RN Maternal Newborn 2023B

A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching? a. "Obtain informed consent prior to obtaining the specimen." b. "Collect at least 1 milliliter of urine for the test." c. "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." d. "Premature newborns may have false negative tests due to immature development of liver enzymes."

c. "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr prior to testing.

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider? a. Report of visual disturbances b. Report of tingling of the fingers c. Report of urinary frequency d. Report of leg cramps

a. Report of visual disturbances Visual disturbances such as blurred vision are a potential prenatal complication associated with hypertension. The nurse should report this finding to the provider so that additional fetal and maternal evaluation can be performed.

A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions? (Place in order) -Wash the newborn's legs and feet. -Clean the newborn's diaper area. -Cleanse the skin around the newborn's umbilical cord stump. -Wash the newborn's neck by lifting the newborn's chin. -Wipe the newborn's eyes from the inner canthus outward.

The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. 1. Wipe the newborn's eyes from the inner canthus outward using plain water. 2. Wash the newborn's neck by lifting the newborn's chin. 3. Cleanse the skin around the umbilical cord stump. 4. Washing the newborn's legs and feet. 5. Clean the newborn's diaper area.

A nurse at a provider's office is caring for a client who is 28 years of age. Complete the following sentence by using the list of options. The nurse should first address the client's ______ followed by the client's ______.

The nurse should first address the client's heart rate followed by the client's vaginal spotting.

A nurse is providing education about family bonding to guardians who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member? a. Allow the sibling to hold the newborn during a bath b. Make sure the sibling kisses the newborn each night c. Obtain a gift from the newborn to present to the sibling d. Switch the sibling's room with the nursery

c. Obtain a gift from the newborn to present to the sibling Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that they understand their role in the family.

A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? a. Blood pressure 136/88 mm Hg b. Report of insomnia c. Weight gain of 2.2 kg (4.8 lb) d. Report of Braxton Hicks contractions

c. Weight gain of 2.2 kg (4.8 lb) A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider.

A nurse is assessing a client who has preeclampsia with severe features. Which of the following manifestations should the nurse expect? a. 2+ deep tendon reflexes b. Hypotension c. Polyuria d. Blurred vision

d. Blurred vision The nurse should identify that a client who has preeclampsia with severe features can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field.

A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia? a. Singleton pregnancy b. BMI of 20 c. Maternal age 32 years d. Pregestational diabetes mellitus

d. Pregestational diabetes mellitus Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis.

A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching? a. "You will need to drink the glucose solution 2 hours prior to the test." b. "Limit your carbohydrate intake for 3 days prior to the test.' c. "If this test is positive, you will be scheduled for a 3-hr glucose tolerance test." "d. You will need to fast for 12 hours prior to the test."

c. "If this test is positive, you will be scheduled for a 3-hr glucose tolerance test." The nurse should instruct the client that if they have an elevated test result, they will be scheduled for a 3-hr glucose tolerance test.

A nurse is preparing to administer magnesium sulfate 2 g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water (D§W). The nurse should set the IV infusion pump to administer how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

50 mL/hr

A nurse at a provider's office is caring for a client who is 28 years of age. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. After reviewing the client's current assessment findings, the nurse should identify that the client is experiencing ______ as evidenced by ______.

After reviewing the client's current assessment findings, the nurse should identify that the client is experiencing ectopic pregnancy as evidenced by right lower quadrant abdominal tenderness.

A nurse is caring for a client who is pregnant. Which of the following actions are the nurse's priorities? Select the 4 actions that the nurse should take immediately. -Assess cervical dilation. -Administer a bolus of IV fluids. -Insert an indwelling urinary catheter. -Reposition the client to their side. -Apply oxygen at 10 to 12 L/min by nonrebreather mask. -Elevate the client's legs. -Evaluate the client's pain level.

