312 exam 4

A primigravid client has just completed a difficult, forceps-assisted birth of a 9-lb (4.08-Kg) neonate. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for uterine inversion. atony. involution. discomfort.

atony

The nurse explains to the mother of a neonate diagnosed with erythroblastosis fetalis that the exchange transfusion is necessary to prevent damage primarily to which organ in the neonate? kidneys brain lungs liver

brain

What conditions would the nurse expect to find in in a preterm neonate suffering from cold stress? yellowish undercast to the skin color increased abdominal girth hyperactivity and twitching slowed respirations

hyperactivity and twiching

A nurse is providing discharge teaching to a postpartum client. Which instruction is the priority to include in the teaching? "Sleep when the neonate sleeps to avoid exhaustion." "The neonate can sleep in the bed with you." "If you have excessive vaginal bleeding, massage your fundus and call the physician." "Don't worry. Women have been having babies for years without postpartum problems."

massage fundus and call HCP

Approximately 15 minutes after giving birth to a viable term neonate, a multiparous client has chills. What should the nurse do next? Assess the client's pulse rate. Decrease the rate of intravenous fluids. Provide the client with a warm blanket. Assess the amount of blood loss.

provide pt with warm blanket

The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be

red/moderate

A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and birth unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client gives birth to a healthy neonate vaginally with a midline episiotomy. Which problem should the nurse identify as the priority for the client? activity intolerance sleep deprivation situational low self-esteem risk for infection

risk for infection

When caring for a post partum client, the student nurse correctly recalls which expected progression of lochia?

rubra, serosa, alba

criteria for hemorrhage

saturating one pad per hour

A nurse is caring for a 1-day postpartum client. The progress note below informs the nurse that the client is in which phase of the postpartum period?

taking in

The nurse is caring for a 22-year-old G2, P2 client who has disseminated intravascular coagulation after delivering a dead fetus. Which finding is the highest priority to report to the health care provider (HCP)? activated partial thromboplastin time (APTT) of 30 seconds hemoglobin of 11.5g/dL (115 g/L) urinary output of 25 mL in the past hour platelets at 149,000/mm3 (149 X 109/L)

urinary output of 25 ml

A client is recovering in the labor and delivery area after giving birth to a 6-lb, 3-oz (2,813 g) newborn. On assessment, the nurse finds that the client's fundus is firm and located two fingerbreadths below the umbilicus. Although she didn't have an episiotomy, her perineal pad reveals a steady trickle of blood. What is the probable cause of these assessment findings?

vaginal laceration

A nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure?

wash hands and wear gloves

After instructing a primiparous client about episiotomy care, which client statement indicates successful teaching? "I will use hot, sudsy water to clean the episiotomy area." "I wipe the area from front to back using a blotting motion." "Before bedtime, I will use a cold water sitz bath." "I can use ice packs for 3 to 4 days after childbirth."

wipe from front to back blotting

A client plans to travel to a country where hepatitis B is common. What should the nurse advise the client about the most effective way to prevent the disease? Drink purified water. Avoid crowed, enclosed spaces. Complete the vaccination series. Observe safe sex practices.

observe safe sex practice

The mother of a newborn is concerned about the number of persons with heart disease in her family. She asks the nurse when she should start her baby on a low-fat, low-cholesterol diet to lower the risk of heart disease. At what age does the nurse should tell the client to start modifying her child's diet?

2 yrs

A newborn weighing 6.5 lb (2,950 g) is to be given naloxone due to respiratory depression as a result of a narcotic given to the mother shortly before birth. The drug is to be given 0.01 mg/kg into the umbilical vein. The vial is marked 0.4 mg/mL. How many milligrams would the newborn receive? Record your answer using two decimal places.

2.95 kg X 0.01 mg = 0.0295 mg, rounded to 0.03 mg.

The nurse is speaking to a group of women about early detection of breast cancer. Which screening does the nurse recommend to women age 50 and older?

annual mammogram

What should the nurse expect to find in a premature female neonate born at 30 weeks' gestation who is small for gestational age?

fine downy hair on back

A viable neonate born to a 28-year-old multiparous client by cesarean birth because of placenta previa is diagnosed with respiratory distress syndrome (RDS). Which factor would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome? mother's development of placenta previa neonate born preterm mother receiving analgesia 4 hours before birth neonate with sluggish respiratory efforts after birth

preterm

Sick and preterm neonates who experience continuity of nursing care directly benefit from higher levels of professional satisfaction among nurses. higher levels of parent satisfaction with nursing care. nursing recognition of subtle changes in high-risk neonates' conditions. decreased hospital liability for professional malpractice.

recongize subtle changes

An adolescent presents to a community clinic for treatment of vulvar lesions associated with type 2 herpes simplex. Which intervention is appropriate to do at this time? Select all that apply. Notify the adolescent's parents and ask permission to treat their daughter. Escort the adolescent to a private examination room. Inform the adolescent that confidentiality is not guaranteed. Ask the adolescent if her parents know about her sexual activity. Provide the adolescent with literature about type 2 herpes simplex.

-escort to private exam room -provide literature

The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains? G4, P1 client who is breastfeeding her infant G3, P3 client who is breastfeeding her infant G2, P2 cesarean client who is bottle-feeding her infant G3, P3 client who is bottle-feeding her infant

G3 P3 BReastfeeding

While assessing a primiparous client 8 hours after birth, the nurse inspects the episiotomy site, finding it edematous and slightly reddened. Which interpretation by the nurse is most appropriate? The client needs application of an ice pack. The episiotomy site is probably infected. A hematoma will likely develop. The client has had a repair of a vaginal laceration.

patient needs application of an ice pack

The nurse is preparing a community education program about preventing hepatitis B infection. Which information should be incorporated into the teaching plan? Hepatitis B is relatively uncommon among college students. Frequent ingestion of alcohol can predispose an individual to development of hepatitis B. Good personal hygiene habits are most effective at preventing the spread of hepatitis B. The use of a condom is advised for sexual intercourse.

the use of a condom is advised

A nurse is assessing a neonate born 1 day ago to a client who smoked one pack of cigarettes daily during pregnancy. Which finding is most common in neonates whose mothers smoked during pregnancy?

SGA

x A school nurse is teaching a class about sexually transmitted infections (STIs). Which statement is correct regarding STIs? STIs are most prevalent among teenagers and young adults. The incidence of STIs is decreasing due to limited sex partners. The signs and symptoms of an STI are obvious. STIs disproportionately affect people with a lower socioeconomic status and education.

