VATI RN Maternal Newborn 2019
A nurse is receiving report on four newborns born in the past 12hrs. Which of the following newborns should the nurse assess first?
A newborn who has an axillary temperature of 36C (96.8F). -Cold stress increases the newborn's need for oxygen and can deplete glucose stores. It also can increase the newborn's respiratory rate and cause cyanosis. The expected axillary temperature for the newborn averages 37C (98.6F) and ranges form 36.5C (97.7F) to 37.2C (99F).
A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock. Which of the following statements should the charge nurse make?
The most accurate indication of organ perfusion is a clients urine output. -Output greater than 30 mL/hr. is an indication of adequate perfusion and oxygenation.
A nurse is teaching a prenatal class to a group of parents and is discussing facilitation of sibling acceptance of the newborn. Which of the following instructions should the nurse include in the teaching?
The patent should plan to spend individual time with the older sibling. -To enhance and facilitate sibling acceptance of the newborn.
A nurse is performing an initial assessment during a client's first prenatal visit. The client states that her last menstrual period began April 22. Use Nagele's rule to calculate the expected date of birth (EDB).
0129 -Begin with the first day of the clients last menstrual period, subtract 3 months, and add 7 days.
A nurse is assessing a client who is in labor, Which of the following findings should the nurse expect?
Decrease in blood glucose level. -Maternal metabolism, physical exertion, and delivery of the placenta can lead to a decreased blood glucose level.
A nurse is assessing a newborn who is breastfed and has a weight loss of 11% at 48hrs after birth. Which of the following findings should the nurse report to the provider?
Depressed fontanels. -Sunken or depressed fontanels are a finding associated with dehydration of the newborn. Additionally, dry oral mucosa, weight loss greater than 10%, and decreased urine output are findings associated with dehydration.
A nurse is assessing a client who is at 32wks of gestation. Which of the following findings is an indication of a potential prenatal complication?
Epigastric pain. -Indication of preeclampsia. Other indications of preeclampsia include abdominal pain, severe HA, HTN, polyuria, and proteinuria.
A nurse is assessing a client who is at 33wks of gestation. Which of the following findings should the nurse report to the provider?
Epigastric pain. -This is a manifestation of preeclampsia. Other findings the nurse should report include severe HA, Blurred vision, confusion, N&V, and decrease urinary output.
A nurse is monitoring a client who is in active labor and observes a pattern of late decelerations on the fetal monitor tracing. Which of the following findings should the nurse recognize as the potential cause of the deceleration?
Fetal hypoxia -Late decelerations are caused by uteroplacental insufficiency or a decreased blood flow from the uterus to the placenta during contractions. This results in a decreased supply of oxygen to the fetus during the contraction. This pattern can be cause by a wide variety of reasons including uterine tone, maternal hypotension, and disorders that affect the placenta such as maternal diabetes, preeclampsia and post maturity.
A nurse is assessing a client who is 2hr postpartum and has saturated a perineal pad in 15min. The clients skin is cool and clammy to touch. Which of the following actions should the nurse take first?
Firmly massage the fundus. -The greatest risk for a postpartum client who is experiencing excessive vaginal bleeding is the development of hypovolemic shock, which can lead to coma and death. Uterine atony is a frequent cause of excessive vaginal bleeding. Therefore, the first action the nurse should take is to massage the clients fundus to encourage muscular contractions, which will decrease bleeding.
A nurse is assessing a 1-hr-old newborn. Which of the following findings should the nurse report to the provider?
Generalized petechiae -Are pinpoint round spots that appear on the skin, which can indicate a clotting factor deficiency or infection.
A nurse is reviewing the laboratory report of a term newborn who is 24hrs old. Which of the following laboratory results should the nurse report to the provider?
Glucose 35 mg/dL. -Reference range is 40-45 mg/dL for a newborn who is 24hrs old.
A nurse is collecting information about a health history for a client who requests a prescription for a combined oral contraceptive (COC). Which of the following information should the nurse identify as a contraindication for the use of a COC?
History of migraine with aura. -Contain both estrogen and progestin. These hormones can cause an increase in the risk for thrombotic stroke for clients who have migraine w/aura. Safe for client to have migraines without aura to use a COC if they have no other contraindications, such as a history of estrogen-dependent tumors or coronary artery disease.
