Archer Maternal & Newborn Health

A client presents to the obstetrics floor at 39 weeks gestation with irregular contractions. After you get the client situated in a labor, delivery, and recovery room, you notice the client's health care provider (HCP) enter the room to evaluate the client. Following the evaluation, the HCP exits the room, and shortly thereafter, you enter. During your discussion, the client states the HCP "went to order oxytocin." In anticipation of that order, you understand this client's oxytocin will be administered via which route of administration? A. Intramuscular administration B. Intravenous administration via mainline infusion using an infusion pump C. Intravenous administration via piggyback using an infusion pump D. Oral administration Submit Answer

A client presents to the obstetrics floor at 39 weeks gestation with irregular contractions. After you get the client situated in a labor, delivery, and recovery room, you notice the client's health care provider (HCP) enter the room to evaluate the client. Following the evaluation, the HCP exits the room, and shortly thereafter, you enter. During your discussion, the client states the HCP "went to order oxytocin." In anticipation of that order, you understand this client's oxytocin will be administered via which route of administration? A. Intramuscular administration B. Intravenous administration via mainline infusion using an infusion pump C. Intravenous administration via piggyback using an infusion pump D. Oral administration Submit Answer

The nurse working in the maternity ward is caring for a 24-hour post-partum client. When assessing the client, the nurse notes that her fundus is firm at the level of the umbilicus and is veering a little bit to the right. The initial action for the nurse is to: A. Check for bladder distention B. Check the client's blood pressure C. Check if the client has been given oxytocin D. Check the pad count Submit Answer

Explanation Choice A is correct. A displaced fundus is an indication of a distended bladder. The nurse should assess the client for bladder distention and encourage the client to empty her bladder. Choice B is incorrect. The nurse can check the client's blood pressure; however, this action is unrelated to the situation. Choice C is incorrect. The nurse has assessed that the client's fundus is firm. Thus, the nurse does not need to check if oxytocin was given. Choice D is incorrect. The nurse does not need to check the client's pad count as the client is not showing any signs of uterine atony. Last Updated - 27, Jan 2022

The nurse is caring for a pregnant client with a decreased alpha-fetoprotein level. The nurse plans to A. notify the primary healthcare provider (PHCP) of the results. B. instruct the client to increase their intake of folic acid. C. document the result as normal. D. obtain a urine specimen. Submit Answer

Explanation Choice A is correct. AFP is a substance made by the baby that enters the amniotic fluid and the mother's bloodstream. A small amount of AFP is usually found in amniotic fluid and the mother's blood. When the amount is high, it signals the physician to look further for the possibility of a neural tube defect. A woman carrying a baby with Down syndrome may have lower blood levels of AFP. High levels may suggest neural tube defects or be caused by a multifetal pregnancy. Regardless of the etiology of the alterations in the level, the nurse needs to notify the PHCP of the result. Choices B, C, and D are incorrect. A neural tube defect can be detected with MSAFP, but an increase in folic acid will not change once the error has occurred. Taking folic acid before becoming pregnant and continuing through the pregnancy can be beneficial to prevent neural tube defects. Obtaining a urine specimen is not needed and is required if the woman is showing signs of pre-eclampsia. Documenting the result as normal is inappropriate. Additional Info Folic acid supplementation prevents neural tube defects (spina bifida, meningocele, myelomeningocele). Foods rich in folic acid include dark green leafy vegetables, whole grains, and grapefruit. Last Updated - 25, Nov 2022

A 28-year-old female presents to the obstetrics office, suspecting she may be pregnant. Which of the following would the nurse recognize as a presumptive sign of pregnancy? A. Amenorrhea B. Positive fetal cardiac activity on ultrasound C. Enlarged uterus D. Auscultation of fetal heart tones Submit Answer

Explanation Choice A is correct. Amenorrhea (absence of menstrual period) is a presumptive sign of pregnancy. Presumptive signs of pregnancy are symptoms and signs that the patient experiences. Presumptive signs may resemble pregnancy signs and symptoms but may also be caused by other etiologies. While amenorrhea is a presumptive sign of pregnancy, missing a period can also result from other conditions such as stress, hypothyroidism, and anorexia. Choices B and D are incorrect. A positive cardiac activity on ultrasound (Choice B) and auscultation of fetal heart tones (Choice D) would be a positive sign of pregnancy. Positive signs of pregnancy are signs that cannot, under any circumstances, be mistaken for other conditions. Positive signs confirm that the pregnancy has occurred. Choice C is incorrect. An enlarged uterus would be detected by the examiner and would be a probable sign of pregnancy. Probable pregnancy signs indicate pregnancy in most cases; however, there is still the chance they can be caused by conditions other than pregnancy. While an enlarged uterus is a probable pregnancy sign, other conditions such as uterine tumors, fibroids, and adenomyomas may also cause such a finding. Another example of a probable sign of pregnancy is a positive urine pregnancy test. NCSBN Client Need Topic: Pregnancy, Subtopic: Antepartum care, system-specific assessment Additional Info Source : Archer Review Last Updated - 16, Feb 2022

The postpartum nurse is monitoring a new mother for signs of illness following vaginal delivery of a newborn infant. Which of the following is an early sign of excessive blood loss? A. Heart rate change from 80 to 125 bpm B. Blood pressure change from 125/90 to 119/82 mmHg C. A decrease in respiratory rate from 22 to 16 breaths per minute D. Reports of perineal soreness Submit Answer

Explanation Choice A is correct. An early sign of illness involves an increase in the patient's heart rate. Tachycardia is a rapid response to hypovolemia. A heart rate change from 80 to 125 bpm warrants further investigation into a possible illness. Choice B is incorrect. A blood pressure change from 125/90 to 119/82 mmHg is not a significant drop enough to indicate hypovolemia or considerable hemorrhage. Shock is defined as mean arterial pressure less than 65 mmHg or systolic blood pressure less than 90 mmHg. Choice C is incorrect. A respiratory rate decrease from 22 to 16 breaths per minute is an expected finding after delivery and is not alarming. Moreover, significant bleeding or hemorrhagic shock is associated with tachypnea (increase in the respiratory rate), not a decrease. Choice D is incorrect. Some perineal soreness is normal after delivery and does not necessarily indicate impending hemorrhage. NCSBN client need Topic: Health Maintenance and Promotion, Postpartum Care Last Updated - 31, Jan 2022

A nurse is caring for a woman that just had a normal delivery an hour ago. The nurse understands that the patient is still at risk for uterine atony at this stage. All of the following interventions should be included in the care plan of the patient for detection of uterine atony, except: A. Checking for saturated perineal pads every shift B. Palpating the fundus at frequent intervals C. Weighing perineal pads once they are changed, noting the time it was changed and the saturation D. Checking vital signs frequently for signs of shock Submit Answer

Explanation Choice A is correct. Checking perineal pads every shift is an incorrect practice and therefore the correct answer to this question. The nurse should assess the perineal pad of the immediate post-partum woman every 30-minutes, not every turn. Perineal pads getting soaked with blood within 30 minutes should be a cause of concern for the nurse for this is a sign of continuous bleeding through the uterus due to uterine atony. Choice B is incorrect. Palpating the fundus frequently is correct practice. The nurse should palpate the patient's fundus frequently to make sure that it is firm and contracted. A firm and contracted uterus prevents blood loss. Choice C is incorrect. Weighing used perineal pads once they are changed is correct practice. The nurse should weigh the perineal pads after they are soaked to accurately assess the amount of blood lost by the patient through the perineum. One gram in weight is equivalent to 1 mL in plasma. Taking note of the time that the pads were changed would signify the frequency of pad changes, which is also essential in the assessment. Choice D is incorrect. Checking vital signs for signs of shock is correct nursing practice. The nurse should assess the patient frequently for signs of trauma. These include low blood pressure, weak, thready pulses, increased heart rate, and increased respiratory rate. Last Updated - 27, Jan 2022

Risk factors for preeclampsia include all of the following, except: A. Chronic hypotension B. Age C. Race D. Family history of preeclampsia

Explanation Choice A is correct. Chronic hypotension is not a risk factor for preeclampsia; therefore, this is the correct answer to the question. Instead, a history of high blood pressure is a risk factor. This hypertension is defined as a blood pressure reading above 140/90 mmHg. Choices B, C, and D are incorrect. Older and very young pregnant women are at higher risk. African-American women are at higher risk than other races. A personal or family history of preeclampsia increases the risk of preeclampsia for a woman. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: Potential for Alterations in Body Systems; Antepartum Additional Info Source : Archer Review Last Updated - 10, Nov 2022

Which of the following maternal deficiencies may result in neural tube defects in a fetus? A. Folic acid B. Vitamin B12 C. Vitamin E D. Iron

Explanation Choice A is correct. Folic acid is essential for the development of the neural tube and might prevent the defect or failure of the machine to close. Neural tube defects are one of the most common congenital disabilities, occurring in approximately one in 1,000 live births in the United States. A neural tube defect is an opening in the spinal cord or brain that occurs very early in human development. The first spinal cord of the embryo begins as a flat region, which rolls into a tube (the neural tube) 28 days after the baby is conceived. When the neural tube does not close completely, a neural tube defect develops. Neural tube defects develop before most women know they are even pregnant. Neural tube defects are congenital disabilities of the brain, spine, or spinal cord. They happen in the first month of pregnancy, often before a woman even knows that she is pregnant. The two most common neural tube defects are spina bifida and anencephaly. Neural tube defects are considered a complex disorder because they are caused by a combination of multiple genes and multiple environmental factors. Known environmental factors include folic acid deficiency, maternal insulin-dependent diabetes, and maternal use of certain anticonvulsant (antiseizure) medications. While only a few environmental factors have been characterized, many different studies provide evidence that NTDs have a genetic component in their development. Studies of twins with NTDs have shown both identical twins have NTDs more than both fraternal twins. Studies of families show that the chance of having a second family member born with an NTD after one child is born with an NTD is increased. For example, the general population's chance of having an NTD is approximately 0.1% (1 in 1000). However, once the couple has one child with an NTD, their chance of

A 35-week pregnant client arrives at an emergency department complaining of heavy, painful vaginal bleeding. The nurse should immediately suspect which condition? A. Abruptio placentae B. Placenta previa C. Prelabor rupture of the membranes D. Passage of the mucus plug Submit Answer

Explanation Choice A is correct. Here, the nurse should immediately suspect abruptio placentae, as this client presents with the classic signs of severe pain and vaginal bleeding. Abruptio placentae (called abruptio placentae, placental abruption, or premature separation of the placenta) is the premature separation of a normally implanted placenta from the uterus. Placental abruption presents a significant risk for both the woman and the fetus. Once the premature placental separation begins, the woman becomes at risk for hemorrhage and consequent hypovolemic shock and clotting abnormalities. Similarly, risks to the fetus include asphyxia, excessive blood loss, prematurity, and fetal demise. Choice B is incorrect. Placenta previa is the implantation of the placenta in the lower uterus. The classic sign of placenta previa is the sudden onset of painless uterine bleeding. In the above scenario, the client presents with "heavy, painful vaginal bleeding," which is not in congruence with a classic placenta previa client presentation. Choice C is incorrect. Prelabor rupture of membranes (PROM) is leakage of amniotic fluid before the onset of labor. Typically, unless complications occur, the only symptom of PROM is leakage or a sudden gush of amniotic fluid from the vagina. The above client's complaints do not align with PROM. Choice D is incorrect. Most women do not realize they have lost their mucus plug. If a woman does, a mucus plug will often appear similar to vaginal discharge in one's underwear and not contain blood. Learning Objective Correlate complaints of heavy, painful vaginal bleeding in a third-trimester pregnant woman with a tentative diagnosis of abruptio placentae. Additional Info Abruptio placenta is a true obstetric emergency. The severity of symptoms and signs depends on the degree of separation of the

An 11-week pregnant client is complaining to the nurse about her hemorrhoids. The nurse understands that hemorrhoids occur because of pressure on the rectal veins from the bulk of the growing fetus. All of the following are measures to alleviate hemorrhoid pain, except: A. Instruct the client to use mineral oil to soften her stools. B. Rest in a side-lying position daily. C. Increase the client's fiber and water intake. D. Apply a cold compress to the area.

Explanation Choice A is correct. Mineral oil is contraindicated in pregnancy as it decreases nutrient absorption in the mother. Choice B is incorrect. Sleeping in a side-lying position removes the weight of the fetus on the superior and inferior vena cava, promoting venous return and decreasing venous pressure. Choice C is incorrect. Increasing fiber and water intake promote the formation of bulkier stools. Preventing constipation and relieving rectal pain. Choice D is incorrect. Cold compresses relieve pain by vasoconstriction of the hemorrhoids. Last Updated - 23, Jan 2022

A client at 32 gestational weeks reports the sudden onset of painless, bright red vaginal bleeding. The assessment showed a normal fetal heart rate and a non-tender uterus. The nurse understands that this client is at the highest risk of developing A. placenta previa. B. threatened abortion. C. placental abruption. D. uterine souffle. Submit Answer

Explanation Choice A is correct. Placenta previa may occur as early as 20 gestational weeks. The manifestations of painless, bright red vaginal bleeding coincide with this condition. Commonly, the presentation of placenta previa is a finding on routine ultrasound examination at approximately 16 to 20 weeks. Choices B, C, and D are incorrect. A threatened abortion may only occur before 20 gestational weeks. Thus, this condition is excluded. Placental abruption is highly serious and manifests with painful vaginal bleeding that causes the uterus to be firm and tender. Uterine souffle is a soft, blowing sound. This sound may be auscultated over the uterus. This is the sound of blood circulating through the dilated uterine vessels, and it corresponds to the maternal pulse. Additional Info Placenta previa is an implantation of the placenta in the lower uterus. As a result, the placenta is closer to the internal cervical os than to the presenting part (usually the head) of the fetus. The classic sign of placenta previa is the sudden onset of painless uterine bleeding in the last half of pregnancy. Many cases of placenta previa are diagnosed by ultrasound examination before any bleeding occurs. Last Updated - 08, Jul 2022

The nurse takes a call at the antepartum clinic from a client who is pregnant at 19 weeks gestation. The client reports feeling a flutter in her abdomen. The nurse understands that this client is likely experiencing A. quickening. B. lightening. C. ballottement. D. ambivalence. Submit Answer

Explanation Choice A is correct. Quickening is often described as a flutter sensation in the client's abdomen. This occurs during 16 to 20 weeks of gestation. The client is likely experiencing this sensation as she is at 19 weeks of gestation. Choices B, C, and D are incorrect. Lightening is the descent of the fetus toward the pelvic inlet before labor, and it occurs about 2 to 3 weeks before the natural onset of labor. Ballottement is an examination technique where a sudden tap on the cervix during the vaginal examination may cause the fetus to rise in the amniotic fluid and then rebound to its original position. Ambivalence is a natural occurring feeling by expected mothers during the first trimester when she feels conflicted about the pregnancy. Additional Info Quickening is usually first noticed by the expectant mother at 16 to 20 weeks of gestation and gradually increases in frequency and strength. Women often describe this initial sensation as a fluttering. Last Updated - 13, May 2022

A woman is in the labor and delivery suite at 37 weeks gestation. She has been under her obstetrician's care for preeclampsia. The labor nurse notices that the fetus is experiencing heart rate decelerations. You are part of the neonatal resuscitation team that responds to the call from the labor room nurse. The infant is born but does not respond to tactile stimulation. The group moves the infant to the warmer. You evaluate the infant and confirm he is still not breathing. You begin positive pressure blowing with room air. Another team member notes that the heart rate is 72 bpm and the newborn's chest is not moving with PPV on room air. The next appropriate action is to: A. Reposition the infant to open the airway B. Begin CPR C. Suction the infant with a bulb syringe D. Increase the oxygen concentration Submit Answer

