ATI Maternal Newborn
A nurse is caring for a client who is at 37 weeks of gestation and is undergoing a nonstress test. The fetal heart rate (FHR) is 130/min without accelerations for the past 10 min. Which of the following actions should the nurse take? A. Use vibroacoustic stimulation on the client's abdomen for 3 seconds. B. Report the nonreactive test result to the provider immediately. C. Request a prescription for an internal fetal scalp electrode. D. Auscultate the FHR with a Doppler transducer.
A. Explanation: The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR.
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? A. "I will eat foods that taste good instead of balancing my meals." B. "I will avoid having a snack before I go to bed each night." C. "I will have a cup of hot tea with each meal." D. "I will eliminate products that contain dairy from my diet."
A. Explanation: clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet.
A nurse is caring for a client who is at 39 weeks of gestation and is in the active phase of labor. The nurse observes late decelerations in the fetal heart rate. Which of the following findings should the nurse identify as the cause of late decelerations? A. Uteroplacental insufficiency B. Fetal head compression C. Fetal ventricular septal defect D. Umbilical cord compression
A. Explanation: A late deceleration in the FHR pattern resulting from fetal hypoxemia due to insufficient placental perfusion. The nurse should reposition the client, initiate oxygen, and increase the infusion rate of IV fluid to enhance placental perfusion.
A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy? A. Palpable fetal movement B. Chadwick's sign C. Positive pregnancy test D. Amenorrhea
A. Explanation: Palpable fetal movements are a positive sign of pregnancy. Quickening, the client's report of fetal movement, is a presumptive sign of pregnancy.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the new Ballard Score. which of the following findings should the nurse expect? A. Minimal arm recoil B. Popliteal angle of 90' C. Creases over the entire foot sole D. Raised areolas with 3 to 4 mm buds.
A. Explanation: The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil.
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? A. Swelling of the face B. Varicose veins in the calves C. Nonpitting 1+ ankle edema D. Hyperpigmentation of the cheeks
A. Explanation: swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.
A nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following medications should the nurse plan to administer? A. Betamethasone B. Misoprostol C. Methylergonovine D. Poractant alfa
A. Explanation: the nurse should plan to administer betamethasone IM, a glucocorticoid, to stimulate fetal lung maturity and thereby prevent respiratory depression.
A nurse is reviewing the medical record of a client who is at 33 weeks of gestation and has placenta previa and bleeding. Which of the following prescriptions should the nurse clarify with the provider? A. Perform a vaginal examination B. Perform continuous external fetal monitoring. C. Insert a large-bore IV catheter D. Obtain a blood sample for laboratory testing.
A. Explanation: when a client has a placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta and increased bleeding.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (select all that apply) A. Flaccid uterus B. Cervical laceration C. Excess vaginal bleeding D. Increased afterbirth cramping E. Increased maternal temperature
A. Oxytocin increases the contractility of the uterus. B. Oxytocin enhances uterine contractility, decreasing vaginal bleeding.
A nurse is caring for a client who is 32 hours postpartum. The client reports nipple soreness and breast engorgement. Which of the following recommendations should the nurse provide? A. "Call me so I can check your baby's latch the next time you breastfeed." B. "You should reduce the frequency of breastfeeding." C. "Apply expressed breast milk to sore nipples and cover them with nursing pads and bra." D. "You should apply warm packs to the breast between nursing sessions."
A. "Call me so I can check your baby's latch the next time you breastfeed." Explanation: Nipple soreness can be a result of a poor latch. The nurse should observe the next feeding session to offer hands on advice and assistance to ensure an ideal latch.
A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching? A. "Do not become pregnant for at least 1 year." B. Seek genetic counseling for yourself and your partner prior to getting pregnant again. C. "You should have an hCG level drawn in 6 weeks. D. "Have your blood pressure checked weekly for the next month."