STI are most prev among teenagers and young adults

The charge nurse observes that a nurse caring for a very sick infant is making inappropriate remarks and acting bizarrely. What is the first action the charge nurse should take? Report this nurse to the supervisor. Remove this nurse from the client assignment. Call security. Talk with the nurse to determine why this behavior is occurring.

remove

Antenatal laboratory testing revealed a negative rubella antibody for a client admitted to the postpartum unit. Which action takes priority for this client during early puerperium? rubella counseling and immunization with adult measles-mumps-rubella (MMR) vaccine rubella counseling and immunization with Rho(D) immune globulin vaccine rubella counseling and immunization with live rubella virus vaccine rubella counseling and instruction to obtain live rubella virus vaccine during her first postpartum examination

rubella counseling and immunization with live rubella virus vaccine

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation? abundance of scalp hair thin, wasted appearance descended testicles numerous scrotal rugae

thin wasted appearance

During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a postterm neonate after an oxytocin induction. When developing the client's plan of care, which problem should the nurse expect to assess for frequently? respiratory depression increased pulse rate hypertension uterine atony

uterine atony

In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal birth with a midline episiotomy. The client asks, "I've heard recommendations about when to resume intercourse have changed since my last baby. What are they saying now?" When should the nurse instruct the client that she can resume sexual intercourse? in 6 weeks when the episiotomy is completely healed after a postpartum check by the health care provider (HCP) whenever the client is feeling amorous and desirable. when lochia flow and episiotomy pain have stopped.

when locia flow and epsitomy pain have stopped

A client has just given birth to her first child, a healthy, full-term girl. The client is Rho(D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility? Administration of Rho(D) immune globulin I.M. to the neonate within 72 hours Administration of Rho(D) immune globulin I.M. to the mother within 72 hours Injection of Rho(D) immune globulin to the mother during her 6 week follow-up visit Administration of Rho(D) immune globulin I.M. to the mother within 3 months

within 72 hrs

Which measure included in the care plan for a client in the fourth stage of labor requires revision? Check vital signs and fundal checks every 15 minutes. Have the client spend time with the neonate to initiate breast-feeding. Obtain an order for catheterization to protect the bladder from trauma. Perform perineal assessments for swelling and bleeding.

obtain an order

While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. What should the nurse do next? Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. Ask the client to assume a side-lying position with the knees flexed. Perform massage vigorously at the level of the umbilicus if the fundus feels boggy. Place the client on a bedpan in case the uterine palpation stimulates the client to void.

place non dominant hand above symphysis pubis

When performing an assessment on a one-day old newborn, which finding would be most suggestive of an imperforate anus? failure to pass a meconium stool abdominal distention ribbon-like stools hydrocele

failure to pass meconium

A newborn diagnosed with phenylketonuria (PKU) is placed on a low-phenylalanine formula. The mother asks the nurse how long her infant will need to have dietary restriction. Which response would be most appropriate? "Your baby needs to stay on low phenylalanine formula until he is taking solid foods well." "Once your child has stopped growing he can come off the phenylalanine restricted diet." "He can switch to a regular diet when his phenylalanine levels remain normal for 6 months." "Most likely he will need to follow a low phenylalanine diet for the rest of his life."

rest of life

A preterm neonate is having frequent blood draws for laboratory specimens. What is most important for the nurse to document about the blood draws? amount of blood drawn for each specimen color of each blood specimen vital signs before each blood draw time of last feeding before each specimen

amount of blood drawn

A primigravid client has completed her first prenatal visit and blood work. Her laboratory test for the hepatitis B surface antigen (HBsAg) is positive. The nurse can advise the client that the plan of care for this newborn will include which interventions? Select all that apply. hepatitis B immune globulin at birth series of three hepatitis B vaccinations per recommended schedule hepatitis B screening when born isolation of infant during hospitalization standard/routine precautions for mother and infant contraindication for breastfeeding

-hep b immune globin at birth -series of 3 vaccinations -standard precautiosn

A couple seeks information about natural family planning. Which of the following should the nurse inform the couple about natural family planning? Select all that apply. requires some period of abstinence uses calculations of menstrual cycles uses estrogen and progestin in various combinations determines ovulation from basal body temperature uses effective methods wherein miscalculations are rare

-requires some period of abstinence -uses calculations of menstrual cycles -basal body temp

A nurse is discussing discharge instructions with a client. Which statement indicates that the client understands the resources and information available if needed after discharge? Select all that apply. "My fertility can return as early as 21 days after my baby's birth." "I have the hospital phone number if I have any questions." "If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance." "My mother is coming to help for a month, so I will be fine." "I know if I get fever or chills or change in lochia to call the health care provider." "I will continue my prenatal vitamins until my postpartum checkup or longer."

-return as early as 21 days -hsopital number if q's -breathing issues seek assistance -fever/chiills call HCP -continue prenatal vitamins

A client with a past history of varicose veins has just given birth to her first neonate. The nurse suspects that the client has developed a pulmonary embolus. Which findings support the nurse's suspicion? Select all that apply. sudden dyspnea chills, fever diaphoresis hypertension confusion

-sudden dyspnea -diaphoresis -confusion

A nurse observes several interactions between a client and her neonate son. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply. Talks and coos to her son. Cuddles her son close to her. Does not make eye contact with her son. Requests that the nurse take the neonate to the nursery for feedings. Encourages the father to hold the neonate. Takes a nap when the neonate is sleeping.

-talks/coos to son -cuddles son close to her

A young adult woman tells the nurse she has a slight yellow vaginal discharge. The nurse should tell the client to contact her health care provider if she has which additional symptoms? Select all that apply. vaginal discharge that has a fishy odor starting her menstrual period abdominal pain a temperature above 101ºF (38.3ºC) loss of appetite

-vaginal discharge -abdominal pain -temp over 101

A client with gestational diabetes had a cesarean birth because the fetus was determined to be large for gestational age. The nurse should assess for which postsurgical complications? Select all that apply. wound-edge separation fever after the first 24 hours postpartum lochia odor purulent drainage from incision fever during the first 24 hours postpartum

-wound edge sepration -fever after 24 hrs -lochia odor -purulent drainage from incision

A client who's breast-feeding has a temperature of 102° F (38.9° C) and complains that her breasts are engorged. Her breasts are swollen, hard, and red. Which action by the client requires intervention? Applying frozen cabbage leaves to the breasts Showering with her back to the water Nursing her baby frequently Applying a breast binder to support the breasts

applying breast binder

A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take?

assess fundus and massage if boggy

The nurse is caring for a client with a diagnosis of early postpartum hemorrhage. Which would not be a priority action at this time? Insert an indwelling urinary catheter. Assess the fundus of uterus. Administrator oxytocic medication as ordered. Assess the number of perineal pads used during the past shift.

assess number of perineal pads used during past shift

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information? The vaccine prevents a future fetus from developing congenital anomalies. Pregnancy should be avoided for 4 weeks after the immunization. The client should avoid contact with children diagnosed with rubella. The injection will provide immunity against the chickenpox.

avoid preg for 4 weeks

While caring for a neonate of a woman with diabetes soon after birth, the nurse has fed the newborn formula to prevent hypoglycemia. The nurse checks the neonate's blood glucose level, and it is 60 mg/dL (3.3 mmol/L), but the neonate continues to exhibit jitteriness and tremors. What should the nurse do first? Request a prescription for a blood calcium level. Administer intravenous glucose. Assess the neonate's temperature. Refeed the infant.

blood calcium level

Which measure would be most effective in helping the infant with a cleft lip and palate to retain oral feedings? Burp the infant at frequent intervals. Feed the infant small amounts at one time. Place the end of the nipple far to the back of the infant's tongue. Maintain the infant in a supine position while feeding.

burp at freuqent intervals

A primiparous client who gave birth to a viable term neonate vaginally 48 hours ago has a midline episiotomy and repair of a third-degree laceration. When preparing the client for discharge, which assessment would be most important? constipation diarrhea excessive bleeding rectal fistulas

constipation

The nurse plans the discharge of a newborn diagnosed with torticollis (wry neck). Which action should the nurse take? Teach the parent the side effects of botulinum toxin. Coordinate outpatient physical therapy. Verify the date for corrective surgery. Demonstrate the use of positioning wedges for sleep.