Explanation Choice A is correct. Reposition the infant to open the airway while ensuring that you have a good seal with the mask on the newborn's face. Following that action, a team member should suction the infant's mouth and nose. Until the team establishes sufficient ventilation, there is no indication to increase oxygen concentration or begin CPR. The AHA and AAP focus on positive-pressure ventilation as the single most crucial step in the resuscitation of the newborn. Choices B, C, and D are incorrect. NCSBN Client Need Topic: Physiological Adaptation, Sub-topic: Alterations in Body Systems, Newborn Last Updated - 19, Jan 2022

A G1P0 client with a blood type A negative is at her 28th-week gestation and was advised a RhoGAM injection today. Which statement by the client indicates the need for further teaching about this therapy? A. "This shot is meant to prevent my baby from developing antibodies against my blood, right?" B. "I understand that if we find out my baby is Rh positive, then I'll need to get another one of these injections." C. "This shot should help to protect me in future pregnancies if this baby comes out Rh positive, like her dad." D. "This shot will prevent me from becoming sensitized to Rh-positive blood." Submit Answer

Explanation Choice A is correct. RhoGAM is administered to Rh-negative mothers to prevent them from producing antibodies against their Rh-positive fetus. "This shot is meant to prevent my baby from developing antibodies against my blood, right?" indicates that the client needs further teaching. Choices B, C, and D are incorrect. If the infant is Rh-positive, the mother needs to receive another dose after delivery to prevent maternal sensitization. This will also protect future pregnancies as the mother's blood will be free of antibodies against her fetus. RhoGAM prevents maternal sensitization of Rh-positive blood. Last Updated - 13, Jan 2022

At her first visit, a prenatal client is found to be suffering from mildly high blood pressure. The nurse should have her client reduce which dietary component? A. Salt B. Magnesium C. Potassium D. Calcium Submit Answer

Explanation Choice A is correct. Salt should be restricted in the client with mildly high blood pressure. A blood pressure that is considered moderately high is about 140/90 mmHg. These patients should begin treatment by reducing salt intake and assessing behavioral areas that may need adjustment, such as smoking cigarettes or failing to exercise. Choices B, C, and D are incorrect. Magnesium, potassium, and calcium do not need to be reduced when a patient presents with high blood pressure. NCSBN client need Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care Last Updated - 21, Jan 2022

Following a pregnant client's report of persistent nighttime leg cramps over the past week, it would be appropriate for the nurse to instruct the client to increase their dietary intake of: A. Whole grains, nuts, egg yolks B. Almonds, sweet potato, avocado C. Lentils, peas, nuts D. Carrots, tomatoes, squash Submit Answer

Explanation Choice A is correct. The client's complaint of nocturnal leg cramps may indicate inadequate magnesium and/or vitamin D intake. Whole grains and nuts are magnesium-rich foods, while egg yolks are a significant source of Vitamin D. The nurse should educate the client on these nutritional sources and how the consumption of these items will assist in alleviating the client's nocturnal leg cramping. Choice B is incorrect. Almonds, sweet potatoes, and avocadoes are foods rich in vitamin E. While the consumption of these foods will benefit the client, consuming foods will not resolve the client's primary complaint of nocturnal leg cramps. Choice C is incorrect. Lentils, peas, and nuts are folic acid-rich foods. Folic acid intake is vital in the early stages of pregnancy, as deficiency of this nutrient may cause spontaneous abortion and/or neural tube defects. However, folic acid does not aid in relieving nocturnal leg cramps during pregnancy. Choice D is incorrect. Squash, carrots, and tomatoes are high in beta-carotene. Although beta-carotene does not prevent nocturnal leg muscle cramps, this nutrient aids in fetal growth and cell differentiation. Learning Objective Correlate a pregnant client's nocturnal leg cramps with the client's need to increase the dietary intake of magnesium and vitamin D. Additional Info Legumes and seeds are also rich in magnesium. Vitamin D-rich foods include butter, soy products, and vitamin D fortified milk or orange juice. Painful contractions of the muscles of the legs occur in 25% to 50% of pregnant women. Typically, these cramps result from a lack of magnesium and/or vitamin D in the diet. Cramps often occur during sleep when the muscles are relaxed or when the woman stretches and extends her feet with the toes pointed. Last Updated - 30, Sep 2022

You are planning an educational series of classes for young pregnant women. Which of the following needs should you include in a class related to nutrition during pregnancy? A. The need to increase caloric intake by about 340 calories during the second trimester of gestation. B. The need to increase caloric intake by about 370 calories during the second trimester of gestation. C. The need to increase caloric intake by about 340 calories during the third trimester of gestation. D. The need to increase caloric intake by about 370 calories during the third trimester of gestation. Submit Answer

Explanation Choice A is correct. The need that you should include in a class related to nutrition during pregnancy for a group of young pregnant women is the need to increase caloric intake by about 340 calories during the second trimester of gestation. This caloric increase is necessary to support the growth and development of the fetus. Similarly, a caloric increase of about 450 calories is indicated during the third trimester of gestation for the same reason. Choice B is incorrect. Although there is a need to increase caloric intake during the second trimester of gestation, this increase is less than 370 calories. Choice C is incorrect. Although there is a need to increase caloric intake during the third trimester of gestation, this increase is more than 340 calories. Choice D is incorrect. Although there is a need to increase caloric intake during the third trimester of gestation, this increase is more than 370 calories. Last Updated - 05, Dec 2021

The nurse is supervising a nursing student to teach a pregnant client about a scheduled chorionic villus sampling (CVS) test. Which statement, if made by the nursing student, would require follow-up? A. You will need to provide both a urine and blood sample for this test. B. Drink plenty of water prior to this test and do not empty your bladder. C. An ultrasound will be used during this procedure to guide the needle. D. It is okay to eat and drink on the day of the procedure. Submit Answer

Explanation Choice A is correct. This statement is untrue and requires follow-up. A CVS is a test utilized to determine the presence of chromosomal abnormalities and involves the aspiration of small samples of the placenta for prenatal genetic diagnosis. Maternal blood and urine specimens are not necessary for this test. Choices B, C, and D are incorrect. These statements are factual and do not require follow-up. The CVS uses ultrasound, and a full bladder allows for an acoustic window to ensure accurate imaging. No eating or drinking restrictions are in place during preprocedure. The client may eat and drink normally. Additional Info Chorionic villus sampling is a test that may be performed as early as ten gestational weeks to determine if the fetus has any chromosomal abnormalities. Chorionic villus sampling has drawbacks that preclude its use, including possible spontaneous abortion of the fetus and fetomaternal hemorrhage. Last Updated - 16, Dec 2022

You are caring for a pregnant woman with a baseline BMI of 22. You educate this client on the desirable weight gain during pregnancy with one baby for her is: A. 28 to 40 pounds B. 25 to 35 pounds C. 15 to 25 pounds D. 11 to 20 pounds

Explanation Choice B is correct. 25 to 35 pounds. The amount of optimal weight gain during pregnancy is determined based on the woman's body mass index (BMI) before pregnancy. BMI is a measure of body fat calculated from weight and height. Please use the following table to determine the recommended weight gain during pregnancy. A baseline BMI of 22 indicates that this woman's baseline is in the healthy range (Normal BMI = 18.5 to 24.9). The recommended weight gain for this client is 25 to 35 pounds. Weight gain during pregnancy is crucial to the health and well-being of the baby and the mother. Gaining too little weight can lead to premature birth and low infant birth weight. Gaining too much weight can also result in premature birth and obesity of the child in later life. Excessive weight gain can result in strenuous labor, the increased possibility of needing a caesarian section, and increased bleeding. Choice A is incorrect. This is the recommended weight gain during singleton pregnancy for an underweight woman. Choice C is incorrect. This is the recommended weight gain during singleton pregnancy for an overweight woman. Choice D is incorrect. This is the recommended weight gain during singleton pregnancy for an obese woman. NCSBN Client Need Topic: Reduction of Risk Potential; Sub-topic: System-Specific Assessment Last Updated - 13, Jun 2021

The nurse is teaching a client about a scheduled contraction stress test (CST). Which of the following statements should the nurse include? A. "You will need to consume a liquid with 50 grams of glucose." B. "You may need to stimulate your nipples during this test." C. "A positive result means your baby has had no late decelerations." D. "A negative result means your baby has had variable decelerations."

Explanation Choice B is correct. A CST is indicated for high-risk clients who are in the third trimester. CST requires the client to have contractions either through oxytocin administration or nipple stimulation. Choices A, C, and D are incorrect. The client consuming a liquid with concentrated glucose is not indicated for a CST. This is appropriate for a glucose tolerance test. The results for a CST are interpreted as follows - Positive (abnormal) indicates that late decelerations were present in the FHR in more than 50% of the contractions. Negative (normal) indicates that no late or variable decelerations were evident during the contractions. Learning Objective Understand that contractions during a contraction stress test can be induced by intravenous administration of oxytocin or by nipple stimulation. Additional Info Source : Archer Review A contraction stress test is indicated for clients with high-risk pregnancies. This test is completed in the third trimester. Relative contraindications to a CST include placenta previa and patients at risk for preterm delivery as this test may hasten delivery or at minimal cause rupture of the membranes. Last Updated - 15, Feb 2022

The nurse is caring for a client in labor experiencing early decelerations. Which of the following actions should the nurse take? A. Reposition the patient on her side B. Document the findings C. Discontinue oxytocin infusion D. Prepare for an amnioinfusion

Explanation Choice B is correct. Early decelerations are a reassuring finding caused by infant head compression, which is a normal part of labor. Choices A, C, and D are incorrect. Repositioning the client and discontinuing an oxytocin infusion would all be appropriate interventions for a client experiencing variable or late decelerations. Early decelerations are a reassuring pattern and do not require the nurse to intervene. Additional Info Source: Archer ReviewSource : Source: Archer Review ✓ Early decelerations are not associated with fetal compromise and do not require intervention. ✓ Early decelerations occur during contractions as the fetal head is pressed against the client's pelvis or cervix. Last Updated - 31, Dec 2022

The nurse is performing a home visit to the parents of a newborn. The nurse witnesses the father's direct eye contact with the infant and shows affection. The nurse should document this finding as A. binding-in. B. engrossment. C. entrainment. D. detachment.

Explanation Choice B is correct. Engrossment is used to describe the initial paternal bonding. This is characterized by the father having a face-to-face fascination with the newborn and the ability for the father to start the bonding process. Choices A, C, and D are incorrect. Binding-in (also known as claiming) is a standard psychosocial process where the mother links the newborn's facial features to other family members. Entrainment is when the newborn moves rhythmically in response to adult speech. Detachment is unexpected and occurs when the bonding process fails and either the infant or parent has no bond with the other. Additional Info Engrossment is a positive finding in the initial bonding phase between the infant and the father. Engrossment is reinforced when the infant awakens and responds to the father's voice. Last Updated - 29, Nov 2022

The nurse is caring for a client in labor who just received epidural analgesia. The nurse should monitor the client for which adverse effects? A. Hypertension B. Bladder distention C. Hypothermia D. Precipitous labor Submit Answer

Explanation Choice B is correct. Epidural analgesia may cause bladder distention. Bladder distention may cause pain that remains after initiation of the block and may interfere with fetal descent in labor. Choices A, C, and D are incorrect. Epidural analgesia is known to cause hypotension; thus, it is routine for a client to receive a preprocedural fluid bolus of isotonic lactated ringers. Hypothermia is unlikely with epidural placement. The fever associated with epidural analgesia is usually not caused by infection but may result from reduced hyperventilation and decreased heat dissipation. Epidural analgesia commonly slows the progression of the second stage of labor because it relaxes pelvic muscles. Additional Info The epidural space is entered at the L3-L4 interspace (below the end of the spinal cord), and a catheter is passed through the needle into the epidural space. The catheter allows continuous infusion or intermittent injection of medication to maintain pain relief during labor and vaginal or cesarean birth. The infusion of epidural medication also may be regulated by a patient-controlled epidural analgesia (PCEA) pump Last Updated - 10, Jul 2022

A 29-year-old is pregnant for the first time. She calls her family care provider and tells the nurse that the first day of her last period was May 5th. She used Nagele's rule to determine this. The nurse anticipates that her estimated due date will be on what date? A. February 5th B. February 12th C. January 28th D. April 12th Submit Answer

Explanation Choice B is correct. February 12th. Remember, the equation for Nagele's Rule is subtract three months from the first day of the woman's last menstrual period plus seven days. Choices A, C, and D are incorrect. Recalculate using the equation for Nagele's Rule. NCSBN client need Topic: Health Care Promotion and Maintenance, Ante / Intra / Postpartum Care Last Updated - 12, Feb 2022

The nurse is caring for a newborn with erythroblastosis fetalis. The nurse understands that this disease is characterized by A. excessive red blood cell production that requires therapeutic blood donation. B. incompatibility between maternal and fetal blood. C. an excessive amount of circulating white blood cells (WBC). D. erythrocytes become shaped like a sickle and sensitive to hypoxia. Submit Answer

Explanation Choice B is correct. Infants with erythroblastosis fetalis are anemic from the destruction of RBCs. Severely affected infants may develop hydrops fetalis, a severe anemia resulting in heart failure and generalized edema. This hemolysis stems from maternal-fetal blood incompatibility. Choices A, C, and D are incorrect. Polycythemia vera is characterized by excessive red blood cell production that requires therapeutic blood donation. Excessive WBCs would be leukocytosis which is a non-specific indicator of possible infection or inflammation. Sickle cell anemia fits the description of erythrocytes becoming shaped like a sickle and sensitive to hypoxia. Additional Info The use of Rho(D) immune globulin (RhoGAM) to prevent the mother from forming antibodies against Rh-positive blood has greatly decreased the incidence of erythroblastosis fetalis. Last Updated - 18, Dec 2022

The nurse is caring for a client two weeks postpartum with reports of flu-like symptoms, headache, and tenderness to the left breast. On examination, the nurse assesses enlarged axillary lymph nodes. The client is demonstrating manifestations of A. Endometritis B. Mastitis C. Pelvic inflammatory disease D. Cystitis

Explanation Choice B is correct. Mastitis commonly occurs 2-4 weeks postpartum. The client often experiences flu-like symptoms (fever, malaise, and axillary lymphadenopathy). The affected breast usually is tender, has erythema, and is swollen. The client's manifestation classically coincides with this infection. Choices A, C, and D are incorrect. These manifestations are not consistent with these disorders. If the client were to have any of these infections, the pain or discomfort would be localized to this area which is not in the client's complaint. Additional Info Mastitis is often caused by Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), E. coli, and streptococci. The bacteria are most often carried on the skin of the mother or in the mouth or the nose of the newborn. The organism enters through an injured area on the nipple, such as a crack or blister. The primary medical treatment is antibiotics and continued emptying of the breast. Comfort measures during mastitis include applying moist heat or ice packs, breast support, bed rest, fluids, and analgesics. Last Updated - 30, Jul 2022

The nurse just finished receiving the shift report from the night nurse. Which of the following newborns should the nurse assess first? A. A 3-hour old newborn weighing 6 pounds B. A 4-hour old newborn delivered at 42 weeks C. A 6-hour old newborn that is 21 inches long D. An 8-hour old newborn delivered at 40 weeks Submit Answer

