NUR 128 Reproduction
The nurse is providing care to a newborn born at 37 2/7 weeks' gestation. The newborn's weight is 1750 g (3 pounds, 10 ounces). What statement would the nurse use to describe these assessment findings? A) Preterm appropriate for gestational age B) Term appropriate for gestational age C) Preterm small for gestational age D) Term small for gestational age
Answer: D
If a woman had a prepregnancy daily requirement of 1800 calories and she decides to breastfeed her newborn, how many calories should the nurse recommend the woman take in each day? A) 2300 calories B) 2500 calories C) 2000 calories D) 1800 calories
Answer: A
A client in the fourth stage of labor is experiencing perineal trauma. Which nursing diagnosis is the priority at this time? A) Health-Seeking Behaviors B) Fear C) Anxiety D) Acute Pain
Answer: D
A premature newborn's neuronal immaturity may contribute to what complication? A) Apnea of prematurity B) Patent ductus arteriosus C) Respiratory distress syndrome D) Anemia of prematurity
Answer: A
Because of the immature development of the kidney, the nurse needs to assess preterm infants for what condition? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis
Answer: A
1) The nurse is providing care to a pregnant client who will undergo chorionic villus sampling. The client is currently 10 weeks pregnant. When teaching the client about this genetic testing, which layer of the embryonic membrane will the nurse say is tested during this procedure? A) Chorion B) Amnion C) Ectoderm D) Endometrium
Answer: A
A client at 16 weeks' gestation is diagnosed with tuberculosis (TB). Which statement by the nurse is appropriate when instructing the client regarding the needs for both the client and fetus? A) "You have been prescribed isoniazid; therefore, you must also take pyridoxine (vitamin B6)." B) "Your contact with the baby will be limited for several months after delivery." C) "You will not be able to breastfeed your baby because of this diagnosis." D) "You are free to have contact with anyone as TB is not contagious when diagnosed during pregnancy."
Answer: A
A client delivers a newborn son and plans to breastfeed. When the nurse attempts to help the newborn latch on for breastfeeding, the client states, "I would like to bottle feed my baby for the first few days." Which reason might the nurse hear regarding why the client wants to delay breastfeeding? A) Colostrum is bad for the baby. B) The birthing process spoils breast milk. C) It will cause "evil eye." D) Newborns require feeding on demand.
Answer: A
A client pregnant with her first child tells the nurse that she is concerned that her husband does not want the baby because he has a renewed interest in playing tennis and visiting with college friends after work. When responding to the client, which should the nurse take into consideration? A) This is a normal reaction by fathers that is seen in the second trimester of pregnancy. B) This is a normal reaction by fathers that is seen in the third trimester of pregnancy. C) This is a normal reaction by fathers that is seen in the first trimester of pregnancy. D) This is an atypical reaction of the father to pregnancy that should be further examined.
Answer: A
A client who gave birth to her first child 12 hours ago has the following assessment findings: nausea for 2 hours; boggy fundus that firmed with massage; moderately heavy lochia rubra; ecchymotic and edematous perineum; and pain rating of 6 on a scale of 0-10. The client's partner is present and supportive. Breastfeeding has been successful three times. Based on this data, which is the priority nursing diagnosis? A) Acute Pain related to perineal trauma B) Risk for Deficient Fluid Volume secondary to boggy fundus and nausea C) Deficient Knowledge related to birth of first child D) Readiness for Enhanced Family Coping related to partner involvement
Answer: A
A client who says she is "about 6 weeks pregnant" hears the baby's heartbeat for the first time through a Doppler. Based on this data, which conclusion by the nurse is the most appropriate? A) The mother is at 8 to 12 weeks' gestation. B) The mother is over 16 weeks' gestation. C) The mother is at 4 to 8 weeks' gestation. D) The mother is at least 20 weeks' gestation.
Answer: A
A pregnant adolescent client asks for information about the pregnancy and the baby because she cannot afford prenatal care. Which action by the nurse is the most appropriate? A) Provide the client with information on resources to assist with medical care during the pregnancy and after delivery. B) Instruct the client on aspects of pregnancy, fetal development, and labor and delivery. C) Ask the client if her parents are aware that she is pregnant and if she is covered by their medical insurance. D) Tell the client that the father of the baby is responsible to pay for medical care for her during the pregnancy and after delivery.
