OB Final

230.A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. Which of the following statements by the client indicates a need for further teaching?

A. "I will breastfeed every 2 hours." B. "I will apply ice packs to my breasts after feeding." C. "I should apply hot packs to my breasts during feeding." D. "I should crush cabbage leaves and place them on my breasts." ANSWER = C The application of heat promotes increased blood flow to the breasts, which are already engorged. This is not an appropriate intervention.

237.A nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching?

A. "My baby will be placed under special lights if the test result is positive." B. "My baby needs to be on formula or breast milk before the test can be done." C. "This test checks for a genetic disorder that can be managed by diet." D. "Sometimes the test is repeated in the doctor's office at the baby's 2-week check-up." ANSWER = A Phototherapy is used to reduce circulating unconjugated bilirubin in infants who have hyperbilirubinemia. Phototherapy for hyperbilirubinemia uses light energy to lower the bilirubin level in the newborn's blood. This would not be appropriate therapy for PKU.

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide?

A. "There is an increased risk of introducing infection." B. "This could initiate preterm labor." C. "This could result in profound bleeding." D. "There is an increased risk of rupture of the membranes." ANSWER = C "Pelvic rest" is essential for clients who have placenta previa because any disruption of placental blood vessels in the lower uterine segment could cause premature separation of the placenta and life-threatening hemorrhage. This means no vaginal examinations, no douching, and no vaginal intercourse.

47.A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, "How will I know if my baby gets enough breast milk?" Which of the following responses should the nurse make?

A. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding." B. "Your baby should wet 6 to 8 diapers per day." C. "Your baby should burp after each feeding." D. "Your baby should sleep at least 6 hours between feedings." ANSWER = B Newborns should wet 6 to 8 diapers per day. This is an indication that the newborn is getting enough fluids.

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?

A. 1+ pitting sacral edema B. 3+ protein in the urine C. Blood pressure 148/98 mm Hg D. Deep tendon reflexes of +1 Answer = D She may switch it to an answer of an elevated BP In a client who has preeclampsia, the nurse should expect to find an increased, rather than a decreased, deep tendon reflex.

A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the provider immediately?

A. A tearful client who is at 32 weeks of gestation and is experiencing irregular, frequent contractions B. A client who is at 28 weeks of gestation and receiving terbutaline reports fine tremors C. A client who has a diagnosis of preeclampsia has 2+ proteinuria and 2+ patellar reflexes D. A client who has a diagnosis of preeclampsia reports epigastric pain and unresolved headache ANSWER--> D

101.A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?

A. Abruptio placentae B. Placenta previa C. Precipitous labor D. Threatened abortion ANSWER = B Painless, bright red vaginal bleeding in the second or third trimester is a manifestation of placenta previa.

202. A nurse is caring for a client who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. The nurse should anticipate a prescription from the provider for which of the following medications for the client?

A. Acarbose B. Repaglinide C. GlyBURIDE D. Glipizide ANSWER = C Answer can also be Insulin With the exception of glyburide, clients who are pregnant do not take oral hypoglycemics because they cross the placenta and can injure the fetus. Approximately 20% of clients who have gestational diabetes mellitus will require insulin. Insulin lowers blood glucose levels without harming the fetus.

A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care?

A. Administer oxygen via nasal cannula. B. Offer option to view products of conception. C. Instruct the client to increase potassium-rich foods in the diet. D. Maintain the client on bed rest. ANSWER = B Providing support for pregnancy loss includes offering the client and her partner the options of viewing the products of conception and making arrangements for handling of the fetal remains. The client should be instructed on possible grief responses, how to manage these, and provided a referral to a support group.

228. A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take?

A. Apply an ice pack to the affected area. B. Offer a warm sitz bath. C. Provide a squeeze bottle of antiseptic solution. D. Place a hot pack to the perineum. ANSWER = A During the first 24 hr, ice packs and cool water sitz baths are used. They reduce edema and promote comfort. The client may also apply witch hazel compresses to reduce edema. The nurse should instruct the client on the use of prescribed anesthetic creams, sprays, and ointments.

68.A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? (Select all that apply.)

A. Apply breast milk to the nipples before each feeding. B. Place breast pads inside the nursing bra. C. Massage the breasts and nipples prior to feeding. D. Start breastfeeding with the nipple that is less sore. E. Change the infant's position on the nipples. ANSWER A, D, E

120.A nurse is caring for a client who is breastfeeding and states that her nipples are sore. Which of the following interventions should the nurse suggest?

A. Apply mineral oil to the nipples between feedings. B. Keep the nipples covered between breastfeeding sessions. C. Increase the length of time between feedings. D. Change the newborn's position on the nipples with each feeding. ANSWER = D When the client's nipple is sore due to breastfeeding, the client should break the suction with her finger, remove the newborn from the breast, and try a different position. The newborn's mouth should be open wide before connecting with the nipple.

