ATI - MATERNAL NEWBORN

A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching?

Correct Answer: C. "Your milk supply will noticeably increase in volume around the third or fourth day after delivery." As the colostrum transitions to mature breast milk, the volume of milk produced will also increase. Typically, the postpartum client will notice that 72 to 96 hours after delivery her breasts feel fuller and firmer and that milk is leaking from her nipples.

A nurse is counseling a female client who expresses a desire to conceive in the near future. Which of the following dietary recommendations should the nurse make to prevent neural tube defects?

Correct Answer: D. Begin taking a folic acid supplement Adequate amounts of folic acid are necessary for fetal neural tube development. All women of child-bearing age and intention should take a folic acid supplement of 0.4 mg.

A nurse is teaching a client about breastfeeding. Which of the following client statements indicates an understanding of the teaching? Show Explanation

Correct Answer: "I may notice increased cramping when I am feeding my baby." The client may notice an increase in uterine cramping while breastfeeding due to the release of oxytocin, which causes uterine muscle contraction. Incorrect Answers: A. A client who is breastfeeding requires an additional 500 calories per day to support lactogenesis. B. The client should not introduce an artificial nipple to the newborn until breastfeeding is well established (in approximately 3 or 4 weeks). D. The client should breastfeed on demand, not place the newborn on a strict feeding schedule. Forcing a newborn to wait for a feeding can lead to weight loss and failure to thrive.

A nurse is teaching a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching? Show Explanation

Correct Answer: "I should press the button on the handheld marker when my baby moves." The purpose of the test is to assess fetal wellbeing. The client should press the button on the handheld marker when she feels fetal movement. Incorrect Answers: A. There is no reason for the client to be NPO for this test. The client is encouraged to eat prior to the test in order for the fetus to be more active. When the fetus is asleep, the nurse often offers the client orange juice to stimulate the fetus. B. The client does not need medication to induce contractions. Oxytocin is used to induce contractions for an oxytocin challenge test. D. The client does not need to perform nipple stimulation to induce contractions; this is needed for a contraction stress test.

A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching?

Correct Answer: "I will place my baby on his back when putting him to sleep." Newborns should always sleep on the back to prevent sudden infant death syndrome. Incorrect Answers: B. The parents should not place the newborn's crib close to a heat source due to the risk of the crib linen catching on fire. C. The parents should always place the newborn in an approved car seat while driving with the newborn. Infant carriers are not approved safety seats for motor vehicles. D. The parents should never tie any type of string or cord around the newborn's neck due to the risk of strangulation.

A nurse is discussing potential complications of newborn hypothermia with a newly licensed nurse. Which of the following complications should the nurse include?

Correct Answer: B. Hypoglycemia Newborn hypothermia can cause hypoglycemia because anaerobic glycolysis can deplete glycogen stores. Incorrect Answers: A. Newborn hypothermia can cause bradycardia and irritability. Hyperthermia can cause tachycardia. C. Newborn hypoglycemia can cause central cyanosis and cool, mottled skin. Hyperthermia can cause flushed skin. D. Generalized petechiae can indicate a clotting disorder; this condition is not caused by hypothermia.

A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include?

Correct Answer: "Place fresh cabbage leaves on your breasts." After 3 days postpartum, the client's breasts can become swollen and distended because of congestion of the vascular structures of the breasts. Fresh cabbage leaves can be applied to engorged breasts to help relieve breast discomfort. The coolness of the leaves and the phytoestrogens exert a therapeutic effect on engorged breasts. Leaves should be replaced when they become wilted. Incorrect Answers: A. The client should be instructed to wear a tight-fitting bra or breast binders to alleviate engorgement and swelling. C. Application of warmth to the breasts should be avoided because heat can stimulate milk production. An ice pack should be used to relieve engorged breasts. D. Milk should not be expressed from the breasts. This intervention would increase milk production rather than decrease it.

A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide?

Correct Answer: "You should slightly increase your exposure to sunlight." Pruritus gravidarum is a condition of pregnancy that causes generalized itching without the presence of a rash. This occurs due to the stretching of the skin. Exposure to sunlight can reduce itching. Incorrect Answers: B. Pruritus gravidarum is a condition of pregnancy that causes generalized itching that occurs due to the stretching of the skin. It will resolve without extensive treatment after delivery. C. Pruritus gravidarum is a condition of pregnancy that will go away after delivery. It has no effect on the liver. Therefore, the client will not require weekly liver function studies. D. Isotretinoin cream is used to treat acne. It should not be prescribed to a client who is pregnant due to its teratogenic effects on the fetus.

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? (Fill in the blank with the numeric value only, round the answer to the nearest hundredth, and use a leading zero if applicable. Do not use a trailing zero.) Show Explanation

Correct Answer: 0.25 To solve using the ratio and proportion method: Step 1: What is the unit of measurement the nurse should calculate? mg Step 2: Set up an equation and solve for X: mg x kg = X 0.04 mg x 2.5 kg = 0.1 mg Step 3: What is the unit of measurement the nurse should calculate? mL Step 4: What is the dose the nurse should administer? 0.1 mg Step 5: What is the dose available? 0.4 mg Step 6: Should the nurse convert the units of measurement? No Step 7: What is the quantity of the dose available? 1 mL Step 8: Set up the equation and solve for X. Have/Quantity = Desired/X 0.4 mg/1 mL = 0.1 mg/X X = 0.25 mL Step 9: Reassess to determine whether the amount to administer makes sense. If 0.4 mg/mL is available and the prescription is 0.1 mg, the nurse should administer morphine oral solution 0.25 mL. To solve using the "desired over have" method: Step 1: What is the unit of measurement the nurse should calculate? mg Step 2: Set up an equation and solve for X: mg x kg = X 0.04 mg x 2.5 kg = 0.1 mg Step 3: What is the unit of measurement the nurse should calculate? mL Step 4: What is the dose the nurse should administer? 0.1 mg Step 5: What is the dose available? 0.4 mg Step 6: Should the nurse convert the units of measurement? No Step 7: What is the quantity of the dose available? 1 mL Step 8: Set up the equation and solve for X. Desired x Quantity/Have = X 0.1 mg x 0.4 mg/1 mL = 0.25 mL X = 0.25 mL Step 9: Reassess to determine whether the amount to administer makes sense. To solve using dimensional analysis: Step 1: What is the unit of measurement the nurse should calculate? mg Step 2: Set up an equation and solve for X: mg x kg = X 0.04 mg x 2.5 kg = 0.1 mg Step 3: What is the unit of measurement the nurse should calculate? mL Step 4: What is the quantity of the dose available? 1 mL Step 5: What is the dose available? 0.4 mg Step 6: What is the dose the nurse should administer? 0.1 mg Step 7: Should the nurse convert the units? No Step 8: Set up the equation and solve for X. X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired 0.4 mg/1 mL x 0.1 mg = 0.25 mL X = 0.25 mL Step 9: Reassess to determine whether the amount to administer makes sense.

A nurse is teaching about preventing engorgement to a client who is planning to use formula to feed her newborn. Which of the following instructions should the nurse include?

Correct Answer: A. "Apply ice packs to your breasts." Applying ice packs to the breasts can assist in reducing the discomforts of engorgement. Incorrect Answers:B. Pumping or hand expressing can cause breast stimulation and continued milk production. C. The client should wear a well-fitted and supportive bra for the first 72 hours after delivery to assist with suppression of lactation. D. No medications are indicated for lactation suppression.

A nurse is providing discharge instructions to the parent of a newborn. Which of the following statements should the nurse include?