A nurse is assessing a newborn. Which of the following findings indicates a need to check the newborn's blood glucose level for hypoglycemia?
Hypotonia -CNS findings of hypoglycemia include lethargy and hypotonia, as well as jitteriness, twitching, poor feeding, temperature instability, apnea, respiratory distress, and seizures.
A nurse is teaching a client who has hyperemesis gravidarum about dietary modifications. Which of the following client statements indicates an understanding of the teaching?
I will eat small, frequent meals throughout the day. -The client should focus on eating small, frequent meals throughout the day and consuming foods that are appealing.
A nurse is teaching routine prenatal care to a group of clients who are pregnant. Which of the following statements by a client indicates an understanding of the teaching?
I will have monthly prenatal visits for the first 28wks of pregnancy. -The initial visit should occur in the first trimester with monthly visits through week 28, and every 2 weeks until week 36, and then every week until the birth of the newborn.
A nurse is providing teaching for a guardian regarding newborn care. Which of the following statements by the guardian indicates understanding of the teaching?
I will use a rear-facing car seat for my baby for the first 2 years. -Infants should travel in rear-facing car seats until the age of 2 years old or until the child reaches the height or weight requirements that are recommended by the manufacturer of the care seat.
A nurse is monitoring the laboratory results for a client who has preeclampsia with severe features. Which of the following results should the nurse expect?
Increased BUN. -Preeclampsia with severe features to exhibit an increase in BUN, or blood urea nitrogen. The increase is caused by a decreased glomerular filtration rate, secondary to impaired renal perfusion.
A charge nurse is teaching a newly licensed nurse about substance use disorders during pregnancy. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
Encourage client who are prescribed methadone to breastfeed. -The nurse should encourage clients who are prescribed methadone during pregnancy to breastfeed their newborns to help with withdrawal symptoms.
A nurse is reviewing the medical record of a client who has preeclampsia prior to administering labetalol. For which of the following findings should the nurse withhold the medication?
Heart rate 54/min -The nurse should identify that a heart rate of 54/min is below the expected reference range of 60 to 100/min. During pregnancy, the heart rate increases 10 to 15/min due to increased blood volume and increase tissue demands for oxygen. Bradycardia is a contraindication for the administration of labetalol, an antihypertensive medication. Therefore, the nurse should withhold the medication and notify the provider.
A nurse is reviewing the laboratory results for a postpartum client who is receiving warfarin for deep-vein thrombosis. Which of the following laboratory tests should the nurse monitor?
International normalized ratio (INR). -The nurse should monitor the INR of a client who is taking warfarin. Prothrombin time(PT) is also measure to regulate warfarin therapy. However, PT values are more difficult to interpret. INR determined by multiplying the PT by a correction factor based on the specific thromboplastin preparation used for the test, as a way of equalizing laboratory to laboratory variations.
A nurse is reviewing the medical records of a client who is at 8 wks. of gestation. Which of the following findings should the nurse identify as a risk factor for developing preeclampsia?
Rheumatoid Arthritis. -The presence of a connective tissue disease, such as rheumatoid arthritis or systemic lupus erythematosus, increase a clients risk for developing preeclampsia.
A nurse is preparing to administer methotrexate to a client who is experiencing an ectopic pregnancy. Which of the following actions should the nurse take?
Wear two pairs of gloves when handling the medication. -Methotrexate is an antineoplastic agent that a pharmacist must prepare in a syringe under a biologic safety cabinet and place in a sealed plastic bag. The nurse should wear two pairs of gloves when removing the syringe from the bag, administering the medication, and disposing of the syringe.
A nurse is providing client teaching regarding an intrauterine device (IUD). Which of the following statements should the nurse include in the teaching? (SATA)
1. You might have to have cultures for sexually transmitted infections prior to placement of the device. -If the provider determines the client is at risk of STI they might require the collection of cultures for STI prior to the placement of the IUD. 2. You might experience irregular spotting the first few months after placement of the device. 3. You will need to sign informed consent prior to the procedure.
A nurse is admitting a client who is at 39wks of gestation and in active labor. The client reports being positive for group B streptococcus (GBS) when screened at 36wks of gestation. Which of the following actions should the nurse expect to take?