Assess cervical dilation is incorrect. Administer a bolus of IV fluids is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the client's hypotension and fetal bradycardia and minimal variability. The nurse should plan to administer a bolus of IV fluids to increase the client's blood volume and improve uterine and intervillous space blood flow. Insert an indwelling urinary catheter is incorrect. Reposition the client to their side is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the fetal bradycardia and minimal variability caused by decreased uteroplacental perfusion. The nurse should plan to turn the client to their side to increase cardiac output and improve uterine and intervillous space blood flow. Apply oxygen at 10 to 12 L/min by nonrebreather mask is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the fetal bradycardia and minimal variability caused by decreased uteroplacental perfusion. The nurse should plan to administer oxygen via nonrebreather mask to increase maternal circulating oxygen levels and improve oxygen transfer through the intervillous spaces to the fetus. Elevate the client's legs is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the client's hypotension and fetal bradycardia and minimal variability. Elevating the client's legs will promote blood return to the heart and increase cardiac output. This action will improve uterine and intervillous space blood flow. Evaluate the client's pain level is incorrect.

A nurse is providing discharge teaching to a client who is postpartum. For which of the following manifestations should the nurse instruct the client to monitor and report to the provider? a. Persistent abdominal striae b. Temperature 37.8° C (100° F) c. Unilateral breast pain d. Brownish-red discharge on day 5

c. Unilateral breast pain Sudden onset of chills, fever, malaise, body aches, headaches, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this manifestation to the provider.

A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? a. "Remain in a side-lying position for 15 minutes after the medication is inserted" b. "You will need a full bladder prior to the insertion of the medication" c. "I can administer oxytocin 4 hours after the insertion of the medication" d. "An antacid will be given 20 minutes prior to the insertion of the medication"

c. "I can administer oxytocin 4 hours after the insertion of the medication" The nurse can administer oxytocin no sooner than 4 hours after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor

A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply.) -Heart rate 154/min -Axillary temperature 36° C (96.8° F) -Respiratory rate 58/min -Length 43 cm (16.9 in) -Weight 2,600 g (5 Ib 12 oz)

Heart rate 154/min is correct. The expected reference range for a newborn's heart rate is from 110/min to 160/min while awake. Axillary temperature 36° C (96.8° F) is incorrect. A healthy newborn's temperature averages 37° C (98.6° F), with a range of 36.5° to 37.5° C (97.7° to 99.5° F). Respiratory rate 58/min is correct. The expected reference range for a newborn's respiratory rate is from 30/min to 60/min. Length 43 cm (16.9 in) is incorrect. The expected reference range for a newborn's length is from 45 to 55 cm (17.7 to 21.7 in). Weight 2.6 kg (5 lb 12 oz) is correct. The expected reference range for a newborn's weight is from 2,500 to 4,000 g (5.5 lb to 8.8 lb).

A nurse at a provider's office is caring for a client who is 28 years of age. Select the 3 findings that require immediate follow-up. -Heart rate -Abdomen assessment -Respiratory assessment -Vaginal spotting -Bowel sounds -Menstrual period -Oxygen saturation -Temperature

Heart rate is incorrect. The client's heart rate is regular and within the expected reference range; therefore, this finding does not require immediate follow up. Abdomen assessment is correct. The client reports dull abdominal pain and rates it as 2 on 0 to 10 pain scale. The nurse noted right lower quadrant abdominal tenderness during their assessment, which is an unexpected finding that requires immediate follow up. Respiratory assessment is incorrect. The client has a history of asthma, which causes wheezing. The client's respirations are regular, non-labored, and their oxygen saturation level is within the expected reference range. There is no indication that the client is in acute distress; therefore, this finding does not require immediate follow up. Vaginal spotting is correct. Spotting is defined as a scant amount of vaginal bleeding. The client reports spotting along with a late menstrual period, which are unexpected findings that require immediate follow up. Bowel sounds are incorrect. The nurse noted hyperactive bowel sounds in all four quadrants, which could indicate increased gastrointestinal motility caused by the client's anxiety; however, these findings do not require immediate follow up. Menstrual period is correct. The client reports a usual regular menstrual period; however, it is currently late by 2 weeks. This is an unexpected finding that requires immediate follow up. Oxygen saturation is incorrect. The client's oxygen saturation level is within the expected reference range; therefore, this finding does not require immediate follow up. Temperature is incorrect. The client's temperature is within the expected reference range; therefore, this finding does not require immediate follow up.

A nurse at a provider's office is caring for a client who is 28 years of age. The nurse is preparing the client for surgery. Which of the following actions should the nurse take? Select all that apply.