Correct Answer: A. "Crib slats should be less than 2.25 inches apart." Crib slats should be no more than 5.7 cm (2.25 in) apart to prevent injuries due to falls or entrapment of the infant's head between the slats. Incorrect Answers:B. Room sharing, not bed sharing, is recommended for safe sleep. Bed sharing can increase the child's risk of suffocation and SIDS. C. The parent should always place the newborn on his back to sleep to decrease the risk of SIDS. D. The parent should not place the crib next to a heating vent or radiator to prevent overheating and injury from burns.

A nurse is caring for a client who is in labor and asks her partner to perform effleurage. The client has on a monitor belt for electronic fetal monitoring. Which of the following instructions should the nurse provide to the client's partner?

Correct Answer: A. "Lightly stroke the upper thighs." Effleurage involves lightly stroking or massaging the abdomen in rhythm with breathing to help relieve labor pain. However, when a monitor belt is in use, the sides of the abdomen, chest, or upper thighs are alternative locations for massage. Incorrect Answers: B. "Steadily apply pressure to the sacrum." - This technique is known as counter-pressure and is used to help decrease lower back pain by relieving occiput pressure on the spinal nerves. C. Gently massaging the abdomen is therapeutic for pain relief; however, massage of the mid-abdominal area is not possible for this client due to the positioning of the monitor belt. D. "Firmly squeeze both hips." - This is a method of counter-pressure and is used to help relieve lower back pain by placing pressure on the hips.

A nurse is providing education to a client who is 4 weeks postpartum and is breastfeeding. The client asks about expected weight loss. Which of the following responses should the nurse make? Show Explanation

Correct Answer: A. "Losing 2.2 pounds each month would be acceptable." 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. Incorrect Answers:B. C. D.. Clients who are not lactating should lose approximately 0.5 to 0.9 kg (1.1 to 2 lb) per week.

A nurse in a provider's office is caring for a client who is in the first trimester of pregnancy. Which of the following psychological tasks should the nurse expect the client to accomplish during this trimester?

Correct Answer: A. Accepting the pregnancy Accepting the pregnancy is a psychological task that the client is expected to accomplish during the first trimester. Incorrect Answers:B. Preparing for the end of pregnancy is a psychological task that the client is expected to accomplish during the third trimester. C. Preparing for parenthood is a psychological task that the client is expected to accomplish during the third trimester. D. Accepting the baby is a psychological task that the client is expected to accomplish during the second trimester.

A nurse is caring for a client in the third trimester of pregnancy who is scheduled to undergo a non-stress test. Which of the following actions should the nurse take prior to the test? Show Explanation

Correct Answer: A. Ask the client to drink a glass of orange juice The nurse should give the client orange juice or a glucose preparation prior to this test. This should raise the client's blood glucose level and help promote fetal movement. Incorrect Answers:B. A non-stress test involves the application of a fetal heart monitor and a tocodynamometer to track uterine contractions and fetal movement. There is no vaginal examination with this procedure. C. A non-stress test evaluates the fetal heart rate's response to uterine contractions and fetal movement. It does not involve the client's hemoglobin level. D. A non-stress test evaluates the fetal heart rate's response to uterine contractions and fetal movement. It does not involve identifying indications of a urinary tract infection in the client.

A nurse is caring for a client at 32 weeks gestation who is experiencing preterm labor. Which of the following medications should the nurse plan to administer?

Correct Answer: A. Betamethasone The nurse should plan to administer betamethasone IM, a glucocorticoid, to stimulate fetal lung maturity and prevent respiratory depression. Incorrect Answers: B. The nurse should administer misoprostol to stimulate uterine contractions for a client who is undergoing labor induction. C. The nurse should administer methylergonovine to stimulate uterine contractions for a client who is experiencing postpartum hemorrhage. D. The nurse should administer poractant alfa, a synthetic lung surfactant, to a preterm newborn who is experiencing respiratory distress.

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?

Correct Answer: A. Copper intrauterine device A history of thrombophlebitis is a contraindication for the use of hormonal contraceptive methods such as oral combinations of estrogen and progesterone in pill form, vaginal inserts that release hormones continuously, and injectable progestins. A copper intrauterine device that does not contain hormones is a safer choice for this client. Other options for this client include barrier methods and spermicides.

A nurse is assessing a client who has placenta previa. Which of the following findings should the nurse expect?

Correct Answer: A. Painless, bright red bleeding Placenta previa is the placement of the placenta low in the uterus. Depending on the severity, manifestations include bright red vaginal bleeding and a fundal height higher than expected for the gestational age. The presenting part is higher due to the placenta taking up space inside the lower part of the uterus. Incorrect Answers:B. Uterine hypertonicity is a manifestation of placental abruption, not placenta previa. C. Uterine tonicity is normal with placenta previa; it does not cause contractions. D. Abdominal tenderness or pain is a manifestation of placental abruption, not placenta previa.

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?

Correct Answer: A. Palpable fetal movement Palpable fetal movements are a positive sign of pregnancy. Quickening, the client's report of fetal movement, is a presumptive sign of pregnancy. Incorrect Answers: B. Chadwick's sign is a bluish discoloration of the cervix, vagina, and vulva that occurs at 6 to 8 weeks of pregnancy. This is a probable sign of pregnancy. After the client's first pregnancy, this discoloration can remain, reducing its value as an indicator in subsequent pregnancies. C. A positive pregnancy test is a probable sign of pregnancy. A client can also have a positive pregnancy test due to menopause, choriocarcinoma, and hydatidiform mole. D. Amenorrhea, or lack of a menstrual period, is a presumptive sign of pregnancy. A client also can have amenorrhea due to stress, endocrine disorders, and significant weight loss.

A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take?

Correct Answer: A. Place the unwrapped newborn on the mother's bare chest. Skin-to-skin contact will maintain the newborn's temperature and illicit instinctive newborn feeding behaviors. Incorrect Answers:B. Breastfed infants should not be fed anything except breast milk unless deemed medically necessary. C. Newborns should never be bathed under running water. The temperature of the water could change and cause burns or cold stress in the newborn. Additionally, bathing should be delayed until the completion of the first breastfeeding. D. Routine care such as bathing, weighing, eye prophylaxis, and a vitamin K injection should all be delayed until after the infant has completed the first feeding.

A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. Which of the following actions should the nurse take?

Correct Answer: A. Promote active movement in and out of bed During the early stages of labor, the nurse should encourage activity through walking, kneeling, squatting, being on hands and knees, or whatever the client prefers. This can help shorten the earlier stage. During the second stage, the client should remain in bed if her membranes have ruptured or if she has received analgesics. In bed, she should lie on her left side often but shift positions frequently for comfort and to promote the progression of labor. Incorrect Answers: B. Having the client hold her breath while pushing increases intrathoracic and cardiovascular pressure and decreases the amount of oxygen that reaches the fetus. C. The nurse should assess the client's vital signs every 5 to 30 minutes while the client is in the second stage of labor. D. The client should remain on bedrest during this stage of labor due to impending delivery.

A nurse is caring for a newborn who is receiving treatment for jaundice with traditional phototherapy lights. Which of the following interventions should the nurse perform? Show Explanation

Correct Answer: A. Turn the newborn every 2 hr Phototherapy lowers serum bilirubin levels by converting bilirubin accumulated in the skin to a form that is excreted in the newborn's urine and stools. The infant must be turned every 2 to 3 hours to maximize skin exposure, which promotes bilirubin breakdown. Incorrect Answers:B. Hydration should be maintained through breastfeeding or formula-feeding, both of which promote the excretion of bilirubin. Glucose water and plain water do not promote bilirubin excretion. C. The infant should be clothed only in a diaper to maximize skin exposure. D. Ointments, creams, and lotions should be avoided because they have the potential to absorb heat and cause burns.