Administer IV antibiotic prophylaxis. -To decrease the risk of the neonate contracting a GBS infection, it is recommended that pregnant clients who test positive for GBS receive antibiotics during labor.
A nurse is caring for a postpartum client who is breastfeeding her newborn and reports that her nipples have become sore and cracked. Which of the following statements should the nurse make?
Apply colostrum to the nipples after feeding to help them heal. -Colostrum and breast milk have healing properties and can help reduce soreness.
A nurse is planning to obtain a blood specimen from a newborn via a heel stick. Which of the following actions should the nurse take?
Cleanse the puncture site with alcohol gauze prior to the procedure. -Or a facility-approved skin cleanser prior to the procedure to minimize the risk of infection.
A nurse is caring for a 2 day old newborn who has a bilirubin level of 14 mg/dL and is to begin phototherapy. Which of the following actions should the nurse take?
Monitor intake and output. -The nurse should monitor intake and output because phototherapy can increase the rate of insensible water loss, which contributes to fluid loss and dehydration. The nurse should also monitor the newborns fontanels. Hydration is achieved by breastfeeding or formula feeding the newborn.
A nurse is assessing a newborn who was born 15min ago and has an axillary temperature of 36.1C (97F). Which of the following actions should the nurse take?
Place the newborn skin to skin on the mother's chest. -Expected reference range is 36.5-37.5C (97.7-99.5F) for a newborn. This temperature indicates hypothermia. Hypothermia can lead to cold stress, causing tachypnea, decreased pulmonary perfusion, and hypoglycemia.
A nurse is providing teaching to a client who is at 8wks of gestation about vaccines that are administered during pregnancy. Which of the following vaccines should the nurse discuss with the client?
Tetanus-diphtheira-acellular pertussis (Tdap) vaccine. -The CDC recommends that clients who are pregnant should receive the Tdap and seasonal inactivated influenza vaccine with each pregnancy. Clients who are pregnant should avoid all live or live attenuated immunizations due to potential for teratogenic effects in the fetus.
A nurse is caring for a client who is in active labor and receiving epidural anesthesia. The client reports feeling nauseated and experiences a blood pressure drop from 125/70 mm Hg to 90/50 mm Hg. Which of the following actions should the nurse take first?
Turn the client to a lateral position. -The greatest risk to this client is injury from maternal hypotension and decreased placental perfusion; therefore, the first action the nurse should take is to place the client in a lateral position to relieve the pressure on the vena cava and restore venous return.
A nurse is assessing a client who has genital herpes. Which of the following findings should the nurse expect?
Ulcerated lesions on the labia. -The nurse should identify that ulcerated lesions on the labia are an expected findings for a client who has genital herpes simplex virus. Other manifestations may include lymphadenopathy, itching, and dysuria.
A nurse is caring for a newborn who was delivered by cesarean birth 1 min ago and displays some flexion of the extremities, is not cry, has irregular respiratory effort, and has a heart rate of 92/min. The nurse notes grimacing but no crying when rubbing the soles of the newborn's feet. The newborn's skin color is pink with blue extremities. What is the correct Apgar score?
1 min is 5.
A nurse is assessing a client who is at 8wks of gestation and has hyperemesis gravidarum. Which of the following are findings of this condition? (SATA)
1. Tachycardia. -Hyperemesis gravidarum typically occurs during the first trimester and results in electrolyte imbalance, excessive weight loss, ketonuria, and nutritional deficiencies. 2. Dry mucous membranes. 3. Poor skin turgor.
A nurse is assessing a client who gave birth 4hrs ago and is receiving 2 units packed RBCs due to a postpartum hemorrhage. Which of the following findings is the best indication of adequate perfusion and oxygenation?
Urinary output. -Greatest risk for the client is coma and cardiac arrest if adequate perfusion and oxygenation are not achieved. The nurse should identify that a urinary output of at least 30 mL/hr. is the best indication of adequate perfusion and oxygenation. The nurse should insert an indwelling urinary catheter in a client who is experiencing manifestations of hypovolemic shock.
A nurse is preparing to obtain a blood specimen from a newborn via a heel stick. Which of the following actions should the nurse take?
