ob mod 2 coursepoint

The nurse is caring for a nullipara client at 40 weeks' gestation. After assessing the client, the health care provider states that the fetus is at a -4 station. Which statement by the client requires clarification by the nurse?

the healthcare provider states that my labor is imminent

Twenty minutes after birth, a baby begins to move his head from side to side, making eye contact with the mother, and pushes his tongue out several times. The nurse interprets this as:

a good time to initiate breast feeding

A 19-year-old woman presents to the emergency department in the late stages of active labor. Assessment reveals she received no prenatal care. As part of her examination, a rapid HIV screen indicates she is HIV positive. To reduce the perinatal transmission to her infant, which intravenous medication would the nurse anticipate administering?

antiretroviral

A client states, "I think my water broke! I felt this gush of fluid between my legs." The nurse tests the fluid with nitrazine paper and confirms membrane rupture if the swab turns:

blue

When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote bonding and attachment based on the rationale that bonding and attachment are most supported by which measure?

early parent-infant contact following birth

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?`

effacement

In an effort to decrease complications for the infant right after birth, the nurse would expect to administer which medication for prophylaxis of potential eye conditions?

erythromycin ophthalmic ointment

A nurse is providing care to a pregnant client in labor. Assessment of a fetus identifies the buttocks as the presenting part, with the legs extended upward. The nurse identifies this as which type of breech presentation?

frank

what is the most important nursing assessment of the mother during the fourth stage of labor

hemorrhage

A nurse teaches a postpartum woman about her risk for thromboembolism. The nurse determines that additional teaching is required when the woman identifies which as a factor that increases her risk?

increase in rbc production

A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that clients empty their bladders. A full bladder can lead to which complication?

increased lochia drainage

during the fourth stage of labor, which mother typically experiences the strongest afterpains

multipara who is breastfeeding

When palpating for fundal height on a postpartum woman, which technique is preferable?

placing one hand at the base of the uterus, one on the fundus

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?

turn her or ask her to turn to her side

A postpartum woman tells the home care nurse, "My hemorrhoids are really uncomfortable. Is there anything I can do?" Which suggestion(s) by the nurse would be appropriate? Select all that apply.

"Applying ice to the area can help." "Witch hazel pads can have a cooling effect." "I will show you how to use a sitz bath."`

A new mother asks the nurse why newborns receive an injection of vitamin K after delivery. What will be the best response from the nurse?

"Newborns lack the intestinal flora needed to produce vitamin K, so it is given to prevent bleeding episodes."

A postpartum woman who is bottle-feeding her newborn asks the nurse, "About how much should my newborn drink at each feeding?" The nurse responds by saying that to feel satisfied, the newborn needs which amount at each feeding?

2-4 ounces

Rho(D) immune globulin is administered to which clients? Select all that apply.

An Rh-negative woman who had a spontaneous abortion (miscarriage) yesterday An Rh-negative woman following an ectopic pregnancy A Rh negative woman who gives birth at 32 weeks gestation to a baby with A+ blood

The nurse is preparing to administer the vitamin K injection to a newborn. Which action would be correct for this client?

Injecting the medication into the vastus lateralis

The nursing student is preparing a presentation illustrating the effects of hypoglycemia on an infant. Which signs or symptoms should the student be sure to include in the presentation? Select all that apply.

Jitteriness Lethargy Seizures

The nurse is assisting with the admission of a newborn to the nursery. The nurse notes what appears to be bruising on the left upper outer thigh of this dark-skinned newborn. Which documentation should the nurse provide?

Mongolian spot noted on left upper outer thigh.

Which client should the postpartum nurse assess first after receiving shift report?

The 2-day postpartum client who has a blood pressure of 138/90 mm Hg.

The above nurse's note was documented in the client's record by the labor room nurse. In which position was the client born?