A nurse is caring for a client at 37 weeks gestation who 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? Show Explanation

Correct Answer: A. Use vibroacoustic stimulation on the client's abdomen for 3 sec 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. Incorrect Answers:B. The nurse will determine a nonstress test to be nonreactive after 40 minutes of continuous monitoring without accelerations in the FHR despite vibroacoustic stimulation. C. The client should have an internal fetal scalp electrode during labor to monitor the FHR. D. The external fetal monitor is recording the FHR. Therefore, it is not necessary for the nurse to auscultate the FHR with a Doppler.

A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or an abruptio placenta?

Correct Answer: A. Uterine tone The uterus will be relaxed, soft, and painless if the bleeding is caused by placenta previa. With abruptio placenta, the uterus will be firm and board-like, and the client will complain of pain. Incorrect Answers: B. Fetal distress may be present in both abruptio placenta and placenta previa. C. Hypotension may be present in both conditions. D. The amount of blood loss is not diagnostic of the cause of the bleeding.

A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the bleeding is caused by placenta previa or an abruptio placenta? Show Explanation

Correct Answer: A. Uterine tone The uterus will be relaxed, soft, and painless if the bleeding is caused by placenta previa. With abruptio placenta, the uterus will be firm and board-like, and the client will complain of pain. Incorrect Answers:B. Fetal distress may be present in both abruptio placenta and placenta previa. C. Hypotension may be present in both conditions. D. The amount of blood loss is not diagnostic of the cause of the bleeding.

A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the following findings should the nurse expect?

Correct Answer: Abundant lanugo Newborns who are premature have abundant lanugo (fine hair), especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinna, and forehead. Incorrect Answers: B. Newborns who are premature demonstrate hypotonia and a relaxed posture. Full-term newborns demonstrate moderate flexion of the arms and legs. C. Newborns who are premature have few heel creases. Full-term newborns have heel creases that cover most of the bottom of the feet. D. Newborns who are premature have abundant vernix caseosa, a thick whitish substance, covering and protecting their skin in utero. Post-mature newborns are likely to have dry, parchment-like skin.

A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take?

Correct Answer: Apply cold ice packs to the client's perineum A third-degree laceration extends from the perineum to the external sphincter of the rectum. This can cause severe discomfort. Cold ice packs are used on the perineal area during the first 24 hours to decrease edema, pain, and discomfort. Incorrect Answers: A. Warm sitz baths are appropriate after the first 24 hours postpartum. A cool sitz bath is recommended within the first 24 hours to reduce edema and promote comfort. B. The nurse should encourage the client to sit on firm surfaces. The client should avoid soft pillows and donut pillows because they separate the buttocks and decrease venous blood flow, resulting in more pain and discomfort to the perineal area. D. The use of suppositories or enemas is contraindicated for a client who has a third-degree perineal laceration due to the severity of the laceration.

A nurse is assessing a client on the first postpartum day. Findings include the following: fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following actions should the nurse take? Show Explanation

Correct Answer: Ask the client when she last voided Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be firm at the midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void. Incorrect Answers: A. A slight maternal temperature increase is commonly seen in the first 6 to 10 days postpartum. A pulse of 52/minute is within the expected reference range. B. The nurse should massage the fundus when it is boggy. D. Administering an oxytocic agent is not an appropriate intervention. Oxytocic agents are given to clients who have increased lochia rubra or a boggy fundus to promote uterine contractions.

A nurse is caring for a client who is in labor and received meperidine for pain 1 hr prior to entering the second stage of labor. Which of the following actions should the nurse take?

Correct Answer: Assess the newborn for respiratory depression Meperidine should not be administered to laboring clients who are expected to deliver within 4 hours of the medication administration. This medication crosses the placenta and causes respiratory depression in the newborn, which peaks in 2 to 3 hours after administration. Narcan is ineffective at reversing the respiratory depression caused by this medication. Incorrect Answers: A. Meperidine does not affect the client's reflexes. It reduces the transmission of pain impulses through stimulation of the mu and kappa opioid receptors. C. Meperidine can cause tachycardia, nausea, vomiting, dizziness, and altered mental status. D. Neonatal abstinence syndrome occurs in newborns who are exposed to opioids over a long period of time during pregnancy. A client receiving an opiate during labor would not lead to opiate dependence in the newborn.

A nurse is caring for a client who experienced a fetal loss. When initiating communication with this client, which of the following statements should the nurse make?

Correct Answer: B. "I'm here for you if you would like to talk." This is a therapeutic statement because it acknowledges the client's loss and invites her to share her thoughts and feelings. Incorrect Answers:A. This is a nontherapeutic statement because the nurse should not presume to know how the client feels after a fetal loss. C. This is a nontherapeutic statement because it gives common advice. Furthermore, the nurse should never deny the bond that many pregnant women feel with the fetus throughout pregnancy. D. This is a nontherapeutic statement because it gives unwanted reassurance that has no basis in fact. Furthermore, the nurse should never assume that any other child could take the place of the lost child.

A nurse is teaching a client who is pregnant about nonstress testing. Which of the following pieces of information should the nurse include?

Correct Answer: B. "If the test is positive, that means your baby's heart rate is healthy." The fetal heart rate is considered healthy if the results of nonstress testing are positive. If the test is negative, fetal health may be affected, and further testing may be necessary to rule out poor oxygen perfusion of the fetus. Incorrect Answers:A. Nonstress testing is noninvasive and causes no risk to either the client or the fetus. It can be used as a screening procedure in all pregnancies. C. The test measures the response of the fetal heart rate to fetal movement. The fetal heart rate should increase by about 15 beats/min when the fetus moves and should remain increased for about 15 seconds. D. The test would be identified as nonreactive if there is no fetal movement during the testing period or if the fetal heart rate variability is under 6 beats/min.

A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which of the following instructions should the nurse include in the teaching?

Correct Answer: B. "Place ice packs on your breasts." The nurse should instruct the client to place ice packs on her breasts using a "15 minutes on and 45 minutes off" schedule to decrease swelling of the breast tissue as the body produces milk. Incorrect Answers: A. Warm water running over the breasts can stimulate milk production. C. The client should wear a well-fitting, supportive bra to provide comfort as the breasts fill with milk. D. The client should drink 2 to 3 L of fluid per day to promote normal bowel function.

A client at a routine prenatal care visit asks the nurse if developing vaginal yeast infections is common during pregnancy. Which of the following responses should the nurse make?

Correct Answer: B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common." This is an information-seeking question; therefore, the therapeutic response is an answer that provides the client with the information she requested. Incorrect Answers:A. This is a close-ended response that discourages further communication. C. This is a close-ended response that discourages further communication and is both nontherapeutic and inaccurate. D. Asking "why" questions typically makes clients feel defensive.

A nurse is caring for a primigravid client who is at 8 weeks gestation with twins. The client states that even though she and her husband planned this pregnancy, she is experiencing ambivalent feelings about it. Which of the following responses should the nurse make? Show Explanation

Correct Answer: B. "These feelings are quite normal at the beginning of pregnancy." This client needs reassurance that these feelings are normal and that there is no reason for concern. Incorrect Answers:A. C. This nontherapeutic response puts the client's feelings on hold and insinuates that there is a problem that needs to be resolved. D. This is an inappropriate response because the client's feelings are normal, and there is no reason for concern.