Inform the client to be NPO prior to surgery is correct. The nurse should inform the client to be NPO prior to surgery. This will prevent aspiration during surgery. Administer Rho(D) immune globulin prior to surgery is incorrect. The nurse should administer Rho D immune globulin after surgery. The client is Rh negative and could develop antibody formation if exposed to Rh positive blood. Prepare to administer AB positive blood products if needed is incorrect. The nurse should only administer O or B negative blood products if the client requires a blood transfusion. Any other blood types are incompatible and can cause a reaction. Insert an 18-gauge peripheral IV prior to surgery is correct. The nurse should provide IV access prior to surgery by inserting a larger bore IV such as an 18- or 20-gauge. An IV is used to administer IV fluids or blood products during surgery. Explain the surgical procedure to the client is incorrect. The provider is responsible for explaining the procedure to the client. The nurse is responsible for ensuring that the client is fully informed about the surgery. Obtain a complete blood count is correct. The nurse should obtain a complete blood count to establish baseline data prior to surgery. Verify a consent form is signed by the client is correct. The nurse should verify that the client has signed a consent form for surgery. This is mandatory prior to any surgical procedure.

A nurse is caring for a newborn who is 72 hr old. The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions regarding the newborn should the nurse anticipate? Select all that apply. -Instruct the mother to discontinue breastfeeding. -Administer scheduled doses of oral morphine. -Give a one-time dose of naloxone IM. -Maintain a low-stimulus environment. -Initiate neonatal abstinence syndrome (NAS) scoring

Instruct the mother to discontinue breastfeeding is incorrect. The nurse should encourage the mother to continue to breastfeed on demand. Breastfeeding will assist to decrease manifestations of NAS in the newborn. Administer scheduled doses of oral morphine is correct. The nurse should administer scheduled doses of oral morphine to the newborn to decrease manifestations of withdrawal. The dosage of the medication is adjusted based on the NAS score of the newborn. Give a one-time dose of naloxone IM is incorrect. The nurse should not administer naloxone to a newborn who has NAS. It is contraindicated in newborns who are born with opioid dependence because it can increase the severity of withdrawal manifestations and result in seizures. Maintain a low-stimulus environment is correct. Supportive care for a newborn who has NAS includes maintaining a low-stimulus environment to help prevent exacerbation of withdrawal manifestations. Initiate neonatal abstinence syndrome (NAS) scoring is correct. The nurse should initiate NAS scoring to evaluate the severity of the newborn's withdrawal manifestations. The score obtained will be used to evaluate the need to titrate the prescription for the morphine dosage.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should plan to obtain a culture of vaginal fluid and to administer IV antibiotics because the client is most likely experiencing endometritis as evidenced by increased pelvic pain, pressure and tenderness, fever, and foul-smelling vaginal discharge. The client had an increased risk of developing endometritis due to the history of anemia, gestational diabetes, operative vaginal birth, and prolonged rupture of membranes. The nurse should plan to monitor the client's temperature and the amount and odor of the lochia. Clients who have endometritis have an increased risk of hemorrhage. A decrease of foul-smelling lochia and fever indicate progression toward resolution of the infection.

A nurse at a provider's office is caring for a client who is 28 years of age. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Transvaginal ultrasound is indicated. The nurse should anticipate a prescription for a transvaginal ultrasound. A transvaginal ultrasound is useful in determining the location of the ectopic pregnancy. Meperidine IM is contraindicated. Clients who receive methotrexate for an ectopic pregnancy should not take analgesics stronger than acetaminophen, because these medications can mask the manifestations of tubal rupture. Repeat quantitative β-hCG level is anticipated. The quantitative β-hCG level should be repeated within 48 hr to see if the level has changed from last recording. If increased levels are identified with no intrauterine pregnancy on ultrasound, this is indicative of ectopic pregnancy. Methotrexate IM is anticipated. The nurse should anticipate a prescription for methotrexate IM administration to prevent further embryonic cell reproduction. Blood typing is anticipated. The nurse should also anticipate potential surgical intervention for the client; therefore, blood typing is indicated.

Which of the following findings should the nurse report to the provider? Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Vital Signs 0900: Temperature 38.3° C (101° F) Pulse rate 89/min Respiratory rate 20/min Blood pressure 128/70 mm Hg Oxygen saturation 98% Nurse's Notes 0900: Client reports, "I've been cramping and have had low back pain since yesterday. It burns when I urinate." Client is placed on electronic fetal monitor. Fundal height palpated above the umbilicus. 0930: Fetal heart rate baseline 150/min, moderate variability, spontaneous accelerations present, no decelerations noted. Uterine contractions occurring every 2 minutes, lasting 40-60 seconds, palpate mild to moderate intensity. Vaginal examination reveals cervix is 2 cm dilated and 80% effaced.