A. "Do not become pregnant for at least 1 year." Explanation: Hydatidiform moles are uncontrolled growths in the uterus arising from placental or fetal tissue in early pregnancy. There is an increased incidence of choriocarcinoma associated with molar pregnancies. Pregnancy must be avoided for 1 year so the client can be closely monitored for manifestations of this condition.
A nurse is teaching a postpartum client how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the teaching? A. "I should stop swaddling my baby once she is able to roll over by herself." B "My baby's legs should be extended out when I swaddle her." C. "I should be able to slide just 1 finger between my baby's chest and the swaddle blanket." D. "After swaddling, I should place my baby on her side in her crib or bassinet."
A. "I should stop swaddling my baby once she is able to roll over by herself." Explanation: the parent should discontinue swaddling the baby once the baby is able to roll over, which occurs around 2 months of age. Rolling over can tighten the swaddle and keep the baby from breathing properly.
A nurse is providing education to a client who is 4 weeks postpartum and is breastfeeding. The client asks about the expected weight loss. Which of the following responses should the nurse make? A. "Losing 2.2 pounds each month would be acceptable." B. "Losing 4.4 pounds each month would be acceptable." C. "Losing 5.5 pounds each month would be acceptable." D. "Losing 66 pounds each month would be acceptable."
A. "Losing 2.2 pounds each month would be acceptable." Explanation: An important postpartum goal is for the client to lose the weight gained during pregnancy. An acceptable amount of weight loss for a client who is lactating is 1 kg (2.2 lb.) per month.
A nurse is caring for a client at 12 weeks gestation who has a BMI of 45. Which of the following pieces of information should the nurse provide for the client regarding the recommended weight gain during her pregnancy? A. "You should plan to gain no more than 20 pounds during your pregnancy." B. "You should plan to gain between 25 and 35 pounds during your pregnancy." C. "You should not plan to gain any weight during your pregnancy because you are already well-nourished." D. "Since you hav
A. "You should plan to gain no more than 20 pounds during your pregnancy." Explanation: Women who have a BMI above 30 should limit their weight gain to 11 to 20 pounds during pregnancy. Excessive wight and weight gain increase the risk of complications during and after pregnancy.
A nurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend? A. Copper intrauterine device B. Combination pill C. Vaginal ring D. Medroxyprogesterone injection
A. Copper intrauterine device Explanation: A history of thrombophlebitis is a contraindication for the use of hormonal contraceptive methods such as oral combinations of estrogen and progesterone pill form.
A nurse in a clinic is caring for a 16-year-old adolescent. which of the following findings should the nurse report to the provider? (select all the apply) A. abdominal assessment B. vaginal discharge C. Heart rate D. Temperature E. Dyspareunia F. condom usage
A. D. E. F.
A nurse is reviewing the laboratory results for a client who is at 10 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider? A. Hemoglobin 10 g/dL B. WBC count 15, 000/mm3 C. RBC count 5.8 million/mm3 D. Hematocrit 34%
A. Hemoglobin 10 g/dL Explanation: A hemoglobin level of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant.
A nurse on the antepartum unit is caring for a client who is at 28 weeks gestation and reports dizziness when lying on her back. Into which of the following positions should the nurse assist the client? A. Lateral B. Lithotomy C. Trendelenburg D. Prone
A. Lateral Explanation: A lateral or side-lying position promotes uteroplacental blood flow and helps relieve the symptoms of supine hypotension, including faintness, dizziness, and breathlessness.
A nurse is reviewing the medical record of a client who is at 20 weeks gestation. Which of the following findings should the nurse identify as a presumptive indication of pregnancy? A. Report of fetal movement by the client B. Auscultation of the fetal heart rate with the Doppler ultrasound C. Presence of Chadwick's sign on pelvic examination D. Report of Braxton-Hicks contractions by the client
A. Report of fetal movement by the client Explanation: Quickening (the report of fetal movement felt by the client) begins around 18 to 20 weeks gestation and is considered a presumptive indication of pregnancy.