coordinate outpatient PT

While caring for a postpartum client who is receiving treatment with bed rest and intravenous heparin therapy for a deep vein thrombosis, the nurse should contact the client's health care provider (HCP) immediately if the client exhibits which symptom? pain in her calf dyspnea hypertension bradycardia

dyspnea

Two hours after a vaginal birth under epidural anesthesia, a client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which factor? prolonged first stage of labor. urinary tract infection pressure of the uterus on the bladder edema in the lower urinary tract area

edema in lower urinary tract area

After the first breastfeeding, the client asks the nurse, "How often should I try to breastfeed?" What frequency should the nurse recommend? at least every hour for the first 48 hours every 2 to 3 hours for the first 48 hours every 4 to 5 hours for the first 5 days after childbirth whenever she desires, until weaning occurs

every 2-3 hours for first 48 hours

As part of the postpartum follow-up, a nurse calls a new mother at home a few days after discharge. The client answers the telephone, begins to cry, and tells the nurse that she has feelings of inadequacy and isn't coping with the demands of motherhood. Based on this information which assessment would the nurse make? The client's behavior represents signs of postpartum depression. The client is acting abnormally and her physician needs to be notified. A home assessment is necessary to assure the well-being of the mother and the neonate. This is expected behavior for a client 3 to 7 days postpartum.

expected for 3-7 days PP

The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal birth. The mother is bottle-feeding her baby. Which client finding indicates a problem at this time? firm fundus at the symphysis menstrual discharge striae that are silver in color soft breasts without milk

firm fundus at the symphysis

The nurse assesses a client during the third stage of labor. Which assessment findings indicate that the client is experiencing postpartum hemorrhage? Heart rate 120 beats/minute, respiratory rate 8 breaths/minute, blood pressure 150/100 mm Hg Heart rate 50 beats/minute, respiratory rate 28 breaths/minute, blood pressure 120/80 mm Hg Heart rate 80 beats/minute, respiratory rate 18 breaths/minute, blood pressure 150/100 mm Hg Heart rate 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 80/40 mm Hg

heart rate 120, RR 28, bp 80/40

In the fourth stage of labor, a full bladder increases the risk of what postpartum complication? shock disseminated intravascular coagulation (DIC) hemorrhage infection

hemorrhage

A septic preterm neonate's IV was removed due to infiltration. The nurse prioritizes restarting the IV to help which complication?

hypoglycemia

While assessing a 4-day-old neonate born at 28 weeks' gestation, the nurse cannot elicit the neonate's Moro reflex, which was present 1 hour after birth. The nurse notifies the health care provider (HCP) because this may indicate which complication? postnatal asphyxia skull fracture intracranial hemorrhage facial nerve paralysis

intracranial hemorage

The nurse is caring for a client who is 2-hours post-partum and experienced a fourth-degree vaginal laceration. Which intervention should the nurse teach the client is contraindicated at this time? Application of ice packs Frequent Kegel exercises Use of sitz baths Use of laxatives

kegel exercises

A nurse is assessing the parent-neonate attachment of postpartum clients. Which finding most indicates a need for further evaluation? Parental desire to room-in with the neonate Limited parent-neonate contact immediately after birth Parental understanding of the importance of parent-neonate bonding Previous cesarean birth

limit parent-neonate contact immediately after birth

A postpartum client's husband calls the nurse and says, "My wife feels funny." The nurse enters the room and notes blood gushing from the client's vagina, pallor, and a rapid, thready pulse. What should be the nurse's first intervention? Pack the vagina with sterile gauze. Call the physician. Insert an indwelling catheter. Massage the fundus.

massage the fundus

A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which liquid?

orange juice

A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which factor? trauma during labor and birth moderate fundal massage after birth lengthy and prolonged second stage of labor overdistention of the uterus from hydramnios

overdistention of the uterus from hydramnios

A multiparous client, 28 hours after cesarean birth, who is breastfeeding has severe cramps or afterpains. The nurse explains that these are caused by which factor? flatulence accumulation after a cesarean birth healing of the abdominal incision after cesarean birth adverse effects of the medications administered after birth release of oxytocin during the breastfeeding session

oxytocin release during breastfeeding

The nurse is caring for a client 24 hours postpartum from a normal, vaginal delivery, and identifies which assessment finding and requiring immediate intervention? Patient reports feeling chilled and cold Patient reports feeling warm and flushed Patient reports feeling too excited to sleep Patient reports pain and warmth behild left knee

pain/warmth behidn let knee

Following a cesarean birth, what should the nurse do first? Check the abdominal dressing. Palpate the fundus. Observe the amount of lochia. Obtain blood pressure and pulse.

palpate fundus

One day after a client gives birth, the nurse performs a postpartum assessment. Which finding indicates a need for further evaluation? The patient reporting relief from ice packs to perinium Small blood clots with mucus evident on the perineal pad The patietn reporting uterine tenderness Evidence of lochia rubra

patient reports uterine tenderness

In developing a plan of care for the client who has just given birth to a 7-lb (3,175-g) baby, the nurse reviews her prenatal, labor, and birth records. Which data in the client's record would alert the nurse to the possibility of a problem? perineal laceration. white blood cell count of 12,000/mm3 (12 X 109/L) blood loss of 400 mL at birth temperature of 99°F (37.2°C) at 1 hour postpartum

perineal laceration

Three hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further? retained placental tissue uterine inversion bladder distention perineal lacerations

perineal lacerations

The nurse is caring for a primipara who gave birth 12 hours ago. The client says, "Look at all of the beautiful things my family brought for the new baby." The nurse should become concerned if the client has received which gift? four neonatal receiving blankets breast-pumping equipment a soft pillow for the neonate's crib a rear-facing infant car seat

pillow

A nurse is providing care for a postpartum client. Which condition increases this client's risk for a postpartum hemorrhage? hypertension uterine infection placenta previa severe pain

placenta previa

The nurse has provided health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding her neonate. Which client statement indicates that this teaching has been effective? "I can expect to have heart palpitations for several weeks." "It's normal for me to have reddish lochia until my 6-week checkup." "Any varicosities I had during pregnancy will disappear within 2 weeks." "My menstrual flow should resume in approximately 6 to 10 weeks."

resume in 6-10 weeks

The nurse carefully documents the premature neonate's response to oxygen therapy, delivering only as much oxygen as is necessary to prevent the development of which complication?

retinopathy (ROP)