Answer: A
The laboring client's fetal heart rate baseline is 120 beats per minute (bpm). Accelerations are present to 135 bpm. During contractions, the fetal heart rate gradually slows to 110 bpm and is at 120 bpm by the end of the contraction. Which nursing action is appropriate? A) Documenting the fetal heart rate B) Preparing for imminent delivery C) Applying oxygen via mask at 10 liters per minute D) Assisting the client into the Fowler position
Answer: A
The nurse is caring for a 14-year-old client who is pregnant. What will the nurse need to consider that may affect this client more than older adolescents? A) The client may be more concerned about modesty. B) The client may be more concerned with state marriage laws. C) The client may be more concerned about parents finding out about the pregnancy. D) The client may be more concerned about finding a support person.
Answer: A
The nurse is caring for a 36-year-old pregnant woman. She has two children, ages 15 and 13, from a previous marriage, and this is her first child from her second marriage. The client has indicated that her two older children seem very upset by her pregnancy and have been increasingly belligerent the closer she gets to delivery. What can the nurse say to support this family? A) "It may help to remind your older children that you will still make time for them and that you won't expect them be responsible for the baby unless they want to." B) "You could tell your older children that the stress and anxiety that comes with a new baby will help improve your family relationships." C) "They are probably just embarrassed because you are pregnant. They'll get over it once you have the baby." D) "Your older children probably just want to know what their new roles will be once the baby is born. You should tell them what their responsibilities will be in caring for the baby."
Answer: A
The nurse is providing care to a client whose last menstrual period was 6 weeks ago. The client believes she is pregnant. Which diagnostic test does the nurse anticipate in order to confirm the pregnancy? A) Serum or urine human chorionic gonadotropin (hCG) B) Fetal heartbeat by Doppler C) Fetal heartbeat by fetoscope D) Fetal movement
Answer: A
The nurse is teaching childbirth exercises to a pregnant client with a history of back pain. Which is most appropriate for this client? A) Perform the pelvic rock exercise only in the standing position. B) Exercise in the supine position throughout the pregnancy. C) Perform the pelvic rock exercise while in the hands and knees position. D) Soak in a hot tub for approximately 30 minutes after exercise.
Answer: A
Which symptom would the nurse recognize as being consistent with postpartum endometritis at 4 weeks postpartum? A) Foul-smelling lochia B) Bright red lochia C) Upper abdominal pain D) Bradycardia
Answer: A
1) The nurse is proving care to a 1-hour-old newborn who was born at 39 weeks' gestation. Which assessment data is cause for concern? Select all that apply. A) Respiratory rate of 82 breaths per minute B) Negative Babinski reflex C) Mean blood pressure of 52 mmHg D) Acrocyanosis E) Presence of soft heart murmur
Answer: A, B
The nurse is planning care for a client who had a cesarean birth 4 hours ago. Which actions should be included in this client's plan of care? Select all that apply. A) Encourage the use of breathing, relaxation, and distraction. B) Encourage deep breathing and coughing every 2 to 4 hours. C) Encourage to ambulate to the bathroom to void. D) Discourage leg exercises. E) Withhold all analgesics.
Answer: A, B
The nurse is providing postpartum care to a client from a different culture. What nursing actions are appropriate to include in the client's plan of care? Select all that apply. A) Assess for any assistance required during breastfeeding. B) Ask if there are any specific customs the client wants to follow. C) Assess for any specific foods or fluids to hasten recovery. D) Limit client visitors to the immediate family. E) Restrict interactions with the client.
Answer: A, B, C
A pregnant client presents to the emergency department reporting that she has started labor and is certain the baby is coming "any minute now." After assessing and monitoring the client, the healthcare team determines that the client is in "false" labor, and the nurse prepares her for discharge. Which observations support the conclusion of false labor? Select all that apply. A) The contractions do not have a regular pattern. B) Her cervix has dilated 2 cm over the 2 hours of observation. C) The frequency and intensity of the contractions have stayed about the same. D) Walking seems to increase the strength of the contractions. E) The contractions are mostly in her abdomen.
Answer: A, C, E
A nurse is caring for the 1-hour-old newborn of a mother with diabetes mellitus. Which actions will the nurse include in the newborn's plan of care? Select all that apply. A) Assess blood glucose frequently. B) Assess for SGA. C) Assess for hyperthyroidism. D) Assess the newborn's temperature hourly. E) Assess for hyperbilirubinemia.
Answer: A, E
The nurse is instructing the parents who delivered their first child at 34 weeks' gestation. Which statements made by the parents indicate that additional teaching is needed? Select all that apply. A) "Tube feedings will be required because his stomach is small." B) "Breathing might be harder for our baby because he is early." C) "Our baby will be in an incubator to keep him warm." D) "The growth of our baby will be slower than if he were term." E) "Because he came early, he will not produce urine for 2 days."