A nurse is assessing a newborn who is 16 hr. old. Which of the following findings should the nurse report to the provider? A. Substernal retractions B. Acrocyanosis C. Overlapping suture lines D. Head circumference 33 cm (13in)
A. Substernal retractions Explanation: The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection or respiratory distress in newborns.
A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5 kg. the amount available is morphine oral solution 0.4 mg/ml. How many mL should the nurse administer?
Answer: 0.25 Explanation: Order/on hand x weight of child 0.04/0.4 = 0.1 x 2.5 kg = 0.25 mL
A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. In what order should the nurse take the following actions when performing a fundal massage? A. Rotate the upper hand to massage the client's uterus. B. Ask the client to lie on her back with her knees flexed. C. Use slight downward pressure to compress the client's fundus. D. Position a hand around the top of the client's fundus. E. Place a hand just above the client's symphysis pubis.
Answer: B, E, D, A, C
A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take? A. Perform a vaginal examination to determine cervical dilation. B. Obtain blood samples for baseline laboratory values. C. place a spiral electrode on the fetal presenting part. D. Prepare the client for a transvaginal ultrasound.
B. Explanation: The nurse should samples of the client's blood for baseline testing of hemoglobin and hematocrit levels.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor? A. Passive descent B. Active C. Early D. Descent
B. Explanation: This phase is characterized by a cervical dilation of 6 to 10 cm and contractions every 1.5 to 5 min, each lasting 40 to 90 seconds.
A nurse is assessing a client who is at 12 weeks of gestation and has a hydatidiform mole. Which of the following findings should the nurse expect? A. hypothermia B. Dark brown vaginal discharge C. Decreased urinary output D. Fetal heart tones
B. Explanation: a molar pregnancy, is a benign proliferative growth of the chorionic villi, which gives rise to multiple cysts. the products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grapelike clusters.
A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. Which of the following statements should the nurse make? A. "Your provider will insert a hand into your uterus and turn your baby around." B. "You will receive a medication to relax your uterus prior to the procedure." C. "This procedure will be performed in the clinic at your next visit." D. "Your baby's heartbeat will be monitored occasionally throughout
B. "You will receive a medication to relax your uterus prior to the procedure." Explanation: A client who is scheduled to undergo an external cephalic version often receives a tocolytic prior to the procedure to allow the uterus to relax.
A community health nurse is planning care for a 4 high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first? A. A 1-week-old newborn who needs another phenylketonuria screening test B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy C. A 10-day-old newborn who is small for gestational age and requires daily weighing. D. A 2-week-old newborn who was born at 35 weeks gestation and weighed 2, 268 g
B. A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy. Explanation: The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. An elevated bilirubin level can lead to kernicterus: therefore: it is imperative for the nurse to initiate phototherapy immediately to help prevent this dangerous outcome.
A nurse is caring for a client who is in active labor and whose birth plan requests only nonpharmacological pain relief strategies. Which of the following strategies should the nurse offer as a form of cutaneous stimulation? A. Breathing techniques B Counter-pressure C. Biofeedback D. Use of a focal point
B. Counter-pressure Explanation: The nurse should implement counter-pressure as a nonpharmacological cutaneous stimulation strategy. Other cutaneous stimulation strategies include walking, effleurage, water therapy, and the application of heat or cold.
A nurse administers betamethasone to a client who is 33 weeks gestation to stimulate fetal lung maturity. When planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? A. Hyperthermia B. Decreased blood glucose C. Rapid pulse rate D. Irritability
B. Decreased blood glucose Explanation: Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery. The nurse must assess the newborn's blood glucose level within the first hour following birth and frequently thereafter until blood glucose levels are stable.