A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority? You Selected: The client will demonstrate self-care and infant care by the end of the shift. Correct response: The client will demonstrate self-care and infant care by the end of the shift. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 5 See full question20sReport this Question In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal birth with a midline episiotomy. The client asks, "I've heard recommendations about when to resume intercourse have changed since my last baby. What are they saying now?" When should the nurse instruct the client that she can resume sexual intercourse? You Selected: in 6 weeks when the episiotomy is completely healed Correct response: when lochia flow and episiotomy pain have stopped. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 6 See full question31sReport this Question While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which statement indicates the need for additional teaching? You Selected: "I should lie on my back as much as possible to relieve the pain." Correct response: "I should lie on my back as much as possible to relieve the pain." Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 7 See full question22sReport this Question A 25-year-old primiparous client who gave birth 2 hours ago has decided to breastfeed her neonate. Which instruction should the nurse address as the highest priority in the teaching plan about preventing nipple soreness? You Selected: placing as much of the areola as possible into the baby's mouth Correct response: placing as much of the areola as possible into the baby's mouth Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 8 See full question15sReport this Question A nurse assesses a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown above). Which terms best identifies the discharge? You Selected: lochia rubra Correct response: lochia rubra Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 9 See full question16sReport this Question Which measure included in the care plan for a client in the fourth stage of labor requires revision? You Selected: Obtain an order for catheterization to protect the bladder from trauma. Correct response: Obtain an order for catheterization to protect the bladder from trauma. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 10 See full question34sReport this Question Antenatal laboratory testing revealed a negative rubella antibody for a client admitted to the postpartum unit. Which action takes priority for this client during early puerperium? You Selected: rubella counseling and instruction to obtain live rubella virus vaccine during her first postpartum examination Correct response: rubella counseling and immunization with live rubella virus vaccine Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 11 See full question20sReport this Question A client one day post-cesarean birth requests pain medication, stating her pain is 8 out of 10 when the nurse enters the room to perform her shift assessment. Which action by the nurse is most appropriate. You Selected: Administer the ordered pain medication, explaining to the patient that she will be back within the hour to examine her. Correct response: Administer the ordered pain medication, explaining to the patient that she will be back within the hour to examine her. Explanation: Add a Note Bookmark this Question What's this? Question 12 See full question22sReport this Question Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after administering the medication, which finding should alert the nurse to the development of a possible side effect? You Selected: dizziness Correct response: dizziness Explanation: Add a Note Bookmark this Question What's this? Question 13 See full question34sReport this Question A multigravida 30-year-old woman has given cesarean birth to a healthy term neonate due to an abnormal fetal heart rate tracing. At 2 hours postpartum, the nurse assesses the client's urinary catheter and observes that the client's urine is slightly red-tinged. What should the nurse do next? You Selected: Contact the client's health care provider (HCP) for further orders. Correct response: Contact the client's health care provider (HCP) for further orders. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 14 See full question19sReport this Question The nurse, while shopping in a local department store, hears a multiparous woman say loudly, "I think the baby is coming." After asking someone to call 911, the nurse assists the client to give birth to a term neonate. While waiting for the ambulance, the nurse suggests that the mother initiate breastfeeding, primarily for what reason? You Selected: to contract the mother's uterus Correct response: to contract the mother's uterus Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 15 See full question12sReport this Question A client is a gravida 1, para 0. During the first 24 hours after birth, she doesn't show consistent interest in her neonate. What should the nurse do next? You Selected: Document these expected behaviors of the taking-in period. Correct response: Document these expected behaviors of the taking-in period. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 16 See full question10sReport this Question A nurse is caring for a 1-day postpartum client. The progress note below informs the nurse that the client is in which phase of the postpartum period? You Selected: taking in Correct response: taking in Explanation: Add a Note Bookmark this Question What's this? Question 17 See full question13sReport this Question The nurse is caring for a primigravida who gave birth to a viable neonate 2 hours ago under epidural anesthesia. The new mother has a midline episiotomy. Which finding by the nurse would warrant further assessment? You Selected: two perineal pads soaked with blood within 30 minutes Correct response: two perineal pads soaked with blood within 30 minutes Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 18 See full question18sReport this Question A primiparous client is on a regular diet 24 hours postpartum. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which principle? You Selected: The mother can bring the daughter any foods that she desires. Correct response: The mother can bring the daughter any foods that she desires. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 19 See full question10sReport this Question During the fourth stage of labor, the client should be assessed carefully for You Selected: uterine atony. Correct response: uterine atony. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 20 See full question11sReport this Question During the postpartum period, a nurse should assess for signs of normal involution. Which statement would indicate that a client is progressing normally? You Selected: The uterus is descending at the rate of one fingerbreadth per day. Correct response: The uterus is descending at the rate of one fingerbreadth per day. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 21 See full question39sReport this Question A client gave birth to a neonate with spina bifida. The client was informed during her pregnancy that this situation could occur. The nurse giving a report on the client states that the client's decision to continue with the pregnancy was selfish and that the neonate will suffer. How should the nurse proceed in caring for this client and her neonate? You Selected: Accept the client's decision and care for her as any other client. Correct response: Accept the client's decision and care for her as any other client. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 22 See full question24sReport this Question While caring for a multiparous client 4 hours after vaginal birth of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/min. Her fundus is firm, midline, and at the level of the umbilicus. What should the nurse do? You Selected: Assess the client's lochia for large clots. Correct response: Continue to monitor the client's vital signs. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 23 See full question41sReport this Question A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which information would the nurse include when explaining to the client about the increased lochia on ambulation? You Selected: The increased lochia occurs from lochia pooling in the vaginal vault. Correct response: The increased lochia occurs from lochia pooling in the vaginal vault. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 24 See full question54sReport this Question The nurse is catheterizing a client who cannot void after a normal birth 8 hours ago. The nurse begins the catheterization process, and the client states, "I forgot to tell the nurse I get hives to betadine." The nurse should take which steps in order of priority from first to last? All options must be used. You Selected: Notify the health care provider (HCP) prescribing catheterization. Clean povidone-iodine from client's vaginal area. File an incident report. Document the incident. Correct response: Clean povidone-iodine from client's vaginal area. Notify the health care provider (HCP) prescribing catheterization. Document the incident. File an incident report. Explanation: Add a Note Bookmark this Question What's this? Question 25 See full question28sReport this Question While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. What should the nurse do next? You Selected: Perform massage vigorously at the level of the umbilicus if the fundus feels boggy. Correct response: Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 26 See full question19sReport this Question A client has just given birth to her first child, a healthy, full-term girl. The client is Rho(D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility? You Selected: Administration of Rho(D) immune globulin I.M. to the mother within 72 hours Correct response: Administration of Rho(D) immune globulin I.M. to the mother within 72 hours Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 27 See full question16sReport this Question A primiparous client planning to breastfeed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth, breasts begin to produce milk within what time period? You Selected: 2 to 4 days Correct response: 2 to 4 days Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 28 See full question8sReport this Question Which practice should a nurse recommend to a client who has had a cesarean birth? You Selected: Coughing and deep-breathing exercises Correct response: Coughing and deep-breathing exercises Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 29 See full question23sReport this Question A nurse is discussing discharge instructions with a client. Which statement indicates that the client understands the resources and information available if needed after discharge? Select all that apply. "My fertility can return as early as 21 days after my baby's birth." "I have the hospital phone number if I have any questions." "If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance." "My mother is coming to help for a month, so I will be fine." "I know if I get fever or chills or change in lochia to call the health care provider." "I will continue my prenatal vitamins until my postpartum checkup or longer." Correct response: Incorrect response: Your selection: Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 30 See full question20sReport this Question A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous, and the client is reporting pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time? You Selected: Administer pain medication per prescription. Correct response: Administer pain medication per prescription. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 31 See full question22sReport this Question While the nurse is palpating the breasts of a client who is breastfeeding her 12-hour-old neonate, what is an expected finding? You Selected: soft breasts that are not tender to touch Correct response: soft breasts that are not tender to touch Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 32 See full question30sReport this Question Following postpartum discharge teaching by the nurse, which statement by the client indicates an understanding of how to provide self-care? You Selected: "I should place a pillow behind my back." Correct response: "I should contract my buttocks before sitting or rising." Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 33 See full question18sReport this Question On the second postpartum day after a cesarean birth, the client reports having gas pains. What should the nurse should instruct the client to do? You Selected: Ask the primary care provider for a simethicone prescription. Correct response: Ambulate more often. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 34 See full question22sReport this Question After giving birth to a viable neonate 12 hours ago, the client's fundus is firm at midline, and her breasts are soft. She has scant lochia and she is voiding sufficiently. The client reports pain in her lower back. What should the nurse do next? You Selected: Administer a prescribed mild analgesic. Correct response: Administer a prescribed mild analgesic. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 35 See full question9sReport this Question When caring for a post partum client, the student nurse correctly recalls which expected progression of lochia? You Selected: Rubra, then serosa, then alba Correct response: Rubra, then serosa, then alba Explanation: Add a Note Bookmark this Question What's this? Question 36 See full question36sReport this Question Approximately 15 minutes after giving birth to a viable term neonate, a multiparous client has chills. What should the nurse do next? You Selected: Assess the client's pulse rate. Correct response: Provide the client with a warm blanket. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 37 See full question34sReport this Question One day after a client gives birth, the nurse performs a postpartum assessment. Which finding indicates a need for further evaluation? You Selected: The patietn reporting uterine tenderness Correct response: The patietn reporting uterine tenderness Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 38 See full question35sReport this Question The nurse has provided health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding her neonate. Which client statement indicates that this teaching has been effective? You Selected: "My menstrual flow should resume in approximately 6 to 10 weeks." Correct response: "My menstrual flow should resume in approximately 6 to 10 weeks." Explanation: Add a Note Bookmark this Question What's this? Question 39 See full question20sReport this Question A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take? You Selected: Assess the fundus and massage it if it's boggy. Correct response: Assess the fundus and massage it if it's boggy. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 40 See full question1m 20sReport this Question A nurse is assessing the parent-neonate attachment of postpartum clients. Which finding most indicates a need for further evaluation? You Selected: Limited parent-neonate contact immediately after birth Correct response: Limited parent-neonate contact immediately after birth Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 41 See full question14sReport this Question A nurse is palpating the uterine fundus of a client who gave birth to a neonate 8 hours ago. Identify the area where the nurse should expect to feel the fundus. You Selected: Your selection and the correct area, market by the green box. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 42 See full question14sReport this Question A multiparous client, 28 hours after cesarean birth, who is breastfeeding has severe cramps or afterpains. The nurse explains that these are caused by which factor? You Selected: release of oxytocin during the breastfeeding session Correct response: release of oxytocin during the breastfeeding session Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 43 See full question1m 8sReport this Question A primiparous client who gave birth to a viable term neonate vaginally 48 hours ago has a midline episiotomy and repair of a third-degree laceration. When preparing the client for discharge, which assessment would be most important? You Selected: excessive bleeding Correct response: constipation Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 44 See full question18sReport this Question When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information? You Selected: The vaccine prevents a future fetus from developing congenital anomalies. Correct response: Pregnancy should be avoided for 4 weeks after the immunization. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 45 See full question29sReport this Question A nurse observes several interactions between a client and her neonate son. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply. Talks and coos to her son. Cuddles her son close to her. Does not make eye contact with her son. Requests that the nurse take the neonate to the nursery for feedings. Encourages the father to hold the neonate. Takes a nap when the neonate is sleeping. Correct response: Incorrect response: Your selection: Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 46 See full question35sReport this Question The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains? You Selected: G4, P1 client who is breastfeeding her infant Correct response: G3, P3 client who is breastfeeding her infant Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 47 See full question39sReport this Question A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which liquid? You Selected: milk Correct response: orange juice Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 48 See full question38sReport this Question A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and birth unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client gives birth to a healthy neonate vaginally with a midline episiotomy. Which problem should the nurse identify as the priority for the client? You Selected: risk for infection Correct response: risk for infection Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 49 See full question14sReport this Question A nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure? You Selected: washing the hands Correct response: washing the hands and wearing gloves Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 50 See full question11sReport this Question The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be You Selected: red and moderate. Correct response: red and moderate. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 51 See full question1m 13sReport this Question The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal birth. The mother is bottle-feeding her baby. Which client finding indicates a problem at this time? You Selected: soft breasts without milk Correct response: firm fundus at the symphysis Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 52 See full question18sReport this Question The nurse is caring for a client 24 hours postpartum from a normal, vaginal delivery, and identifies which assessment finding and requiring immediate intervention? You Selected: Patient reports pain and warmth behild left knee Correct response: Patient reports pain and warmth behild left knee Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 53 See full question1m 32sReport this Question A client who's breast-feeding has a temperature of 102° F (38.9° C) and complains that her breasts are engorged. Her breasts are swollen, hard, and red. Which action by the client requires intervention? You Selected: Applying a breast binder to support the breasts Correct response: Applying a breast binder to support the breasts Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 54 See full question9sReport this Question After the first breastfeeding, the client asks the nurse, "How often should I try to breastfeed?" What frequency should the nurse recommend? You Selected: every 4 to 5 hours for the first 5 days after childbirth Correct response: every 2 to 3 hours for the first 48 hours Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 55 See full question55sReport this Question While assessing a primiparous client 8 hours after birth, the nurse inspects the episiotomy site, finding it edematous and slightly reddened. Which interpretation by the nurse is most appropriate? You Selected: The client has had a repair of a vaginal laceration. Correct response: The client needs application of an ice pack. Explanation: Remediation: Add a Note Bookmark this Question What's this? Question 56 See full question13sReport this Question A nurse is providing discharge teaching to a postpartum client. Which instruction is the priority to include in the teaching? You Selected: "Sleep when the neonate sleeps to avoid exhaustion." Correct response: "If you have excessive vaginal bleeding, massage your fundus and call the physician." Explanation: Remediation: Add a Note Bookmark this Question What's this? x A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority? By discharge, the family will bond with the neonate. The client will demonstrate self-care and infant care by the end of the shift. The client will state instructions for discharge during the first postpartum day. By the end of the shift, the client will describe a safe home environment.