With the occiput facing the right anterior quadrant of the pelvis

When assessing a postpartum woman, the nurse suspects the woman is experiencing a problem based on which finding?

acute decrease in hematocrit

A nurse is caring for a female client in the postpartum phase. The client reports "afterpains." Which intervention should the nurse complete first?

admin pain meds

When teaching new parents about the sensory capabilities of their newborn, which sense would the nurse identify as being the least mature?

vision

When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartum day and how should it feel?

fundus two fingerbreadths below umbilicus and firm

Which type of anesthesia is anticipated when the delivery of the fetus must be done quickly due to an emergency situation?

general

What measure(s) will the nurse implement to help ensure that a newborn is not misidentified in the hospital? Select all that apply.

Place an identification band on both the mother and the newborn immediately after birth, before separating them.

The nurse is caring for a client who is a gravida 2 para 1 and had a previous cesarean section. The client has had no complications with the pregnancy and prefers to have this delivery vaginally. Which monitoring system best assesses for the ability to delivery vaginally?

Continuous internal monitoring of uterine contractions

The nursery head nurse is conducting a staff in-service on prevention of hypoglycemia. What information would she share with this group? Select all that apply.

Encourage breastfeeding mothers to nurse immediately after delivery. Keep the newborns warm in the nursery and covered with a blanket. Initiate early feedings for all bottle-fed newborns.

The nurse is monitoring a client at 38 weeks' gestation who is bleeding. Which assessment findings indicate the client is hemodynamically unstable? Select all that apply.

Fetal heart rate 198 bpm Urine output: 20 ml/hr

an Rh-negative mother delivered an Rh-positive infant. What information would the nurse need to gather prior to administering Rho (D) immune globulin injection? Select all that

Has the mother ever been sensitized to Rh-positive blood? Has the mother had any previous pregnancies? Has the mother experienced any miscarriages or abortions?

A woman delivered her infant 2 hours ago and calls to tell the nurse that she needs to go to the bathroom. When the nurse arrives, the mother is getting out of bed alone. What should the nurse do?

Have the client sit dangling her legs off the side of the bed for 5 minutes

A new mother delivered 1 week ago and is tearful, anxious, sad, and has no appetite. She is diagnosed with postpartum blues. What factors contribute to this problem? Select all that apply.

Hormonal changes Fatigue Discomfort Disrupted sleep patterns

A nurse is explaining the benefits of breastfeeding to a client who has just given birth. Which statement correctly explains the benefits of breastfeeding to this mother?

Immunoglobulin IgA in breast milk boosts a newborn's immune system.

What measures can a nurse take to reduce the risk of hypoglycemia in a newborn? Select all that apply.

Initiate early and frequent breastfeeding. Dry the newborn off immediately after birth to prevent chilling. Begin skin-to-skin (kangaroo) care for the newborn.

The nurse is inspecting a new mother's perineum. What actions would the nurse take for this client? Select all that apply.

Inspect the episiotomy for sutures and to ensure that the edges are approximated. Note any hemorrhoids. Gently palpate for any hematomas

A nurse is performing a detailed assessment of a female newborn. Which observations indicate normal findings? Select all that apply.

Mongolian spots swollen genitals short, creased neck

Which nursing interventions align with the outcome of preventing maternal and fetal injury in the latent phase of the first stage of labor? Select all that apply.

Monitor maternal and fetal vital statistics every hour. Report an elevated temperature over 38℃ (100.4℉). Answer questions and encourage verbalization of fears.

The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply

Nasal flaring Respiratory rate of 64 breaths per minute Chest retractions

The multigravida client is moving into the transition phase and asks for a narcotic, stating she doesn't remember the pain being this bad before. Which response from the nurse will be best?

Pain medication can affect the baby's breathing; let's try to focus and breathe."

The nurse is caring for a pregnant client admitted for abdominal trauma following an assault. The nurse will monitor the client for which potential complications? Select all that apply.

Spontaneous abortion (miscarriage) Placental abruption (abruptio placentae) Uterine rupture Preterm labor

Which interventions would the nurse take to reduce the incidence of infection in a postpartum woman? Select all that apply.

Teach proper positioning of the infant for breastfeeding. Encourage intake of fluids following delivery and after discharge. Wash her hands before and after caring for the client.

A nurse is caring for the client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. Which should the nurse do next?