Explanation Choice B is correct. Post-maturity refers to any baby born at or beyond 42 weeks gestation (42 0/7 weeks) or at or beyond 294 days from the first day of the mother's last menstrual period (LMP). Post-maturity is also referred to as prolonged pregnancy, post-term, and post-dates pregnancy. At about 40-42 weeks, placental insufficiency ensues due to the aging placenta. Therefore, the infants rely on their subcutaneous fat reserves to sustain them after 40 to 42 weeks since the aging placenta is unable to provide the necessary nutrition. Due to these depleted subcutaneous fat reserves, the post-term infant is at risk for hypoglycemia and hypothermia. In at-risk infants, the incidence of neonatal hypoglycemia is highest in the first few hours after birth. In this case (Choice B), a 4-hour old infant delivered at 42 weeks is at-risk. Additionally, the risk of meconium aspiration is high in the post-term fetuses and can cause respiratory distress when the baby is born. The nurse should prioritize and assess this post-term infant first. Choice A is incorrect. According to the World Health Organization (WHO), the average birth weight for a full-term baby is around 7.5 lb. However, a birth weight range between 5.5 lb. (2.5 kg) and 8.2 lb. (4.0 kg) is considered normal. Small for gestational age (SGA) is defined as a birth weight of less than 10th percentile for gestational age. Large for gestational age (LGA) refers to a birth weight equal to or more than the 90th percentile for a given gestational age. Macrosomia refers to a birth weight greater than 4000 to 4500 grams ( 4 to 4.5 kg), regardless of gestational age. The infant weighing 6 pounds (Choice A) is within the normal weight range for a newborn; the nurse does not need to see this infant first. Choice C is incorrect. The average length of full-term babies a

A G1P0 client in the first trimester of pregnancy informs the clinic nurse that she has replaced coffee with hot tea at breakfast. Her hemoglobin level was 10 g/dL today. She tells the nurse that she is taking her iron supplements twice per day. Which response by the nurse would be most appropriate? A. "You're off to a great start! Tea has much less caffeine than coffee." B. "A little lemon would be a great addition to your cup of tea, as this will help the absorption of your iron pill." C. "Right now, your iron levels are low. Please eliminate all caffeine from your diet, including tea and coffee." D. "That's alright. Drinking coffee or tea will not affect the fetus." Submit Answer

Explanation Choice B is correct. Tannins are compounds found in coffees and teas, which often inhibit or decrease the body's absorption of iron. Specifically, concerning tea intake, research has shown that adding lemon juice (which is high in vitamin C) appears to cancel the inhibitory effect of tannins on iron absorption. Choice A is incorrect. There is also no evidence that caffeine itself affects iron absorption. Still, when consumed in large amounts during pregnancy, it may increase the risk of spontaneous abortion, preterm birth, and small-for-gestational-age (SGA) newborns. Additionally, large quantities of caffeine consumption also affect calcium and zinc in terms of absorption and excretion. Choice C is incorrect. There is also no evidence that complete caffeine elimination will remedy iron-deficiency anemia. A further discussion with the client's health care provider (HCP) should occur to clarify this instruction. Choice D is incorrect. The "[d]rinking coffee or tea will not affect the fetus" by the nurse is inappropriate and not based on scientific research. This comment could lead to pregnancy complications and, therefore, should not be made by the nurse. Learning Objective Identify that adding lemon to a cup of tea will help the absorption of an iron pill. Additional Info Pregnant clients require higher amounts of iron per day than non-pregnant clients. The National Institutes of Health recommends pregnant clients consume 27 mg of iron daily. Discuss herbal teas or coffee with your health care provider (HCP) prior to adding these items to your diet during pregnancy. Last Updated - 21, Oct 2022

While working in the newborn nursery, you are called to L&D and asked to assign the APGAR score after birth. When you evaluate the infant at 1 minute of life, you find the following: cyanotic trunk and extremities, HR is 30 bpm, slight withdrawal when you pinch her foot, floppy muscles, and RR is 10 and irregular. What APGAR score do you assign? A. 1 B. 3 C. 5 D. 7 Submit Answer

Explanation Choice B is correct. The APGAR score is 3. The infant gets 0 points for blue skin color all over, 1 point for an HR below 100 bpm, 1 point for a minimal response to stimulation, 0 points for absent muscle tone, and 1 point for a slow and irregular respiratory rate. This APGAR score indicates severe distress; therefore, the baby needs immediate action. Choices A, C, and D are incorrect. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn Last Updated - 10, Feb 2022

A client in her second trimester presents to the maternity clinic expressing concern that the dark, verticle line present on the midline of her abdomen may pose a danger to her baby. Which of the following would be the most appropriate action for the nurse to take in response to the client's concern? A. Refer the client to a dermatologist for assessment. B. Educate the client that this is a common occurrence in pregnancy called linea nigra, which usually disappears after childbirth. C. Ask the client what types of foods she has been ingesting. D. Educate the client that this is a common occurrence in pregnancy called linea nigra, which typically remains following childbirth.

Explanation Choice B is correct. The linea alba—the line that marks the longitudinal division of the midline of the abdomen—darkens to become the linea nigra due to hormone changes during pregnancy. This dark line of pigmentation may extend from the symphysis pubis to as high as the top of the fundus and becomes darker as pregnancy progresses. This hyperpigmentation typically disappears after childbirth. Choice A is incorrect. There is no need for further assessment or evaluation by a dermatologist, as this is a common occurrence of pregnancy. Choice C is incorrect. There is no connection between food intake and the appearance of the linea nigra. Choice D is incorrect. Hormonal changes during pregnancy cause temporary pigmentation darkening making the linea nigra more visually prominent in some women. This hyperpigmentation is not permanent and will typically disappear following childbirth. Learning Objective Recognize that a linea nigra is a temporary hyperpigmentation that appears vertically down the abdomen due to hormone changes during pregnancy. Additional Info Those with darker complexions tend to have a more pronounced linea nigra than those with fair complexions. In most individuals, the linea nigra darkens enough to be visible in the second trimester. Following delivery, fading is gradual, occurring over several weeks or months. The exact cause of linea nigra is unknown, but the hypothesis is that the melanocyte-stimulating hormone created by the placenta causes melanin to rise during pregnancy. Source : Archer Review Last Updated - 25, Aug 2022

Your new client presented with a positive home pregnancy last night. She has abdominal pain, some vaginal bleeding. and you note an adnexal mass on palpation. You order a progesterone level, which returns as 13 ng/mL. Your initial impression is: A. Early normal pregnancy B. Possible ectopic pregnancy C. Abnormal intrauterine pregnancy D. Incorrect home pregnancy test Submit Answer

Explanation Choice B is correct. The nurse should suspect a possible ectopic pregnancy. Abdominal pain, vaginal bleeding, and an adnexal mass are the classic triad for an ectopic pregnancy. The developing chorion produces progesterone. A normal progesterone level is > 15 ng/mL. A lower than normal progesterone level is uncommon in normal pregnancies but is very common in an ectopic pregnancy. Further testing will usually be done to confirm the diagnosis. Choices A, C, and D are incorrect. NCSBN Client Need Topic: Reduction of Risk Potential, Sub-topic: Potential for Alterations in Body Systems; Antepartum Last Updated - 31, Jan 2022

The obstetric nurse is reading the prenatal client's chart. The nurse notes that the patient is suffering from preeclampsia and knows to observe for which complications in the newborn? A. Shaking and agitation [23%] B. Low birth-weight [53%] C. Abnormal kidney function [13%] D. Blurred vision

Explanation Choice B is correct. The nurse with this patient should expect an infant born with low birth weight. Preeclampsia often results in blood being shunted away from the fetus; growth restriction is commonly found in infants born to these women. Choice A is incorrect. Shaking and agitation aren't commonly connected with preeclampsia. These symptoms may be related to drug abuse or gestational diabetes. Choice C and D are incorrect. Blurred vision and abnormal kidney function affect mothers who are suffering from preeclampsia, not their infants. NCSBN client need Topic: Health Promotion and Maintenance Last Updated - 07, Feb 2022

A pregnant woman is admitted to the ER with an initial diagnosis of placenta previa. The nurse carries out orders to start an IV infusion, administer oxygen, and extract blood for laboratory tests. The client is getting anxious and asks the nurse what is happening. The nurse tells her not to worry and that everything is under control. What is the best description of the nurse's statement? A. Incorrect, the doctor should be the one to offer information and assurances. B. Questionable, because the patient has the right to understand the type of treatment and the reason for the treatment. C. Effective, because the response lowers the client's anxiety. D. Adequate, because the preparations are routine and need no explanation.

Explanation Choice B is correct. This is a violation of the client's rights. The client has the right to accurate and complete explanations about any procedures to be performed. Choice A is incorrect. In the Patients' Bill of Rights, the patient has the right to be informed by healthcare staff about any procedure that will be done to her. Choice C is incorrect. The nurse has the responsibility to inform the client regarding the procedure that is going to be performed on her. Choice D is incorrect. The procedure may be routine work for the nurse, but it is not routine for the client and should be explained to her. Last Updated - 08, Feb 2022

While performing a cardiovascular assessment on an infant at 2 hours of life, you note the following: Normal sinus rhythm HR = 178 Systolic murmur +1 pedal pulses +3 radial pulses 5 second capillary refill No edema What is the priority nursing action after this assessment? A. Continue to monitor B. Notify the health care provider C. Administer PRN acetaminophen D. Re-evaluate the patient in one hour Submit Answer

Explanation Choice B is correct. This patient is displaying signs and symptoms of congenital heart disease; specifically coarctation of the aorta. Even if you did not know which congenital heart disease they may have, you would be expected to know that the healthcare provider needs to be notified of these symptoms. Your patient is in normal sinus rhythm and has a normal heart rate for the newborn age group. The systolic murmur, the gradient in peripheral pulses, and 5 second capillary refill are all abnormal. The murmur indicates that there is an opening somewhere in the heart where there should not be. This could be an ASD, VSD, or one of the bypasses in fetal circulation (the ductus arteriosus or foramen ovale) may not have closed on their own. The gradient in pulses indicates that there is more blood flow in the top half of the body than in the lower half - this is what points to coarctation of the aorta. A capillary refill time of 5 seconds is the last abnormal sign for this patient. Capillary refill should be less than 3 seconds in a newborn - delayed capillary refill indicates poor perfusion and must be addressed quickly. It is important to recognize that these are abnormal signs and symptoms and need to be reported to the health care provider for prompt intervention. Choices A, C, and D are incorrect. These are not the priority action. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn Last Updated - 14, Feb 2022

The nurse is caring for a client in labor. The following tracing was on the fetal heart rate monitoring strip. The nurse recognizes that this tracing is a See the exhibit. A. variable deceleration. B. late deceleration. C. early deceleration. D. normal variability pattern.

Explanation Choice B is correct. This strip indicates a late deceleration. Late decelerations are visually apparent and usually symmetric in shape, with a gradual decrease and return of the fetal heart rate (FHR) to baseline. Late decelerations are caused by decreased perfusion to the fetus. Maternal repositioning is an effective intervention for this nonreassuring pattern. Other interventions include oxygen administration and the administration of intravenous isotonic fluids. Choice A is incorrect. This strip does not show a variable fetal deceleration. This strip indicates the presence of another fetal heart pattern other than variable fetal deceleration. Choice C is incorrect. This strip does not show early fetal deceleration. This strip indicates the presence of another fetal heart pattern other than initial fetal deceleration. Choice D is incorrect. This strip does not have a normal variability pattern. This strip indicates a non-reassuring finding. Additional Info Source : Archer Review Late decelerations become more concerning when they are recurrent (present with 50% or more of the uterine contractions in a 20-minute period). Late decelerations are caused by placental insufficiency. Interventions for late decelerations include - • Maternal repositioning (either lateral or hands and knees) • Intravenous fluid boluses • Administering oxygen (via nonrebreather 10 L/min) • Discontinuing oxytocin infusion (if applicable) Last Updated - 01, May 2022

The nurse is providing a 5-month pregnant woman with her options regarding birthing locations. The nurse would be most correct in suggesting which possibility to a woman who would like freedom of movement with drug-free labor and birth but is not comfortable with a home-birth? A. The nearest hospital to her home B. A birthing center C. She should continue with a home-birth if she is low risk D. A clinician's office with her OB/GYN

Explanation Choice B is correct. This woman should consider a birthing center. Birthing centers are generally drug-free, allow women to roam around the facility to relieve discomfort, and provide a home-like environment. Choice A is incorrect. The nearest hospital may not be the best location for a pregnant woman concerned about her freedom of movement and drug-free labor. Choice C is incorrect. A woman not comfortable with a home birth should not have one. Home births are more successful when the woman is confident about her birth choice. Choice D is incorrect. Most births do not occur at a clinician's office. NCSBN Client need Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care Last Updated - 28, Jan 2022

The nurse is working in the NICU for the morning shift. While assessing four neonates less than 6-hours old, which neonate warrants additional attention from the nurse? A. A neonate with a molded head and overriding sutures. B. A neonate with cyanotic hands and feet that has not passed meconium. C. A neonate that is spitting up excessive mucus, with a temperature of 36.1 °C (97°F), and is dusky in appearance. D. A neonate with abdominal respirations and intermittent tremors of the extremities. Submit Answer

Explanation Choice C is correct. A neonate is expected to be pinkish in appearance. Saliva should be minimal and the normal temperature for a newborn is from 36.5 °C to 37 °C. These signs need to be evaluated by the nurse to determine whether the baby needs further assessment. Choice A is incorrect. Molding and overriding sutures in a neonate are normal and may persist for a few days. Choice B is incorrect. Acrocyanosis in the newborn may be present for 2 to 6 hours. Meconium is expected to be passed within 24 hours after delivery. Choice D is incorrect. Tremors in the neonate are common. There is no need to worry about this sign. Last Updated - 15, Jan 2022

A nurse in the nursery is assessing a newborn in the unit. Which finding would necessitate further investigation? A. A soft spot just above the newborn's head B. Greasy, white substances that resemble cheese on the baby's neck, back, and thighs C. A single crease on the palm D. Acrocyanosis Submit Answer

Explanation Choice C is correct. A single crease on the palm is also called a Simian crease and would indicate that the child has Down's syndrome. The nurse should further assess this finding to confirm Down's syndrome in the child. Choice A is incorrect. The soft spot on the newborn's head is the anterior fontanel. They allow the bony plates of the baby's skull to flex so the baby's head can get through the birth canal. They do not close until 9-18 months. Choice B is incorrect. This is the vernix caseosa, which is a greasy, cheese-like substance on the newborn that occurs naturally to provide insulation on the newborn. Choice D is incorrect. Acrocyanosis is cyanosis of the newborn's extremities. This is a regular occurrence during the first hours of the newborn's life. Last Updated - 13, Oct 2021

The nurse is educating clients that are attending a prenatal class. Which of the following statements should the nurse include? A. "Chorionic Villous Sampling (CVS) may detect neural tube defects." B. "Maternal serum alpha-fetal protein (MSAFP) may determine gender." C. "Amniocentesis may be used to assess for chromosomal abnormalities." D. "A biophysical profile (BPP) assesses six variables such as fetal glucose." Submit Answer