self care

A client gave birth to a healthy full-term girl 2 hours ago by cesarean birth. When assessing this client which finding requires immediate nursing action? tachycardia and hypotension gush of vaginal blood when she stands up blood stain 2″ (5.1 cm) in diameter on the abdominal dressing complaints of abdominal pain

tachycardia and hypotension

A 34-year-old primigravid client at 39 weeks' gestation admitted to the hospital in active labor has type B Rh-negative blood. The nurse should instruct the client that if the neonate is Rh positive, the client will receive an Rh immune globulin injection for what reason? to prevent Rh-positive sensitization with the next pregnancy to provide active antibody protection for this pregnancy to decrease the amount of Rh-negative sensitization for the next pregnancy to destroy fetal Rh-positive cells during the next pregnancy

to prevent Rh positive sensitization within the next pregnancy

A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information? Wear a loose-fitting bra to avoid constricting the milk ducts. Stop breast-feeding permanently. Take antibiotics until the pain is relieved. Use a warm moist compress over the painful area.

warm compress

The nurse is caring for a primigravida who gave birth to a viable neonate 2 hours ago under epidural anesthesia. The new mother has a midline episiotomy. Which finding by the nurse would warrant further assessment? distended vaginal tissue edema around the episiotomy site two perineal pads soaked with blood within 30 minutes tenderness around the episiotomy site