A nurse is planning care for a client in labor who is positive for HIV. Which of the following actions should the nurse take after the baby is born? Show Explanation

Correct Answer: B. Administer the hepatitis B vaccine prior to discharge Infants who are exposed to HIV should receive all routine vaccinations. Infants who are infected with HIV can receive all inactivated vaccinations. Incorrect Answers:A. In the United States and Canada, breastfeeding should be avoided by mothers who are HIV-positive. C. The nurse should use standard precautions when caring for a newborn who has been exposed to HIV. D. To test a newborn for the presence of HIV, a sample of the newborn's blood must be obtained. Maternal antibodies will be present in the cord blood and can affect the test results.

A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform?

Correct Answer: B. Assess the newborn's blood glucose level Infants who become cold attempt to generate heat through increased muscular and metabolic activity. This process increases glucose consumption and puts the newborn at risk of hypoglycemia. Incorrect Answers: A. The nurse should not obtain a rectal temperature from a newborn due to the risk of rectal perforation. Instead, the nurse should obtain an axillary temperature. C. Bathing a newborn will increase heat loss. The infant should not be bathed until the temperature has stabilized within the normal range. D. Placing the infant in front of a heater vent can incur heat loss through convection. Additionally, there is a potential fire risk from the bassinet linens and the vent.

A nurse is caring for a recently delivered newborn whose mother had gestational diabetes. What action should the nurse take within 1 hr after birth?

Correct Answer: B. Assess the newborn's blood glucose level Newborns whose mothers have diabetes have a greater risk of developing hypoglycemia due to the cessation of the fetal blood glucose supply and fetal hyperinsulinemia. Blood glucose levels should be assessed within 1 hour after birth, followed closely, and treated promptly when needed. Incorrect Answers:A. The nurse should administer the HBV vaccine prior to discharge. There is no indication to administer the vaccine within 1 hour after birth. C. The nurse should not bathe the newborn until the newborn's temperature has stabilized in the extra-uterine environment. Ideally, the nurse should place the infant in skin-to-skin contact with the mother for at least the first 1 to 2 hours after birth. Alternately, the nurse can place the newborn under a radiant heat source and assess the newborn's temperature every hour until it is stabilized. D. The nurse should use a pulse oximeter to screen for congenital heart disease 24 to 48 hours after birth. If the nurse performs the screening prior to 12 hours after birth, acrocyanosis might alter the results.

A nurse is providing teaching for new parents about formula feeding. Which of the following instructions should the nurse include?

Correct Answer: B. Discard opened cans of formula after 48 hr refrigeration. Opened cans and prepared bottles of formula must be refrigerated and discarded after 48 hours due to the risk of bacterial contamination.

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider?

Correct Answer: B. Double vision Double vision, blurred vision, or visual disturbances are signs of potential complications associated with preeclampsia. The nurse should report this finding to the provider. Incorrect Answers:A. Varicose veins are a common manifestation associated with pregnancy. They are caused by the relaxation of the smooth muscle walls of the veins and pelvic vasocongestion. C. Leukorrhea is a hormonal production of an abundant amount of mucus. It is a common manifestation associated with pregnancy. D. Flatulence is a common manifestation associated with pregnancy. Progesterone causes reduced gastrointestinal motility.

A nurse is caring for a client who is in labor and has received epidural analgesia. The client's blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take?

Correct Answer: B. Increase the rate of the primary IV infusion Late decelerations can be caused by uteroplacental insufficiency. The fetal heart tracing shows a gradual decrease in fetal heart rate with a return to baseline on uterine contractions. This could be related to maternal hypotension, which can be corrected with increased IV fluids to increase maternal blood volume. This improves uterine and cardiac perfusion as well. Incorrect Answers: A. A client who has received epidural analgesia should not be assisted out of bed to the toilet or a bedside commode due to inhibited muscle control and the increased risk of falling. C. Maternal position influences both maternal hypotension and the fetal response to low blood pressure. Positioning the client in a lateral or Trendelenburg position improves maternal circulation. D. Hypotension is a function of low blood pressure rather than low blood glucose. The nurse should address low blood pressure through positioning and bolus IV fluids.

A nurse is caring for a client who is in labor and has received epidural analgesia. The client's blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take? Show Explanation

Correct Answer: B. Increase the rate of the primary IV infusion Late decelerations can be caused by uteroplacental insufficiency. The fetal heart tracing shows a gradual decrease in fetal heart rate with a return to baseline on uterine contractions. This could be related to maternal hypotension, which can be corrected with increased IV fluids to increase maternal blood volume. This improves uterine and cardiac perfusion as well. Incorrect Answers:A. A client who has received epidural analgesia should not be assisted out of bed to the toilet or a bedside commode due to inhibited muscle control and the increased risk of falling. C. Maternal position influences both maternal hypotension and the fetal response to low blood pressure. Positioning the client in a lateral or Trendelenburg position improves maternal circulation. D. Hypotension is a function of low blood pressure rather than low blood glucose. The nurse should address low blood pressure through positioning and bolus IV fluids.

A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of the following actions should the nurse take to promote development?

Correct Answer: B. Position the naked newborn on the parent's bare chest Positioning the naked newborn on the parent's bare chest can decrease stress in the parent and the newborn. This action can help maintain thermal stability, raise oxygen saturation, increase feeding strength, and promote breastfeeding. Incorrect Answers: A. The nurse should assess the newborn to determine how well she will tolerate feedings and gradually make changes. Rapidly advancing feedings can lead to fluid retention, hyponatremia, vomiting, diarrhea, and apnea. C. Newborns need uninterrupted periods of sleep to promote self-regulation. Light and sounds are adverse stimuli and can increase stress in a newborn who is premature. D. Nonnutritive sucking can decrease oxygen use and energy, which can lead to decreased restlessness.

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?

Correct Answer: B."You will receive a medication to relax your uterus prior to the procedure." 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 relaxed uterus allows an easier version by the provider. Incorrect Answers: A. This action is appropriate for internal version. With external version, the provider attempts to turn the fetus around externally and not internally. C. External version is a high-risk procedure that is performed in a hospital setting in the event of an emergency. D. During the external version, the fetal heart-rate pattern is monitored continuously because the fetus is at risk of bradycardia and variable decelerations. The nurse also monitors the fetal heart rate for at least 60 minutes following the procedure.

A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include?

Correct Answer: B.Sponge bathe the newborn every other day 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. Incorrect Answers: A. In uncircumcised males, the foreskin adheres to the glans of the penis. Parents should not attempt to retract the foreskin before the age of 3 years. Parents should wash the penis with soap and water. C. The parents should avoid using antimicrobial soaps and instead use soap with a neutral pH and no preservatives to protect the acid mantle of the newborn's skin. D. The parents should maintain the bath water temperature between 38° and 40°C (100° and 104°F).

A nurse is teaching a client during the client's first prenatal visit. Which of the following instructions should the nurse include?

Correct Answer: C. "A Doppler device can detect your baby's heart rate at 12 weeks." The nurse should be able to detect the fetal heartbeat with a Doppler device toward the end of the first trimester, often as early as 10 weeks of gestation. Incorrect Answers: A. The nurse should be able to hear fetal heart tones with a fetoscope by the end of the sixteenth week of gestation. B. Typically, the sex of the fetus is distinguishable on a sonogram by the end of the twelfth week. D. Quickening (feeling fetal movement) is typically possible at 14 to 16 weeks in multiparous clients; however, it is sometimes not possible until week 18 or later in nulliparous clients.