Explanation Choice C is correct. Amniocentesis is a widely used antepartum test that may determine the gender of a fetus, the presence of neural tube defects, chromosomal abnormalities, and fetal lung maturity. This test may also be used therapeutically for polyhydramnios as it may remove some excessive amniotic fluid volumes. Choices A, B, and D are incorrect. CVS is a test that may be performed as early as week ten to determine if the fetus has any chromosomal abnormalities - not neural tube defects. MSAFP is a test that assesses neural tube defects, not gender. A BPP considers five variables, and fetal glucose is not one of these variables. Additional Info Amniocentesis is utilized to detect fetal neural tube defects and chromosomal abnormalities. This test can also be used later in pregnancy to determine fetal lung maturity. The client will need to consent before the procedure, and if the client is Rh-negative, she will need to receive prescribed RhoGAM. The client should be instructed to report post-procedure fever, decreased fetal movement, leaking of amniotic fluid, or bleeding. Last Updated - 06, Dec 2022

The nurse is caring for a neonate with a decreased cardiac output. If noted in this patient, which of the following is not a sign of decreased cardiac output? A. Oliguria B. Difficulty breastfeeding C. Bradycardia D. Hypotension Submit Answer

Explanation Choice C is correct. Bradycardia is not a typical symptom of decreased cardiac output in neonates. Instead, a decreased cardiac output generally results in tachycardia as the heart pumps faster to compensate. Typical signs of decreased cardiac output in an infant include oliguria, difficulty feeding, hypotension, irritability, restlessness, pallor, and decreased distal pulses. Choice A is incorrect. Oliguria is an expected finding in an infant with a decreased cardiac output. As the kidneys are perfused less efficiently in an infant with decreased cardiac output, urination reduces or ceases altogether. Choice B is incorrect. Difficulty breastfeeding may be seen in infants with low cardiac output. Feeding is increasingly difficult for babies with poor circulation. Choice D is incorrect. Hypotension is an expected finding in an infant with low cardiac output. Normal cardiac output is required to keep blood pressure regulated. Last Updated - 06, Feb 2022

The nurse is assessing a newborn that was delivered 8 hours ago. The nurse notices hyperactivity, a persistent shrill cry, and jitteriness. The nurse suspects which condition? A. Sepsis B. Hypoglycemia C. Drug dependence D. Hypothermia

Explanation Choice C is correct. Neonates born to drug-dependent mothers exhibit jitteriness, hyperactivity, and a shrill cry. These signs usually appear within 24 hours of being delivered. Choice A is incorrect. Signs of sepsis include varying unstable temperatures and tachycardia. The symptoms presented do not indicate sepsis. Choice B is incorrect. Hypoglycemia in the neonate is manifested by low body temperature, diaphoresis, muscle twitching, and respiratory distress. The signs presented in the question are not related to hypoglycemia. Choice D is incorrect. Signs of hypothermia in the neonate include cool extremities, acrocyanosis, bradycardia, poor feeding, and respiratory depression. Last Updated - 03, Jan 2022

A primigravida patient at 38 weeks arrives at the hospital maternity triage unit reporting a "sudden gush of clear fluid" from her vagina shortly before arrival. The maternity triage nurse suspects the patient has experienced a prelabor rupture of membranes (PROM). Which of the following is the most appropriate method for the nurse to use to confirm her suspicion? A. An internal vaginal examination B. Ultrasound C. Nitrazine paper test D. A Gram stain Submit Answer

Explanation Choice C is correct. Nitrazine paper is used to measure the pH of the fluid to determine if the amniotic membrane has ruptured. Once the fluid comes into contact with nitrazine paper, the pH of the fluid will cause the paper's color to change. The resulting color will correlate to a pH allowing the nurse to decipher whether the fluid is amniotic fluid (i.e., PROM) or vaginal fluid. Choice A is incorrect. An internal vaginal examination is done when the client is in labor to determine cervical dilatation and effacement. Here, the membranes are suspected of having ruptured, but the client is not exhibiting any active signs of labor, making an internal vaginal examination an inappropriate assessment method. Choice B is incorrect. An ultrasound cannot be used to determine whether a prelabor rupture of membranes has occurred. Choice D is incorrect. Gram staining is performed to detect the presence of bacterial infections. Learning Objective Recognize when a client presents with a possible rupture of membranes, a nitrazine paper is typically used to assess the pH level of the fluid to identify whether the fluid is amniotic. Additional Info Prelabor rupture of membranes (PROM) is leakage of amniotic fluid before the onset of labor. Diagnosis of PROM is clinical. Delivery is recommended when gestational age is ≥ 34 weeks and is generally indicated for infection or fetal compromise regardless of gestational age. Prelabor rupture of membranes (PROM) may occur at term (≥ 37 weeks) or earlier (called preterm PROM if < 37 weeks). Source : Archer Review Last Updated - 13, Feb 2022

The nurse is collecting the health history from a pregnant patient. Which of the following conditions would not put this patient at an increased risk of developing preeclampsia? A. Obesity B. Chronic hypertension C. Frequent urinary tract infections D. Multifetal gestation Submit Answer

Explanation Choice C is correct. Preeclampsia is a dangerous complication in pregnancy that is characterized by high blood pressure and protein in the urine. A history of frequent urinary tract infections would not put this patient at increased risk for developing preeclampsia. Choice A is incorrect. Obesity is associated with an increased risk of preeclampsia in pregnancy. Choice B is incorrect. Chronic hypertension is associated with an increased risk of preeclampsia in pregnancy. Choice D is incorrect. Multifetal gestation is associated with an increased risk for preeclampsia in pregnancy. NCSBN Client Need Topic: Maternal and newborn health, Subtopic: Antepartum care, alterations in body systems, pathophysiology Additional Info Source : Archer Review Last Updated - 10, Nov 2022

A woman in her 37th week of gestation is wary about recognizing the signs of labor. She asks the nurse how she will know when it is time to go to the labor and delivery unit. The best response by the nurse is: A. "When the mucus plug comes out." B. "When you feel a heaviness in your bladder." C. "When you see a large gush of fluid coming out of your vagina." D. "When you feel nauseated and vomit simultaneously."

Explanation Choice C is correct. Prelabor rupture of membranes (PROM) may occur at term (≥ 37 weeks) or earlier (called preterm PROM if < 37 weeks). Upon the prelabor rupture of membranes, amniotic fluid is expelled from the vagina, typically as a sudden gush of fluid from the vagina (unless complications are present). Some women experience membrane rupture as the first sign of labor onset. If this occurs, the woman should go to the birth center for evaluation. Choice A is incorrect. Although the passage of the mucus plug is a sign that the cervix is beginning to dilate, in some cases, the mucus plug is passed weeks prior to the onset of labor. Choice B is incorrect. The mother may experience bladder pressure and frequency as the fetus settles into the pelvis during the final weeks of pregnancy. Choice D is incorrect. The symptoms of nausea and vomiting are not indicative of actual labor. Learning Objective Identify prelabor rupture of membranes as the best response when a client asks how to recognize the onset of labor. Additional Info Prelabor rupture of membranes (PROM) may occur at term (≥ 37 weeks) or earlier (called preterm PROM if < 37 weeks). Preterm PROM predisposes to preterm delivery. PROM at any time increases the risk of the following: Infection in the woman (intra-amniotic infection [chorioamnionitis]), neonate (sepsis), or both Abruptio placentae Abnormal fetal presentation Intraventricular hemorrhage in neonates (which may result in neurodevelopmental disabilities (e.g., cerebral palsy)) Compression of the fetal umbilical cord Last Updated - 21, Oct 2022

A woman was admitted to the obstetric unit in active labor and has had a frank rupture of membranes. A fetal scalp electrode and intrauterine pressure catheter were inserted promptly. The woman had progressed to 8-cm dilation when the nurse noticed abrupt decreases in the fetal heart rate of 15-20 bpm that quickly returned to baseline. The changes in fetal heart rate occurred with and without contractions. At this point, the nurse should prepare to initiate a client teaching about the possibility of which procedure? A. High forceps delivery B. Oxytocin induction C. Amnioinfusion D. Cesarean birth

Explanation Choice C is correct. The fetus is experiencing variable decelerations of heart rate in the setting of ruptured membranes. Amnioinfusion refers to the infusion of a warmed isotonic solution into the uterine cavity through the IUPC. It is mostly used as a treatment to correct fetal heart rate changes caused by umbilical cord compression, indicated by variable decelerations seen on cardiotocography. It can help cushion the cord and relieve pressure when the membranes have ruptured. Choice A is incorrect. A high forceps delivery is contraindicated because it is associated with fetal and maternal tissue damage. The situation does not meet the criteria for assisted delivery with forceps. Per ACOG, appropriate forceps deliveries are indicated as in the following: 1. Outlet forceps (the scalp is visible at the vaginal opening), 2. Low Forceps (when the leaning edge of the fetal skull is at station 3), 3. Mid Forceps (when the leaning side of the fetal head is between stations 0 and 2 ). Choice B is incorrect. The fetal heart rate findings in this case of ruptured membranes describe variable decelerations caused by cord compression. Oxytocin infusion could increase the pressure on the umbilical cord. It is also not recommended when labor is progressing adequately. Choice D is incorrect. Even when there is cord compression, the situation states that compression is relieved, as indicated by the quick return of the heart rate to baseline. If the patient is stable, there is no need for immediate delivery or cesarean delivery. Last Updated - 23, Jan 2022

A client who is pregnant and is attending a prenatal class. Which statement, if made by the client, requires further teaching? A. "Since my body mass index is normal, I should be gaining 25-35 pounds." B. "It will be okay for me to continue using sugar substitutes, such as sucralose." C. "Since I am pregnant, I will have to abandon my vegan diet." D. "I will need to keep my caffeine intake less than 200 mg/day."

Explanation Choice C is correct. This statement is false and requires follow-up. A vegan diet may be continued during pregnancy if the woman is methodical in her food choices. The concern with vegan diets is the consumption of complete proteins. However, evidence has indicated that plant proteins can meet pregnancy needs. Choices A, B, and D are incorrect. These statements are true and do not require follow-up. For a woman with a normal BMI, the average weight during pregnancy should be 25-35 pounds. Sugar substitutes are permitted in moderation. The current recommendation for daily caffeine intake is not to exceed 200 mg/day. Additional Info Individuals who follow a vegan diet avoid all animal products and may have the most difficulty meeting their nutrient needs. Through careful consideration of foods and supplemental vitamins, it is entirely possible for a woman who follows the vegan diet to have a successful pregnancy. Last Updated - 09, Jul 2022

The nurse is caring for a neonate experiencing cold stress. The nurse should also assess the neonate for A. hyperglycemia. B. increased muscle tone. C. hypoglycemia. D. metabolic alkalosis. Submit Answer

Explanation Choice C is correct. When a neonate develops hypoglycemia, norepinephrine is released, causing tachycardia which causes an increase in glucose metabolism. This increase in glucose metabolism depletes the neonate's reserve of glucose. If a neonate is experiencing cold stress, the nurse should warm the neonate by applying warm clothes, removing the neonate from any drafts, and ensuring the neonate is dry. The nurse should assess the neonate for hypoglycemia via heel stick once the neonate's temperature stabilizes. Choices A, B, and D are incorrect. Cold stress would deplete glucose stores because of the sympathetic response. Thus, hyperglycemia would not occur. Manifestations of hypoglycemia include poor muscle tone and a weak, jittery cry. Metabolic acidosis would develop due to cold stress because the lack of glucose would cause fat to be the fuel source, causing metabolic acidosis. Additional Info Last Updated - 27, Nov 2022

The nurse is caring for a married 31-year-old second-time pregnant female. Her first child is 4-years-old who was born vaginally and is considered to be a healthy preschooler. The patient explains that she's worried that her newborn child will be born with cystic fibrosis because her sister's daughter has it. What information about this genetic condition should the health care provider share? A. Her child is at an extremely high risk for passing cystic fibrosis to her child. B. Her child is not at risk for developing cystic fibrosis. C. While it is unlikely that this child will be born with cystic fibrosis, genetic testing may relieve some of the distress. D. She needs to adjust her diet in order to prevent passing on the medical condition.

Explanation Choice C is correct. While it is unlikely that this child will have cystic fibrosis, genetic testing can provide more information. Carrier testing may be recommended for people with a family history of this genetic disorder. Cystic fibrosis is an inherited autosomal recessive disorder that only appears in an infant whose parents have the mutated gene. Choice A is incorrect. There is not enough evidence to tell the patient that her child is at high risk for developing cystic fibrosis. Choice B is incorrect. There is not enough information to say that this child will not be born with cystic fibrosis. Choice D is incorrect. Her diet is irrelevant in regards to whether or not she will pass cystic fibrosis to her child. Last Updated - 11, Nov 2021

A breastfeeding mother is struggling to care for her infant with lactose intolerance. Which of the following foods should the mother avoid? A. Leafy greens B. Red meats C. Yogurt D. Wheat rolls

Explanation Choice C is correct. Yogurt is a dairy product and therefore contains lactose. Breastfeeding mothers with infants who are lactose intolerant should avoid dairy products such as cheese, milk, and yogurt. Choice A is incorrect. Leafy greens do not contain lactose and do not need to be avoided by the mother nursing a lactose intolerant infant. Choice B is incorrect. Red meat does not contain lactose and does not need to be avoided by the mother nursing a lactose intolerant infant. Choice D is incorrect. Wheat rolls generally do not contain lactose and do not need to be avoided by the mother nursing a lactose intolerant infant. NCSBN client need Topic: Physiological Integrity, Basic Care and Comfort Last Updated - 19, Feb 2021

Which of the following clinical manifestations should the nurse document as a positive sign of pregnancy? A. Amenorrhea B. Uterine soufflé C. Positive pregnancy test D. Fetal heartbeat

Explanation Choice D is correct. A fetal heartbeat can be detected with a doppler as early as 10-12 weeks of pregnancy and is considered a positive or diagnostic sign of fertility. Signs of pregnancy can be possible, probable, or definite. Because likely signs of pregnancy may also occur when other conditions are present, the nurse needs to know what each possible indicator of pregnancy means. Choice A is incorrect. Amenorrhea, the absence of menses, is considered a possible sign of pregnancy. It is a more helpful sign when more than one cycle has been missed. Choice B is incorrect. Uterine soufflé is the sound heard on auscultation over the uterus that is caused by blood flow through the placenta. It is considered a probable sign of pregnancy, but not a definite sign of pregnancy since other conditions like uterine myomas or ovarian tumors can cause it. Choice C is incorrect. A positive pregnancy test is based on the detection of human chorionic gonadotropin. It is present during pregnancy, but other conditions can cause it to be elevated, so it is considered a probable sign of fertility. NCSBN Client Need Topic: Health Promotion and Maintenance, Subtopic: Physical and Psychological Changes of Pregnancy Additional Info Source : Archer Review Last Updated - 07, Feb 2022

The nurse is caring for a newborn immediately after delivery. Which of the following actions would be appropriate? A. Perform APGAR assessment at five and ten minutes B. Suctions the nose then the mouth C. Administer RhoGAM intramuscularly D. Place the infant skin to skin with a parent

Explanation Choice D is correct. A newborn is at risk of cold stress during the first few hours of post-intrauterine life. The nurse should dry the newborn thoroughly and place the newborn skin-to-skin with a parent. Choices A, B, and C are incorrect. The APGAR assessment is completed at one and five minutes. If suctioning is indicated, the nurse should suction the mouth, then the nose, not the nose, then the mouth. RhoGAM is indicated for Rh-negative mothers - not newborns. Medications administered to a newborn include intramuscular Vitamin K and erythromycin eye ointment. Additional Info ✓ When caring for a newborn, the nurse should perform an APGAR assessment at one and five minutes. ✓ The higher the score, the more stable the infant. Scores 7 to 10 are reassuring. ✓ The assessment evaluates a newborn's color, heart rate, reflexes, muscle tone, and respiration. ✓ Suctioning is only performed if indicated. ✓ If indicated, the correct sequence for suctioning a newborn is the mouth, then the nose. Last Updated - 31, Dec 2022