2 pads

The nurse plans care for four mothers and their newborns. After reviewing the clients' medical records, the nurse should make rounds on which client first? an 18-year-old G2 P2 with an uncomplicated spontaneous vaginal birth 12 hours ago who has abdominal cramps a 35-year-old G4 P4 with an uncomplicated vaginal birth 4 hours ago; the nurse's notes indicated she soaked two peripads over the last 2 hours; fundus is firm a 16-year-old G1 P1 with a caesarean birth 4 hours ago, diagnosed with preeclampsia and receiving magnesium sulfate at 2 g/h; reflexes are 2+, and the nurse's notes indicate she has a headache; vital signs are T 99.4 F (37.4 C), P 88, R 20, BP 128/86 mm Hg an 18-year-old G2 P2 who had a caesarian birth 2 days ago and now has severe breast pain; vital signs are T 99.8 F (37.7 C), P 96, R 22

35 year old. soaked 2 pads over last 2 hours, fundus is firm

The nurse is making clinical rounds on a group of clients in a newborn nursery. Which infant is at greatest risk of developing respiratory distress syndrome (RDS)? a neonate born at 36 weeks' gestation a neonate born by cesarean section a neonate experiencing apneic episodes a neonate who is 42 weeks' gestation

36 weeks

The nurse at the gynecologic clinic is teaching the client about the results of her Papanicolaou test, which demonstrated dysplasia. Which represents the nurse's best intervention? Reinforce that the cells are cancerous and will require treatment. Discuss the implications of hysterectomy for this client and her partner. Ask client if she and her partner would like information about infertility treatments. Explain that results show alteration in the size and shape of cells, which requires follow-up.

Explain that results show alteration in the size and shape of cells, which requires follow-up.

A newborn who is 20 hours old has a respiratory rate of 66 breaths/min, is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98° F (36.6° C); he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before birth. What nursing actions are most indicated? Continue recording vital signs, voiding, stooling, and eating patterns every 4 hours. Place a pulse oximeter, and contact the health care provider (HCP) for a prescription to draw blood cultures. Arrange a transfer to the neonatal intensive care unit with diagnosis of possible sepsis. Draw a complete blood count (CBC) with differential and feed the infant.

place pulse ox and call HCP

After giving birth to a viable neonate 12 hours ago, the client's fundus is firm at midline, and her breasts are soft. She has scant lochia and she is voiding sufficiently. The client reports pain in her lower back. What should the nurse do next? Contact the primary care provider for a prescription to obtain a urinalysis. Ask the client how long she was in labor. Administer a prescribed mild analgesic. Instruct the client to perform abdominal exercises.

adminster prescirbed mild anagelsic

While caring for a multiparous client 4 hours after vaginal birth of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/min. Her fundus is firm, midline, and at the level of the umbilicus. What should the nurse do? Continue to monitor the client's vital signs. Assess the client's lochia for large clots. Notify the client's health care provider (HCP) about the findings. Offer the mother an ice pack for her forehead.

continue moniotr VS

A nurse places a neonate with hyperbilirubinemia under a phototherapy lamp, covering the eyes and gonads for protection. The parents asked the nurse to tell them how their baby will benefit from having phototherapy done. Which statement by the nurse is the most appropriate response about phototherapy? "Phototherapy prevents hypothermia." "Phototherapy promotes respiratory stability." "Phototherapy increases the baby's iron level." "Phototherapy decreases the serum unconjugated bilirubin level."

decreases serum unconjugated bilirubin level

After receiving a change-of-shift report in the normal newborn nursery, the nurse should see which neonate first? 3-hour-old neonate , 30 minutes of age with increased respiratory grunting 6-hour-old neonate with a blood glucose of 25 mg/dL (1.38 mmol/L) 12-hour-old neonate with a temperature of 97.4°F (36.4°C) 24-hour-old neonate with no urine output for the past 12 hours

hypoglycemia

For an infant who's about to undergo a lumbar puncture, the nurse should place the infant in: an arched, side-lying position, with the neck flexed onto the chest. an arched, side-lying position, avoiding flexion of the neck onto the chest. a mummy restraint. a prone position, with the head over the edge of the bed.

an arched, side-lying position, avoiding flexion of the neck onto the chest.

A postmenopausal woman is worried about pain in the upper outer quadrant of her left breast. The nurse's best course of action is to: Do a breast examination and report the results to the physician. Explain that pain is caused by hormonal fluctuations. Reassure the client that pain is not a symptom of breast cancer. Teach the client the correct procedure for breast self-examination (BSE).

do a breast exam and report results

The nurse is gathering data from a female client that states she has had difficulty conceiving. Which statement made by the client would the nurse find most significant related to the difficulty getting pregnant? "I have used oral contraceptives for 2 years." "I had gonorrhea that went untreated for about 3 months." "I had iron deficiency anemia" "I was told I had the beginning of osteoporosis."

i had gonorrhea untreated for 3 motnhs

Which finding provides the most evidence that a fetus might have a gastrointestinal tract anomaly? meconium in the amniotic fluid low implantation of the placenta increased amount of amniotic fluid preeclampsia in the last trimester

increase amount of AF

The nurse, while shopping in a local department store, hears a multiparous woman say loudly, "I think the baby is coming." After asking someone to call 911, the nurse assists the client to give birth to a term neonate. While waiting for the ambulance, the nurse suggests that the mother initiate breastfeeding, primarily for what reason? to begin the parental-infant bonding process to prevent neonatal hypothermia to provide glucose to the neonate to contract the mother's uterus

contract mom uterus

While the nurse is caring for a neonate at 32 weeks' gestation in an isolette with continuous oxygen administration, the neonate's mother asks why the neonate's oxygen is humidified. What should the nurse should tell the mother? "The humidity promotes expansion of the neonate's immature lungs." "The humidity helps to prevent viral or bacterial pneumonia." "Oxygen is drying to the mucous membranes unless it is humidified." "Circulation to the baby's heart is improved with humidified oxygen."

dry mucous membranes

A 49-year-old woman has sought help from her primary care provider because of "intimacy problems." Upon questioning, the woman reveals that she is experiencing sexual desire, but that intercourse causes significant pain. In the absence of sexual activity, the woman states that she does not have any significant vaginal discomfort. What would the clinician recognize that this client is most likely experiencing? dyspareunia vaginismus vulvodynia a sexually transmitted infection (STI)

dyspareunia

What should the nurse assess in a newborn diagnosed with an anorectal malformation? Select all that apply. abdominal distension loose stools vomiting meconium in the urine meconium stools

abdominal distention, vomiting, meconium in urine

Which practice should a nurse recommend to a client who has had a cesarean birth?

coughing/deepbreathign

During the postpartum period, a nurse should assess for signs of normal involution. Which statement would indicate that a client is progressing normally? The uterus is descending at the rate of one fingerbreadth per day. Blood pressure drops as a result of the birth and changed circulatory load. Urine output remains about the same as in the client's prenatal period. Perineal pad usage remains at 10 to 15 per day.