Tell the client to take an NSAID orally

The nurse is caring for a client at 39 weeks' gestation who is noted to be at 0 station. The nurse is correct to document which?

The fetus is in the true pelvis and engaged.

A mother asks the nurse about having her son circumcised. The nurse understands that circumcision is contraindicated under which circumstances? Select all that apply.

There is a family history of hemophilia. The infant is at 33 weeks' gestation.

The nurse educator is teaching new nurses on risk factors for intimate partner violence to watch for when caring for pregnant clients. Which risk factors will the nurse include in the teaching? Select all that apply.

Uncertainty of the baby's father Unwanted pregnancy Unemployed mother

A mother asks the nurse why her newborn is getting a Vitamin K injection in the birth room. The nurse explains that the injection is necessary because:

Vitamin K is needed for coagulation, and the newborn does not produce vitamin K in the few days following birth.

a woman's amniotic fluid is noted to be cloudy. the nurse interprets this finding to indicate

a possible infection

A nurse is conducting a class for a group of nurses who are newly hired for the labor and birth unit. After teaching the group about fetal heart rate patterns, the nurse determines the need for additional teaching when the group identifies which finding as indicating normal fetal acid-base status? Select all that apply.

a sinusoidal pattern recurrent variable decelerations fetal bradycardia

Which assessment findings indicate a distressed fetus? Select all that apply.

absent acceleration persistent bradycardia late decel patterns

A woman is in labor with her second child. She knows that she will want epidural anesthesia, and she has already signed her consent form. What must the nurse do before the woman receives the epidural?

administer a fluid bolus through the IV line to reduce the risk of hypotension.

at which time is it most important to monitor for umbilical cord prolapse

after rom

A newborn's parents ask the nurse how to prevent the newborn from becoming ill. What is the best response by the nurse?

always wash hands before you pick up or provide care to your infant

A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure?

apply an ice pack to the site

the nurse institutes measures to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

are unable to shiver effectively to increase heat production

A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?

ask mom to describe her pain from 1-10

A postpartum woman has a history of thrombophlebitis. Which action would help the nurse determine if she is developing this postpartum?

assess for calf redness and edema

which action is a priority for a woman during the fourth stage of labor

assessing the uterine fundus

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

asymmetrical chest movement

The nurse is assessing a client who has given birth within the past hour. The nurse would expect to find the woman's fundus at which location?

at level of umbilicus

A nurse is reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as:

attachment

what's the best way for the nurse to assess the newborn's heartbeat

auscultating the apical pulse for 60 seconds

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing?

bathe baby under radiant warmer

A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply.

bloody show, lightening, backache

Prior to infusing medication into an epidural catheter inserted into a laboring mother, which vital sign is a priority?

bp

When performing an assessment on a neonate, which assessment finding is suggestive of hypothermia?

bradycardia

A nurse is assessing a term neonate and notes transient tachypnea. When reviewing the mother's history, which conditions would the nurse most likely find as contributing to this finding? Select all that apply.

c section use of heavy sedation during labor

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?

check blood glucose

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor?

client's cervix is fully dilated

A nurse is caring for a client administered general anesthesia for an emergency cesarean birth. The nurse notes the client's uterus is relaxed upon massage. What would the nurse do next?

continue to massage the client's fundus

The nurse cares for a pregnant client in labor and determines the fetus is in the right occiput anterior (ROA) position. Which action by the nurse is best?

continue to monitor the progress of labor

A new dad is alarmed at the shape of his newborn's head. When responding to the dad, the nurse reminds him this is due to:

cranial bones overlapping at the suture lines.