A 38-week pregnant client is scheduled to undergo a nonstress test (NST). While speaking with the nurse, the client inquires regarding the purpose of this type of testing. The most appropriate response by the nurse would be which of the following? A. "This test determines whether you are ready for labor induction." B. "A nonstress test assesses your blood sugar control." C. "This testing provides an accurate determination of fetal age." D. "A nonstress test assesses the fetal condition in the third trimester." Submit Answer

Explanation Choice D is correct. A nonstress test (NST) is a non-invasive test performed in pregnancies over 28 weeks gestation. During the procedure, fetal heart rate and uterine contractions are recorded using external electronic monitors and correlated with fetal movements as reported by the mother. This test determines the fetus's condition during the third trimester of pregnancy. Choice A is incorrect. Cervical assessment estimates whether the cervix is favorable for labor induction. More specifically, the Bishop scoring system assesses cervical readiness for labor via five factors: cervical dilation, effacement, consistency, position, and fetal station. Choice B is incorrect. Blood sugar control can be assessed during pregnancy by random blood glucose assessments or, for a larger assessment, by glycated hemoglobin (HbA1c). Additionally, during pregnancy, several tests are used to identify gestational diabetes. The first, called the Glucose Challenge Screening, is a preliminary screening test performed between 26 and 28 weeks. If a woman tests positive during this screening test, the second test, called the Oral Glucose Tolerance Test (OGTT), may be performed. Choice C is incorrect. A nonstress test does not determine fetal age. Ultrasound measurement of the embryo or fetus in the first trimester is the most accurate method to establish or confirm gestational age. Learning Objective Correctly identify a nonstress test (NST) as a non-invasive procedure that determines fetal condition during the third trimester of pregnancy. Additional Info Source : Archer ReviewSource : Archer ReviewSource : Archer ReviewSource : Archer Review Last Updated - 22, Nov 2022

You are caring for a newborn born at term. On your assessment. You note that central cyanosis is present and persistent at five minutes after birth. You attach a pulse oximeter to the newborn. When determining whether or not the infant requires supplemental oxygen, you know that the expected oxygen saturation at 5 minutes after birth is: A. 65-70% B. 70-75% C. 75-80% D. 80-85%

Explanation Choice D is correct. At five minutes after birth, the expected SpO2 is in the 80-85% range. Regardless of the cyanosis, if the oxygen saturation is within this range, the infant probably does not need supplemental oxygen at this point. The American Heart Association and American Academy of Pediatrics suggest the following table for Target Pre-ductal Oxygen Saturation levels following birth. Choices A, B, and C are incorrect. NCSBN Client Need Topic: Physiological Adaptation, Sub-topic: Hemodynamics, Newborn Last Updated - 02, Sep 2021

The nurse is educating a pregnant woman with an above-average BMI about her risk factors. Which of the following issues does not correlate with an above-normal BMI pre-pregnancy? A. Gestational diabetes B. Preeclampsia C. Swelling D. Frequent UTI Submit Answer

Explanation Choice D is correct. Frequent urinary tract infections are not associated with maternal above-average body mass index. Choices A, B, and C are incorrect. The development of gestational diabetes, preeclampsia, and swelling are positively correlated with maternal above-average BMI. Other issues include increased C-section rates, stillbirth, and poor wound healing. NCSBN client need Topic: Maintenance and Health Promotion, Ante / Intra / Postpartum Care Last Updated - 31, Jan 2022

A pregnant woman with preexisting hypertension is being seen in the clinic. Her blood pressure continues to rise despite attempting first-line therapy with anti-hypertensives. Which of the following medications will be used for the prenatal patient resistant to other blood pressure-lowering medications? A. A calcium channel blocker B. Methyldopa C. Labetalol D. Hydralazine

Explanation Choice D is correct. Hydralazine is the second-line therapy for high blood pressure in prenatal patients who are not seeing any results from other medications. Choice A, B, and C are incorrect. Calcium channel blockers, methyldopa, and labetalol are all common first-line anti-hypertensives for treating prenatal clients with high blood pressure. NCSBN client need Topic: Pharmacologic and Parenteral Therapies: Parenteral/Intravenous Therapies Last Updated - 05, Jan 2022

A G3P3 client in labor tells the nurse, "I would like to breastfeed, but my breasts got so engorged last time. I could not take it. Do I have to go through that again?" Which of the following responses is most appropriate? A. "Keeping your baby on an every 4-hours schedule would help slow the milk production and lessen the engorgement." B. "You can feed your baby formula milk until your milk comes in. This will reduce stimulation and prevent engorgement." C. "You can take Parlodil to stop your milk production and prevent engorgement." D. "You need to feed your baby as soon as possible. Also, feeding your baby often would prevent breast engorgement."

Explanation Choice D is correct. Immediate and frequent breastfeeding is the key to decreasing breast engorgement in breastfeeding women. Also, the first step in treating engorgement is encouraging the mother to immediately breastfeed and continue to do so every 2 hours. The most common causes of engorgement include: A missed session of feeding or breast milk expression. Feeding the baby on a strict schedule. Less feeding by the baby due to illness/sickness. Rapid weaning from breast milk. The mother should be educated to slow down the weaning process if she experiences engorgement during weaning. Choices A and B are incorrect. Feeding and emptying the breasts less often (Choice A) and substituting it with formula (Choice B) increases the risk of engorgement. Having a strict feeding schedule increases the risk of breast engorgement. The amount of milk that can be stored in the breasts without causing engorgement varies from person to person. Therefore, following a fixed schedule of feeding/expression may predispose the mother to breast engorgement and mastitis because of inadequate milk drainage. Choice C is incorrect. Parlodel (Bromocriptine) completely stops milk production; it also has serious side effects including stroke, when given to postpartum women. Last Updated - 20, Jul 2022

A nurse is assigned to care for four clients who are each one day postpartum. Following the nurse performing an initial assessment on each client, which finding would prompt further evaluation by the nurse? A. A client complaining of mild pain B. A client with a pulse rate of 65 bpm C. A client with colostrum discharge from both breasts D. A client with red, foul-smelling lochia Submit Answer

Explanation Choice D is correct. Lochia is vaginal discharge following childbirth. At one day postpartum, the client's discharge is expected to be dark red or red-brown, similar to a heavy menstrual discharge, and should have a fleshy, earthy odor. A client with foul-smelling lochia should prompt further evaluation by the nurse, as lochia which smells foul or fishy could indicate infection. Additionally, the nurse may need to elaborate further on the discharge color rather than simply using the term "red," as the anticipated discharge color at this point in the postoperative period should likely be darker in color. Choice A is incorrect. It is reasonable for a client who is one day postpartum to have mild pain; therefore, further assessment is not required. Choice B is incorrect. A pulse rate of 65 beats per minute is within normal limits and is not cause for concern. Choice C is incorrect. Colostrum discharge from the client's bilateral breasts is anticipated in a client who is one day postpartum and, therefore, does not warrant further assessment. Learning Objective Recognize that a finding of foul-smelling lochia in a postpartum client warrants additional evaluation by a nurse. Additional Info Lochia consists of the contents from the uterus accumulated during the nine months of pregnancy. The lochia will have an odor similar to a typical menstrual period. Because estimating the amount of lochia on a peripad (perineal pad) is difficult, nurses frequently document lochia in terms that are difficult to quantify, such as scant, moderate, or heavy. Typically, lochia flow is greater immediately after delivery and gradually decreases. Lochia flow is less following a cesarean birth, as some of the endometrial lining is removed during surgery. The lochia of a client who had a cesarean birth will go through the same phas

The nurse is preparing to measure the fundal height of a client at 16 gestational weeks. The nurse should prepare the client for this assessment by instructing the client to A. lay in a side-lying position with the knees bent. B. prepare for the insertion of an intravenous (IV) catheter. C. not to eat or drink two hours after this assessment. D. empty their bladder. Submit Answer

Explanation Choice D is correct. Measuring the fundal height is a painless and noninvasive way to evaluate fetal growth patterns and confirm gestational age. For this assessment, the client should empty their bladder to prevent elevation of the uterus. Choices A, B, and C are incorrect. The client should be instructed to lay supine with their knees bent. This is a noninvasive examination and does not require the client to get an intravenous catheter or refrain from eating or drinking after the assessment. Additional Info ➢ To measure the fundal height, the client should empty their bladder and lay supine with her knees slightly flexed ➢ The nurse should take a tape measure and measure the height from the top of the symphysis pubis, over the abdominal curve, to the top of the fundus ➢ At 16 gestational weeks, the fundus can be found approximately halfway between the symphysis pubis and the umbilicus ➢ At 20-22 gestational weeks, the fundus can be found at the umbilicus ➢ At 36 weeks, the fundus is at the xiphoid process Last Updated - 25, Dec 2022

The nurse is interviewing a client who reports frequent urination and nausea. The client is concerned that she may be pregnant. The nurse understands that these manifestations are A. a possible sign of pregnancy. B. probable sign of pregnancy. C. positive sign of pregnancy. D. presumptive sign of pregnancy. Submit Answer

Explanation Choice D is correct. Nausea and urinary frequency are manifestations associated with presumptive signs of pregnancy. Choices A, B, and C are incorrect. Positive signs of pregnancy include visualization of the embryo or fetus via ultrasound, fetal movements detected by the examiner or auscultation of fetal heart sounds. Presumptive signs of pregnancy include amenorrhea, nausea and vomiting, and an increase in urinary frequency. Possible signs of pregnancy are not a category utilized. Additional Info Presumptive signs of pregnancy Amenorrhea Nausea and vomiting Fatigue Urinary frequency Quickening (slight fluttering movement usually between 16-20 weeks gestation) Probable signs of pregnancy Goodell's sign (softening of the cervix) Chadwick's sign (bluish appearance of the cervix) Hegar's sign (softening of the isthmus of the cervix) Ballottement (sudden tap on the cervix during the vaginal examination may cause the fetus to rise in the amniotic fluid and then rebound to its original position) Braxton hicks contractions Positive pregnancy test Palpation of fetal outline Positive signs of pregnancy Fetal movements detected by an examiner Auscultation of fetal heart sounds Visualization of embryo or fetus Last Updated - 04, May 2022

A nurse at an obstetric clinic has conducted a teaching class on sexuality during pregnancy. Which of the following comments from a participant would indicate that the teaching has been effective? A. "At around the time I would normally have my period, I should abstain from intercourse." B. "I should no longer have sex during the last trimester of pregnancy." C. "My sexual desire will remain the same for the entire pregnancy." D. "The best time to enjoy sex is in the second trimester." Submit Answer

Explanation Choice D is correct. Sexual pleasure is heightened during the second trimester of pregnancy. In the second trimester, most women experience significant relief from the discomforts of early pregnancy (nausea and vomiting, breast tenderness). The uterus is not too large to interfere with comfort and rest. The second trimester is also the time when pelvic organs are congested with blood, increasing pleasure in sexual activities. Choices A and B are incorrect. As long as risk factors such as preterm labor or incompetent cervix are not present, intercourse should not harm the pregnancy. Sexual intercourse should not be a cause of concern even in the third trimester unless risk factors such as preterm labor or placenta previa are present. Choice C is incorrect. Many women experience changes in sexual desire at different stages in pregnancy, depending on their general sense of well-being and the presence of certain discomforts brought about by the pregnancy. It is not the same throughout pregnancy. Last Updated - 25, Jan 2022

The client, who is 24 weeks pregnant, is complaining to the nurse about her "worsening varicosities." The nurse would advise her to: A. Avoid exercise as blood pools in her legs during movement B. Wear knee-high hose with garters C. Avoid citrus fruits D. Sleep in a side-lying position Submit Answer

Explanation Choice D is correct. Sleeping in a side-lying position ( "SOS," Sleep On Side) moves the fetus away from the inferior vena cava ( IVC). Therefore, the fetus's weight and pressure on the IVC are minimized, promoting venous return. Better venous drainage reduces potential lower extremity swelling, varicose veins, and hemorrhoids in the pregnant woman. Sleeping supine during pregnancy must be avoided because it increases the risk of late stillbirths. Traditionally, the left side-lying position is preferred over the right side because there is a theoretical risk of IVC compression due to the liver being present on the ride side. If the pregnant client is comfortable sleeping on the right side, it should not be discouraged because a 2019 meta-analysis has revealed both left and right-side lying positions are equally safe in pregnancy. Choice A is incorrect. Contrary to the statement, exercise promotes venous return when coupled with frequent rest periods. Pregnant women should be encouraged to exercise regularly. Choice B is incorrect. The client should avoid wearing knee-high stockings with garters. Garters are tight straps present at the top of the stockings to prevent the stockings from slipping down the leg. These garters can cause occlusion of the blood flow and increase the venous pressure in the extremities. The nurse must ensure that the stockings are not causing a garter effect at the knee or thigh level. The nurse should advise the pregnant client to wear graduated compression stockings ( GCS) or thrombo-embolus deterrent stockings ( TEDs). These should be applied up to above the point of varicose enlargement. In pregnancy, GCS or TEDs also serve as mechanical prophylaxis against deep vein thrombosis ( DVT). Choice C is incorrect. The client should increase her intake of vitamin C found in citrus frui

The prenatal client is 7 months pregnant and wants to start an exercise program. The nurse should suggest which of the following exercises to the patient? A. Bike riding B. Circuit training C. Aerial yoga D. Swimming

Explanation Choice D is correct. Swimming is the best exercise at this point in the mother's pregnancy. Swimming is low impact and requires no balance, which can be troublesome with the weight a woman carries in her third trimester. Choices A, B, and C are incorrect. These activities are too high of an intensity for a woman who is just starting an exercise regimen and require careful steadiness. NCSBN client need Topic: Health Promotion and Maintenance Last Updated - 29, Jan 2022

The nurse in the postpartum ward is looking at laboratory results of clients that just arrived. The nurse would go to which client immediately? A. A patient with WBC of 15,000/cubic mm B. A patient with a creatinine level of 0.8 mg/dL C. A patient with a platelet count of 360,000/cubic mm D. A client with a blood glucose of 260 mg/dL Submit Answer

Explanation Choice D is correct. The average blood glucose level is 70 - 120 mg/dL. The client's blood glucose level is 260, thus warranting the attention and intervention of the nurse. Choice A is incorrect. During labor and after birth, the WBC count would rise to 25,000. This is a normal response of the body and should not warrant any concern. Choice B is incorrect. The serum creatinine level is within normal limits (0.6-1.2 mg/dL for males and 0.5-1.1 mg/dL for females). This does not need any intervention. Choice C is incorrect. Normal platelet count is 150,000 to 450,000. This is within normal limits. Last Updated - 01, May 2022

A nurse in a gynecology clinic is assessing a first-time client (G1P0) who is eight weeks pregnant. Which assessment finding would alert the nurse of a high-risk pregnancy? A. The client reports nausea and vomiting four to five mornings per week. B. The client expresses her ambivalence toward the pregnancy to the nurse. C. The client reports intermittent constipation since learning she was pregnant. D. The client reports intermittent vaginal spotting and abdominal cramping.