Warm the newborn's heel for 10mins prior to the puncture. -Warm heel for 5-10mins prior to puncture. Warming the heel causes vasodilation which enhances blood flow to the puncture site.
A nurse is providing discharge instructions to the parents of a newborn about bathing. Which of the following statements by the parent indicates an understanding of the instructions?
We will wash out newborn's face first. -Bathing should proceed from the cleanest part of the body to the most soiled areas. First, from the eyes and face, then to the trunk and extremities, and then to the diaper area to prevent the spread of infection or cross contamination.
A nurse is completing a health history and assessment for a client who reports they are pregnant. Which of the following findings is a presumptive sign of pregnancy?
Amenorrhea. -A client can present with amenorrhea for a variety of reasons besides pregnancy.
A nurse is providing teaching for a client who is 2wks postpartum and has mastitis. Which of the following instructions should the nurse include in the teaching?
Apply moist heat to the affected breast. -The application of warm compresses prior to feeding or pumping promotes the flow of the breast milk and assists to ensure complete emptying of the breast. This is important to prevent the development of further complications such as the formation of a breast abscess or chronic mastitis.
A nurse is planning to use a Doppler device to auscultate fetal heart tones (FHTs) for a client who is at 12wks of gestation. Which of the following actions should the nurse plan to take?
Count the radial pulse of the client while auscultating FHTs. -The nurse should count the client's radial pulse while auscultating FHTs to differentiate it from the fetal heart rate.
A nurse is providing discharge teaching to a postpartum client who had no immunity to rubella and received the rubella immunization. Which of the following statements by the client indicates an understanding of the teaching?
I can breastfeed my baby even though I received this immunization. -According to the CDC, breastfeeding should not delay a client from receiving the rubella immunization.
A nurse is assessing a client who is 6hrs postpartum, tachycardia, and has cool skin. The client reports that they have been bleeding excessively. Which of the following actions should the nurse take?
Initiate and infusion of oxytocin. -The nurse should identify that the client is exhibiting manifestations of hypovolemic shock, which can be caused by uterine atony and is a medical emergency. The nurse should initiate an infusion of 10-20 units of oxytocin, which is an oxytocic medication. This will cause the uterus to contract and decrease bleeding.
A charge nurse is discussing care of clients who are in labor with a newly licensed nurse. Which of the following actions should the charge nurse include in the teaching regarding situations requiring an amniotomy?
Placing a fetal scalp electrode. -A fetal scalp electrode is attached to the presenting part of the fetus in order to provide accurate continuous monitoring of the fetal heart rate. If the client's membranes are intact, the amniotic sac must be artificially ruptured prior to attaching the electrode to enable access to the presenting part.
A nurse is reviewing the laboratory report of a client who is at 31wks of gestation and has gestation hypertension. Which of the following laboratory results should the nurse report to the provider?
Platelet count 99,000/mm3. -A platelet count of 99,000/mm3, or thrombocytopenia, is an indication of HELLP syndrome, a serious complication of gestational HTN.
A nurse is monitoring a client who is receiving oxytocin to augment labor and observes a pattern of late decelerations on the fetal monitor tracing. Which of the following actions is the nurse's priority?
Position the client laterally. -Late decelerations occur because of uteroplacental insufficiency. First position the client in a lateral position to improve oxygenation to the fetus.
A nurse is teaching a new guardian how to correctly use a car seat. Which of the following statements by the guardian indicates an understanding of the teaching?
I should keep my baby in a rear-facing car seat until he is 2yrs old. -Or until the child reaches the maximum height and weight for the seat.
A nurse is providing teaching about nifedipine for a client who is at 34wks of gestation and has gestational HTN. For which of the following adverse effects should the nurse instruct the client to notify the provider?
Irregular heartbeat. -Cardiac arrhythmia is a potential life-threatening adverse effect of nifedipine. Therefore, the client should report an irregular heartbeat to the provider.
A nurse is caring for a client who is 3 days postpartum. Which of the following actions should the nurse take?
Obtain a vaginal culture. -Fever for 2 consecutive days, chills, foul-smelling lochia, and abdominal tenderness are manifestations of endometritis, an infection of the lining of the uterus. The nurse should obtain a vaginal culture using a sterile swab to collect the fluid from the client's vaginal cavity to identify the organism.