A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?

A. Assess deep tendon reflexes every hour. B. Obtain a daily weight. C. Continuous fetal monitoring D. Ambulate twice daily. Answer = D A provider's order to allow the client to ambulate requires clarification. The client who has severe preeclampsia should be placed on bedrest in a quiet, nonstimulating environment to prevent seizures and promote optimal placental blood flow

72.A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

A. At the level of the umbilicus B. 2 cm above the umbilicus C. One fingerbreadth above the symphysis pubis D. To the right of the umbilicus ANSWER = A Within 12 hr, the fundus should be palpable at the level of the umbilicus and then recede 1 to 2 cm each day.

242. A nurse is assessing a client who is 12 hr postpartum and received spinal anesthesia for a cesarean birth. Which of the following findings requires immediate intervention by the nurse?

A. Blood pressure 100/70 mm Hg B. Headache pain rated a 6 on a scale of 0 to 10 C. Respiratory rate 10/min D. Urinary output 30 mL/hr ANSWER = C A client who has received spinal anesthesia is at risk for respiratory depression and hypotension. A respiratory rate of 10/min indicates bradypnea and requires immediate intervention.

129.A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?

A. Cervical dilation B. Report of pain above the umbilicus C. Brownish vaginal discharge D. Amniotic fluid in the vaginal vault ANSWER = A Cervical dilation and effacement are indications of true labor.

180.A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum?

A. Chvostek's sign B. Cullen's sign C. Chadwick's sign D. Goodell's sign ANSWER = B Cullen's sign is a blue discoloration similar to ecchymosis around the umbilicus. It indicates hematoperitoneum, a common clinical manifestation of a ruptured ectopic pregnancy.

198. A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

A. Client report of frequent uterine contractions B. Less than 2.5 cm of rubra lochia on perineal pad C. Fundus palpable to right of midline D. Client report of increased thirst ANSWER = C Bladder distention results in uterine displacement, pushing the fundus above the umbilicus and away from the midline. The fundus might feel boggy to palpation and does not contract normally.

nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching?

A. Consume 40 to 50 g of protein daily. B. Avoid salting of foods during cooking. C. Drink 48 to 64 ounces of water daily. D. Limit intake of whole grains, raw fruits, and vegetables. ANSWER = C The client who has preeclampsia is encouraged to drink six to eight 8-ounce glasses of water (48 to 64 ounces) per day. She should avoid alcohol and limit intake of caffeinated beverages.

250. A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?

A. Decreased urge to void B. Increased urine output C. Displaced fundus from the midline D. Fundal height below the umbilicus ANSWER = C A distended bladder can cause uterine atony and lateral displacement of the fundus from the midline of the lower abdomen, usually to the right. This requires immediate intervention because the distended bladder pushes the uterus up and to the side, which prevents it from contracting firmly. Uterine atony results from the inability of the uterine muscle to contract adequately after birth. This can lead to postpartum hemorrhage.

114.A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

A. Encourage the client to perform Kegel exercises. B. Encourage the client to move to the left lateral position. C. Ask the client to rate her pain. D. Assist the client to the bathroom to void. ANSWER = D A full bladder causes the uterus to be displaced above the umbilicus and off to one side. This prevents the uterus from contracting normally and increases the risk of hemorrhage.

240. A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

A. Evaluate the firmness of the uterus. B. Initiate oxygen therapy by nonrebreather mask. C. Administer oxytocin infusion. D. Obtain a type and crossmatch. ANSWER = A The first action the nurse should take using the nursing process is to assess the client. A blood pressure of 60/50 mm Hg can indicate postpartum hemorrhage; therefore, the first action the nurse should take is to evaluate the firmness of the uterus to determine if there is uterine atony.

181.A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which of the following assessment findings should the nurse report to the provider first?

A. Expulsion of a blood-tinged mucous plug B. Continuous contraction lasting 2 min C. Pressure on the perineum causing the client to bear down D. Expulsion of clear fluid from the vagina ANSWER B A uterus contracting for more than 90 seconds is a sign of tetany and could lead to uterine rupture, which is the greatest risk to the client at this time. The nurse should report this finding immediately.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following?

A. Fetal lung maturity B. Location of the placenta C. Viability of the fetus D. The biparietal diameter ANSWER = B Painless, spontaneous vaginal bleeding might indicate that the client has placenta previa. Placenta previa is a condition in which the placenta is implanted low in the uterus, sometimes to the point of covering the cervical os. As the cervix effaces, the client begins to bleed. The ultrasound will show the location of the placenta and help to determine what sort of delivery the client requires and how emergent it is.