A nurse in labor and delivery is teaching a newly licensed nurse about performing the McRoberts maneuver to relieve shoulder dystocia. Which of the following pieces of information should the nurse include? A. Position the client on her hands and knees while in bed. B. Flex the client's legs apart and raise her knees to her abdomen. C. Apply gentle pressure on the client's fundus while she is lying supine. D. Push the fetus's anterior shoulder under the symphysis pubis externally
B. Flex the client's legs apart and raise her knees to her abdomen. Explanation: The McRoberts maneuver includes helping the client flex her knees apart, which rotates the pubic bone anteriorly. This movement releases the anterior shoulder, but the nurse should not apply pressure directly to the anterior shoulder during this maneuver.
A nurse is preparing to help with a vacuum-assisted birth. Which of the following actions should the nurse plan to take? A. Instruct the client to stop pushing during contractions B. Inform the client that caput succedaneum resolves in a few days. C. Monitor the newborn for decreased levels of bilirubin after birth D. Identify that the newborn is at risk for facial palsy.
B. Inform the client that caput succedaneum resolves in a few days. Explanation: the nurse should expect the newborn to have caput succedaneum due to the application of suction. The nurse should inform and reassure the client that this effect is expected to resolve on its own in 3 to 5 days.
A nurse is reviewing the laboratory values of a client who is pregnant and has a low progesterone level. Which of the following complications should the nurse expect? A. Gestational diabetes B. Preterm labor C. Inadequate milk supply D. Inadequate uterine growth
B. Preterm labor Explanation: Progesterone maintains the lining of the uterus, which maintains the pregnancy. It also reduces uterine contractility. A client who has low progesterone level is at risk for preterm labor.
A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication of the oxygen therapy? A. Atelectasis B. Retinopathy C. Interstitial emphysema D. Necrotizing enterocolitis
B. Retinopathy Explanation: Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. It is a disorder of retinal blood vessel development in premature newborns. The vessels grow abnormally from the retina into the clear gel that fills the back of the eye. This condition can reduce vision or result in complete blindness.
A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? A. Gently retract the foreskin to wash the glans with soap and water. B. Sponge bathe the newborn every other day. C. Use an antimicrobial soap for bathing. D. Bathe the newborn with water between 46' and 49'C (115' and 120'F)
B. Sponge bathe the newborn every other day. Explanation: daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The parents should sponge bathe the infant until the cord stump has detached and the area has healed.
A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord? A. They can cause increased pain from the cord. B. They can cause delayed cord separation. C. They can cause swelling of the surrounding tissue. D. They can cause skin discoloration
B. They can cause delayed cord separation Explanation: Keeping the cord moist with any kind of preparation prevents drying and separation and also increases the risk for infection.
A nurse is monitoring a newborn who is receiving phototherapy. The nurse should identify which of the following findings as requiring intervention? A. Bilirubin level 5 mg/dL B. Weight loss 12% of birth weight C. Loose, green stools D. Axillary temperature of 36.6 'C (97.9 F)
B. Weight loss 12% of birth weight. Explanation: An acceptable weight loss over the first 3 to 5 days is 10%. The nurse should report this finding to the provider.
A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse take? A. Prepare the client for an ultrasound B. Prepare the client for an emergency cesarean birth. C. Prepare equipment needed for newborn resuscitation D. Perform endotracheal suctioning as soon as the fetal head is delivered.
C. Explanation: Endotracheal suctioning is recommended in cases f meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.
A nursing is caring for a client who is at 35 weeks of gestation and has severe pre-eclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status? A. Blood pressure B. Intake and output C. Daily weight D. Severity of edema
C. Explanation: Evidence-based practice indicates that daily weight is the most accurate assessment to determine a client's fluid and electrolyte status.