When recognizing cues the nurse should report the client's temperature, which is above the expected reference range, and the burning upon urination to the provider. These are manifestation of an infection. The nurse should also report the client's statement of "cramping and lower back pain", the frequency and duration of the uterine contractions, and cervical dilation and effacement. These findings in a client who is less than 37 weeks gestation are all manifestations of preterm labor.

A nurse is caring for a client who is in labor. A nurse reviews the most recent assessment findings. What actions should the nurse take? Select all that apply. -Discontinue the magnesium infusion. -Infuse a 500 mL bolus of lactated Ringer's. -Decrease the rate of the oxytocin infusion. -Collect a specimen for a fetal fibronectin test. -Request a prescription for an amnioinfusion. -Administer calcium gluconate. -Apply oxygen at 10 L by nonrebreather mask.

When taking action the nurse should discontinue the magnesium infusion, administer calcium gluconate, and apply oxygen at 10L by nonrebreather mask. The client is exhibiting signs of magnesium toxicity. The client's urine output is less than 25 to 30 mL/hr. Decreased renal function can lead to inadequate clearance of the magnesium. Other manifestations of magnesium toxicity the client is experiencing include decreased level of consciousness, decreased respiratory rate and absent deep tendon reflexes. Calcium gluconate is the antidote for magnesium sulfate toxicity and should be administered to prevent a cardiac arrest. The client's pulse oximeter reading is < 95%. Low circulating levels of maternal oxygen can lead to fetal distress.

A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? a. Abruptio placenta b. Placenta previa c. Preeclampsia d. Maternal bradycardia

a. Abruptio placenta Cocaine use increases the risk for vasoconstriction and possible abruptio placenta.

A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions? a. Administer terbutaline. b. Discuss possible genetic anomalies with the client. c. Administer nalbuphine. d. Discontinue external fetal monitoring.

a. Administer terbutaline The nurse should administer terbutaline to stop contractions because the laboratory results indicate that the fetus's lungs are not mature enough for birth.

A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? a. Biophysical profile b. Amniocentesis c. Cordocentesis d. Kleihauer-Betke test

a. Biophysical profile A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound.

A nurse is providing teaching about nompharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items? a. Cold cabbage leaves b. Purified lanolin cream c. A snug-fitting support bra d. Breast shells

a. Cold cabbage leaves The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement. The nurse should instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the application for two to three sessions as needed. More frequent applications could decrease the client's milk supply.

A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication? a. Hypertension b. Hypothermia c. Constipation d. Muscle weakness

a. Hypertension The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension.

A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe? a. Kleihauer-Betke test b. Progesterone serum level c. Lecithin/sphingomyelin (L/S) ratio d. Maternal alpha-fetoprotein (AFP)

a. Kleihauer-Betke test The nurse should expect the provider to prescribe a Kleihauer-Betke test for a client who has suspected placental abruption to determine if fetal blood is in maternal circulation. This test is useful to determine if Rh.-(D) immune globulin therapy should be administered to a client who is Rh-negative.

A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? a. Protect the client's head and feet from cold air. b. Bathe the client within 12 hr following birth. c. Ambulate the client within 24 hr following birth d. Offer the client a glass of cold milk with their first meal.

a. Protect the client's head and feet from cold air. Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period.

A nurse is calculating a client's expected date of birth using Naegele's rule. The client tells the nurse that their last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth? a. September 3rd b. September 20th c. August 3rd d. August 20th

a. September 3rd When using Naegele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.

A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching? a. "I will not gain more than 15 to 20 pounds during my pregnancy." b. "I will likely need to use alternative positions for sexual intercourse." c. "I'm glad I had a breast reduction years ago, so they will not enlarge with my pregnancy." d. "I'm glad I have a light complexion and will not get any stretch marks."

b. "I will likely need to use alternative positions for sexual intercourse." The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This client statement indicates that they understand the nurse's teaching about the physiological changes that occur during pregnancy.