Answer: A, E
A client who is in the first trimester of pregnancy tells the nurse that she is constantly nauseated and can vomit at any time. To assist this client, the nurse should instruct her to do which of the following? A) Drink a glass of water every time nausea occurs. B) Take a multivitamin each day. C) Take over-the-counter Benadryl for the nausea. D) Eat a snack any time nausea occurs.
Answer: B
A nurse is caring for a premature infant with a central line. The otherwise healthy, growing infant suddenly develops apnea, bradycardia, and metabolic acidosis. Which is the most likely condition causing this change in health status? A) Hyperbilirubinemia B) Bacterial sepsis C) Hypoglycemia D) Intracranial hemorrhage
Answer: B
A nurse working in an OB/GYN outpatient clinic finds that on a routine anemia screen, a pregnant client in her second trimester has a hemoglobin of 10 g/dL. The client confirms fatigue, but otherwise feels fine. Which action by the nurse is the priority when providing care to this client? A) Tell the client to rest any time she feels fatigued. B) Recommend the client add supplemental iron to her diet. C) Ask the client to return in 2 months for a repeat check of her hemoglobin. D) Order a screening for sickle cell anemia.
Answer: B
A pregnant woman at 41 weeks' gestation has a Bishop score of 5. What does this score indicate? A) The cervix is favorable for a normal vaginal delivery. B) The cervix is unfavorable and induction of labor may be necessary. C) The cervix is unfavorable and a cesarean section may be necessary. D) The cervix is favorable and labor has been successfully induced.
Answer: B
An adolescent client at 34 weeks' gestation states to the nurse, "I am stressed out about becoming a mother. I hope that I can get back to my normal day to day activities after the baby is born, like hanging out with friends and studying." If the nurse wants to assess whether the client is performing normal developmental tasks for this stage of pregnancy, which question by the nurse is the most appropriate? A) "Are your friends excited about the baby coming and planning a shower for you?" B) "Are you prepared to delay some of your own needs and desires for your baby?" C) "Do you miss going out with your friends on the weekends?" D) "Have you been able to get enough rest while keeping up with your studies?"
Answer: B
Before a first-time mother is discharged from the hospital with her newborn, the nurse notices that the mother is taking directions on newborn care from her parents and in-laws. What stage of maternal role attainment is the new mother in? A) Anticipatory stage B) Formal stage C) Informal stage D) Personal stage
Answer: B
During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the nurse assesses the following: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood noted from the vagina. Which assessment finding requires immediate follow-up? A) Moderate lochia rubra B) Steady trickle of blood C) Fundus at the umbilical level D) Firm fundus
Answer: B
During which phase of the ovulatory cycle does the ovum get fertilized? A) Follicular phase B) Luteal phase C) Proliferative phase D) Secretory phase
Answer: B
The nurse is caring for a 15-year-old pregnant adolescent during the labor and delivery process. The client has no support person with her, and she plans to give up her baby for adoption. What nursing intervention can the nurse implement to facilitate the grieving process for this client? A) Encourage the client to avoid seeing and holding the baby. B) Encourage the client to see and hold the baby. C) Encourage the client to have the adoptive parents present for the birth. D) Encourage the client to sign the adoption papers as soon as possible after the birth.
Answer: B
The nurse is caring for a newborn boy who was circumcised an hour ago. Which is the priority nursing diagnosis for the newborn? A) Risk for Injury B) Risk for Infection C) Risk for Imbalanced Nutrition D) Risk for Ineffective Breathing Pattern
Answer: B
The nurse is preparing to provide an enteral feeding to a preterm infant. Which is the priority nursing action prior to administering the feeding? A) Weigh the current diaper. B) Measure abdominal girth. C) Weigh the baby. D) Measure pulse oximetry.
Answer: B
The nurse is providing care to a pregnant client who is experiencing ptyalism. Which will the nurse include in the plan of care for this client? A) Use a cool-mist vaporizer B) Suck on hard candy C) Avoid use of nasal sprays and decongestants D) Use low-sodium antacids
Answer: B
The nurse is providing discharge instructions for a healthy 37-year-old first-time mother and her newborn. What should the nurse include in her instructions for this mother and her spouse? A) Information related to contraception and sexually transmitted infections (STIs). B) A reminder that addition of a newborn will alter established routines. C) A referral to a group class that provides information on newborn care. D) A referral for follow-up care with healthcare providers other than the obstetrician.