Explanation Choice D is correct. The first sign of threatened abortion is vaginal bleeding, which is relatively common during early pregnancy. Approximately 25% of pregnant women experience "spotting" or bleeding in early pregnancy, and up to 50% of these pregnancies end in spontaneous abortion. Vaginal bleeding, which may be brief or last for weeks, may be accompanied by uterine cramping, persistent backache, or feelings of pelvic pressure. These added symptoms are more likely to be associated with loss of pregnancy. Choice A is incorrect. Nausea and vomiting are a result of fluctuating hormone levels during pregnancy. Unless nausea and vomiting cause severe dehydration and electrolyte loss, the pregnancy is not considered in jeopardy. Choice B is incorrect. Ambivalence is a normal emotional response to pregnancy, especially in early pregnancy, when the mother realizes a separate individual is growing inside her. The mother may have various feelings, including excitement, anxiety, apprehension, trepidation, worry, fear, eagerness, and anticipation. Moreover, various factors pertaining to the relationship with the father of the child may influence the client's emotional response to the pregnancy. Choice C is incorrect. Increased progesterone level is associated with the relaxation of smooth muscles, resulting in stasis of urine and increasing the risk for urinary tract infections and constipation. Learning Objective Correlate vaginal spotting and abdominal cramping in the early stages of pregnancy as the first signs of a threatened abortion, rendering the client a high-risk pregnancy. Additional Info Women should be advised to notify their health care provider (HCP) if brownish or red vaginal bleeding is noted. Bleeding during the first half of pregnancy should be considered a threatened abortion. The nurse should

Shortly after checking into the obstetrics unit, a client currently at 39 weeks gestation spontaneously ruptured her membranes when ambulating to the bathroom. After the client returns to bed, which of the following should be the nurse's initial action? A. Assess the color and quantity of the fluid. B. Perform a vaginal examination to assess the cervix for dilation. C. Inform the client she is now on strict bed rest until further notice. D. Assess the fetal heart tones.

Explanation Choice D is correct. The priority is for the nurse to assess the fetal status following the spontaneous rupture of the client's membranes. Although numerous methods may be utilized to evaluate fetal status, the assessment of fetal heart tones provides reliable information in a relatively prompt manner. Following the assessment of fetal heart tones, the nurse should then assess the color and quality of the amniotic fluid. Choice A is incorrect. Following a spontaneous rupture of the client's membranes, the priority is for the nurse to assess the fetal status via fetal heart tones. Assessment of the color and quantity of the amniotic fluid does not provide any indication regarding the current status of the fetus. Choice B is incorrect. While certain circumstances may justify performing a vaginal examination to assess for cervical dilatation, nothing in this scenario suggests such intervention. As such, in this scenario, the nurse's priority following a spontaneous rupture of the client's membranes remains to assess the fetal status via fetal heart tones. Choice C is incorrect. Fetal head engagement and descent are not dependent on the client's movement during labor. Keeping the client on bed rest is not necessary. Often, the client will be encouraged to ambulate. Learning Objective Following the spontaneous rupture of a 39-week gestation pregnant client's membranes, prioritize assessing the fetal status via assessment of the fetal heart tones. Additional Info To confirm the rupture of a client's membranes, the pH of the fluid may be tested. Vaginal fluid may be tested with Nitrazine paper, which turns deep blue at a pH >6.5 (pH of amniotic fluid is 7.0 to 7.6). Amniotic fluid should be assessed for meconium-stained fluid, other discoloration, etc.

While working in the Neonatal Intensive Care Unit (NICU), you are notified that a "small for gestational age" infant is being brought to the unit. Being a NICU nurse, you understand that this means which of the following? A. The infant's weight is less than 2500 grams. B. The infant's weight is below the 20th percentile. C. The infant's weight is less than 1500 grams. D. The infant's weight is below the 10th percentile. Submit Answer

Explanation Choice D is correct. The term "Small for Gestational Age (SGA)" is used when the infants are smaller than normal for the number of weeks of pregnancy (gestational age). When an infant's weight is below the 10th percentile for the gestational age, it is considered small for gestational age. By definition, about 10 percent of all newborns are labeled as SGA. Not all "Low Birth Weight" babies are SGA. Infants may be of low birth weight but may still fall above the 10th percentile for gestational age. It is important to distinguish SGA from other related terms, "Low Birth Weight (LBW)", "Very Low Birth Weight (VLBW), and "Extremely Low Birth Weight (ELBW)." These definitions are based on the infant's weight at the time of birth. These are not percentile scores and are defined on the absolute weight limit. An LBW infant is defined as an infant with a weight of less than 2500 grams (5 lb. and 8 ounces), regardless of gestational age at the time of birth. A VLBW infant is defined as one with a weight less than 1500 grams at the time of birth. An ELBW infant is less than 1000 grams at the time of birth. Choice A is incorrect. When infants are born at less than 2500 grams, they are considered low birth weight. A classification that considers only the weight and not the gestational age, is LBW, VLBW, and ELBW whereas percentiles are used for the small/average/large for gestational age comparison. Choice B is incorrect. The 20th percentile is considered average for gestational age. Infant's size falling between 10th - 90th percentile is considered average. One that is less than the 10th percentile is "small for gestational age", and greater than 90th percentile is "large for gestational age". Choice C is incorrect. When infants are born at less than 1500 grams, they are considered as "very low birth weight". Percenti

The nurse is triaging phone calls at a local obstetrics clinic. Which client situation requires immediate follow-up? A client reporting A. a decrease in fetal movements of ten in the past hour. B. irregular, painful contractions that are decreased with repositioning. C. abdominal cramping following her amniocentesis six hours ago. D. epigastric pain and a frontal headache not relieved with acetaminophen. Submit Answer

Explanation Choice D is correct. These symptoms are strongly suggestive of severe pre-eclampsia. Severe pre-eclampsia manifests as epigastric to right-upper quadrant pain suggestive of a liver injury. This, combined with a frontal headache, is highly concerning for severe pre-eclampsia. The client needs to be immediately evaluated as these symptoms may worsen to an eclamptic seizure. Choice A, B, and C are incorrect. A decrease in fetal movements is only concerning if the fetal movements are less than ten in two consecutive hours. Irregular, painful contractions that are decreased with repositioning is false labor, also known as Braxton-hick contractions. This does not require follow-up; the client should be instructed to hydrate and rest. Abdominal cramping that occurs less than 24 hours from the amniocentesis is normal and does not require follow-up. Additional Info Source : Archer Review Preeclampsia is hypertension (systolic blood pressure ≥140 mm Hg or diastolic ≥90 mm Hg) occurring after 20 weeks of pregnancy in women with previously normal blood pressure, usually accompanied by proteinuria. The client with preeclampsia should be instructed to check her blood pressure and report symptoms that suggest worsening preeclampsia, such as visual disturbance, severe headache, or epigastric pain. Symptoms that suggest fetal compromise, such as reduced fetal movement, also should be taught. Last Updated - 10, Nov 2022

You are seeing patients in an outpatient obstetrical clinic for their regularly scheduled prenatal appointments. Your patient is a G2P1 32-year-old woman who is 32 weeks pregnant. She says to you that she is concerned because she thinks she is developing striae gravidarum. When you assess the patient, what would you expect to see if she does present with this condition? Select the correct image. A . B . C . D .

Explanation Choice D is correct. This is the image showing striae gravidarum. These are reddish-purple stretch marks on the abdomen, breasts, thighs, and upper arms that are due to increasing levels of the melanocyte-stimulating hormone with the increase in estrogen and progesterone levels. Choice A is incorrect. This is an image showing chloasma. This is also known as the 'mask of pregnancy.' It is hyperpigmentation that appears blotchy and brown over the forehead, cheeks, and nose. Choice B is incorrect. This is an image showing linea nigra. This is a dark streak down the midline of the abdomen that sometimes occurs in pregnancy due to increasing levels of the melanocyte-stimulating hormone with the increase in estrogen and progesterone levels. Choice C is incorrect. This is an image showing the typical presentation of the gravid abdomen around 32 weeks gestation. NCSBN Client Need Topic: Health Promotion and Maintenance Subtopic: Ante/Intra/Postpartum and Newborn Care Last Updated - 11, Nov 2021

A mother in her first trimester of pregnancy is very upset that she feels constantly nauseous. You reassure her that the nausea is common in the first trimester. In addition, which of the following advice would you share with her? Select all that apply. A. Eat dry crackers before getting out of bed in the morning. B. Drink small sips of liquids throughout the day rather than large amounts with meals. C. Eat only three moderate size meals a day. D. Brush teeth immediately after eating to avoid smells and tastes that trigger nausea. Submit Answer

Explanation Choices A and B are correct. Eating dry crackers in the morning before rising is standard advice to help decrease nausea (Choice A). It is recommended to drink small sips of liquids throughout the day rather than drinking large amounts with meals (Choice B). Choice C is incorrect. It would be better to recommend eating small frequent meals spread throughout the day. Low-fat meals are also advised to decrease nausea. Choice D is incorrect. It is better to avoid brushing teeth immediately after a meal and shortly after getting out of bed in the morning to prevent nausea. NCSBN Client Need: Topic: Health Promotion and Maintenance, Subtopic: Antepartum Last Updated - 02, Nov 2021

Which of the following are bypasses in fetal circulation? Select all that apply. A. Ductus arteriosus B. Foramen ovale C. Ductus pulmonic D. Foramen aortic Submit Answer

Explanation Choices A and B are correct. The ductus arteriosus is a bypass in fetal circulation. It connects the pulmonary artery to the aorta (choice A). The foramen ovale is a bypass in fetal circulation. It is an opening between the right and left atriums of the heart (choice B). Choice C is incorrect. There is no ductus pulmonic; this is not a bypass in fetal circulation. Choice D is incorrect. There is no foramen aortic; this is not a bypass in fetal circulation. Last Updated - 20, Jan 2022

Which of the following medications is contraindicated for a pregnant client? Select all that apply. A. Warfarin B. Finasteride C. Celecoxib D. Clonidine E. Transdermal Nicotine F. Clofazimine

Explanation Choices A and B are correct. Warfarin (coumadin) has a pregnancy category X. It is associated with central nervous system defects, spontaneous abortion, stillbirth, prematurity, illness, and ocular defects when given any time during pregnancy and a fetal warfarin syndrome when given during the first trimester (Choice A). Finasteride (Propecia, Proscar) also has a pregnancy category X, which has a high risk of causing permanent damage to the fetus (Choice B). Fetal age affects the type of drug effect: Before the 20th day after fertilization: Drugs that were given at this time typically have an all-or-nothing effect, killing the embryo or not affecting it at all. Teratogenesis is unlikely during this stage. During organogenesis (between 20 and 56 days after fertilization): Teratogenesis is most likely at this stage. Drugs reaching the embryo during this stage may result in spontaneous abortion, a sublethal gross anatomic defect (exact teratogenic effect), covert embryopathy (a permanent subtle metabolic or functional defect that may manifest later in life), or an increased risk of childhood cancer (e.g., when the mother is given radioactive iodine to treat thyroid cancer); or the drugs may have no measurable effect. After organogenesis (in the 2nd and 3rd trimesters): Teratogenesis is unlikely, but drugs may alter the growth and function of customarily formed fetal organs and tissues. As placental metabolism increases, doses must be higher for fetal toxicity to occur. Choice C is incorrect. Celecoxib (Celebrex) in large doses causes congenital disabilities in rabbits, but it is not known if the effect is the same on humans. Choice D is incorrect. Clonidine (Catapres) crosses the placenta, but no adverse fetal effects have been observed. Choice E is incorrect. Nicotine replacement products have been assigned

Which of the following neurological assessments would be considered abnormal in a newborn? Select all that apply. A. High pitched cry B. Pupils are 2mm, equal, round, and react briskly to light. C. Lethargy D. Sleeping between each feeding Submit Answer

Explanation Choices A and C are correct. A high, pitched cry is an irregular finding in a newborn. It can be a sign of withdrawal in neonatal abstinence syndrome, or a sign of increased ICP if there is birth trauma (Choice A). For the level of consciousness, lethargy is not a normal finding. We expect the newborn to be alert. Lethargic, obtunded, stuporous, or comatose are all abnormal findings (Choice C). Choice B is incorrect. This is the usual pupil assessment. 2-3 mm, equal in size, round in shape, and briskly reactive to light are the expected findings for a pupil assessment in a newborn. Choice D is incorrect. For behavior, an infant is expected to be sleeping between their feedings. This is considered appropriate for the age and is a reasonable assessment finding. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn Last Updated - 07, Nov 2021

Which of the following are true regarding physiological changes during pregnancy? Select all that apply. A. Increase in heart size B. Increase in gastric motility C. Reduced renal threshold for glucose D. Decreased basal metabolic rate

Explanation Choices A and C are correct. There is an increase in heart size during pregnancy, as well as a heart position shift upward and to the left due to the displacement of the diaphragm as the uterus enlarges (Choice A). The renal threshold for glucose is reduced during pregnancy (Choice C). Choice B is incorrect. There is a decrease in gastric motility, which can sometimes cause poor appetite. Choice D is incorrect. There is an increased basal metabolic rate as metabolic function increases during pregnancy. NCSBN Client Need: Topic: Health Promotion and Maintenance, Subtopic: Antepartum Last Updated - 10, Feb 2022

Which of the following signs or symptoms would you expect in a postpartum patient experiencing subinvolution? Select all that apply. A. Boggy uterus B. Board-like abdomen C. Decreased fundal height D. Increased bleeding Submit Answer

Explanation Choices A and D are correct. A boggy uterus is a sign of subinvolution. Boggy, refers to a womb that is not firm and contracting as it is expected to in the postpartum stage. The uterus should contract to clamp down and prevent bleeding, but in sub-involution, it does not do so (Choice A). Increased bleeding is a sign of subinvolution. When the uterus is not contracting and clamping down on itself, it is not preventing postpartum bleeding. A healthy postpartum uterus would be contracting firmly, but this does not occur with subinvolution, so the mother is at risk for increased bleeding (Choice D). Choice B is incorrect. A board-like abdomen is not an expected finding with subinvolution. In subinvolution, the uterine muscle is not contracting as it should, therefore it is boggy and soft. A board-like abdomen is usually described as a stomach that has filled with blood due to an abruption or a traumatic accident. Choice C is incorrect. Fundal height would not be decreased in subinvolution. Instead, it would be increased. We expect the fundal height to decrease by 1 cm per day, but with subinvolution, the uterus is not returning to its standard pre-pregnancy size, so it stays at the same height. Choice D is correct. Increased bleeding is a sign of subinvolution. When the uterus is not contracting and clamping down on itself, it is not preventing postpartum bleeding. A healthy postpartum uterus would be contracting firmly, but this does not occur with subinvolution, so the mother is at risk for increased bleeding. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Labor and Delivery Last Updated - 11, Jul 2021

Which of the following integumentary assessments in the newborn are normal? Select all that apply. A. Lanugo B. Milia C. Mongolian spots D. Vernix caseosa Submit Answer

Explanation Choices A, B, C, and D are all correct. A is correct. Lanugo is fine, soft hair that covers the body and limbs. This is a common finding in newborns and is considered normal. B is correct. Milia are small white bumps typically found on the noses and cheeks of newborns. They are very common, considered normal, and usually go away on their own. C is correct. Mongolian spots are usual in newborns. They are a type of birthmark due to the extra pigment in certain parts of the skin. D is correct. Vernix caseosa is the "cheese-like" coating that covers the skin of a newborn immediately after birth. This is a normal finding and should not be removed from the baby until their first bath, as it provides moisture to their skin. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn Last Updated - 25, Sep 2021