The nurse has just administered morphine 2 mg IV to a laboring client. Which change in the fetal heart rate pattern would the nurse prioritize?

decreased variability

the nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rh-positive newborn based on the understanding that this drug will prevent her from:

developing rh sensitivity

The nurse is caring for a client experiencing pruritus secondary to opioid medication administration during labor. When reviewing the medication administration record, which medication would the nurse offer the client?

diphenhydramine

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?

diuresis

When assessing a 1-day postpartum woman's pulse, what is the first action a nurse should take in response to a rate of 56 beats/min?

do nothing this is normal

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take?

document as it is a normal finding at this time

While changing a female newborn's diaper, the nurse observes a mucus-like, slightly bloody vaginal discharge. Which action would the nurse do next?

document this as pseudo menstruation

Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn?

dry the newborn and place skin to skin

When assessing the episiotomy site of a postpartum client that delivered 3-hours ago, the nurse would document which findings as expected? Select all that apply.

edema and slight bruising

A nurse is making a home visit to a postpartum woman who gave birth to a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as:

engorgement

A client receives an epidural anesthetic. Which medication would the nurse anticipate the primary care provider will prescribe if the client develops moderate hypotension?

ephedrine

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as:

epstein pearls

The nurse is assessing the skin of a newborn and notes a rash on the newborn's face and chest. The rash consists of small papules and is scattered with no pattern. The nurse interprets this finding as:

erythema toxicum

common risk factors for developing newborn jaundice

fetal-maternal blood group incompatibility prematurity breastfeeding certain drugs maternal gestational diabetes

Which physical findings would the nurse observe in a newborn that would indicate that the newborn is full-term? Select all that apply.

fingernails are present and extend to the end of the fingers, pinnae are flexible with rapid recoil, creases on the feet cover two thirds of the bottom of the feet

A nurse is caring for a client in her third stage of labor. The nurse would predict the placenta is separating from the uterus based on which assessment findings? Select all that apply.

fresh gush of blood from vagina, umbilical cord descending lower down, globular shaped uterus

A nurse is explaining the various methods of pain control used during labor and birth. When explaining why general anesthesia is rarely used, which information would the nurse include? Select all that apply.

general anesthesia readily crosses the placenta a pregnant woman has a risk for vomiting and aspiration

A nurse is preparing a presentation about changes in the various body systems during the postpartum period and their effects for a group of new mothers. The nurse explains which event as influencing a postpartum woman's ability to void? Select all that apply

generalized swelling of the perineum decreased bladder tone from regional anesthesia use of oxytocin to augment labor

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as:

harlequin sign

Screening for this most common birth defect is required by law in most states. Each nurse should know the law for his or her state and the requirements for screening. The nurse would expect a newborn to be screened for which defect as the most common?

hearing

A pregnant client is admitted to the labor and birth unit in the first stage of labor. A nurse reviews a pregnant client's birth plan. Which response from the client would indicate to the nurse that further teaching is indicated?

i will remain in my bed for labor and birth like last time

A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility?

increased risk of infection

The nurse is reviewing the monitoring strip of a woman in labor who is experiencing a contraction. The nurse notes the time the contraction takes from its onset to reach its highest intensity. The nurse interprets this time as which phase?

increment

The nurse is developing a teaching plan for a client who has decided to bottle-feed her newborn. Which information would the nurse include in the teaching plan to facilitate suppression of lactation?

instruct her to apply ice packs to both breasts every other hour

A new mother asks the nurse, "Why has my baby lost weight since he was born?" The nurse integrates knowledge of which cause when responding to the new mother?

insufficient calorie intake

The nurse is caring for a client who is gravida 3 para 2. The obstetric history reveals that all labors were uncomplicated with two vaginal deliveries. The client is 6 cm dilated and effaced. Which is the minimal acceptable amount of monitoring?

intermittent fhr auscultation

The nurse is preparing a client for an epidural block. Which intervention is a priority before the epidural anesthesia is started?

iv fluid bolus

Upon examination of the skin, which assessment findings would the nurse recognize as normal findings for a full-term newborn at 3 hours of age? Select all that apply.

lanugo on the back milia acrocyanosis

The nurse is preparing discharge teaching for a young couple and their infant. Which axillary temperatures should the nurse point out should be reported to the primary care provider?

less than 97.7° F (36.5° C) or greater than 100° F (37.8° C)

when caring for a mother who has has a c section, the nurse would expect the client's lochia to be

less than after a vaginal birth

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

lochia rubra

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as:

mongolian spots

The nurse is assisting with the circumcision of a male infant. Which nursing intervention is priority immediately after the procedure?