A nurse is caring for a client who is in the second stage of labor and is experiencing shoulder dystocia. Which of the following actions should the nurse take?
Position the client using the McRoberts maneuver. -Decreases shoulder dystocia. The nurse should flex the client's thighs sharply against their abdomen, with their legs apart, to straighten the sacral area and rotate the symphysis pubis toward the client's head.
A nurse is assessing a client who has just undergone a cesarean birth and was given epidural morphine for postpartum pain relief 1hr ago. The nurse notes that the clients respiratory rate is 10/min. Which of the following actions should the nurse take first?
Administer oxygen by nonrebreather face mask. -The first action the nurse should take when using the airway, breathing, circulation approach to client care is to administer oxygen by nonrebreather mask to treat manifestations of respiratory depression due to morphine administration.
A nurse is caring for a client who received terbutaline subcutaneously. Which of the following findings is an indication the medication was effective?
Decreased frequency of contractions. -Terbutaline is a tocolytic medication that is used to halt preterm labor. Terbutaline cause relaxation of smooth muscle, which decrease uterine activity. Therefore, the nurse should identify that a decrease in frequency of contractions is an indication that terbutaline was effective.
A nurse is interviewing a client who is at 10wks of gestation. Which of the following statements by the client should the nurse investigate further?
I just want to stay in bed all day because nothing interest me anymore. -Feelings of sadness marked by loss of interest in usual activities can indicate depression, which is not a normal adaptation to pregnancy.
A nurse is preparing to administer methotrexate 1 mg/kg IM to a client who weights 110lbs and is receiving care for an ectopic pregnancy. Available is methotrexate 25 mg/mL. How many mL should the nurse administer?
2
A charge nurse is discussing syphilis with a newly licensed nurse. Which of the following statements should the charge nurse make?
A chancre lesion appears within 90 day after infection during the primary stage. -The charge nurse should identify that a chancre is the primary lesion that occurs during a syphilis infection. This lesion appears within 90 days of exposure to the infection and begins as a painless papule, which then erodes into an ulcer.
A nurse is caring for a group of clients who are postpartum. Which of the following clients is at an increased risk for a fall?
A client who has an indwelling urinary catheter. -The client's required medical interventions, such as IVs and urinary catheters, increase the risk for falls from tripping over tubing. The nurse should assist the client when getting out of bed and ambulating to prevent an injury from a fall.
A nurse is teaching a class to clients who are pregnant. Which of the following topics should the nurse include in the discussion about cesarean birth? (SATA)
1. Management of postpartum pain -The nurse should discuss with clients that they will have incisional pain associated with uterine involution. 2. Advantage of early ambulation post-surgical procedure. -Early ambulation following a cesarean birth facilitates circulation in the lower extremities, preventing stasis, and assists with relieving gas pains. 3. The need for an indwelling urinary catheter during delivery. -The nurse should place an indwelling urinary catheter prior to the cesarean birth to keep the client's bladder empty and to avoid interference with the surgical procedure.
A nurse is caring for a client who is at 30 weeks of gestation and observes the client choking while eating lunch. The client is unable to speak or cough. Identify the sequence of steps the nurse should take to clear the airway obstruction.
1. Stand posterior to the client. 2. Position arms under the client's axilla and across the client's chest. 3. Place thumb-side of a clenched fist to the client's mid-sternum area. 4. Initiate chest thrust to the client using a backward motion. -If the client becomes unconscious, the nurse should perform CPR and activate emergency medical services.
A nurse is caring for a client who had a vaginal delivery 2hrs ago and is reporting increasing perineal pain and pressure. The nurse examines the clients perineum and sees a 4cm (1.6in) area of purplish discoloration with swelling. The nurse should interpret these findings as which of the following?
A hematoma -A hematoma is a collection of blood in the connective tissue while the overlying skin or mucous membranes remain intact. Hematomas develop from injury to soft tissue in spontaneous deliveries, as well as forceps-and-vacuum-assisted deliveries. Small hematomas usually reabsorb on their own, but large ones might require incision and ligation of bleeding vessels.
A nurse is caring for a client who is in active labor and is scheduled to receive epidural anesthesia. Which of the following actions should the nurse take?