Answer: B
The nurse will commonly need to work with all except which member of the healthcare team to provide care to the newborn? A) Audiology specialist B) Cardiac surgeon C) Lactation consultant D) Pediatrician
Answer: B
A client who recently learned of being pregnant tells the nurse that she stopped eating meat years ago and started eating fish daily because it is healthier. Which teaching points are appropriate for this client based on her current diet? Select all that apply. A) Avoid shrimp, salmon, and catfish because these have higher mercury levels. B) Eat up to 12 ounces a week of a variety of fish and shellfish. C) Do not eat more than 6 ounces per week of albacore tuna. D) Eat plenty of fish such as king mackerel while pregnant. E) Follow a complete vegetarian diet while pregnant as an alternative to eating fish.
Answer: B, C
The nurse is instructing a new mother on how to care for the newborn's circumcision site. Which statements indicate that the nurse's education session was effective? Select all that apply. A) "I should not use petroleum jelly on the penis." B) "Every time I change the diaper I am to wash the area with warm water." C) "I should report any pus drainage or change in diaper wetness to the physician." D) "Swelling is expected." E) "I am to use soap and water to remove yellow tissue on the penis."
Answer: B, C
The nurse is providing care to a client with a history of rheumatoid arthritis (RA) who is 5 months pregnant. Which nursing actions are appropriate when providing care to this client? Select all that apply. A) Telling the client there is an increased risk for preterm delivery because of salicylate therapy B) Monitoring the client for anemia due to salicylate therapy C) Suggesting the client begin supplemental pyridoxine D) Educating the client that medication therapy may be discontinued due to remission E) Teaching the client that RA may be contracted by the fetus during pregnancy
Answer: B, D
When administering an intramuscular dose of vitamin K (phytonadione) to a newborn, which actions by the nurse are appropriate? Select all that apply. A) Using a 23-gauge 1/2-inch needle B) Cleaning the skin with an alcohol swab C) Preparing 5 mg of the medication for injection D) Using the middle third of the vastus lateralis muscle E) Washing the skin with soap and water
Answer: B, D
A postpartum client is experiencing pain from an episiotomy. Which actions will the nurse suggest to the client to decrease discomfort? Select all that apply. A) Washing the area with soap and water every day B) Tightening the buttocks before sitting C) Changing peripads daily D) Performing leg scissor kicks several times a day E) Increasing the intake of meat, cheese, fish, eggs, and nuts
Answer: B, E
A 16-year-old has just given birth, and she plans to keep and care for the baby. However, the nurse determines that the young mother has low self-esteem, and she does not appear to have adequate social support. The nurse should encourage adequate follow-up care for this young mother for what reason? A) She is at risk for postpartum hemorrhage. B) She is at risk for postpartum endometritis. C) She is at risk for postpartum depression. D) She is at risk for postpartum weight gain.
Answer: C
A client who is at 12 weeks' gestation is experiencing nausea, breast tenderness, and fatigue. She tells the nurse her husband is upset with her constant complaints. Which is the priority nursing diagnosis based on this data? A) Ineffective Breastfeeding B) Dysfunctional Family Processes C) Nausea D) Fatigue
Answer: C
During an assessment, the nurse notes the client in the fourth stage of labor is experiencing intense shaking and chills. Based on this data, which conclusion by the nurse is appropriate? A) This is evidence of incomplete expulsion of the placenta. B) The client has a full bladder. C) This is a normal reaction to the ending of the physical exertion of labor. D) The client has a fever from a postpartum infection.
Answer: C
The nurse is assessing a premature newborn who is being cared for in the newborn intensive care unit (NICU). Which assessment finding indicates the newborn is experiencing respiratory distress? A) Acrocyanosis B) Respiratory rate of 58 breaths per minute C) Substernal and intercostal retractions D) Abdominal breathing
Answer: C
The nurse is caring for a pregnant client who has asthma. The client has a cold and has an exacerbation of asthma symptoms, including mild wheezing. To help avoid hypoxia-related complications in the fetus, which medication prescription does the nurse anticipate? A) IV corticosteroid (e.g., prednisone) B) Oral pseudoephedrine (e.g., Sudafed) C) Inhaled beta2-agonist (e.g., albuterol) D) Oral acetylsalicylic acid (e.g., aspirin)
Answer: C
The nurse is instructing a client who is at 10 weeks' gestation on avoiding substance abuse. Which is the rationale for why substances of abuse should be avoided during pregnancy? A) Interferes with hormone excretion of the fetus B) Facilitates the transfer of viruses and other diseases into the developing fetus C) Passes into the developing fetus through the placenta very easily D) Stops the synthesis of protein in the developing fetus
Answer: C
The nurse is instructing a pregnant client on how the baby's condition is evaluated during labor. Which client statement indicates appropriate understanding of the information presented? A) "During labor, the nurse will verify that my contractions are strong but not too close together." B) "During labor, the nurse will look at the color and amount of bloody show that I have." C) "During labor, the nurse will assess the baby's heart rate with a Doppler ultrasound." D) "During labor, the nurse will regularly check my cervix by doing a pelvic exam."