monitor the site for bleeding

A nurse is assessing a woman after birth and notes a second-degree laceration. The nurse interprets this as indicating that the tear extends through which area?

muscles of perineal body

A woman in labor who received an opioid for pain relief develops respiratory depression. The nurse would expect which agent to be administered?

nalaxone or narcan

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?

nasal flaring

The nurse is caring for a client who is sent to the obstetric unit for evaluation of fetal well-being. At which location is the nurse correct to place the tocodynamometer?

on uterine fundus

A nurse is teaching a new mother about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down?

oxytocin

A client in labor has been admitted to the labor and birth suite. The nurse assessing the woman notes that the fetus is in a cephalic presentation. Which description should the nurse identify by the term presentation?

part of the fetal body entering the maternal pelvis first

The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep?

place the infant on the back when sleeping

A nurse is reviewing the laboratory test results of a newborn. Which result would the nurse identify as a cause for concern?

platelets 75,000/uL

The nurse is teaching new parents how to clear the secretions from their infant's mouth and nose. The nurse determines they are prepared when they correctly perform which initial step?

position the newborn on side with head slightly below the body, use a bulb syringe to clear

a nurse is developing a teaching plan about sexuality and contraception for a postpartum woman who is breastfeeding. Which information would the nurse most likely include? Select all that apply.

possible experience of fluctuations in sexual interest use of a water-based lubricant to ease vaginal discomfort possibility of increased breast sensitivity during sexual activity

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?

pulmonary vascular resistance is decreased as lungs begin to function

When assessing a postpartum woman, the nurse would find which factor to be most significant in identifying possible postpartum hemorrhage?

pulse rate

A multigravida woman arrives in the emergency department panting and screaming, "The baby's coming!" Which action should the nurse prioritize?

quickly evaluate the perineum

a woman in labor received an opioid dose close to the time of birth. the nurse watches the newborn for

respiratory depression

Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn's respiratory status. What would the nurse expect to assess?

respiratory rate 45 breaths/minute, irregular

fentanyl has been administered to a client in labor. what assessment is priority

respiratory status

A pregnant client is admitted to a maternity clinic after experiencing contractions. The assigned nurse observes that the client experiences pauses between contractions. The nurse knows that which event marks the importance of the pauses between contractions during labor?

restoration of blood flow to uterus and placenta

Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be most appropriate?

rewarm the newborn gradually

A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn?

sternal retraction

Which factor might result in a decreased supply of breast milk in a postpartum client?

supplemental feedings with formula

A nurse is describing how the fetus moves through the birth canal. Which component would the nurse identify as being most important in allowing the fetal head to move through the pelvis?

sutures

While waiting for the placenta to deliver during the third stage of labor the nurse must assess the new mother's vital signs every 15 minutes. What sign would indicate impending shock?

tachycardia and falling bp

A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor?

the client reports back pain, and the cervix is effacing and dilating

The nurse is caring for four clients in labor. Which client would the nurse anticipate having continuous internal electronic fetal monitoring?

the client who is very restless and is moving around in bed

The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason?

to facilitate maternal-infant bonding

A nurse is preparing a client for rhythm strip testing. She places the woman into a semi-Fowler position. What is the appropriate rationale for this measure?

to prevent supine hypotension syndrome

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?

two fingerbreadths below the umbilicus

A nurse is discussing the advantages and disadvantages of intermittent and continuous fetal heart rate monitoring with a colleague. What would the nurse cite as being able to be detected when using continuous monitoring but not intermittent monitoring? Select all

types of decelerations and variability

Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action?

using bulb syringe, suction the mouth and then the nose

A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage?

uterine atony

Which factor in a client's history would alert the nurse to an increased risk for postpartum hemorrhage?

uterine atony placenta previa operative procedures

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.

uterine infection prolonged labor hydramnios

The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event?

uteroplacental insufficiency

A woman delivered her infant 24 hours ago by cesarean section. Which assessment findings should be reported to the assigned nurse? Select all that apply.