You are a nurse in the local childcare facility. You are feeding an infant from a bottle containing expressed breast milk from the mother, halfway through the feeding, you realize that the breastmilk you are supplying is not for this child. You have mistakenly picked up the breastmilk that was for another woman's child. You should: Select all that apply. A. Inform the parent of the child that you are feeding. B. Inform the mother of the child whose milk you fed to the child. C. Complete an incident report per facility policy. D. Inform the providers who are caring for the infants. Submit Answer

Explanation Choices A, B, C, and D are correct. All of these actions are appropriate and expected in this situation. Also, the team should assess both of the mothers for any infectious process. Additionally, the nurse should educate both sets of parents that the risk of transmission of the disease is small. The mother may have concerns about exposure to hepatitis B and C; however, these infections cannot be spread from a woman to an infant through breastmilk. Probably the most critical intervention is to put processes in place to prevent mix-ups of milk from happening again. NCSBN Client Need Topic: Safety and Infection Control, Sub-topic: Reporting of Incident, Newborn Last Updated - 12, Jan 2022

For a nonstress test to be considered reactive, several factors have to be present. Which of the following are components of a reactive nonstress test? Select all that apply. A. The test occurs over a 20-minute period B. There are 2 or more accelerations C. Accelerations are 15 beats/minute lasting 15 seconds D. Moderate variability is present Submit Answer

Explanation Choices A, B, and C are correct. A standard nonstress test occurs over 20 minutes. If the required two accelerations of 15 beats/minute over 15 seconds are not met in 20-minutes, the analysis is extended to 40 minutes (Choice A). There must be at least two accelerations in a 20-minute time frame for the nonstress test to be reactive (Choice B). The accelerations must be at least 15 beats/minute and last 15 seconds during the nonstress test for the test to be reactive (Choice C). Choice D is incorrect. Although moderate variability is a reassuring sign, variability is not a component of a nonstress test and is therefore not a part of it's reading. NCSBN Client Need: Topic: Health Promotion and Maintenance, Subtopic: Antepartum Additional Info Source : Archer Review Last Updated - 22, Nov 2022

The nurse is caring for a 30-year-old patient who has developed iron-deficiency anemia during pregnancy. Which complication would this patient be at an increased risk for due to iron deficiency anemia? Select all that apply. A. Low birth weight B. Preterm delivery C. Gestational diabetes D. Perinatal mortality Submit Answer

Explanation Choices A, B, and D are correct. During pregnancy, there is an increased demand for oxygen to supply both the mother and the developing fetus. Iron deficiency anemia occurs as a result of insufficient amounts of iron (needed to make hemoglobin) to meet oxygen demand. Iron deficiency anemia is associated with an increased risk for low birth weight, preterm delivery, and perinatal mortality. Choice C is incorrect. Iron deficiency anemia in pregnancy is not associated with an increased risk of developing gestational diabetes. NCSBN Client Need Topic: Maternal and newborn health, Subtopic: ante/Intra/postpartum care, illness management, pathophysiology Last Updated - 10, Feb 2021

The nurse is assessing a client with preeclampsia. Which clinical findings should the nurse anticipate? Select all that apply. A. Hyperreflexia B. Headache C. Uncontrolled vomiting D. Epigastric pain E. Glycosuria Submit Answer

Explanation Choices A, B, and D are correct. Hyperreflexia, headache, and epigastric pain are typical symptoms of preeclampsia. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Hyperreflexia is a common finding and may occur with ankle clonus. These findings arise because of neuromuscular irritability. Other findings associated with preeclampsia include hypertension, facial swelling, and proteinuria. Choice C is incorrect. Uncontrolled vomiting is the defining characteristic of hyperemesis gravidarum. Glycosuria is not specific to preeclampsia. This finding could be expected or concerning for diabetes mellitus. Proteinuria would be found in preeclampsia. Additional Info Source : Archer Review Last Updated - 27, Dec 2022

You are caring for a young woman who is pregnant for the first time. Common possible complications you should inform her about include: Select all that apply. A. Anemia B. Mood changes C. Hypotension D. Nausea and vomiting Submit Answer

Explanation Choices A, B, and D are correct. Possible complications during pregnancy include anemia, mood changes, and nausea/vomiting. Anemia is typically caused by dilution of red blood cells as blood volume increases. Depression usually occurs after birth and is often called postpartum depression or "baby blues." However, as hormones change during pregnancy, the mother-to-be can experience mood changes. Nausea and vomiting usually occur during the first trimester as a result of increasing levels of human chorionic gonadotropin (HCG). This "morning sickness" is thought to be a sign of a healthy pregnancy during the first three months, but when the vomiting is persistent and prolonged, it can result in hyperemesis gravidarum. This condition may require intervention to prevent weight loss and dehydration. Choice C is incorrect. Pregnancy often leads to hypertension rather than hypotension. NCSBN Client Need Topic: Physiological Adaptation, Subtopic: Alterations in Body Systems, Antepartum Last Updated - 18, May 2021

The nurse is caring for a client experiencing prolonged labor with hypotonic contractions. Which of the following actions should the nurse take? Select all that apply. A. Encourage frequent voiding B. Maintain strict bedrest C. Prepare for a prescribed infusion of oxytocin D. Encourage frequent repositioning E. Prepare for an infusion of intravenous (IV) fluids

Explanation Choices A, C, D, and E, are correct. Prolonged labor with hypotonic contractions is classified as labor dystocia. Labor dystocia is a broad term that indicates that labor is not progressing. Key interventions for a client experiencing labor dystocia include encouraging the client to void frequently (when she feels the urge) because a full bladder will impede uterine contractions. A potential infusion of oxytocin to augment uterine contractions is a plausible prescription to be anticipated from the primary healthcare provider (PHCP). Frequent maternal repositioning is a key and noninvasive intervention that helps with fetal descent and effective contractions. The nurse should keep the client upright and encourage frequent repositioning. Fluid and electrolyte imbalances may be a cause of stunted labor. The nurse should be prepared to administer parenteral fluids because fluid and electrolyte abnormalities may cause labor dystocia. Choice B is incorrect. Strict bedrest is not an effective intervention considering her hypotonic labor. Dystocia can present in different forms, but a key intervention is frequent maternal repositioning, especially upright. This could be the client ambulating or standing upright under a warm shower. Additional Info The following factors may contribute to labor dystocia, which may reduce the progression of labor: Maternal fatigue Uterine overdistention such as with multiple gestation Maternal inactivity Uncontrolled maternal pain Fluid and electrolyte imbalance Hypoglycemia Excessive analgesia or anesthesia Murray, S., McKinney, E. (032018). Foundations of Maternal-Newborn and Women's Health Nursing, 7th Edition. Last Updated - 29, Dec 2022

The nurse is assessing her prenatal client for sexually transmitted infections by looking for risk factors. Which of the following are risks of acquiring an STI? Select all that apply. A. Low socioeconomic status B. A monogamous relationship C. A past history of working in the sex industry D. Illicit drug use E. History of cancer F. Previous history of STIs Submit Answer

Explanation Choices A, C, D, and F are correct. Low socioeconomic status, a history of being a sex worker, illicit drug use, and a previous history of sexually transmitted infections (STIs) are all risk factors for contracting STIs. Other factors include numerous sexual partners and being unmarried. Choices B and E are incorrect. A history of cancer and exclusive relationships are not examples of risk factors for acquiring an STI. NCSBN client need Topic: Health Promotion and Maintenance, High-Risk Behaviors Last Updated - 15, Feb 2022

Which of the following statements is true regarding fetal circulation? Select all that apply. A. There are high pressures in the fetal lungs causing decreased pulmonary circulation. B. Blood shunts from left to right in the fetal circulation. C. The ductus venosus allows freshly oxygenated blood to go to the fetal brain first. D. There are higher pressures in the right atrium in the fetal circulation. Submit Answer

Explanation Choices A, C, and D are correct. A is correct. In fetal circulation, the alveoli are filled with fluid. This causes high pressures in the fetal lungs, which shunts blood away from the pulmonary circulation. C is correct. The ductus venosus is a bypass in fetal circulation that shunts blood away from the weak fetal liver and to the brain. This allows the brain to get fresh oxygen first. D is correct. The pressures on the right side of the heart are higher in fetal circulation than on the left side of the heart. Choice B is incorrect. Blood shunts from right to left in the fetal circulation; this is due to increased pulmonary pressures caused by the fluid-filled alveoli. The high pulmonary pressures increase pressure on the right side of the heart, creating a gradient across the foramen ovale shunting blood from right to left. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn Last Updated - 07, Nov 2021

While caring for a newly pregnant mother, the nurse notes that she has a rubella infection. Which of the following conditions would the nurse be concerned about in this case? Select all that apply. A. Intrauterine growth restriction (IUGR) B. Hemolytic disease of the newborn C. Hydrocephaly D. Large for gestational age infant (LGA) E. Stillbirth Submit Answer

Explanation Choices A, C, and E are correct. Women infected with rubella are at an increased risk of having a miscarriage or a stillbirth. Their infants are more likely to suffer from intrauterine growth restriction and hydrocephaly. Choice B is incorrect. Hemolytic disease of the newborn is an alloimmune condition that occurs when the mother is Rh-negative and is pregnant with an Rh-positive baby. Choice D is incorrect. Women infected with rubella while pregnant are not at an increased risk for delivering an infant who is large for gestational age. Last Updated - 26, Jan 2022

Which of the following statements about reflexes in the newborn assessment are true? Select all that apply. A. The Babinski reflex is also known as the startle reflex. B. A positive Babinski sign is normal in the newborn. C. The Moro reflex is demonstrated when the infant is startled and stretches out their arms in response. D. The Moro reflex is pathologic in the newborn. Submit Answer

Explanation Choices B and C are correct. A positive Babinski sign is when the toes splaying outward after stroking the plantar surface of the foot. It is normal in the newborn but pathologic in the adult population (Choice B). When a baby is startled and responds by suddenly stretching out his arms, this is the Moro reflex (Choice C). Choice A is incorrect. The Moro reflex is also known as the startle reflex, not the Babinski reflex. Choice D is incorrect. The Moro reflex is standard in the newborn and is not pathologic. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn Last Updated - 07, Nov 2021

Which of the following signs and symptoms would you expect to see in an infant withdrawing from heroin? Select all that apply. A. Temperature 36.5 degrees Celsius B. Respiratory rate 88 C. Diaphoretic D. Constipation Submit Answer

Explanation Choices B and C are correct. A respiratory rate of 88 is tachypneic, which is what we would expect for an infant experiencing neonatal abstinence syndrome (NAS). Tachypnea is a common sign of NAS, as is respiratory distress. It is not uncommon to appreciate an increased work of breathing, including things such as nasal flaring, head bobbing, and retractions in these infants (Choice B). Diaphoresis or excessive sweating is a common symptom of infants in neonatal abstinence syndrome. Most of these infants are incredibly irritable, hot, and sweaty. It is similar to the withdrawal you would expect in an adult that goes cold turkey on a drug (Choice C). Choice A is incorrect. A temperature of 36.5 degrees Celsius is an average temperature, whereas an infant withdrawing from heroin would likely present with a fever. For NAS scoring, an illness is higher than 37.8 degrees Celsius. Most of these infants are incredibly irritable, hot, and sweaty. It is similar to the withdrawal you would expect in an adult that goes cold turkey on a drug. Choice D is incorrect. In an infant experiencing neonatal abstinence syndrome, you would expect to see very loose frequent stools, not constipation. These loose stools are so prevalent that many of these infants end up with horrible skin breakdown due to sitting in diapers filled with loose stool. It is essential to know that diarrhea is a common sign of NAS, so that you may monitor for these complications. NCSBN Client Need: Topic: Health Promotion and Maintenance; Subtopic: Newborn Last Updated - 10, Nov 2021

Which of the following obstetrical procedures can be used to assist the head of the fetus during vaginal delivery? Select all that apply. A. Amniotomy B. Forceps assisted delivery C. External version D. Vacuum assisted delivery

Explanation Choices B and D are correct. Forceps are tools used to help pull on the head of the baby to assist with the delivery. Vacuum-assisted delivery is a method where suction is applied to the head of the baby and pulled while the mother pushes. This helps to deliver the head of the infant. Choice A is incorrect. An amniotomy is the use of a hook or finger to break the amniotic sac. This helps to induce labor but does not assist in the delivery of the head of the fetus. Choice C is incorrect. The external version is a technique used when the baby is not in an appropriate position for vaginal delivery. The external cephalic version is used to turn a fetus from a breech position or side-lying (transverse) position into a more favorable head-down (vertex) position to help prepare the baby for a vaginal delivery. The external version is typically done before the labor begins, often around 37 weeks. Occasionally, it is done during labor but before the membranes have ruptured. If the amniotic sac has ruptured or if there is not enough amniotic fluid around the fetus (oligohydramnios), external version must not be done as it may end up injuring the fetus. External version does not directly assist in the delivery of the head of the fetus. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Risk potential reduction Last Updated - 19, Dec 2021

A 25-year-old female client at ten weeks gestation has mild fatigue. While reassuring her that this is expected, the nurse also knows that which of the following are regular changes during various trimesters of a healthy pregnancy? Select all that apply. A. Thyroid gland decreases in size B. Maternal blood volume increases C. Intestinal mobility increases D. Diastolic blood pressure decreases Submit Answer

Explanation Choices B and D are correct. To provide adequate nutrition and gas exchange for the developing fetus, a woman's body undergoes several changes during pregnancy, including cardiovascular, hematologic, metabolic, renal, and respiratory changes. In a healthy pregnancy, maternal blood volume may increase by as much as 40 to 50% by week 32 of the pregnancy. Despite this increase in red blood cell production, the mother may develop dilutional physiological anemia. Mild to moderate fatigue may be experienced. During the second trimester, the nurse might note a decrease in diastolic blood pressure. Cardiac output may decrease as the mother changes positions. Choice A is incorrect. The thyroid and pituitary glands typically increase in size during pregnancy, not decrease. Reflecting the increased metabolic needs during pregnancy, TSH (thyroid-stimulating hormone) increases, and therefore, thyroid volume increases. Choice C is incorrect. Intestinal mobility decreases as progesterone levels increase to allow for increased absorption of nutrients. The nurse should be aware that this change may also increase the risk of constipation. NCSBN Client Need Topic: Health Promotion and Maintenance; Subtopic: Ante/Intra/Postpartum Care Last Updated - 11, Jan 2022

Which of the following signs and symptoms are expected for your patient experiencing placental abruption? Select all that apply. A. Painless bleeding B. Dark red bleeding C. Hypotension D. Rigid abdomen Submit Answer

Explanation Choices B, C, and D are correct. B is correct. A massive amount of dark red bleeding is a prominent sign of placental abruption. This is due to the placenta separating from the wall of the uterus. This enormous amount of bleeding causes hypotension as the mother enters hypovolemic shock and fetal distress as perfusion to the baby decreases dramatically. C is correct. Due to the massive amounts of dark red bleeding, hypotension is a sign of placental abruption. When the mother loses large amounts of blood, her blood pressure will drop. This hypovolemia is treated with IV fluids and blood products such as PRBCs. D is correct. A rigid, board-like abdomen is a sign of placental abruption. This is also due to massive blood loss. As the placenta separates from the wall of the womb, blood starts to accumulate in the abdomen, causing it to become rigid, and board-like. Choice A is incorrect. Painless bleeding is NOT a sign of placental abruption. Instead, it is a sign of placenta previa. In placenta previa, the placenta is covering the cervix. This causes painless bleeding. In placental abruption, the placenta separates from the wall of the womb. This creates a massive amount of very painful dark red bleeding. It is important to remember the difference between these two emergencies. Placenta previa presents with painless bleeding, whereas placental abruption presents with painful bleeding. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Labor and Delivery Last Updated - 08, Oct 2021

The nurse is caring for a pregnant client who is experiencing late decelerations. Which of the following actions should the nurse take? Select all that apply. A. Initiate intravenous magnesium sulfate B. Reposition the patient on her side C. Administer oxygen via face mask D. Discontinue oxytocin infusion E. Prepare for an amnioinfusion Submit Answer

Explanation Choices B, C, and D are correct. Late decelerations are a non-reassuring fetal heart pattern that requires immediate intervention. The nurse should place the client in a left lateral position, administer oxygen via face mask, and discontinue oxytocin. Repositioning the client will relieve the vena cava compression. Oxygen will correct any maternal hypoxia, and oxytocin should be stopped because uterine contractions decrease uteroplacental blood flow. Choices A and E are incorrect. Magnesium sulfate is indicated for clients with preeclampsia or eclampsia. It has no use for late decelerations. Amnioinfusion of an isotonic solution is utilized for variable decelerations - not late decelerations. Additional Info Source : Archer Review Late decelerations are primarily caused by uteroplacental insufficiency, and the client should be repositioned into a left lateral position. If the left lateral position is ineffective, then the nurse may consider using the right lateral position. The nurse should also consider prescribed intravenous (IV) fluids to restore maternal blood volume.