113. A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

A. Fundus soft, 1 cm to the right of the umbilicus B. Fundus firm, at the level of the umbilicus C. Fundus present, to the left of the umbilicus D. Fundus soft, 2 cm above the umbilicus ANSWER = B Within 12 hours after birth, the fundal tone is expected to be firm and the location is typically palpated midline and at the level of the umbilicus.

A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client's newborn at risk for which of the following complications?

A. Hearing loss B. Intrauterine growth restriction C. Type 1 diabetes mellitus D. Congenital heart defects ANSWER = B Clients who smoke place their newborns and themselves at risk for diverse complications, including fetal intrauterine growth restriction, placental abruption, placenta previa, preterm delivery, and fetal death.

200.A nurse in a clinic is caring for a client who is at 11 weeks of gestation and reports that she has had slight occasional vaginal bleeding over the past 2 weeks. Following an examination by the provider, the client is told that the fetus has died and that the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings?

A. Incomplete miscarriage B. Missed miscarriage C. Inevitable miscarriage D. Complete miscarriage ANSWER = B With a missed miscarriage, the fetus has died but the client retains the products of conception for several weeks. The client might have spotting or no bleeding at all.

80. A nurse is caring for a client who is breastfeeding her newborn and asks the nurse about the changes she should make in her diet. Which of the following dietary changes should the nurse suggest?

A. Increase her caloric intake by 600 kcal/day B. Increase her fluid intake to 2.5 L/day. C. Reduce her intake of iron. D. Avoid shellfish. ANSWER = C Recommendations for some nutrients, such as iron and folic acid, are less during lactation than during pregnancy. Because maternal blood volume decreases after childbirth, the client's need for these nutrients also diminishes.

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder?

A. Increased urine output B. Vaginal discharge C. Elevated blood pressure D. Joint pain ANSWER = C Hypertension is one of the cardinal symptoms of preeclampsia, along with excessive weight gain, edema, and albumin in the urine.

A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action?

A. Insert an indwelling urinary catheter. B. Initiate IV access. C. Witness the signature for informed consent for surgery. D. Prepare the abdominal and perineal areas. ANSWER = B Insertion of a large-bore IV catheter is the priority nursing action. The client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops.

133. A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?

A. Massage the fundus. B. Insert a urinary catheter. C. Have the client urinate. D. Administer an analgesic. ANSWER = C A full bladder displaces the uterine fundus and elevates it above the level of the umbilicus. This can lead to uterine atony and excessive bleeding. Having the client urinate allows the uterus to return to midline and remain below the umbilicus.

A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Which of the following is the priority nursing action?

A. Monitor vaginal bleeding. B. Administer glucocorticoids. C. Insert an IV catheter. D. Apply an external fetal monitor. ANSWER = D Based on Maslow's hierarchy of needs, the nurse should immediately apply the fetal monitor to determine if the fetus is in distress.

15.A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?

A. Notify the provider of the findings. B. Position the client with one hip elevated. C. Ask the client if she needs pain medication. D. Have the client void. ANSWER = B Based on Maslow's hierarchy of needs, the client's need for an adequate blood pressure to perfuse herself and her fetus is a physiological need that requires immediate intervention. Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By turning the client on her side and retaking her blood pressure, the nurse is attempting to correct the low blood pressure and reassess.

99. A nurse in is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure? Nursing action for prolapsed umbilical cord: complication related to the labor process

A. Observe color and consistency of fluid. B. Assess the fetal heart rate pattern. C. Assess the client's temperature. D. Evaluate client for the presence of chills and increased uterine tenderness using palpation. ANSWER = B Variable fetal heart rate decelerations and bradycardia can occur with an amniotomy as a result of umbilical cord prolapse or compression. Cord prolapse necessitates an emergent delivery.

205.A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

A. Orthostatic hypotension B. Fundus palpable at the umbilicus C. Urine output of 3,000 mL in 12 hr D. Heart rate 110/min ANSWER = D A rapid or increasing heart rate can be a manifestation of fluid volume depletion related to hemorrhage. The nurse should further evaluate the client for evidence of postpartum hemorrhage.

A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis?

A. Painless red vaginal bleeding B. Increasing abdominal pain with a nonrelaxed uterus C. Abdominal pain with scant red vaginal bleeding D. Intermittent abdominal pain following passage of bloody mucus ANSWER = A Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester.

130 A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

A. Palpate the client's uterine fundus. B. Assist the client on a bedpan to urinate. C. Prepare to administer oxytocic medication. D. Increase the client's fluid intake. ANSWER = A Although the expectation is moderate bleeding in the first 2 hr after delivery, saturating a perineal pad in 15 min or less indicates excessive blood loss. The priority nursing intervention is to palpate the client's fundus to determine the presence of uterine atony, followed by fundal massage to stimulate uterine muscle tone.

A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

A. Placenta previa B. Prolapsed cord C. Incompetent cervix D. Abruptio placentae ANSWER = D The classic signs of abruptio placentae include vaginal bleeding, abdominal pain, uterine tenderness, and contractions.