uterus feels boggy, the client reports breakthrough pain level 7-8

A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in FHR below the baseline, appearing as a U-shape. The nurse interprets these changes as reflecting which type of deceleration?

variable decels

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next?

check fhr

A nurse is completing the assessment of a woman admitted to the labor and birth suite. Which information would the nurse expect to include as part of the physical assessment? Select all that apply.

fundal height measurement, membrane status, contraction pattern

During the birth, the primary care provider performed an episiotomy. The client is now reporting discomfort. To reduce this discomfort and increase hygiene to the perineum, the nurse would encourage the client to use which intervention?

peribottle and warm wate

The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue?

the tint is due to jaundice

A newborn is experiencing cold stress. Which findings would the nurse expect to assess? Select all that apply.

respiratory distress hypoglycemia jaundice

which occurs as a result of contraction decreement

fhr should return to baseline, blood flow to fetus improves

on an apgar eval, how if reflex irritbility tested

flicking the soles of the feet and observing the response

which is the best place to perform a heel stick on a newborn

the fat pads on the lateral aspects of the foot

When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a third-degree laceration. The nurse understands that the laceration extends to which area?

through anal spinchter muscle

a postpartum client reports urinary frequency and burning. what can cause this

uti

The nurse is auscultating a newborn's heart and places the stethoscope at the point of maximal impulse at which location?

lateral to the midclavicular line at the fourth intercostal space

The nurse is assessing a client for rupture of membranes. Which findings would confirm the presence of ruptured membranes? Select all that apply.

nitrazine paper turns blue, ferning, pool of fluid is visible in the vagina

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:

normal progression of behavior

the five p's of labor

passageway, passenger, position, powers, psych

The nurse has been asked to conduct a class to teach new mothers how to avoid developing stress incontinence. Which action would the nurse include in the discussion as possible strategies for the new mothers to do? Select all that apply.

performing Kegel exercises avoiding smoking losing weight if obese

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor?

placenta removed via manual extraction

A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says, "I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?

"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two."

A nursing instructor is teaching about changes the newborn must make to survive outside of the uterus. The instructor realizes that further teaching is needed when a student makes which statement?

"The baby takes the first breath when ready to leave the uterus."

A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective?

"We will fold down the front of her diaper under the umbilical cord until it falls off."

The nurse is providing care to a client in labor. On examination, the nurse determines the fetus is at -1 station. The nurse interprets this as indicating that the fetus is:

1 cm above the ischial spines

The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention?

30 mg/dl

One minute after birth, the neonate's heart rate is 98 beats per minute (bpm), respirations are slow and irregular, arms are flexed, hips are extended, the neonate has no grimace, and the hands/feet are acrocyanotic. What Apgar score should the nurse assign to the neonate?

4

The nurse performs a quick assessment of an infant who is now 5 minutes old and determines the heart rate is 110 bpm, has a weak cry, acrocyanosis, extremities are held in partial flexion, and a catheter placed in the nose produces grimacing. What Apgar score does the nurse record and what action should the nurse prioritize?

6 repeat apgar scoring in 10 miunutes

A nurse is providing care to a newborn in the immediate newborn period. Which nursing intervention is priority?

Administer aquamephyton

A hepatitis B positive mother delivers a newborn. What precautions would the nurse take in caring for this infant? Select all that apply.

Bathe the newborn thoroughly soon after birth to remove maternal blood. Give the newborn the HBV vaccination within 12 hours after birth.

A nurse is preparing a class on newborn adaptations for a group of soon-to-be parents. When describing the change from fetal to newborn circulation, which information would the nurse include? Select all that apply.

Decrease in right atrial pressure leads to closure of the foramen ovale. Onset of respirations leads to a decrease in pulmonary vascular resistance. Increase in pressure in the left atrium results from increases in pulmonary blood flow. Closure of the ductus venosus eventually forces closure of the ductus arteriosus.

What findings should the nurse report to the health care provider for a postpartum client who delivered 12 hours ago? Select all that apply.