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include? A. Shortness of breath when climbing stairs B. Swelling of feet and ankles at the end of the day. C. Headache that is unrelieved by analgesia D. Braxton Hicks contraction
C. Headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to provider.
A nurse is assessing a client who is 2 days postpartum. In which of the following locations should the nurse expect to locate the client's fundus? A. 3 cm above the umbilicus B. 1 cm above the umbilicus C. 3 cm below the umbilicus D. 1 cm below the umbilicus
C. 3 cm below the umbilicus Explanation: the client's fundus should descend about 1 to 2 com every 24 hours; therefore; at 2 days postpartum, the client fundus should be located 3 cm below the umbilicus.
A nurse is assessing a client who gave birth vaginally 12 hr. ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform? A. Reassess the client in 2 hr. B. Administer simethicone C. Assist the client to empty their bladder. D. Instruct the client to lie on their right side.
C. Assist the client to empty their bladder. Explanation: Assessment finding indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage.
A nurse is teaching a parent of a newborn about circumcision care. Which of the following instructions should the nurse include? A. Wash the site with soap and warm water once daily B. Gently remove the yellow exudate that forms around the site C. Avoid using diaper wipes on the site during diaper changes. D. Apply the diaper tightly to apply pressure to the site
C. Avoid using diaper wipes on the site during diaper changes. Explanation: The parent should use plain warm water to clean the penis, as diaper wipes may contain alcohol or other chemicals that can cause pain and irritation.
A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer? A. Protamine sulfate B. Naloxone C. Calcium gluconate D. Flumazenil
C. Calcium gluconate Explanation: The nurse should discontinue the magnesium sulfate infusion immediately and prepare to administer calcium gluconate IV to reverse the effects of magnesium to prevent cardiac and respiratory arrest.
A nurse is caring for a clint who states, "I think I am pregnant." Which of the following findings should the nurse identify as a positive sign of pregnancy? A. Positive serum pregnancy test B. Amenorrhea C. Fetal heart tones auscultate by Doppler D. Chadwick sign
C. Fetal heart tones auscultated by Doppler Explanation: fetal heart tones heard by doppler are a positive sign of pregnancy. The only explanation for hearing fetal heart tones is the presence of a fetus.
A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Respiratory rate 52/min B. Weight 2500 grams (5.5lb ) C. Head circumference 28 cm (11 inch) D. Blood glucose 48 mg/dL
C. Head circumference 28 cm (11 in) Explanation: A head circumference of 28 cim (known as microcephaly) is below the expected reference range of 32 to 36.8 cm for a newborn. Microcephaly can indicate fused cranial sutures or prenatal infection with rubella, toxoplasmosis, or cytomegalovirus. The nurse should report this to the provider.
A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should the charge nurse include in the teaching? A. Newborn respiratory depression at birth B. Impaired ability of the neonate to maintain body temperature. C. Impaired placental perfusion D. Decreased fetal heart rate (FHR) variability
C. Impaired placental perfusion Explanation: Maternal hypotension can occur in 10% to 30% of women who receive epidural or spinal anesthesia. This can result in decreased blood flow to the placenta and impair the delivery of oxygen to the fetus.
A nurse is planning care for a client who is postpartum and has cardiac disease. For which of the following prescription should the nurse seek clarification? A. Monitor the client's intake and output B. Initiated a high-fiber diet for the client C. Monitor the client weekly weight D. Initiate bedrest with the head of the bed elevated
C. Monitor the client's weight weekly Explanation: The nurse should weigh the client daily to monitor for fluid overload.
A nurse is caring for a client at 36 weeks gestation who has pre-eclampsia. Which of the following findings should the nurse identify as the priority? A. 1+ proteinuria B. Blood pressure 140/98 mmHg C. Nonreactive nonstress test D. Fundal height 33 cm
C. Nonreactive nonstress test Explanation: A fetal acceleration is a positive sin when the FHR increases by 15/min and last 15 seconds. In a nonreactive nonstress test, there are no accelerations. An absence of FHR accelerations suggest that the fetus might be going into distress.