Answer: C
The nurse is planning for several women who are pregnant for the first time who are in the labor and delivery process. Which woman has the highest risk of labor and delivery complications? A) A healthy 38-year-old woman B) A 24-year-old woman with asthma C) A 36-year-old woman with diabetes D) A 31-year-old woman with hypertension
Answer: C
The nurse is providing care to a client in labor who experiences spontaneous rupture of membranes. The fetus is in the vertex position. The nurse notes that the amniotic fluid is meconium stained. Based on this data, which is the priority action by the nurse? A) Notifying the healthcare provider that birth is imminent B) Changing the client's position in bed C) Beginning continuous fetal heart rate monitoring D) Administering oxygen at 2 liters per minute
Answer: C
The nurse is providing care to the client during the second stage of labor. Which nursing action is appropriate? A) Assessing maternal temperature every 1-2 hours after amniotic membranes have ruptured B) Encouraging the client to void every 1-2 hours C) Assessing fetal heart rate every 5 minutes D) Administering antibiotics for a positive group beta strep
Answer: C
The nurse is providing discharge instructions for a first-time mother and her baby. Which statement is appropriate for the nurse to include in the teaching session? A) "Your baby's stools will change to a dark green color when your milk comes in." B) "Your baby may spit up frequently for the first few weeks." C) "Compress the bulb syringe before placing it in your baby's nose or mouth." D) "You can wipe away any green drainage that might form around the umbilical cord."
Answer: C
The nurse is reviewing the immunization record for a client who just learned she is pregnant. Which vaccine is not safe to give during pregnancy? A) Pertussis B) Annual influenza C) Rubella D) Tetanus
Answer: C
The spouse of a pregnant client tells the nurse that he is not sure he is ready to be a father and wishes his wife had not gotten pregnant. Which response by the nurse is appropriate? A) "Do you think your wife got pregnant on purpose, without your consent?" B) "Have you considered giving the baby up for adoption?" C) "Tell me more about why you feel this way." D) "Every husband has these feelings, and many times they never go away."
Answer: C
Upon delivery of the newborn, which nursing intervention promotes parental attachment? A) Placing the newborn under the radiant warmer B) Placing the newborn on the bed next to the mother C) Placing the newborn on the maternal chest D) Taking the newborn to the nursery for the initial assessment
Answer: C
When palpating the fundus of a woman on her first day postpartum, the nurse finds that the woman's uterus is higher than expected and is deviated to the right. She is not having excessive uterine bleeding. Which is the priority nursing action for this client? A) Notify the client's midwife of this condition. B) Ask another nurse to assess the client to verify the findings. C) Ask the client to void and then reassess fundal height. D) Perform a straight catheterization on the client and then reassess fundal height.
Answer: C
The nurse is providing care to a client who is experiencing nausea and vomiting during the first trimester of pregnancy. Which actions by the nurse are appropriate based on this data? Select all that apply. A) Notify the healthcare provider that the client is experiencing hyperemesis gravidarum. B) Educate the client to notify the healthcare provider if she vomits once per day. C) Suggest the client use acupressure to pressure points on the wrist. D) Teach the client that ginger may relieve her symptoms. E) Caution the client against using over-the-counter medications such as over-the-counter antihistamines.
Answer: C, D
After giving birth to a preterm infant who is being cared for in the neonatal intensive care unit (NICU), a client says, "My baby doesn't seem real because she's in the hospital and I'm at home." What can the nurse do to promote parent-infant attachment? A) Limit visits to the intensive care unit so as not to disrupt care the baby needs. B) Explain that once the baby is discharged to home, she will have evidence that the baby is real. C) Have the mother visit when the baby is asleep or resting. D) Provide a picture of the infant including a footprint and current weight and length.