A nurse is providing teaching about the rubella immunization to a client who is 24 hours postpartum. Which of the following client statements indicates an understanding of the teaching? Show Explanation

Correct Answer: C. "I should be careful to avoid becoming pregnant within the next month." While the chances of fertility in the first 4 weeks postpartum are low, clients who receive a rubella immunization must be additionally careful to avoid pregnancy either through maintaining abstinence or through using an effective contraceptive. The rubella vaccine is a live virus vaccine and can cause birth defects. Incorrect Answers:A. The rubella vaccine is a live virus vaccine, but the live attenuated rubella virus is not passed via breastmilk. However, it can be spread via other bodily fluids such as urine. If there are other family members who are immunocompromised, the vaccine should not be administered to the client. B. A single rubella vaccine postpartum is adequate for most non-immune clients. If a client also receives RhoGAM postpartum, the client should be tested 3 months postpartum to verify immunity. D. The rubella vaccine is administered as the MMR (measles, mumps, and rubella) vaccine subcutaneously.

A nurse is teaching a client who is in labor about the use of nitrous oxide analgesia for pain control. Which of the following statements by the client indicates an understanding of the teaching? Show Explanation

Correct Answer: C. "I will feel the effects of the nitrous oxide almost immediately." The effects of nitrous oxide are felt within 1 minute of inhalation. Incorrect Answers:A. Nitrous oxide does not appear to cause neonatal sedation or a difference in Apgar scores. B. The client should inhale nitrous oxide through a face mask as the contraction begins and use it during the contraction. D. Nitrous oxide induces a feeling of relaxation and decreases the client's perception of pain. It does not cause feelings of disorientation.

A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure? Show Explanation

Correct Answer: C. Administer immune globulin to the client to prevent fetal isoimmunization Because the client is Rh-negative, Rh immune globulin is administered after the procedure to prevent fetal isoimmunization or help ensure maternal antibodies will not form against any placental red blood cells that might have accidentally been released into the maternal bloodstream during the procedure. Incorrect Answers:A. The provider screens the client for chlamydia during a pelvic examination rather than through an amniocentesis. B. Testing the client's blood for Rh antibodies is done at the beginning of pregnancy and repeated at 28 weeks. This diagnostic test is performed on the client's blood rather than amniotic fluid. D. The provider performs the amniocentesis with sterile technique; although infection is a risk with any invasive procedure, the routine administration of prophylactic antibiotics is not indicated.

A nurse is assessing a client who delivered vaginally 8 hours ago. The nurse notes that the client's fundus is 2 fingerbreadths above the umbilicus and has shifted to the left, and there is a large amount of lochia rubra on the perineal pad. Which of the following actions should the nurse take first? Show Explanation

Correct Answer: C. Assist the client to the toilet Evidence-based practice indicates that the nurse should first help the client empty her bladder. Displacement of the fundus to the left indicates that the cause of the excessive bleeding is uterine atony due to bladder distention, so this action is the nurse's priority. Incorrect Answers:A. The nurse should administer analgesia because pain can prevent the client from emptying her bladder; however, evidence-based practice indicates that another action is the priority. B. The nurse should administer a prescribed prostaglandin preparation to help control the bleeding; however, evidence-based practice indicates that another action is the priority. D. The nurse should obtain a blood specimen for Hct and Hgb to monitor the systemic effect of the client's blood loss and the effectiveness of treatment; however, evidence-based practice indicates that another action is the priority.

The parents of a child with phenylketonuria (PKU) ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns responsible for PKU?

Correct Answer: C. Autosomal recessive PKU is inherited by autosomal-recessive gene patterns. In these types of disorders, neither parent may actually have the disorder, but both mother and father must carry and contribute a variant gene for it to occur. Other autosomal-recessive disorders are cystic fibrosis and sickle cell anemia. Incorrect Answers: A. PKU does not have an X-linked recessive pattern of inheritance. In X-linked recessive disorders, the abnormal gene is carried on the X chromosome. In males, only 1 copy of the abnormal gene is required for the disorder to be expressed in males since the Y chromosome does not carry the disorder. Females must have 2 copies of the gene. Examples of this type of disorder are hemophilia and color blindness. B. PKU does not have an X-linked dominant pattern of inheritance. In X-linked dominant disorders, the abnormal gene is carried on the X chromosome. Only 1 copy of the abnormal gene is necessary for the disorder to occur. However, males are more likely to be severely affected due to the homozygous expression. There are only a few disorders that follow this pattern of inheritance. Examples include vitamin D-resistant rickets and Rett syndrome. D. PKU does not have an autosomal-dominant pattern of inheritance. In these disorders, only 1 copy of the variant gene is necessary for the disorder to occur. Examples of this type of disorder are neurofibromatosis and Treacher Collins syndrome.

A nurse is caring for a client who has eclampsia and just had a tonic-clonic seizure. After turning the client's head to the side, which of the following actions should the nurse take next? Show Explanation

Correct Answer: C. Give oxygen at 10 L/min via face mask The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to administer oxygen to help stabilize the client's respiratory status. Incorrect Answers:A. The nurse should administer magnesium sulfate to prevent further seizure activity; however, there is another action the nurse should take first. B. The nurse should insert an indwelling urinary catheter to monitor the client's fluid output. Fluids should be restricted for a client who has eclampsia, but the client's output should be at least 25 mL/hr. However, there is another action the nurse should take first. D. The nurse should reduce environmental stimuli to help prevent further seizure activity and to promote rest following the seizure; however, there is another action the nurse should take first.

A nurse is caring for a client labor who has an epidural for pain relief. Which of the following is a complication of the epidural block?

Correct Answer: C. Hypotension Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of epidural anesthesia in order to decrease the likelihood of this complication.

A nurse is performing a physical assessment of a newborn. Which of the following actions should the nurse take?

Correct Answer: C. Measure the circumference of the newborn's head with a tape measure just above the eyebrows Shortly after birth, the nurse should measure the circumference of the newborn's head at its largest diameter, which is around the occipitofrontal area. Incorrect Answers:A. The nurse should measure the newborn's length from the top of the head to the heel. B. The nurse should remove the newborn's diaper and clothing to measure weight. D. The nurse should measure the newborn's chest circumference at the nipple line, not below it.

A nurse is calculating a pregnant client's estimated date of delivery using Naegele's rule. The client's last menstrual period started on January 20. Which of the following is the client's expected date of delivery? Show Explanation

Correct Answer: C. October 27 Naegele's rule involves subtracting 3 months from the first day of the last menstrual period and adding 7 days. Incorrect Answers:A. An expected date of delivery of October 13 would follow a last menstrual period date of January 6. B. An expected date of delivery of November 13 would follow a last menstrual period date of February 6. D. An expected date of delivery of November 27 would follow a last menstrual period date of February 20.

A nurse is caring for a client who had a precipitous delivery. Which of the following assessments is the priority during the fourth stage of labor?

Correct Answer: C. Palpating the client's fundus The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. 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. A precipitous delivery follows a labor of <3 hours. Regardless of the cause of the rapid delivery, uterine atony can result, causing postpartum hemorrhage. The nurse should palpate the fundus and massage as needed to monitor for and reduce the risk of hemorrhage. Incorrect Answers:A. The nurse should monitor the client's temperature during the fourth stage of labor; however, another assessment is the priority. B. The nurse should assess the client's perineum, especially if an episiotomy or laceration is present; however, another assessment is the priority. D. The nurse should check the client for hemorrhoids during the fourth stage of labor; however, another assessment is the priority.

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?