Administer lactated Ringer's 500 mL bolus via intermittent IV infusion prior to epidural placement. -To prevent hypotension.
A nurse is performing a contraction stress test (CST) on a client who is at 40wks of gestation. The results of the test indicate a negative CST. Which of the following actions should the nurse take?
Allow the labor to progress naturally. -The absence of late deceleration (a negative results) indicates that the fetus will probably tolerate labor; therefore, the nurse should allow the labor to progress naturally.
A nurse is reviewing the laboratory results for a client who is at 29wks of gestation. Which of the following results should the nurse identify as an indication of a prenatal complication?
BUN 30 mg/dL -Above the expected reference range of 10-20 mg/dL for a client who is pregnant. The BUN typically decreases during pregnancy due to the increase in the glomerular filtration rate. The nurse should identify that an elevated BUN is a manifestation of preeclampsia or HELLP syndrome, potentially serous complications of pregnancy's.
A nurse is caring for a newborn immediately following birth who has meconium-stained amniotic fluid and exhibits good muscle tone and respiratory efforts. Which of the following actions should the nurse take first?
Begin suctioning of mouth and nose. -The nurse should assess the newborns' condition at birth and suction the newborn's mouth and nose with a bulb syringe based on the assessment findings. If the newborns respiratory status is depressed, endotracheal suctions must be done as well to remove any meconium that has entered the newborn's airways.
A nurse is caring for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following actions should the nurse plan to take?
Change the newborn's position every 2hrs. -Reposition the newborn every 2-3hrs during phototherapy. This will maximize exposure of the skin to the light, enhancing the effectiveness of phototherapy.
A client who is in active labor is admitted to a labor and delivery unit and reports, "My water just broke and my baby is breech." Which of the following actions should the nurse take first?
Check fetal heart tones. -A variation in fetal heart tones can occur due to a prolapsed umbilical cord. The risk of a prolapsed cord is increased with noncephalic presentations when the membranes are ruptured. Prolapse of the cord compromises circulation to the fetus.
A nurse is developing a plan of care for a client who is in the latent phase of labor. Which of the following interventions should the nurse include in the plan to manage the client's pain?
Encourage the client to listen to music -The nurse should implement nonpharmacological strategies to encourage relaxation and provide pain relief. There are a wide variety of cutaneous and sensory measures that are simple to implement during this stage of labor, such as music, rocking, breathing techniques, walking and application of hot and cold packs.
A nurse is assessing a client who is in active labor. The client reports back labor pains. Which of the following nonpharmacological interventions should the nurse provide to manage the clients pain?
Encourage the support person to apply sacral counterpressure. -Consistent pressure applied by the support person using the heel of the hand or fist against the client's sacral area will lift the fetal head off the spinal nerves and provide relief of the pain in the lower back.
A nurse is reviewing the laboratory results for a client who is at 29wks of gestation. Which of the following results should the nurse report to the provider?
Hct 31% -Below the minimal expected value of greater than 33% during pregnancy. The nurse should report this finding to the provider as it is an indication of anemia.
A nurse is assessing a newborn following a circumcision 48hrs ago. The nurse should identify that yellow exudate covering the newborn's glans penis indicates which of the following?
Healing. -After 24hrs, yellow exudate usually forms over the glans penis and remains for the next 2-3 days. It sometimes forms a crust, which is expected. The nurse should explain that the yellow film the guardians will see is granulation tissue as the circumcision heals. The guardians should not remove this tissue.
A nurse is preparing to administer an opioid analgesic to a client who is in active labor. Which of the following assessments should the nurse perform? (SATA)
Maternal blood pressure. -Opioid analgesic can cause hypotension. The nurse should assess the clients blood pressure before and after administering opioids. Pain level. -The nurse should assess the clients baseline pain level prior to administering pain medication and again after administering pain medication to determine the effectiveness of the medication. Opioid analgesic are indicated for the relief of moderate to sever labor pain. Fetal heart rate. -Opioid analgesics can cause fetal bradycardia and changes in variability. The nurse should assess the fetal heart rate prior to administering an opioid analgesic to ensure the rate is within the expedited reference range and to have a baseline for future assessments. The nurse should provide ongoing assessments of fetal heart rate throughout labor according to facility protocol.