Answer: D
During the fourth stage of labor, a client's blood pressure is 110/60 mmHg, pulse 90, and the fundus is firm, midline, and halfway between the symphysis pubis and the umbilicus. Based on this data, which is the primary action by the nurse? A) Massage the fundus. B) Turn the client onto the left side. C) Place the bed in the Trendelenburg position. D) Continue to monitor.
Answer: D
The mother of a preterm infant tells the nurse that she was not looking forward to having a baby and now that the baby is sick, she feels worse. Which nursing diagnosis is appropriate based on this data? A) Parental Role Conflict B) Impaired Parenting C) Dysfunctional Family Processes D) Compromised Family Coping
Answer: D
The nulliparous client states, "I have been in labor for 4 hours and I am still only 2 cm dilated. Why is this happening? I feel like I should be ready to push by now." Which is the best response by the nurse? A) "When your perineal body thins out, your cervix will begin to dilate much faster than it is now." B) "The hormones that cause labor to begin are just getting to the levels that will change your cervix." C) "What did you expect? You've only had contractions for a few hours. Labor takes time." D) "Your cervix has also effaced, or thinned out, and that change in the cervix is also labor progress."
Answer: D
The nurse conducting a 5-minute Apgar assessment on a newborn assigns the following ratings: Heart rate <100 beats per minute (1 point); slow, irregular respirations (1 point); some flexion of the extremities (1 point); a vigorous cry with flicking of the baby's foot (2 points); and a pink body with blue extremities (1 point). Based on this data, which nursing action is appropriate? A) Having the aide reassess the newborn's heart rate and respiratory rate when admitted to the nursery B) Swaddling the newborn to decrease the risk of increased energy expenditure C) Placing the newborn in the mother's arms and asking her to monitor her baby's breathing D) Repeating the assessment every 5 minutes for up to 20 minutes
Answer: D
The nurse is monitoring the intake and output for a preterm infant. Which action by the nurse indicates correct assessment technique when monitoring urine output? A) Document "unable to obtain" on the graphic sheet. B) Apply an external condom catheter. C) Insert an indwelling urinary catheter. D) Weigh diapers using the estimate that 1 mL = 1 gram of weight.
Answer: D
The nurse is providing care to a newborn during the first 24 hours of life. Which is an abnormal finding? A) Respiratory rate of 58 breaths per minute B) Heart rate of 140 beats per minute C) Presence of meconium stool D) Yellowing of the skin
Answer: D
The nurse is providing care to a pregnant client and her spouse. The client requires an amniocentesis. Which client statement indicates appropriate understanding of the information presented? A) "The test has to be done before the 14th week of pregnancy." B) "If the test determines our baby has Down syndrome, we will not need to take childbirth classes." C) "It is not unusual for amniocentesis to misdiagnose a problem with the baby." D) "The results of the amniocentesis will take up to 2 weeks."
Answer: D
The nurse is reviewing exercises with a pregnant woman to help the client maintain physical fitness and appropriate weight gain throughout the pregnancy. After the teaching session, the client tells the nurse that she was taught never to reach over the head because this will harm the baby. Based on this data, which action by the nurse is appropriate? A) Provide dietary instruction instead to ensure the client does not gain excessive weight. B) Tell the client to just perform the exercises that don't require her to reach over her head. C) Provide alternative activities to do instead of exercise. D) Assure the client that reaching over the head will not harm the baby.
Answer: D
The nurse receives shift change report on infants born within the last 4 hours. Which newborn should the nurse assess first? A) Newborn born at 37 weeks' gestation. Respiratory rate of 45 breaths per minute. B) Term newborn, 2 hours old, who has not passed a meconium stool. C) Term newborn born 3 hours ago. Heart rate is 150 beats per minute. D) Term newborn born 1 hour ago who is exhibiting grunting respirations.
Answer: D
When planning the care for a preterm infant with ineffective thermoregulation, the nurse should include which intervention? A) Keep the baby's head uncovered. B) Rinse hands with cold water before providing care to the infant. C) Place incubator near a window or source of fresh air. D) Allow skin-to-skin contact with the mother to maintain warmth.
Answer: D
Which factor contributes to increased respiratory complications in the preterm infant? A) Increased constriction of blood vessels B) Decreased prostaglandin E levels C) Absence of muscular coat on pulmonary blood vessels D) Inadequate surfactant
Answer: D
Which pregnant client would have the greatest need for a nutritional assessment and individualized meal plan? A) A client who is lactose intolerant B) A client who is vegetarian C) A client who requires a Kosher diet D) A client with anorexia nervosa
Answer: D