Correct Answer: C. Calcium gluconate The nurse should discontinue the magnesium sulfate infusion immediately and prepare to administer calcium gluconate IV to reverse the effects of magnesium sulfate and to prevent cardiac and respiratory arrest. Incorrect Answers: A. Protamine sulfate helps reverse the effects of heparin, not magnesium sulfate. B. Naloxone is an opioid reversal agent. It does not reverse the effects of magnesium sulfate. D. Flumazenil reverses the effects of benzodiazepines such as lorazepam and alprazolam, not magnesium sulfate.

A nurse is teaching a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include?

Correct Answer: C. Stress incontinence The nurse should teach the client that stress incontinence can occur due to the shrinking of the uterus, vulva, and distal portion of the urethra. Urinary incontinence and uterine displacement can occur because of common age-related changes but are not necessarily a result of menopause-related changes. Incorrect Answers: A. The nurse should teach the client that urinary frequency, not hesitancy, can occur due to the shrinking of the uterus, vulva, and distal portion of the urethra. B. The nurse should teach the client that hematuria is a manifestation of irritation to the bladder mucosa and might indicate a urinary tract infection. It is not an expected change associated with menopause. D. The nurse should teach the client that vaginal dryness can occur with menopause due to the vaginal walls becoming thinner and drier, delaying lubrication. This can lead to painful intercourse.

A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min and respiratory rate of 36/min. The newborn has well-flexed extremities, responds to stimuli with a cry, and has blue hands and feet. Which Apgar score should the nurse assign to the newborn?

Correct Answer: C.9 The nurse should use the Apgar scoring system to perform a quick assessment of the newborn at 1 minutes and 5 minutes after birth. The nurse should assign a score of 0, 1, or 2 to each of 5 categories. The nurse should assign a score of 2 for a heart rate >100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well-flexed extremities, which shows normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a score of 1 for blue hands and feet, which is known as acrocyanosis. Incorrect Answers: A. 7 is not the correct Apgar score for this newborn. B. 8 is not the correct Apgar score for this newborn. D. 10 is not the correct Apgar score for this newborn.

A nurse is caring for a client who is receiving magnesium sulfate IV. Which of the following medications should the nurse have available as an antidote to magnesium sulfate? Show Explanation

Correct Answer: Calcium gluconate Calcium gluconate should be kept available as the antidote for magnesium sulfate toxicity. Incorrect Answers: A. Betamethasone is administered to help mature the lungs of the premature fetus before delivery. It is not an antidote to magnesium sulfate. B. Terbutaline is a smooth muscle relaxer administered to inhibit uterine contractions in premature labor. It is not an antidote to magnesium sulfate. D. Indomethacin relaxes uterine smooth muscle and is administered to stop preterm labor. It is not an antidote to magnesium sulfate.

A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following medications should the nurse have available at the client's bedside?

Correct Answer: Calcium gluconate The nurse should have calcium gluconate available for a client who is receiving magnesium sulfate by continuous IV infusion in case of magnesium sulfate toxicity. The nurse should monitor the client for a respiratory rate of ≤12/min, muscle weakness, and depressed deep-tendon reflexes. Incorrect Answers: A. The nurse should have naloxone available for a client who is receiving opioid medication in case of respiratory depression. C. The nurse should have protamine sulfate available for a client who is receiving heparin in case of hemorrhage. D. The nurse should have atropine available for a client who is receiving medications that can lead to asystole or sinus bradycardia, such as beta-adrenergic blockers.

A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect?

Correct Answer: D. Fetal gastrointestinal anomaly Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurological disorders are expected findings for a fetus experiencing the effects of polyhydramnios. Incorrect Answers: A. Polyhydramnios will result in a fundal height greater than expected for gestational age. B. Polyhydramnios will result in an increase in weight gain, not a decrease. C. Gestational hypertension causes oligohydramnios, which is a decrease in the amount of amniotic fluid surrounding the fetus.

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?

Correct Answer: D. "A progestin-only pill or injection is available for use while you are breastfeeding." Progestin-only injections, implants, and birth control pills are acceptable options for clients who are breastfeeding, although some experts recommend waiting until 6 weeks postpartum to initiate the medication. Incorrect Answers: A. Breastfeeding can inhibit ovulation or prolong menstruation; however, it is not a reliable and effective means of birth control. The client may experience an unplanned pregnancy if she waits until her periods resume before considering birth control options. B. Estrogen-containing birth control pills, implants, patches, and vaginal rings are not recommended for clients who are breastfeeding due to the risk of inhibiting breast milk production and supply. C. Condoms and other non-hormonal birth control methods are appropriate for clients who are breastfeeding; however, there are other methods that are also appropriate.

A nurse is assessing a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements?

Correct Answer: D. "The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract." Oxytocin is released in response to breastfeeding. This hormone also causes the uterus to contract, which decreases the risk for postpartum hemorrhage and increases involution.

A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make?

Correct Answer: D. "This is a source of your fluid loss after delivery." Postpartum diuresis is the loss of the remaining pregnancy-induced increase in blood volume. The loss of excess tissue fluid begins within 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. Incorrect Answers: A. Postpartum diuresis is attributed to decreased estrogen levels, the removal of increased venous pressure in the lower extremities, and the loss of the remaining pregnancy-induced increase in blood volume. B. Postpartum diuresis is caused by decreased estrogen levels. Fluid loss by urination and perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum period. C. Postpartum diuresis is caused, in part, by the removal of increased venous pressure in the lower extremities. Urine output can exceed 3000 mL/day during the first 2 to 3 days postpartum.

A nurse is teaching a client who is at 12 weeks gestation and has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching?

Correct Answer: D. "You should continue to take zidovudine throughout the pregnancy." The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmitting HIV to her newborn. Incorrect Answers:A. The client can transmit HIV through breast milk and should bottle-feed her newborn. B. The client can continue to have sexual intercourse during pregnancy, as long as a condom is used. C. The client and her newborn will only require standard precautions after delivery.

A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse include in the teaching?

Correct Answer: D. "You should eat dry foods that are high in carbohydrates when you wake up." The nurse should instruct the client to eat foods that are high in carbohydrates such as dry toast or crackers upon waking or when nausea occurs. Incorrect Answers: A. The nurse should instruct the client to eat foods served at cool temperatures to decrease nausea and vomiting. B. The nurse should instruct the client to avoid brushing her teeth immediately after eating to decrease vomiting. C. The nurse should instruct the client to eat salty and tart foods during periods of nausea.

A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take?

Correct Answer: D. Apply pressure to the client's sacral area during contractions The nurse should provide counter-pressure to the sacral area with a palm or a firm object, such as a tennis ball, during contractions. Counter-pressure lifts the fetal head away from the sacral nerves, which decreases pain. Incorrect Answers: A. The nurse should instruct the client to pant during contractions to prevent pushing or bearing down before the cervix is completely dilated during the transition phase of labor. Panting will not alleviate back pain during the latent phase of labor. B. The nurse should not place the client supine during labor because this will increase her back pain. C. The nurse should initiate hydrotherapy when the client is in the active phase of labor or approximately 5 cm (2 in) dilated. The use of hydrotherapy during the latent phase of labor can prolong the labor process.

A nurse is providing teaching to a client who is at 8 weeks gestation about manifestations to report to the provider during pregnancy. Which of the following pieces of information should the nurse include in the teaching?

Correct Answer: D. Blurred or double vision A client who is pregnant should report experiencing blurred or double vision, as these could be a manifestation of gestational hypertension or preeclampsia. Incorrect Answers:A. A client who is pregnant can have nausea upon awakening due to changes in hormone levels. B. A client who is pregnant can experience leg cramps while sleeping due to the compression of the pelvic nerves by the enlarged uterus. C. A client who is pregnant can have an increase in vaginal discharge due to hyperstimulation of the cervix from an increase in hormones.