Fundal height level of one fingerbreadth above the umbilicus Temperature of 101.8°F (38.8°C)

the nurse has completed assessing the vital signs of several clients who are from 36 to 48 hours postpartum. For which set of vital signs should the nurse prioritize for interaction?

Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85

Which reason explains why women should be encouraged to perform Kegel exercises after birth?

They promote blood flow, enabling healing and muscle strengthening.

What treatments would the nurse perform in caring for a newly circumcised newborn? Select all that apply.

Wash the penis with warm water at each diaper change. Fasten the diaper loosely to prevent unnecessary friction as irritation.

A primigravida has an office appointment at 39 weeks' gestation. Which assessment data is most definitive of the onset of labor?

cervical ripening

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed?

docusate

After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?

dry the baby

While trying to decide whether to bottle feed or breastfeed her newborn infant, a new mother questions the lactation specialist concerning the greatest benefit of breastfeeding her infant. What would be the best response?

immunity against many different bacteria

A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?

improves pelvic floor tone

A nursing instructor informs students that recent research has shown that delayed cord clamping provides which advantages? Select all that apply.

improving the newborn's cardiopulmonary adaptation preventing childhood anemia increasing blood pressure improving oxygen transport increasing red blood cell flow

The nurse is reviewing the laboratory test results of a client in labor. Which finding would the nurse consider normal?

increases wbc

A nurse is caring for a newborn with hypoglycemia. For which symptoms of hypoglycemia should the nurse monitor the newborn? Select all that apply.

lethargy cyanosis jitteriness

Assessment reveals that the fetus of a client in labor is in the vertex presentation. The nurse determines that which part is presenting?

occiput

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result?

6.5

The nurse is assessing the respirations of several newborns. The nurse would notify the health care provider for the newborn with which respiratory rate at rest?

68 breaths/min

Following the birth, the nurse is responsible for assessing the cord pH. The nurse recognizes that which value would be considered a normal pH?

7.2

A nurse is providing care to a neonate and his mother. On reviewing the maternal history, the nurse notes that the mother's glucose level at birth was 102 mg/dL. The nurse would anticipate that the neonate's blood glucose level would be approximately:

71-82 mg/dl

A nurse is assessing a newborn five minutes after birth and notes: HR 110 bpm; a good, strong cry; well flexed extremities; grimacing when slapped on the sole of the foot; and normal pigment in most of the body, with blue hands and feet. What Apgar score will the nurse document for this infant?

8

The nurse is assessing the Apgar score for a 1-minute-old newborn and notes the following: HR 105 bpm, a pink body with blue feet, a strong cry, sneezing and minimal flexion. Which Apgar score will the nurse document as appropriate for this infant?

8

The nurse is conducting a breast exam on a postpartum mother on the second day following delivery. What findings would the nurse determine to be normal? Select all that apply.

Breasts feel slightly firm. Flattened nipple on the right breast Breasts are non-painful

A breastfeeding client presents with a temperature of 102.4°F (39°C) and a pulse of 110 bpm. She reports general fatigue and achy joints, and her left breast is engorged, red, and tender. Which instructions would the nurse anticipate being given to this client?

Continue breastfeeding on the left side, if the infant is willing to latch on. Take prescribed antibiotics until all prescribed doses are completed. If infant refuses to feed, pump the breast to maintain flow.

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:

caput succedaneum

Which suggestion by the nurse about pushing would be most appropriate to a woman in the second stage of labor?

choose whatever method you feel most comfortable with for pushing

A pregnant client at 32 weeks' gestation has been admitted to a health care center reporting decreased fetal movement. Which fetal structure should the nurse determine first before auscultating the fetal heart sounds?

fetal back

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor?

fetal heart rate declining late with contractions and remaining depressed Explanation:

Prior to discharge is an appropriate time to evaluate the client's status for preventative measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh negative mother?

indirect coombs test

There are advantages and disadvantages to any kind of method used to control pain during labor and birth. What is an advantage of opioid administration?