While participating in interdisciplinary rounds on the Mother-Baby floor, the provider mentions that your 2-day old patient is at risk for phenylketonuria (PKU). Which of the following statements are true regarding this condition? Select all that apply. A. It is a genetic disorder that is autosomal dominant. B. Children with phenylketonuria commonly have a musty odor to their urine C. Hypopigmentation of the hair, skin, and irises is a prominent sign of the disorder. D. All 50 states require routine screening of newborns for phenylketonuria. Submit Answer

Explanation Choices B, C, and D are correct. Phenylketonuria, or PKU, is a genetic disorder that results in central nervous system damage from toxic levels of the essential amino acid phenylalanine. The musty odor urine smell and hypopigmentation of the hair, skin, and irises are signs of PKU. It is also true that all 50 states require routine screening of newborns for this disorder. Choice A is incorrect. The disease is inherited in an autosomal recessive manner. NCSBN client need: Topic: Physiological Adaptation Subtopic: Alterations in Body Systems Last Updated - 01, Feb 2022

Which of the following would not be a normal change during late pregnancy? Select All That Apply. A. Waddling gait B. Sudden edema C. Vaginal bleeding D. Dark cloudy urine Submit Answer

Explanation Choices B, C, and D are correct. Sudden edema is abnormal and may indicate preeclampsia (Choice B). Vaginal bleeding (more than scant spotting) is never healthy in pregnancy before the start of labor (Choice C). Dark cloudy urine is abnormal and suggests infection or renal impairment (Choice D). Choice A is incorrect. Increased levels of relaxin loosen the cartilage between the pelvic bones, which results in the characteristic "waddling" walk of the third trimester. This is a healthy change during pregnancy. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Reduction of Risk Potential; Pregnant Women Additional Info Source : Archer Review Last Updated - 10, Nov 2022

The nurse is caring for a client at 32 gestational weeks. Which laboratory data should be reported to the primary healthcare provider (PHCP)? Select all that apply. A. Hemoglobin 11.5 g/dL B. Platelets 90,000 mm3 C. Fasting blood glucose 254 mg/dL D. White blood cell 9,500 mm3 E. Creatinine 3.9 mg/dL

Explanation Choices B, C, and E are correct. These laboratory values are abnormal and require follow-up. A platelet count of fewer than 150,000 mm3 is concerning for thrombocytopenia and suggests severe preeclampsia. The blood glucose is significantly elevated as the normal fasting blood glucose is 70-100 mg/dL. This client has clinical hyperglycemia and requires follow-up. Finally, the creatinine is quite elevated, suggesting acute kidney injury. This, combined with a low platelet count, is more convincing of severe preeclampsia. Choices A and D are incorrect. These findings are within normal limits. For a client who is pregnant, the normal hemoglobin level may decrease to 11.5 g/dL without any intervention. Finally, this white blood cell count is normal (the normal range is 5000 - 10000 mm3). Additional Info The following are the clinical criteria for severe preeclampsia If one or more of the following criteria are present: 1. Blood pressure of ≥160 mm Hg systolic or ≥110 mm Hg diastolic or higher on two occasions at least 6 hr apart while the patient is on bed rest 2. Oliguria of <500 mL in 24 hr 3. Cerebral or visual disturbances 4. Pulmonary edema or cyanosis 5. Epigastric or right upper quadrant pain 6. Impaired liver function as indicated by abnormally elevated blood concentrations of liver enzymes (to twice normal concentration), severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses, or both 7. Thrombocytopenia 8. Renal insufficiency Last Updated - 03, Nov 2022

You are educating a 25-year-old obese client with a body mass index (BMI) of 31 at 12 weeks gestation, who presents for a routine antenatal check-up. She gained 3 pounds compared to pre-pregnancy weight. Which of the following statements by the client reflect correct understanding regarding recommended weight changes in pregnancy? Select all that apply. A. "Since I am obese, I should try to lose weight now to limit my risk of gestational diabetes." B. "Typically, there is 3 to 6 pounds of weight gain during the first trimester of pregnancy." C. "In the third trimester, a weight gain of 2 pounds or more each week is considered high." D. "I should aim to gain a total of 25 to 35 pounds during this pregnancy." E. "Going forward in my pregnancy, I should aim to gain ½ pound per week." Submit Answer

Explanation Choices B, C, and E are correct. Weight gain is considered crucial during pregnancy. A pregnant woman should be educated regarding what is deemed to be reasonable in terms of pregnancy weight gain and the implications of gaining too much or too little weight. The client needs to keep track of the rate of weekly weight gain. Guidelines have been proposed to assist with determining the rate of healthy weekly weight gain. Weight gain of 3 to 6 pounds during the entire first trimester (first three months) is considered normal and healthy (Choice B). Gaining 2 pounds or more per week at any time (Choice C) during pregnancy would be abnormally high and such a client should focus on limiting the further rate of weight gain. The client in the question has already gained 3 pounds, which is healthy. Going forward, she should aim to gain about 8 to 17 pounds in the next six months (about half a pound per week for the rest of her pregnancy). This is based on the recommended weight gain of 11-20 pounds during the entire pregnancy for someone with a BMI of 30 or above (obese). Recommended weight gain is based on pre-pregnancy BMI and is shown in the table below: Choices A and D are incorrect. Weight-loss is dangerous during pregnancy. Regardless of their pre-pregnancy weight, every woman is expected to gain weight during pregnancy. The amount of recommended weight gain, however, is based on their pre-pregnancy BMI. A weight gain of 25 to 35 pounds (Choice D) is an ideal range recommended for those clients with healthy pre-pregnancy BMI (18.5 to 24.9). For an obese client, gaining 11 to 20 pounds during the entire pregnancy is considered ideal. Gaining more than the recommended weight will put the clients at risk for maternal hyperglycemia, reduced glucose tolerance, and increased risk of fetal complications. Fetal comp

The nurse is caring for a client scheduled for an amniocentesis. Which of the following statements would require follow-up? Select all that apply. A. "This test may tell me the gender of my baby." B. "I will receive intravenous (IV) sedation for this test." C. "I may have cramping after this procedure." D. "I may be given a medicine to stimulate contractions." E. "The results will tell me how my baby will handle labor." Submit Answer

Explanation Choices B, D, and E are correct. These statements are false and require follow-up. Amniocentesis is an ultrasound-guided test used in the detection of fetal abnormalities. Under ultrasound guidance, a thin needle is inserted into the amniotic sac to remove a sample of amniotic fluid. The fluid is then sent for analysis. Amniocentesis does not require intravenous sedation (choice B). The client will not be given medication to stimulate contractions for the amniocentesis procedure (choice D). Ureterotonic drugs (oxytocin challenge) are administered in a contraction stress test (CST), not amniocentesis. Once again, a CST will determine how the fetus will handle labor, not an amniocentesis (choice E). These statements require follow-up counseling and education to correct the client's understanding. Choices A and C are incorrect. These statements reflect correct understanding and do not require follow-up. The gender of the fetus can indeed be determined based on the results of amniocentesis (choice A). This procedure can be performed as early as fourteen weeks. The client may also expect cramping after this procedure, as this is the most common complaint (choice C). Learning Objective Understand that the amniocentesis procedure is indicated in a high-risk pregnancy to detect chromosomal abnormalities and neural tube defects. Additionally, it helps in gender identification. Additional Info An amniocentesis may be conducted on patients who have a high-risk pregnancy. This procedure can be performed as early as fourteen weeks and is often used to detect fetal neural tube defects and chromosomal abnormalities. Amniocentesis can also be used later in pregnancy to determine fetal lung maturity. The client will need to consent before the procedure, and if the client is Rh-negative, she will need to receive prescri

Which of the following antepartum test results indicate a need to further follow up? Select all that apply. A. Contraction stress test - negative B. Nonstress test - reactive C. Contraction stress test - positive D. Nonstress test - nonreactive Submit Answer

Explanation Choices C and D are correct. A positive contraction stress test means the baby had decelerations in response to contractions and therefore, may not tolerate labor. Therefore, follow-up is needed (Choice C). A nonreactive nonstress test means that the baby did not have two or more 15 by 15 accelerations during the 20 minute test period and is not responding appropriately to movement. Follow-up would be needed for this test result, most likely with a contraction stress test (Choice D). Choice A is incorrect. In a contraction stress test, the result we want is negative. This means that the baby did not have decelerations in response to contractions. Follow up would not be needed for this test result. Choice B is incorrect. In a non-stress test, the result we want is reactive. This means that the baby had two or more 15 by 15 accelerations during the 20 minute test period and is responding appropriately to movement. Follow up would not be needed for this test result. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn Additional Info Source : Archer Review Last Updated - 22, Nov 2022

You are discussing the signs and symptoms of postpartum thrombophlebitis with an expectant mother. You should tell her to monitor for which of the following symptoms? Select all that apply. A. +2 pulses B. Bilateral redness C. Edema in one leg D. Tenderness Submit Answer

Explanation Choices C and D are correct. It is right to advise the mother to monitor for edema in one leg as a sign of postpartum thrombophlebitis. There will be edema, pain, redness, and tenderness in whichever leg the clot is occluding (Choice C). It is right to advise the mother to monitor for tenderness in one leg as a sign of postpartum thrombophlebitis. There will be edema, pain, and redness in whichever leg the clot is occluding (Choice D). Choice A is incorrect. +2 pulses are healthy, intense pulses. In postpartum thrombophlebitis, you would expect to see weak +1 pulses in the affected leg. This is due to decreased blood flow into the leg where the clot is preventing blood flow. Choice B is incorrect. You would expect to see unilateral redness in a patient with postpartum thrombophlebitis, so you would not advise this mother to monitor for bilateral redness. The edema, pain, redness, and tenderness are all unilateral, relating to the clot in one leg. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation; Labor and Delivery Last Updated - 12, Feb 2022

Which of the following signs are indicative of respiratory distress in the newborn? Select all that apply. A. Respiratory rate of 48 breaths per minute B. Mild subcostal retractions C. Nasal flaring D. Head bobbing

Explanation Choices C and D are correct. Nasal flaring is a sign of respiratory distress. If the newborn is working hard to breathe, they use extra effort when trying to pull air in through their nose and their nares flare out with inhalation. This is a sign that they are struggling to breathe and indicates respiratory distress (Choice C). Head bobbing is a severe sign of respiratory distress in the newborn. As they work harder and harder to breathe, they start using the muscles in their neck to pull their head forward with each inhalation. This is a sign that they are struggling to breathe and indicates respiratory distress (Choice D). Choice A is incorrect. A respiratory rate of 20 to 60 breaths per minute is standard in the newborn. Choice B is incorrect. Mild subcostal retractions are not considered a normal finding in the newborn, however, they are not enough to indicate respiratory distress. Since newborns breathe using their abdominal muscles, it is common to see some mild subcostal retractions, especially when they cry. Moderate to severe withdrawals would indicate respiratory distress. NCSBN Client Need: Topic: Physiological Integrity, Subtopic: Physiological adaptation, Newborn Last Updated - 31, May 2021

The nurse is caring for a 1-day old newborn client diagnosed with jaundice. Which of the following statements is true regarding jaundice in newborns? Select all that apply. A. Jaundice within the first 24 hours of life is physiologic. [17%] B. Unconjugated bilirubin is excreted in the stool. [14%] C. Assessing a newborn for jaundice involves inspection of the skin, sclera, and mucous membranes. [34%] D. When treating a jaundiced infant with phototherapy, an important nursing consideration is to ensure their eyes and genitals are covered.

Explanation Choices C and D are correct. When assessing an infant suspected to have jaundice, the most important thing to do will be to evaluate the skin, sclera, and mucous membranes (Choice C). When bilirubin levels are high, there will be a yellow tinge to these areas due to the high levels of the bilirubin pigment in the blood. Jaundice usually starts in the face and forehead area, so the nurse should begin her assessment looking there. The sclera and mucous membranes are a common location to appreciate the yellow discoloration, especially in a patient with darker skin. When treating a jaundiced infant with phototherapy, important nursing considerations are to ensure their eyes and genitals are covered (Choice D). Phototherapy helps reduce serum bilirubin levels by converting bilirubin into water-soluble isomers that can be eliminated without conjugation in the liver. Phototherapy light can be harmful to the infant's eyes and genitals. Nurses should ensure these areas are covered with an eye mask and a diaper. Choice A is incorrect. Jaundice, within the first 24 hours of life, is pathologic. This means that there is some other disease process or condition, causing jaundice that needs to be investigated. Often, etiology includes ABO incompatibility leading to hemolysis, or liver pathology. Physiologic jaundice is noted 2-3 days after birth and is simply due to the normal process of the infant's liver taking over the processing of bilirubin. Since the liver is not mature enough to conjugate and excrete the bilirubin in the bile, predominantly unconjugated physiological jaundice appears. This type of disease should not be of any concern. Choice B is incorrect. It is the conjugated bilirubin that gets excreted in the stool, not unconjugated. Unconjugated bilirubin is the waste product that is released when the heme is

At the time of birth, the nurse should accomplish the following tasks: Assess the newborn's heart rate Provide positive pressure ventilation Assess muscle tone and presence of respiratory effort Clear secretions as needed. The correct sequence for these tasks is: Assess the newborn's heart rate. Clear secretions as needed. Provide positive pressure ventilation. Assess muscle tone and presence of respiratory effort. Submit Answer

Explanation Correct answer: According to the American Heart Association and the American Academy of Pediatrics Neonatal Resuscitation Program algorithm, the team should first assess the newborn's muscle tone and breathing. If those are abnormal, the team should provide a patent airway, including positioning and suctioning as needed. At the same time, the team should ensure that the infant is warm. The third task is to assess the newborn's heart rate to ensure that it is at least 100 beats per minute. The fourth task in this sequence is to provide positive pressure ventilation if the heart rate is less than 100 bpm. NCSBN Client Need Topic: Health Promotion and Maintenance, Sub-Topic: Newborn Care Last Updated - 07, Nov 2021