A nurse is caring for a newborn immediately following birth. Which of the following actions should the nurse take first?

Correct Answer: D. Dry the newborn The greatest risk to the newborn immediately after birth is heat loss, which can cause cold stress, respiratory distress, and hypoglycemia. Therefore, the first action the nurse should take is to dry the newborn to prevent heat loss from evaporation. Incorrect Answers:A. The nurse should obtain the newborn's weight within 1 to 2 hours after birth. However, there is another action the nurse should take first. B. The nurse should instill erythromycin ophthalmic ointment in the newborn's eyes after the first breastfeeding to prevent infection. However, there is another action the nurse should take first. C. The nurse should administer vitamin K to the newborn within 1 to 2 hours after birth to prevent bleeding. However, there is another action the nurse should take first.

A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department? Show Explanation

Correct Answer: D. Gonorrhea Gonorrhea is often asymptomatic. The client might have purulent endocervical discharge. Gonorrhea is one of the infectious conditions on the Nationally Notifiable Infections list and should be reported by the nurse to the community health department, which will report the infection to the CDC. Incorrect Answers:A. Bacterial vaginosis, also known as vaginitis, is the most common vaginal infection. Manifestations include client report of a "fishy odor" and vaginal discharge that appears thin, watery, gray, white, or milky. The client might also report pruritus. This vaginal infection does not require reporting; however, it should be treated with metronidazole or clindamycin cream. B. Trichomoniasis can be asymptomatic. Manifestations include greenish to yellowish mucopurulent, frothy, malodorous discharge. This vaginal infection does not require reporting. C. Candidiasis, also known as a yeast infection, is the second-most common vaginal infection. Manifestations include a client report of thick, cottage cheese-like discharge and vaginal itching. This vaginal infection does not require reporting.

A nurse is caring for a client who is 3 days postpartum and has chosen to formula-feed her newborn. During an examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take?

Correct Answer: D. Instruct the client to apply cold compresses To help relieve breast engorgement, the client should apply cold compresses for about 15 minutes every hour. The client can also try applying fresh, cold cabbage leaves to the breasts. Incorrect Answers: A. If the client pumps her breasts, milk production will increase. A client who is formula-feeding her newborn needs to decrease milk production. B. Taking warm showers will increase milk production. C. Breast massage will not only be uncomfortable but also will increase milk production.

A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement?

Correct Answer: D. Slow-paced breathing Slow-paced breathing is an easy technique for the client to learn quickly and practice immediately. It provides distraction, which can help reduce the perception of pain. The pattern is In-2-3-4/Out-2-3-4/In-2-3-4/Out-2-3-4. Repeating this cycle slows the client's breathing to about half of its usual rate, which can help relax the client and improve oxygenation. Incorrect Answers: A. Self-hypnosis can help relieve labor pain, but clients might not be able to perform it if they haven't already learned from specially trained practitioners. B. Biofeedback can help relieve labor pain, but clients might not be able to implement it if they haven't already learned from specially trained practitioners. C. Specially trained practitioners perform acupuncture, so this is not something the nurse can initiate.

A nurse is performing an admission assessment of a client who just arrived at the labor and delivery unit. Which of the following findings should the nurse identify as the priority?

Correct Answer: D. The fetal heart rate is 90/min. Fetal bradycardia indicates that this client is at greatest risk for fetal consequences due to a cardiac disorder or infection, leading to hypoxia and asphyxiation; therefore, this is the priority finding.

A nurse is performing an admission assessment of a client who just arrived at the labor and delivery unit. Which of the following findings should the nurse identify as the priority?

Correct Answer: D. The fetal heart rate is 90/min. Fetal bradycardia indicates that this client is at greatest risk for fetal consequences due to a cardiac disorder or infection, leading to hypoxia and asphyxiation; therefore, this is the priority finding. Incorrect Answers:A. The nurse should intervene to help ease the client's pain; however, another assessment finding is the priority. B. The nurse should recheck the client's blood pressure in 30 minutes after the client has relaxed and between contractions to help rule out preeclampsia; however, another assessment finding is the priority. C. The nurse should notify the provider and perform a thorough assessment to rule out an infection such as chorioamnionitis; however, another assessment finding is the priority.

A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump following a cesarean birth. Which of the following findings should the nurse report to the provider?

Correct Answer: D. Urine output 20 mL/hr Opioid analgesics such as morphine can cause urinary retention. The client should have a urinary output of at least 30 mL/hr. The nurse should report this finding to the provider. Incorrect Answers: A. Opioid analgesics can cause respiratory depression. However, this respiratory rate is within the expected reference range. B. This temperature is within the expected reference range. C. Dizziness is a common adverse effect of receiving opioid analgesics. The nurse should instruct the client to sit on the side of the bed before getting up, assist the client with ambulation, and implement general safety measures. However, it is not necessary to report this finding to the provider.

A nurse is caring for a client at 35 weeks gestation who has severe pre-eclampsia. Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status? Show Explanation

Correct Answer: Daily weight Evidence-based practice indicates that daily weight is the most accurate assessment to determine a client's fluid and electrolyte status. Incorrect Answers: A. The nurse should assess the client's blood pressure to evaluate circulatory status. However, evidence-based practice indicates that another assessment provides more accurate information. B. The nurse should assess the client's intake and output to evaluate fluid status. However, evidence-based practice indicates that another assessment provides more accurate information. D. The nurse should assess the severity of the client's edema to evaluate fluid status. However, evidence-based practice indicates that another assessment provides more accurate information.

A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect?

Correct Answer: Renal agenesis Oligohydramnios is a volume of amniotic fluid that is <300 mL during the third trimester of pregnancy. This occurs when there is a renal system dysfunction or obstructive uropathy. The absence of fetal kidneys will cause oligohydramnios. Incorrect Answers: A. Fetal cardiac anomalies do not affect the volume of amniotic fluid. C. Fetal neural tube defects do not affect the volume of amniotic fluid. D. Fetal hydrocephalus does not affect the volume of amniotic fluid.

A nurse is assessing a client who is at 12 weeks gestation and has a hydatidiform mole. Which of the following findings should the nurse expect? Show Explanation

Correct Answer: Dark brown vaginal discharge A hydatidiform mole (a molar pregnancy) is a benign proliferative growth of the chorionic villi that 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 grape-like clusters. Incorrect Answers: A. The nurse should expect the client's temperature to be within the expected reference range because a hydatidiform mole does not lead to hypothermia. C. The nurse should expect the client to have increased urinary output due to the elevated maternal blood volume and pressure of the uterus on the maternal bladder. D. The nurse should not expect to hear fetal heart tones because a viable embryo or fetus is not present.

A nurse is caring for a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects?

Correct Answer: Fetal asphyxia Oxytocin may cause tachysystole, which can lead to uteroplacental insufficiency. Inadequate oxygen transfer to the placenta will result in fetal asphyxia. Incorrect Answers: A. Diarrhea is not an adverse effect of oxytocin administration. Oxytocin can have adverse effects that include fetal asphyxia, water intoxication, hypotension, and abruptio placentae. B. Thromboembolism is not an adverse effect of oxytocin administration. D. Oliguria is not a likely complication of oxytocin administration.

A nurse is reviewing the medical record of a client at 39 weeks gestation who has polyhydramnios. Which of the following findings should the nurse expect?