115. A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications?

A. Puerperal infection B. Retained placental fragments C. Thrombophlebitis D. Uterine atony ANSWER = D A uterus that is over distended, such as from a macrosomic fetus, has an increased risk of uterine atony.

nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

A. Rapid decline in human chorionic gonadotropin (hCG) levels B. Profuse, clear vaginal discharge C. Irregular fetal heart rate D. Excessive uterine enlargement ANSWER = D A hydatidiform mole is a rare tumor that forms inside the uterus at the beginning of a pregnancy and results in the over-production of tissue that would normally develop into the placenta. This tissue consists of fluid-filled vesicles. A rapidly enlarging uterus is a classic finding in clients who have a molar pregnancy. It is often accompanied by severe nausea and vomiting, elevated human chorionic gonadotropin levels, signs of hyperthyroidism, and early onset of preeclampsia.

16.A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

A. Rupture of the membranes B. Changes in the cervix C. Station of the presenting part D. Pattern of contractions ANSWER = B Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor.

2.A nurse is assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

A. Saturated perineal pad in 30 min B. Deep tendon reflexes 4+ C. Fundus at level of umbilicus D. Approximated edges of episiotomy ANSWER = B Deep tendon reflexes 4+ are hyperactive and indicate that the client is at greatest risk for preeclampsia and seizures. The nurse should identify this as the priority finding. The nurse should also monitor for headaches, visual disturbances and epigastric pain. The provider will likely prescribe magnesium sulfate IV infusion.

42.A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

A. Severe nausea and vomiting B. Large amount of vaginal bleeding C. Unilateral, cramp-like abdominal pain D. Uterine enlargement greater than expected for gestational age ANSWER = C An ectopic pregnancy is one in which the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop in this area. The most common site is within a fallopian tube; however, ectopic pregnancies can occur in the ovary, the abdomen, and in the cervix.

247. A nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?

A. Swelling in both breasts B. Cracked and bleeding nipples C. Red and painful area in one breast D. A white patch on a nipple ANSWER = C Mastitis often appears as a red, hard, and painful area on the breast, commonly in the upper outer quadrant. Although mastitis can occur in both breasts, it is usually unilateral. A client who has mastitis can also influenza-like manifestations, such as fever, chills, headache, and myalgia. After delivery, the nurse should instruct the client to observe the breasts for indications of mastitis and to notify her provider if they occur.

193.A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

A. The client is carrying more than one fetus. B. There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid. C. An excessive amount of amniotic fluid is present. D. The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor. ANSWER = C An excess of amniotic fluid is defined as amniotic fluid pockets of >8 cm or an amniotic fluid index of greater than 25. Polyhydramnios or hydramnios is associated with neural tube defects, obstructions of the fetal gastrointestinal tract, multiple fetuses, and fetal hydrops.

8. A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?

A. Two veins and one artery B. One artery and one vein C. Two arteries and one vein D. Two arteries and two veins ANSWER = C The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta.

136.A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching?

A. "I should limit my carbohydrates to 50% of caloric intake." B. "I will reduce my exercise schedule to 3 days a week." C. "I will take my glyburide daily with breakfast." D. "I know I am at increased risk to develop type 2 diabetes." ANSWER = B Increased exercise benefits the client and can result in improved management of gestational diabetes

159.A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care? Spina bifida EXTRA

A. Obtain rectal temperatures. B. Place the newborn in the prone position. C. Cover the lesion with a dry dressing. D. Apply snug, clean diapers. ANSWER = B Placing the newborn in the prone position prevents trauma to the lesion. The newborn's knees should be assessed for evidence of skin breakdown.

203.A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

A. Tachycardia B. Absence of clonus C. Polyuria D. Report of headache ANSWER = D Manifestations of severe preeclampsia include severe (usually frontal) headache, blurred vision, photophobia, scotomas, right upper quadrant pain, irritability, presence of clonus and brisk deep tendon reflexes, nausea, vomiting, hypertension, oliguria, and proteinuria.

65. A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make?

A. The client is exhibiting early indications of mastitis. B. Additional interventions are not indicated at this time. C. Application of a heating pad to the breasts is indicated. D. The client should be advised to remove her nursing bra. ANSWER = B For this postpartum day, the client's fundal location and lochia characteristics are within the expected reference range. Breast engorgement is typical, as this is the time when the breasts begin producing milk. Frequent breastfeeding and routine care can help relieve engorgement.

20.A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching?

A. Vaginal intercourse can be resumed after 2 weeks. B. Products of conception will be present in vaginal bleeding. C. Increased intake of zinc-rich foods is recommended. D. Aspirin may be taken for cramps. ANSWER = A The client should avoid vaginal intercourse and the use of tampons for 2 weeks following discharge.