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration? a. "This medication will stop your labor." b. "This medication stimulates fetal lung maturity." c. "This medication will decrease your risk for uterine infections." d. "This medication will increase your baby's weight."

b. "This medication stimulates fetal lung maturity." The nurse should inform the client that betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of enzymes that release lung surfactant.

A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, "What effects will this procedure have on my sex life?" Which of the following responses should the nurse make? a. "I think that is something you should discuss with your doctor." b. "This procedure should have no effect on your sexual performance or adequacy." c. "You'll be fine. I can't imagine you and your partner will have any problems with sexual function." d. "If this concerns you, perhaps you should reconsider and use another form of contraception."

b. "This procedure should have no effect on your sexual performance or adequacy." The nurse is giving the client the information they are seeking. Sexual function depends on various hormonal and psychological factors. Therefore, tubal occlusion should have no physiological effect on sexual function.

A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching? a. "You should replace the diaphragm every 5 years." b. "You should leave the diaphragm in place for at least 6 hours after intercourse." c. "You should use an oil-based product as a lubricant when inserting the diaphragm." d. "You should insert the diaphragm when your bladder is full."

b. "You should leave the diaphragm in place for at least 6 hours after intercourse." The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy.

A nurse is planning discharge for a client who is 3 days postpartum. Which of the following non-pharmacological interventions should the nurse include in the plan of care for lactation suppression? a. Place warm, moist packs on the breasts b. Apply cabbage leaves to the breasts c. Wear a loose-fitting bra d. Put green tea bags on the breasts

b. Apply cabbage leaves on the breasts Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement

A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on their forehead. Which of the following actions should the nurse take? a. Tell the client to follow up with a dermatologist. b. Explain to the client this is an expected occurrence. c. Instruct the client to increase their intake of vitamin D. d. Inform the client they might have an allergy to their skin care products.

b. Explain to the client this is an expected occurrence. Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery.

A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority? a. Check the client's capillary refill. b. Massage the client's fundus. c. Insert an indwelling urinary catheter for the client. d. Prepare the client for a blood transfusion.

b. Massage the client's fundus. Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's funds to minimize blood loss.

A nurse is providing discharge teaching to the guardian of a newborn about car seat safety. Which of the following instructions should the nurse include? a. Place the shoulder harness in the slots above the newborn's shoulders. b. Place the retainer clip at the level of the newborn's armpits. c. Place the newborn at a 60° angle in the car seat. d. Place the newborn in a blanket before securing them in the car seat.

b. Place the retainer clip at the level of the newborn's armpits. The nurse should instruct the guardian to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits.

A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? a. Administer antiviral medication b. Schedule an ultrasound examination c. Administer Haemophilus influenzae type b vaccine d. Schedule an indirect Coombs test

b. Schedule an ultrasound examination The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth.

A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound? a. To estimate the fetal weight b. To locate a pocket of fluid c. To determine multiparity d. To prescreen for fetal anomalies

b. To locate a pocket of fluid An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus.

A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching? a. "My sibling will be able to carry my baby from the nursery to my room when they arrive." b. "The nurse will match my wrist band to my baby's crib card when they bring them to me." c. "The person who comes to take my baby's pictures will be wearing a photo identification badge." d. "My baby doesn't need to wear the electronic security bracelet when they're in my room."

c. "The person who comes to take my baby's pictures will be wearing a photo identification badge." All personnel working on the unit should be wearing a photo identification badge. The nurse should instruct the guardian to never allow anyone who is not wearing an identification badge to come in contact with the newborn.

A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure? a. Monitor the FHR b. Assess uterine activity c. Administer oxygen via a nonrebreather mask d. Start a bolus of IV fluids

c. Administer oxygen via a nonrebreather mask When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask at 10 L/min to ensure adequate oxygenation to the fetus

A nurse is assessing a newborn who is 12 hr old. Which of the following findings should the nurse report to the provider? a. Subconjunctival hemorrhages b. Petechia on the trunk and face c. Central cyanosis d. Respiratory rate of 40/min

c. Central cyanosis Central cyanosis or mottling can indicate a potential complication and ineffective breathing or circulation and should be reported to the provider.