A nurse is monitoring a client who is in the active phase of labor and has an intrauterine pressure catheter and fetal scalp electrode. Which of the following findings should the nurse expect?
Montevideo units (MVU) of 220 mm Hg. - The nurse should identify that an MVU of 220 mm Hg is within the expected range during the active phase of labor. MVUs generally range between 100 to 250 mm Hg during the first stage of labor and increase to 300 to 400 mm Hg during the second stage of labor. MVUs are calculated by subtracting the baseline uterine pressure from the peak contraction pressure for every contraction that occurs during a 10-min period. The nurse then adds the pressure produced by each contraction during that time to determine the MVUs.
A nurse is assessing a client who has placenta previa and is receiving fetal monitoring. Which of the following clinical findings should the nurse expect?
Painless vaginal bleeding. -The placenta implants in the lower uterine segment, partially or completely covering the cervix. With cervical changes, the placental blood vessels can tear, which results in bleeding.
A nurse is assessing a client who has preeclampsia and received a dose a calcium gluconate to treat magnesium sulfate toxicity. Which of the following findings should the nurse identify as an indication that calcium gluconate was effective?
Respiratory rate 12/min -Respiratory depression is a manifestation of magnesium sulfate toxicity.
A nurse is teaching a client about iron supplementation during pregnancy. Which of the following client statements indicates an understanding of the teaching?
I will be certain to consume 29 grams of fiber daily. -The client should consume a diet high in fiber and increase fluid intake to help reduce the occurrence of constipation.
A nurse is providing teaching to a postpartum client about strategies to reduce the risk of newborn abduction from the facility. Which of the following instructions should the nurse include in the teaching?
Bring your newborn in the bassinet into the bathroom with you. -The client should wheel the newborn in the bassinet into the bathroom with her rather than leave the newborn unattended. The nurse should instruct the client never to leave the newborn unattended.
A nurse is assessing a client who delivered a 4.5kg (10lbs) newborn 2hrs ago. Identify the level in the abdomen a nurse should expect to find the client's uterus when assessing the fundus.
C is correct. -Immediately after birth, the fundus should be firm, midline with the umbilicus, and approximately 2cm below the level of the umbilicus. At 12hrs postpartum the nurse should palpate the fundus at 1cm (0.4in) above the umbilicus. Every 24hrs the fundus should descend approximately 1-2cm (0.4-0.8in) It should be halfway between the symphysis pubis and the umbilicus by 6 days postpartum.
A nurse is assessing a newborn who was born 15mins ago. Which of the following actions should the nurse take?
Count the respiratory rate for 60 seconds. -Newborn often have an irregular respiratory rate. Short periods of apnea, and shallow respirations are expected findings for a newborn. The nurse should also assess for symmetry of chest and abdominal movements during inhalation and exhalation.
A nurse is assessing a client who is at 33wks of gestation. Which of the following findings should the nurse report to the provider?
Episodes of blurred vision. -Blurred vision is a manifestation of preeclampsia. Arterial vasospasms and decreased perfusion to the retina cause visual disturbances, such as blurred vision, double vision, or dark spots in the visual field.
A nurse is reviewing the results of a nonstress test for a client who is at 37wks of gestation. Which of the following findings indicates a reactive nonstress test?
Fetal heart rate (FHR) accelerations occur with fetal movement. -A nonstress test measures the response of the FHR to fetal movement. Accelerations of the FHR with fetal movement are a reassuring sign of fetal well being.
A nurse is caring for a client who is at 28wks of gestation and has received two doses of terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to report to the provider?
Heart rate: 132/min -The nurse should notify the provider of tachycardia greater than 130/min; therefore, this is the priority finding. The client might also report chest discomfort, palpitations and have arrhythmias.
A nurse is providing prenatal education to a client who is at 16wks of gestation. Which of the following statements by the client indicated an understanding of anticipated body changes during the second trimester?
I might notice a change in my skin coloring. -Skin pigmentation deepens during the second trimester of pregnancy due to actions of the melanocyte-stimulating hormone.
A nurse is creating a plan of care for a client who is at 35wks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following interventions should the nurse include?
Initiate continuous monitoring of the FHR. -Initiate continuous monitoring of the FHR and uterine activity using an external fetal monitor.