1 fingerbreath per day

A client one day post-cesarean birth requests pain medication, stating her pain is 8 out of 10 when the nurse enters the room to perform her shift assessment. Which action by the nurse is most appropriate. Offer to help the client get out of bed to wash up which may make her feel better while the pain medication is starting to work. Explain to the client the nurse must complete the postpartum assessment and then will obtain her pain medication. Administer the ordered pain medication, explaining to the patient that she will be back within the hour to examine her. Explain to the client that the pain may subside if she changes position

administer and be back in hour

The nurse is catheterizing a client who cannot void after a normal birth 8 hours ago. The nurse begins the catheterization process, and the client states, "I forgot to tell the nurse I get hives to betadine." The nurse should take which steps in order of priority from first to last? All options must be used. 4File an incident report. 1Clean povidone-iodine from client's vaginal area. 2Notify the health care provider (HCP) prescribing catheterization. 3Document the incident. TAKE A PRACTICE QUIZ

clean idone from vaginal area, notify HCP, document, file

A primigravid client at 8 weeks' gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago, she has noticed flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the client to a primary health care provider because the nurse suspects which sexually transmitted infection? gonorrhea Chlamydia trachomatis infection syphilis herpes genitalis

herpes gentialis

A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which information would the nurse include when explaining to the client about the increased lochia on ambulation? The increased lochia needs to be reported to the health care provider (HCP) immediately. The increased lochia occurs from lochia pooling in the vaginal vault. The increase in lochia may be an early sign of postpartum hemorrhage. This increase in lochia usually indicates retained placental fragments.

lochia pooling from vaginal vault

A client at 4 weeks postpartum tells the nurse that she cannot cope any longer and is overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she does not want to care for the infant. The nurse should encourage the client and her husband to call their health care provider (HCP) because the mother should be evaluated further for which complication?

pp depression

The nurse makes a home visit to a primigravid client on the fourth postpartum day after birth of a term neonate. When the nurse enters the house, the nurse finds the client sitting in a chair, crying inconsolably, while the neonate is crying in another room. The client tells the nurse that she has not been sleeping well and has been hearing voices. The nurse determines that the client is most likely experiencing which condition?

pp psychoiss

The physician orders docusate sodium 100 mg at bedtime for a primiparous client after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication?

soften stool

Which assessment finding would lead a nurse to suspect dehydration in a preterm neonate? Bulging fontanels Excessive weight gain Urine specific gravity below 1.012 Urine output below 1 ml/hour

urine output below 1

Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after administering the medication, which finding should alert the nurse to the development of a possible side effect? dizziness hypertension diarrhea urinary frequency

dizzy

A primiparous client planning to breastfeed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth, breasts begin to produce milk within what time period?

2-4 days

While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks' gestation to a primiparous client who admits to opiate use during pregnancy, which finding would alert the nurse to possible opiate withdrawal? bradycardia high-pitched cry sluggishness hypocalcemia

high pitch cry

The nurse determines that a newborn is experiencing hypoglycemia based on which findings? Select all that apply. a blood glucose reading of less than 30 mg/dL (1.7 mmol/L) or less at 1 hour family history of insulin-dependent diabetes internal fetal monitor tracing irregular respirations, tremors, and hypothermia large for gestational age

BG less than 30 -irregula respiartors, tremors, hypothermia

A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks' gestation is placed in an oxygenated isolette. The neonate's mother tells the nurse that she was planning to breastfeed the neonate. Which instructions about breastfeeding would be most appropriate? Breastfeeding is not recommended, because the neonate needs increased fat in the diet. Once the neonate no longer needs oxygen and continuous monitoring, breastfeeding can be done. Breastfeeding is contraindicated because the neonate needs a high-calorie formula every 2 hours. Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

Gavage feedings using breast milk can be given until the neonate can coordinate sucking and swallowing.

An adolescent with pneumonia shares fears of having contracted human immunodeficiency virus (HIV). The adolescent wants to be tested but does not want parental involvement. What should the nurse say? "Tell me why you think you may have contracted HIV." "You'll have to talk with the hospital's nurse ethicist." "The healthcare provider will run the test confidentially." "You're very young to have HIV."

HCP will run confidentialyy

e second postpartum day, a client tells the nurse she feels anxious and tearful. Which assessment finding is most consistent with the client's statement?

PP blues

A nurse caring for a preterm neonate knows that positioning can benefit high-risk neonates. Which position is appropriate for a preterm neonate? hyperabduction and extension of the arms with external rotation of the hips neck extension and back arching with flattened shoulders adduction and flexion of the extremities with gently rounded shoulders abduction and flexion of the arms with flattened shoulders

adduction adn felxion with gently rounded shoulders

A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous, and the client is reporting pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time?

administer pain` medication per perscription

On the second postpartum day after a cesarean birth, the client reports having gas pains. What should the nurse should instruct the client to do? Ask the primary care provider for a simethicone prescription. Chew on some ice chips. Drink some hot coffee. Ambulate more often.

ambulate more

A primiparous client is on a regular diet 24 hours postpartum. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which principle? Foods from home are generally discouraged on the postpartum unit. The mother can bring the daughter any foods that she desires. This is permissible as long as the foods are nutritious and high in iron. The client's health care provider (HCP) needs to give permission for the foods.`

any food she desires

Which information would the nurse include in a teaching plan about treatments for sexually transmitted infections? Acyclovir can be used to cure herpes genitalis. Chlamydia trachomatis infections are usually treated with penicillin. Ceftriaxone sodium may be used to treat Neisseria gonorrhoeae infections. Metronidazole is used to treat condylomata acuminata.

ceftriaxone sodium

A client with human papillomavirus (HPV) infection is being treated by a colposcopy. The client asks the nurse if this procedure is really necessary. The nurse can tell the client that if the HPV infection is not treated which health problem is likely to occur? infertility cervical cancer pelvic inflammatory disease rectal cancer

cervical cancer

A multigravida 30-year-old woman has given cesarean birth to a healthy term neonate due to an abnormal fetal heart rate tracing. At 2 hours postpartum, the nurse assesses the client's urinary catheter and observes that the client's urine is slightly red-tinged. What should the nurse do next? Continue to monitor the client's input and output. Palpate the client's fundus gently every 15 minutes. Assess the placement of the Foley catheter. Contact the client's health care provider (HCP) for further orders.

contact HCP for further orders

Following postpartum discharge teaching by the nurse, which statement by the client indicates an understanding of how to provide self-care? "I should contract my buttocks before sitting or rising." "I should support my body weight on the arms of a chair." "I should place a pillow behind my back." "I should sit on a hard surfaceas soon as I am able"

contract butt before sitting/risign

The nurse should assess a newborn with esophageal atresia and tracheoesophageal fistula (TEF) for which complications? Select all that apply. copious frothy mucus episodes of cyanosis several loose stools distended abdomen poor gag reflex

copious frothy mucucs epsidoes of cyanosis distended abdomen

x A sexually active male client has burning on urination and a milky discharge from the urethral meatus. What documentation should be included on the client's medical record? Select all that apply. history of unprotected sex (sex without a condom) length of time since symptoms presented history of fever or chills presence of any enlarged lymph nodes on examination names and phone numbers of all sexual contacts allergies to any medications

history of unprotected sex (sex without a condom) length of time since symptoms presented history of fever or chills presence of any enlarged lymph nodes on examination allergies to any medications

pp term for lochia 2 days after

lochia rubra

Twenty-four hours after cesarean birth, a neonate at 30 weeks' gestation is diagnosed with respiratory distress syndrome (RDS). When explaining to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body's secretion of which substance?