A nurse is caring for a client who is nulliparous and experiencing hypertonic uterine dysfunction. An assessment indicates 3 cm dilation. Which of the following actions should the nurse take? A. Encourage the client to bear down with contractions B. Request a prescription to initiate oxytocin C. Offer the client hydrotherapy D. Assist the client with ambulation
C. Offer the client hydrotherapy Explanation: Therapeutic rest measures should be initiated for a client who has hypertonic uterine dysfunction. Therapeutic rest can include hydrotherapy and analgesia to relieve pain. Decreasing uterine contractions and helping the client relax and sleep will help prevent early exhaustion.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? A. Feed the newborn 1 oz. of water every 4 hr. B. Apply lotion to the newborn's skin three times per day. C. Remove all clothing from the newborn except the diaper. D. Discontinue therapy if the newborn develops a rash.
C. Remove all clothing from the newborn except the diaper. Explanation: Remove all the newborn's clothing except diaper maximize skin exposure to the ultraviolet light is needed to breakdown the excess bilirubin.
A nurse is teaching a postpartum client about the steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make? A. "the nurse will carry your baby in their arms to the nursery for scheduled procedures." B. "We will document the relationship of visitors in your medical record." C. It's okay for your baby to sleep in the bed with you while in the hospital. D. "Staff members who take care of your baby will be wea
D. All staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety.
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A. "I should increase my protein intake to 60 grams each day." B. "I should drink 2 liters of water each day." C. "I should increase my overall daily caloric intake by 300 calories." D. "I should take 600 micrograms of folic acid each day."
D. Explanation: Folic acid assist with preventing neural tube birth defects.
A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that which of the following laboratory tests will be used to confirm her pregnancy? A. A blood test for the presence of estrogen. B. A blood test for the amount of circulating progesterone. C. A urine test for the presence of human chorionic somatomammotropin. D. A urine test for the presence of human chorion
D. Explanation: Human chorionic gonadotropin is excreted by the placenta and promotes the excretion of progesterone and estrogen. This hormone is the basis for pregnancy testing.
A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make? A. "You will not get pregnant while you are breastfeeding, so you will not need any birth control." B. "A birth control pill that contains only estrogen is available for use while you are breastfeeding." C. "Condoms are the only method of contraception that
D. "A progestin-only pill or injection is available for use while you are breastfeeding." Explanation: Progestin-only injections, implants, and birth control pills are acceptable options for clients who are breastfeeding.
A nurse is evaluating a client who has just received instructions about breastfeeding. Which of the following statements should the nurse identify as an indication that the client understands how to prevent mastitis? A. "I will wear an underwire bra to provide support when my milk comes in." B. "I will apply petroleum jelly if my nipples become cracked." C. "I will apply warm compresses to my breast twice a day." D. "I should avoid waiting too long between feedings."
D. "I should avoid waiting too long between feedings." Explanation: Mastitis is an inflammation or infection of the breast. Risk factors include insufficient emptying of the breasts during breastfeeding, stress, illness, poor nutrition, and fatique.
A nurse is providing teaching about newborn care to the parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will wash my baby's umbilical cord stump with antibacterial soap." B. "I will cover my baby with a lightweight blanket during nap time." C. " I will use a cotton-tipped swab to clean my baby's ear canals." D. " I will place a hat on my baby's head prior to going outside."
D. "I will place a hat on my baby's head prior to going outside." Explanation: The parent should place a hat or bonnet on the newborn's head to protect the scalp, minimize heat loss, and protect against sunburn.
A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I must drink milk every day in order to assure good-quality breast milk." B. "Drinking lots of fluids will increase my breast milk production." C. "After the first few weeks, my nipples will toughen, and breastfeeding won't hurt anymore." D. "My baby may sometimes feed every hour for several hours in a row."
D. "My baby may sometimes feed every hour for several hours in a row." Explanation: Cluster feeding is an expected finding for newborns who are breastfeeding. The mother should follow her newborn's cues and feed her 8-12 times per day.