Correct Answer: Fetal gastrointestinal anomaly Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurological disorders are expected findings for a fetus experiencing the effects of polyhydramnios. Incorrect Answers: A. Polyhydramnios will result in a fundal height greater than expected for gestational age. B. Polyhydramnios will result in an increase in weight gain, not a decrease. C. Gestational hypertension causes oligohydramnios, which is a decrease in the amount of amniotic fluid surrounding the fetus.

A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which of the following findings should the nurse report to the provider? Show Explanation

Correct Answer: Frequent headaches The nurse should report frequent headaches to the provider. Frequent headaches, swelling of the face and fingers, visual disturbances, and epigastric pain are associated with preeclampsia. Incorrect Answers: B. Leukorrhea is a common discomfort of pregnancy and is an abundant amount of vaginal mucus that may occur throughout pregnancy. C. Epistaxis is a common discomfort of pregnancy related to the increase of estrogen. D. Periodic numbness of the fingers is a common discomfort of pregnancy due to compression of the nerves and does not need to be reported to the provider.

A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse perform first? Show Explanation

Correct Answer: Massage the fundus The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The primary cause of early postpartum bleeding is uterine atony, which is manifested by a relaxed, boggy uterus. Thus, the greatest risk for this client is hemorrhage. The nurse should massage the client's fundus first. 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. Incorrect Answers: A. A full bladder can cause uterine atony. However, there is another action the nurse should take first. C. Vital signs are important but will not help in identifying the reason for this client's bleeding. There is another action that the nurse should take first. D. Administering carboprost is an appropriate action for managing postpartum hemorrhage. However, there is another action the nurse should take first.

A nurse is monitoring a client who is receiving spinal anesthesia. The nurse should identify which of the following findings as a complication of the infusion? Show Explanation

Correct Answer: Maternal hypotension Maternal hypotension is a common adverse effect of a spinal block. To prevent supine hypotension, the client should lie on a side or lie supine with a wedge under a hip to displace the uterus. Incorrect Answers: B. Spinal anesthesia is more likely to cause fetal bradycardia than fetal tachycardia. C. Spinal anesthesia is more likely to cause minimal or a lack of fetal heart rate variability than increased fetal heart rate variability. D. Spinal anesthesia is more likely to cause a fever than hypothermia.

A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy?

Correct Answer: Pelvic inflammatory disease (PID) An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and the 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 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. Incorrect Answers: A. Anemia does not place the client at increased risk of an ectopic pregnancy. B. Frequent urinary tract infections do not increase the risk of ectopic pregnancy. C. A previous cesarean birth does not place the client at increased risk of an ectopic pregnancy.

A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take? Show Explanation

Correct Answer: Provide a sitz bath with warm water for the client The nurse should provide a client who is postpartum with a sitz bath to decrease episiotomy discomfort. The use of a sitz bath provides warm, moist, direct heat to the incision area, which helps relieve the pulling and stinging associated with the healing incision. The warm water increases blood flow to the area through vasodilatation, which also promotes healing and comfort. Incorrect Answers: C. The nurse should instruct the client to perform Kegel exercises to strengthen perineal muscles following a vaginal delivery. However, these exercises do not decrease episiotomy discomfort. D. The nurse should administer prescribed analgesics, including topical anesthetic cream. However, the cream should be applied no more than three to four times per day.

A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings should the nurse expect?

Correct Answer: Urinary retention After delivery, many clients have a reduced urge to urinate. This can result from birth trauma, a larger bladder capacity after birth, analgesia, pelvic soreness, an episiotomy, and other factors. Incorrect Answers: A. Breast engorgement does not generally become problematic until 3 to 5 days after birth. B. Hypothermia is unlikely during the fourth stage of labor. The nurse should measure the client's temperature at this time, then every 4 hours for the first 8 hours, and then at least every 8 hours after that. The client might feel chilly during this stage; if so, the nurse should provide a warmed blanket. D. Rupture of membranes occurs spontaneously or via amniotomy prior to the second stage of labor.

A nurse is preparing a client who is in labor for the insertion of an intrauterine pressure catheter. The client asks why this type of monitoring is needed. Which of the following responses should the nurse make?

Correct Answer: D. "This type of monitoring will allow us to measure the intensity of your contractions." A tocotransducer can monitor the frequency and duration of contractions, but only an intrauterine pressure catheter can monitor the intensity of contractions. Incorrect Answers: A. Although the intrauterine pressure catheter will show the frequency of contractions, the external tocotransducer is also an adequate and noninvasive method of timing contractions. B. Intrauterine pressure catheters are invasive monitoring equipment and used only when deemed necessary for high-risk labors. C. An intrauterine pressure catheter monitors the frequency, intensity, and duration of contractions. The ultrasound transducer and spiral electrode will monitor fetal heart tones.

A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching?

Correct Answer: D. Encourage non-nutritive sucking for pain relief Allowing the newborn to suck on a pacifier is an effective form of nonpharmacological pain management.

A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk of uterine atony? (Select all that apply.)

Correct Answers: A. Magnesium sulfate infusion B. Distended bladder D. Prolonged labor Magnesium sulfate is a smooth muscle relaxant and can prevent adequate contraction of the uterus. After birth, clients can experience a decreased urge to void due to birth-induced trauma, increased bladder capacity, and anesthetics, which can result in a distended bladder. A distended bladder displaces the uterus and can prevent adequate contraction of the uterus. Also, prolonged labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus from contracting.

A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take?

D. Use a photometer to monitor the lamp's energy The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective.

A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect?

Dark red vaginal bleeding The nurse should expect this client with a mild placental abruption to have minimal dark red vaginal bleeding.

A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn? Show Explanation

orrect Answer: C. Infection Blood group incompatibilities, maternal infection, maternal diabetes, and the administration of oxytocin during labor are potential risk factors for the development of hyperbilirubinemia in newborns. Incorrect Answers:A. Placenta previa is not a potential risk factor for hyperbilirubinemia in newborns. B. Multiple gestation is not a potential risk factor for hyperbilirubinemia in newborns. D. Anemia is not a potential risk factor for hyperbilirubinemia in newborns.

A nurse is assessing a postpartum client who has preeclampsia and notes a boggy uterus and excessive uterine bleeding. The nurse should plan to administer which of the following medications? Show Explanation

orrect Answer: C. Oxytocin Oxytocin is a uterotonic medication that causes the uterus to contract and reduces excessive uterine bleeding. Incorrect Answers:A. Terbutaline is a tocolytic medication that causes uterine relaxation and is used to treat preterm labor. It is not an appropriate medication to treat uterine atony. B. Magnesium sulfate is a tocolytic medication used to treat preterm labor and decrease the risk of eclamptic seizures. It is not an appropriate medication to treat uterine atony. D. Methylergonovine is a uterotonic medication that has an adverse effect of hypertension. Therefore, this medication is contraindicated for a client who has preeclampsia.

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? Show Explanation

orrect Answer: Copper intrauterine device A history of thrombophlebitis is a contraindication for the use of hormonal contraceptive methods such as oral combinations of estrogen and progesterone in pill form, vaginal inserts that release hormones continuously, and injectable progestins. A copper intrauterine device that does not contain hormones is a safer choice for this client. Other options for this client include barrier methods and spermicides. Incorrect Answers: B. A history of thrombophlebitis is a contraindication for taking oral contraceptives. Safer methods of contraception for this client include barrier methods and spermicides. C. A history of thrombophlebitis is a contraindication for a vaginal insert that releases hormones continuously. Safer methods of contraception for this client include barrier methods and spermicides. D. A history of thrombophlebitis is a contraindication for injectable progestins. Safer methods of contraception for this client include barrier methods and spermicides.