surfactant

A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The health care provider (HCP) has prescribed IV fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4 mEq/L (3.4 mmol/L). What should the nurse do first? Notify the HCP. Administer the prescribed fluids. Verify that the infant has urinated. Have the potassium level redrawn.

verify if urinated

The nurse is developing a community health education program about sexually transmitted infections. Which information about women who acquire gonorrhea should be included? Women are more reluctant than men to seek medical treatment. Gonorrhea is not easily transmitted to women who are menopausal. Women with gonorrhea are usually asymptomatic. Gonorrhea is usually a mild disease for women.

women with gonorrhea are usually asymptomatic

Immediately after the first oral feeding after corrective surgery for pyloric stenosis, a 4-week-old infant is fussy and restless. What action would be most appropriate at this time? Encourage the parents to hold the infant. Hang a mobile over the infant's crib. Give the infant more to eat. Give the infant a pacifier to suck on.

give pacifier

A neonate born at 28 weeks' gestation has been receiving 80% to 100% oxygen via mechanical ventilation for the past 2 weeks. The neonate also has received multiple blood transfusions to treat anemia and has experienced several episodes of apnea. The nurse caring for the neonate should anticipate which iatrogenic complication?

ROP

Examination of a primigravid client having increased vaginal secretions since becoming pregnant reveals clear, highly acidic vaginal secretions. The client denies any perineal itching or burning. The nurse interprets these findings as a response related to which factor? a decrease in vaginal glycogen stores development of a sexually transmitted infection prevention of expulsion of the cervical mucus plug control of the growth of pathologic bacteria

control of the growth of pathologic bacteria

The nurse provides a neonate with an initial feeding. The nurse would suspect a tracheoesophageal fistula if the neonate demonstrated which behavior? sucking attempts that are too poorly coordinated to be effective projectile vomiting that occurs after drinking 4 oz (120 mL) coughing, choking, and cyanosis that occur after several swallows of formula sleeping that occurs after taking 10 mL of formula

coughing, choking, cyanosis after several swallows of formula

A client is a gravida 1, para 0. During the first 24 hours after birth, she doesn't show consistent interest in her neonate. What should the nurse do next? Call the physician for an order for an antidepressant. Question the client about how she feels about being a mother. Document these expected behaviors of the taking-in period. Request a social service consultation.

document expected behaviors

A mother with a history of gestational hypertension gives birth to a neonate at 26 weeks' gestation. After the neonate receives surfactant through an endotracheal tube in the delivery room, a nurse takes the neonate to the neonatal intensive care unit (NICU), places the neonate on an overbed warmer, and provides mechanical ventilation. When the mother arrives in the NICU for the first time, the nurse's priority should be to explain the NICU visiting policy for the mother and family. enhance bonding by pointing out the neonate's features. obtain a family medical history. question the mother about her preterm labor.

enhance bonding

The nurse is interviewing a client with newly diagnosed syphilis. In order to prevent the spread of the disease, the focus of the interview should include which approach? motivating the client to undergo treatment obtaining a list of the client's sexual contacts increasing the client's knowledge of the disease reassuring the client that medical records are confidential

obtaining list of pt sexual contacts

A 25-year-old primiparous client who gave birth 2 hours ago has decided to breastfeed her neonate. Which instruction should the nurse address as the highest priority in the teaching plan about preventing nipple soreness? keeping plastic liners in the brassiere to keep the nipple drier placing as much of the areola as possible into the baby's mouth smoothly pulling the nipple out of the mouth after 10 minutes removing any remaining milk left on the nipple with a soft washcloth

place as much in mouth as possible

x The nurse is caring for a newborn of a primiparous woman with insulin-dependent diabetes. When the mother visits the neonate at 1 hour after birth, the nurse explains to the mother that the neonate is being closely monitored for symptoms of hypoglycemia because of which reason? increased use of glucose stores during a difficult labor and birth process interrupted supply of maternal glucose and continued high neonatal insulin production a normal response that occurs during transition from intrauterine to extrauterine life increased pancreatic enzyme production caused by decreased glucose stores

interrupted supply of maternal glucose and continued high neonatal insulin production

What should the nurse include in a community health program designed to control sexually transmitted infections (STIs)? mass screening of all individuals education about safe sex practices treatment of those with the disease isolation of those suspected of having STIs

education about safe sex practices

When developing the plan of care for an infant diagnosed with myelomeningocele and the parents who have just been informed of the infant's diagnosis, the nurse should include which action as the priority when the parents visit the infant for the first time? Emphasize the infant's normal and positive features. Encourage the parents to discuss their fears and concerns. Reinforce the health care provider's (HCP's) explanation of the defect. Have the parents feed their infant.

emphaisze norm/positive features

While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which statement indicates the need for additional teaching? "I should ask my health care provider about using a stool softener." "Analgesic sprays and witch hazel pads can relieve the pain." "I should lie on my back as much as possible to relieve the pain." "I should drink lots of water and eat foods that have a lot of roughage."

lay on back

While the nurse is palpating the breasts of a client who is breastfeeding her 12-hour-old neonate, what is an expected finding? soft breasts that are not tender to touch slightly firm, filling breasts firm breasts beginning milk production firm breasts that are tender to touch

soft breasts not tedner to touch

Which group has experienced the greatest rise in the incidence of sexually transmitted diseases (STDs) over the past two decades?

teenagers

A term neonate's mother is O-negative, and cord studies indicate that the neonate is A-positive. Which finding indicates that the neonate developed hemolytic disease? Increased activity Frequent feeding patterns Weight loss of less than 10% Signs of kernicterus

kernicterus

A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which action in the infant's plan of care? urine toxicology screening notifying hospital security limiting contact with visitors contacting local law enforcement

urine toxicologyt

During the fourth stage of labor, the client should be assessed carefully for uterine atony. complete cervical dilation. placental expulsion. umbilical cord prolapse.

uterine atony

A 17-year-old high school senior calls the clinic because she thinks she might have gonorrhea. She wants to be seen but wants assurances that no one will know. Which is the most appropriate response by the nurse? "Because you are underage, we will need your parent's consent to treat you." "We can treat you without your parents' consent, but they have the right to review your medical record." "We can see you without your parents' consent but have to report any positive results to the public health department." "We can see you, treat any infections, and will not share your results with anyone."

we can see you without your parents ocnsent but have to report any positive results to the health public department

A male neonate born at 36 weeks' gestation is admitted to the neonatal intensive care nursery with a diagnosis of probable fetal alcohol syndrome (FAS). The mother visits the nursery soon after the neonate is admitted. Which instructions should the nurse expect to include when developing the teaching plan for the mother about FAS? Withdrawal symptoms usually do not occur until 7 days postpartum. Large-for-gestational-age size is common with this condition. Facial deformities associated with FAS can be corrected by plastic surgery. Symptoms of withdrawal include tremors, sleeplessness, and seizures.

symptoms: tremor, sleeplessness, seizures

A nurse is conducting a physical assessment on an adolescent who does not want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse would implement in this situation? Respect the adolescent's wishes and maintain her confidentiality. Because the adolescent is a minor, inform her parents about her medical history. Discussing the adolescent's medical history with her parents and thoroughly document it in the medical record. Before agreeing to maintain confidentiality, determine whether the adolescent is an emancipated minor.

respect wishes and maintain confidentialty