A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statement should the nurse make? A. "This is an attempt by your body to retain the fluid gained during pregnancy." B. "This is cause by an increase in your estrogen hormonal levels." C. "This is caused by the increased pressure on your veins in your lower legs." D. "This is a source of your fluid loss after delivery."
D. "This is a source of your fluid loss after delivery." Explanation: Postpartum diuresis is the loss of the remaining pregnancy-induced increase in blood volume. The loss of excess tissue fluid begins with 12 hours after birth. Fluid loss by urination and perspiration results in a weight loss of approximately 2.27 kg (5 lb.) during the early postpartum period.
A nurse is creating a plan of care for a client who is in active stage of labor and expresses a desire to use nonpharmacologic methods of pain relief. Which of the following interventions should the nurse include? A. Encourage the client to listen to music B. Instruct the client how to use informational biofeedback C. Ask the client to reconsider using a regional anesthetic D. Assist the client into a warm shower
D. Assist the client into a warm shower. Explanation: This method stimulates the release of endorphins and increases circulation.
A nursed is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurse's priority? A. Perform Nitra-zine testing B. Assess the fluid C. Check cervical dilation D. Begin FHR monitoring
D. Begin FHR monitoring Explanation: The greatest risk to the client and their fetus following a rupture of membrane is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care? A. Maintain the client NPO throughout the procedure. B. Place the client in a supine position. C. Instruct the client to massage the abdomen to stimulate fetal movement. D. Instruct the client to press the provided button each time fetal movement is detected.
D. Instruct the client to press the provided button each time fetal movement is detected. Explanation: Fetal movement may not be evident on the fetal monitor and tracing.
A nurse at a prenatal clinic is assessing an adolescent who is pregnant and is visiting the clinic for the first time. Which of the following factors is the nurse's priority to evaluate? A. Psychological readiness B. Partner support C. Socioeconomic status D. Nutritional status
D. Nutritional status Explanation: When using Maslow's hierarchy of needs, the nurse should determine that the priority factor to evaluate is the adolescent's nutritional status.
A nurse is caring for a client who has clinical manifestations of ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? A. Anemia B. Frequent urinary tract infections C. Previous cesarean birth D. Pelvic inflammatory disease (PID)
D. Pelvic inflammatory disease (PID) Explanation: An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and placenta, and the fetus begin to develop in this area. The most common site is within a fallopian tube, but ectopic pregnancies can occur in the occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, PID places the client at risk of an ectopic pregnancy.
A nurse is caring for a pregnant client who is at 37 weeks of gestation and who had a biophysical profile with a total score of 4. Which of the following actions should the nurse anticipate taking? A. Discharge the client home B. Administer betamethasone C. preform amnio fusion D. Prepare for delivery of the infant
D. Prepare for delivery of the infant Explanation: Delivery is considered when a biophysical profile score of 6 or lower is obtained after 36 weeks of gestation or with a score or 4 or lower at any gestational age.
A nurse is assessing a client who has hyperemesis gravidarum. Which of the following findings should the nurse expect? A. Elevated serum potassium level B. Rapid weight gain C. Peripheral edema D. Presence of ketones in the urine
D. Presence of ketones in the urine Explanation: the nurse should expect a client who has hyperemesis gravidarum to have ketonuria due to an inadequate dietary intake, resulting in the breakdown of protein and stored fat.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take? A. Administer penicillin G 2.4 million unit IM to the client. B. Instruct the client to schedule an annual pelvic examination C. Tell the client they will start medication for HIV immediately after delivery. D. Report the client's condition to the local health department.
D. Report the client's condition to the local health department. Explanation: HIV is one of the conditions on the list of Nationally Notifiable infections conditions that is required to be reported.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? A. Hypertonia B. Increased feeding C. Hyperthermia D. Respiratory distress
D. Respirator distress Explanation: Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestation include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.
