotic fluid. Check cervical dilation. Monitor the fetal heart rate.
Monitor the fetal heart rate. Rupture of the membranes places the fetus at risk for umbilical cord prolapse; therefore, this is the priority action the nurse should take.
A nurse is assessing a newborn who is 24 hr old. Which of the following is an appropriate action for the nurse to take? (There are three tabs that contain separate categories of data. Look at this data to answer the question.) EXHIBIT Initiate oxygen via nasal cannula Administer IV bolus of 0.9% sodium chloride Obtain a blood glucose level Place the newborn in a warmer
Obtain a blood glucose level Assessment data indicates possible hypoglycemia; therefore, this is an appropriate action for the nurse to take.
A nurse is caring for a client who is postpartum and has a history of preeclampsia. Upon assessment, the nurse observes petechiae and serosanguineous fluid oozing from the IV insertion site. Which of the following findings should be reported to the provider? Hct 39% Serum albumin 4.5 g/dL WBC count of 9,000/mm3 Platelet count of 50,000/mm3
Platelet count of 50,000/mm3 This is below the expected reference range, which indicates disseminated intravascular coagulation and should be reported to the provider.
A nurse is caring for a client undergoing an oxytocin-stimulated contraction test. The nurse notes three contractions in 10 min with late decelerations occurring with two of the contractions. Which of the following findings should the nurse report to the provider? Reactive Nonreactive Positive Negative
Positive A positive oxytocin-stimulated contraction test indicates an adverse reaction by the fetus and should be reported to the provider.
A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. This infection places the client at increased risk for which of the following during pregnancy? Excessive bleeding Oligohydramnios Premature rupture of membranes Proteinuria
Premature rupture of membranes Premature rupture of membranes is a risk for the client who has gonorrhea.
A nurse is caring for a client who has a vaginal hematoma in the immediate postpartum period. Which of the following assessment findings should the nurse expect to find? Lochia serosa draining from vagina Pressure in the vagina Intermittent vaginal pain Yellow exudate draining from vagina
Pressure in the vagina The client who has a vaginal hematoma will report pressure in the vagina.
A nurse is conducting an initial prenatal visit for a client who is at 6 weeks of gestation. Which of the following laboratory tests should be performed at this time? 24-hr urine for protein Group B Streptococcus (GBS) culture 3-hr glucose tolerance Rubella titer
Rubella titer A rubella titer is obtained at the initial prenatal visit to determine immunity to rubella. The 24-hr urine for protein is performed for clients who have protein noted on a urinalysis and is useful for diagnosing pregnancy induced hypertension. The GBS culture is obtained at 35 to 37 weeks of gestation. A 3-hr glucose tolerance test is a screening tool for women with elevated glucose levels after the 1-hr test. This screens for gestational diabetes and is done at 28 weeks of gestation.
A nurse is assessing a newborn. Which of the following findings are expected? (Select all that apply). Slight yellow skin color Breast nodule 6 mm Posterior fontanel larger than the anterior fontanel Overlapping suture lines Lanugo over the shoulders
Slight yellow skin color is incorrect. The newborn should not exhibit any yellowing of the skin. Breast nodule 6 mm is correct. Breast nodules up to 10mm can occur in a newborn Posterior fontanel larger than the anterior fontanel is incorrect. The posterior fontanel should be smaller than the anterior fontanel. Overlapping suture lines is correct. Overlapping suture lines is an expected finding in a newborn. Lanugo over the shoulders is correct. Lanugo over the shoulders is an expected finding in a newborn.
A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? Warm the heel prior to the puncture. Request a prescription for IM analgesic. Use a manual lance blade to pierce the skin. Swaddle the newborn after the heel puncture.
Swaddle the newborn after the heel puncture. Swaddling the newborn immediately after the puncture is an effective technique to diminish the pain experience for the newborn.
A nurse is performing a newborn assessment 12 hr after delivery. Which of the following findings indicate possible neonatal sepsis? (Select all that apply.) Temperature instability Tachypnea Hypertonicity Nasal flaring Irritability
Temperature instability Temperature instability is correct. Temperature instability is a sign of neonatal sepsis. Tachypnea is correct. Tachypnea is a sign of neonatal sepsis. Nasal flaring is correct. Nasal flaring is a sign of neonatal sepsis. Irritability is correct. Irritability is a sign of neonatal sepsis. Tachypnea Temperature instability is correct. Temperature instability is a sign of neonatal sepsis. Hypertonicity is incorrect. Hypertonicity is not a sign of neonatal sepsis. Septic newborns exhibit hypotonia and lethargy.
A client in the transitional phase of labor is using breathing techniques to manage her pain. Which of the following actions by the client should indicate to the nurse that the client's plan of care should be altered? The client can talk but not walk through contractions. The client increases her rate of breathing to relax. The client requests to move from the chair to the bed. The client reports tingling sensations in her fingers.
The client reports tingling sensations in her fingers. Report of tingling sensations in the fingers indicates that the client is hyperventilating. This causes respiratory alkalosis, resulting in dizziness, tingling of the fingers, and circumoral numbness. This can be reversed by having the client breathe into her cupped hands or placing a paper bag tightly around her mouth and nose to breathe carbon dioxide.
A nurse is caring for a client who is at 38 weeks of gestation and is in labor. The nurse notes late decelerations on the fetal monitor. (Order the steps of the process by placing the letters in the correct sequence.)
The nurse should first reposition the client on her side, increase the maintenance IV solution per protocol or the provider's prescription, palpate the uterus to assess for tachysystole, and then administer oxygen via face mask at 8 L/min.
A nurse is assessing a newborn. Which of the following images indicate an appropriate technique to assess a newborn?
The nurse should measure the newborn's head circumference by positioning the tape measure above the newborn's eyebrows and ears to obtain an accurate head circumference. >The nurse should weigh a newborn without any clothing on to obtain an accurate weight. >The nurse should measure the newborn from the top of the head to the heel with the body as straight as possible to obtain an accurate height. >The nurse should measure the newborn's chest across the nipple line to obtain an accurate chest circumference.
A nurse in a provider's office is assessing a client who is breastfeeding and reports a fever and body aches. Which of the following additional clinical findings is associated with mastitis? Pink shiny nipples and a visible rash Burning or stinging of the breast during feedings Unilateral breast pain with tenderness Firm areolae with flattened nipples
Unilateral breast pain with tenderness Sudden onset of fever, chills, body aches, and unilateral breast pain with tenderness are clinical findings associated with mastitis.