it can be administered by the nurse

A nurse is caring for a client who has had a vaginal birth. The nurse understands that pelvic relaxation can occur in any woman experiencing a vaginal birth. Which should the nurse recommend to the client to improve pelvic floor tone?

kegels

A nurse is assisting with the gestational age assessment of a newborn. When assessing the newborn's physical maturity, which areas would the nurse likely address? Select all that apply.

lanugo breast tisue

A nurse is monitoring a fetal heart rate (FHR) pattern on her client in labor and notes a change from the earlier baseline FHR of 140 bpm to 168 bpm. The nurse is aware that which factors can result in fetal tachycardia? Select all that apply.

maternal fever, fetal movement, fetal distress, uteroplacental insufficiency

The nurse is assessing an infant's reflexes. While eliciting a rooting reflex, the infant strongly sucks on the nurse's finger. How does the nurse interpret this finding?

rooting reflex was tested incorrectly

Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider?

rr of 15 breaths/min with nasal flaring

A nurse is teaching a woman in her third trimester about Braxton Hicks contractions. When describing these contractions, which information would the nurse likely include? Select all that apply.

they go away when you walk around or change position, they feel like a tightening across the top of your uterus, they often spread downward before they go away

A client has just given birth to a healthy baby boy, but the placenta has not yet delivered. What stage of labor does this scenario represent?

third

A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate?

this is meconium stool and is normal for a newborn

At what point should the nurse expect a healthy newborn to pass meconium?

within 24 hours after birth

The nurse is explaining the care the newborn will be receiving right after birth to the parents. The nurse should point out the infant will receive an ophthalmic antibiotic ointment by approximately which time?

within one hour

A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching?

you should be seen by your provider if you have blurred vision

When a client is counseled about the advantages of epidural anesthesia, which statement made by the counselor would indicate the need for further teaching?

youll have no trouble walking around and using the bathroom after the epidural

A nurse is caring for a client who has had a cesarean birth with general anesthesia. The nurse would assess the woman closely for which possible complication?

uterine atony

Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?

fetal heart rate in relation to contractions

Assessment of a woman in labor reveals that the fetus is in a cephalic presentation and engagement has occurred. The nurse interprets this finding to indicate that the presenting part is at which station?

0

A nurse receives the shift report on four infants. Baby A is 16 hours old, HR 117, RR 32, axillary temperature 98oF (36.6oC), BP 72/43 mm Hg, bilirubin 3.5 mg/dL rooming in with mother Baby B is 8 hours old, HR 152, RR 48, axillary temperature 97.7oF (36.5oC), BP 60/40 mm Hg, bilirubin 3 mg/dL, returning to nursery for night Baby C is 19 hours old, HR 140, RR 45, axillary temperature 98.6oF (37oC), BP 68/45 mm Hg, bilirubin 4 mg/dL, rooming in with mother Baby D is 4 hours old, HR 160, RR 60, axillary temperature 98.6oF (37oC), BP 80/45 mm Hg, bilirubin 2 mg/dL, returning to nursery for night.

baby c

The nurse determines that the fetal heart rate averages approximately 140 beats per minute over a 10-minute period. The nurse identifies this as:

baseline fhr

A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving?

billirubin went from 15-11

The nurse notes persistent early decelerations on the fetal monitoring strip. Which action should the nurse take in this situation?

continue to monitor fhr because this is benign

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?

have the client void, and then massage the fundus until it is firm.

A nurse is observing a new mother interacting with her newborn. Which statement would alert the nurse to the potential for impaired bonding between mother and newborn?

he looks like a frog to me

The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2oF (36.2oC) an hour after birth. Which intervention should the nurse prioritize for this family?

help the mother provide kangaroo care

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

hemorrhage

The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life?

hep b

A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which information? Select all that apply.

history of diabetes hemoglobin level 10 mg/dL placenta requiring manual extraction

While assessing a postpartum client who gave birth about 12 hours ago, the nurse evaluates the client's bladder and voiding. The nurse determines that the client may be experiencing bladder distention based on which finding? Select all that apply.

rounded mass over symphysis pubis dullness on percussion over symphysis pubis fundus boggy to the right of the umbilicus