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take? a. Apply oxygen to the client at 2 L/min via nasal cannula. b. Wrap the visible cord tightly with c. Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. d. Place the client in the lithotomy position and apply fundal pressure.

c. Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. The nurse should quickly apply gloves and insert two fingers into the vagina toward the cervix, exerting upward pressure onto the presenting part to relieve umbilical cord compression and increase oxygenation to the fetus.

A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occiput anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart? a. Left upper quadrant b. Right upper quadrant c. Left lower quadrant d. Right lower quadrant

c. Left lower quadrant The fetal heart tones of a fetus in the left occiput anterior position are best heard in the left lower quadrant

A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan? a. Monitor the client's blood pressure every hour b. Restrict the total hourly intake to 200 ml. c. Monitor the FHR continuously. d. Administer protamine sulfate for manifestations of toxicity.

c. Monitor the FHR continuously. Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The FHR and uterine contractions should be monitored continuously while the client is receiving magnesium sulfate.

A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? a. Client reports nausea b. Urinary output of 40 mL/hr c. Respiratory rate 10/min d. Client reports feeling flushed

c. Respiratory rate 10/min The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available.

A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse? a. Acrocyanosis of the extremities b. Murmur at the left sternal border c. Substernal chest retractions while sleeping d. Positive Babinski reflex

c. Substernal chest retractions while sleeping Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This manifestation requires further assessment and intervention by the nurse

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? a. "I will get injections of the medication once daily until my labor stops" b. "My blood sugar may be low while I'm on this medication" c."I will have blood tests because my potassium might decrease" d. "My blood pressure may increase while I'm on this medication"

c."I will have blood tests because my potassium might decrease" An adverse effect of terbutaline is hypokalemia

A nurse is teaching a client who is Rh negative about Rh.(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching? a. "I will receive this medication if my baby is Rh-negative." b. "I will receive this medication when I am in labor." c. "I will need a second dose of this medication when my baby is 6 weeks old." d. "I will need this medication if I have an amniocentesis."

d. "I will need this medication if I have an amniocentesis." Rh(D) immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.

A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? a. Discuss contraceptive options with the client and their partner. b. Repeat information to ensure client understanding. c. Listen to the client and their partner as they reflect upon the birth experience. d. Demonstrate to the client how to perform a newborn bath.

d. Demonstrate to the client how to perform a newborn bath. Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new guardian moves from being passively dependent to taking a stronger interest in their new role as a guardian. They are now focusing on the care of thier newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new guardian confidence and promote maternal adjustment.

A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following actions should the nurse take? a. Perform a vaginal exam to determine cervical dilation every 2 hr b. Instruct the client to ambulate in the hallway once every 4 hr c. Administer betamethasone to the client via IM injection d. Initiate continuous external fetal monitoring

d. Initiate continuous external fetal monitoring the nurse should identify that a client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor laboratory values. Also, the nurse should implement interventions to prepare for an emergency birth

A nurse is caring for a client who is pregnant and is at the end of their first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)? a. Just above the umbilicus b. Just above the symphysis pubis c. The right lower quadrant d. The left lower quadrant

d. Just above the symphysis pubis At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis.

A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? a. Apply a cool pack for 10 min to the heel prior to the puncture b. Request a prescription for IM analgesic. c. Use a manual lance blade to pierce the skin. d. Place the newborn skin to skin on the caregiver's chest.

d. Place the newborn skin to skin on the caregiver's chest. Placing the newborn skin to skin on the caregiver's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure.

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following findings indicate that the client has progressed to preeclampsia with severe features? a. Blood pressure 152/98 mm Hg b. Elevated liver enzymes c. Epigastric pain relieved with d. Pulmonary edema

d. Pulmonary edema The nurse should identify that a client who has preeclampsia and is experiencing pulmonary edema has progressed to preeclampsia with severe features.

A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? a. Reports blurred vision b. Diaphoresis c. Shallow respirations d. Reports increased urinary output

d. Reports increased urinary output Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain, constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations include weak rapid pulse, fruity breath odor, urine positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL.

A nurse is teaching a new caregiver how to use a bulb syringe to suction their newborn's secretions. Which of the following instructions should the nurse include? a. Insert the syringe tip before compressing the bulb b. Suction each of the nares before suctioning the mouth. c. Insert the tip of the syringe into the center of the newborn's mouth. d. Stop suctioning when the newborn's cry sounds clear.

d. Stop suctioning when the newborn's cry sounds clear. The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus.