ATI Maternal newborn assessment A

a nurse is preparing to administer hepatitis B immune globulin to a newborn. The prescription states, "Administer 5 mcg IM once today." Available is 5 mL vial with 10 mcg/mL. How many mL should the nurse administer? (Round to nearest tenth.)

0.5 mL IM

a nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. the client appears anxious and asks the nurse if she is pregnant. which of the following responses should the nurse make? a. "you can miss you period for several other reasons. describe your typical menstrual cycle" b. "if you have been sexually active and haven't used protection, it is likely that you are pregnant" c. "let's check to see if you have any other signs of pregnancy. have you noticed any abdominal enlargement yet?" d. "because you have missed your period, you should try taking a home pregnancy test before you start worrying"

a. "you can miss you period for several other reasons. describe your typical menstrual cycle" amenorrhea is a presumptive sign of pregnancy, not a positive sign. therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions. b. The nurse's response dismisses the client's concerns, which can cause the client to have increased anxiety. c. The nurse's response is making a false assumption that the client is pregnant based only on the client's statement. The nurse should gather more information from the client before making any false assumptions. d. The nurse's response dismisses the client's concerns and does not answer or address the client's question, which can increase the client's anxiety level.

a nurse is providing discharge teaching to a client who is postpartum and was taking insulin for gestational diabetes. which of the following instructions should the nurse include in the teaching? a. "you should get a 2 hour glucose test in 6-12 weeks" b. "you should avoid using low-dose oral contraceptives for birth control" c. "you will need to monitor you blood glucose levels daily at home for 2-3 weeks" d. "you will need to take a lower dose of insulin than you took during you pregnancy"

a. "you should get a 2 hour glucose test in 6-12 weeks" the nurse should instruct the client to get a 2 hour oral glucose tolerance test 6-12 weeks postpartum and every 3 years to screen for type 2 diabetes b. The nurse should instruct the client that low-dose oral contraceptives are safe to use for clients who have a history of gestational diabetes mellitus. c. The nurse should instruct the client that blood glucose levels return to the expected reference range after childbirth. Therefore, the client does not need to monitor her blood glucose levels at home. d. The nurse should instruct the client that blood glucose levels return to the expected reference range after childbirth. Therefore, the client does not need to continue to take insulin.

a nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. which of the following findings should the nurse report to the provider? a. BUN 25 mg/dL b. serum creatinine 0.8 mg/dL c. urine output of 280ml within 8 hours d. urine negative for ketones

a. BUN 25 the nurse should report an elevated BUN to the provider since it can indicate dehydration. b. A serum creatinine level of 0.8 mg/dL is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. c. A urine output of 280 mL within 8 hr is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. d. Testing the urine for ketones is the most important laboratory test for a client who has hyperemesis gravidarum. Dehydration causes the catabolism of fat, which produces ketones that will be present in urine. *Dehydration increases the risk of preterm labor.* Therefore, the nurse does not need to report this finding to the provider.

A nurse is performing a physical assessment of a newborn. which of the following clinical findings should the nurse expect? (Select all that apply) a. Heart rate 154/min b. Axillary temperature 36 C (96.8 F) c. Respiratory rate 58/min d. Length 43 cm (16.9 in) e. Weight 2.6 kg (5 lb 12 oz)

a. Heart rate 154/min c. Respiratory rate 58/min e. Weight 2.6 kg (5 lb 12 oz) a. The expected reference range for a newborn's heart rate is from 110/min to 160/min while awake. c. The expected reference range for a newborn's respiratory rate is from 30/min to 60/min. e. The expected reference range for a newborn's weight is from 2.5 to 4 kg (5.5 lb to 8.8 lb). ----- b. A healthy newborn's temperature averages 37° C (98.6° F), with a range of 36.5° to 37.5° C (97.7° to 99.5 F). d. The expected reference range for a newborn's length is from 45 to 55 cm (17.7 to 21.7 in).

a nurse is calculating a client's expected date of birth using Naegel's rule. the client tells the nurse that her last menstrual cycle started on November 27th. which of the following dates is the client's expected date of birth? a. September 3rd b. September 20th c. august 3rd d. august 20th

a. September 3rd when using Naegele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals august 17th. august 27th plus 7 days equals September 3rd.

a nurse in a prenatal clinic is assessing a group of clients. which of the following clients should the nurse request the provider to see first? a. a client who is 11 weeks gestation and reports abdominal cramping b. a client who is 15 weeks gestation and reports tingling and numbness in her right hand c. a client who is 20 weeks gestation and reports constipation for the past 4 days d. a client who is 8 weeks gestation and reports having 3 bloody noses this week

a. a client who is 11 weeks gestation and reports abdominal cramping when using the urgent vs nonurgent approach to care, the nurse should determine that the priority finding is a client who is 11 weeks gestation and reports abdominal cramping. *abdominal cramping can indicate an ectopic pregnancy* or manifestations of spontaneous abortion. the nurse should request that the provider see this client first b. Tingling and numbness of the right hand is nonurgent because it is a common discomfort related to pregnancy for a client who is at 15 weeks of gestation. . c. Constipation is nonurgent because it is common discomfort related to pregnancy for a client who is at 20 weeks of gestation. d. Epistaxis is nonurgent because it is a common discomfort related to pregnancy for a client who is at 8 weeks of gestation.

a nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. the client is dilated to 8cm and reports back pain. which of the following actions should the nurse take? a. apply sacral counter pressure b. perform trancutaneous electrical nerve stimulation (TENS) c. initiate slow-paced breathing d. assist with biofeedback

a. apply sacral counter pressure the nurse should apply sacral counter pressure to assist in relieving back labor pain related to fetal posterior position b. the nurse should perform TENS during the first stage of labor. c. the nurse should transition a client to pattern-paced breathing during this stage of labor. d. The nurse should teach the client about biofeedback during the prenatal period for it to be effective during labor.

a nurse is caring for a client who is 36 weeks gestation and has a positive contraction stress test. the nurse should plan to prepare the clients for which of the following diagnostic tests? a. biophysical profile b. amniocentesis c. cordocentesis d. Kleihauer- Burke test

a. biophysical profile a positive contraction stress test indicate further evaluation of the fetus is necessary. a biophysical profile will provide further evaluation with real-time ultrasound b. An amniocentesis is used to determine lung maturity, detect congenital anomalies, and diagnose fetal hemolytic disease. c. A cordocentesis is used to identify fetal blood type and RBC when there is a risk of isoimmune hemolytic anemia. d. The Kleihauer-Betke test is used to determine the amount of fetal blood in the maternal circulation when there is a risk of Rh-isoimmunization.

a nurse is caring for a client who becomes unresponsive upon delivery of the placenta. which of the following actions should the nurse take first? a. determine respiratory function b. increase IV fluid rate c. access emergency medications from cart d. collect a maternal blood sample for coagulopathy studies

a. determine respiratory function the priority action the nurse should take when using the ABCs approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation b. The nurse should increase the IV fluid rate to maintain circulation. However, this is not the first action the nurse should take. c. The nurse should access emergency medication to assist in resuscitative efforts. However, this is not the first action the nurse should take. d. The nurse should collect a maternal blood sample in preparation for a blood transfusion. However, this is not the first action the nurse should take.

a nurse int he antepartum clinic is assessing a client's adaptation to pregnancy. the client states that she is, "happy one minute and crying the next." the nurse should interpret the client's statement as an indication of which of the following? a. emotional lability b. focusing phase c. cognitive restructuring d. couvade syndrome

a. emotional lability the nurse should recognize and interpret the client's statements an indication of emotional lability. many women experience rapid and unpredictable changes in mood during pregnancy. intense hormonal changes may be responsible for mood changes that occur during pregnancy. tears and anger alternate with feelings of joy or cheerfulness for little or no reason b. The *focusing phase* is the *third phase* of the father's emotional response to the pregnancy. It is characterized by his active involvement in the pregnancy and his relationship with the child. c. Cognitive restructuring is accepting the idea of pregnancy and assimilating it into the woman's life. The degree of acceptance is shown in the mother's emotional responses. d. Couvade syndrome is pregnancy-like manifestations experienced by the expectant father. Manifestations include nausea, weight gain, and other physical manifestations of pregnancy.

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 temp

a. flaccid uterus c. excess vaginal bleeding oxytocin increases the contractibility of the uterus. oxytocin enhances uterine contractibility, decreasing vaginal bleeding. b. Bleeding resulting from a cervical laceration continues even when the uterus is contracted and firm. It will require repair by the provider. d. The use of oxytocin will increase, rather than decrease, afterbirth cramping. e. The use of oxytocin will have no effect on maternal temperature.

a nurse is performing a physical assessment of a newborn. which of the following clinical findings should the nurse expect? select all that apply a. heart rate 154/min b. axillary temp of 96.8f c. respiratory rate 58/min d. length 16.9 inches e. weight 5lb 12 oz

a. heart rate 154/min c. respiratory rate 58/min e. weight 5lb 12 oz the expected reference range fro a newborn's heart rate is 110-160. the expected reference range for a newborn's respiratory rate is 30-60. the expected reference range for a newborn's weight is 5.5 - 8.8 lbs.

a nurse is observing a new mother caring for her crying newborn who is bottle feeding. which of the following actions by the mother should the nurse recognize as a positive parenting behavior? a. lays the newborn across her lap and gently sways b. places the newborn in the crib in a prone position c. offers the newborn a pacifier dipped in formula d. prepares a bottle of formula mixed with rice cereal

a. lays the newborn across her lap and gently sways this is a correct technique fro a quieting a newborn. this tactile stimulation promotes a sense of security for the newborn. b. The mother should place the infant in the supine position, not a prone position, in the bassinet or crib because of the risk of sudden infant death syndrome. c. Pacifiers may be used for a newborn who needs extra sucking for self-soothing. However, formula should not be placed on the tip of the pacifier because the newborn may become accustomed to it and refuse to take the pacifier in the future without added supplement. d. Rice cereal should not be added to the bottle of a newborn because solids should not be introduced until 4 to 6 months of age.

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next? a. massage the client's fundus b. insert an indwelling urinary catheter c. administer oxygen at 10L/min d. elevate the client's right hip

a. massage the client's fundus the greatest risk to the client is hemorrhage. therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions b. The nurse should insert an indwelling urinary catheter to monitor perfusion of the kidneys. However, this is not the next action the nurse should take. c. The nurse should administer oxygen at 10 L/min to enhance perfusion. However, this is not the next action the nurse should take. d. The nurse should elevate the client's right hip to enhance perfusion. However, this is not the next action the nurse should take.

a nurse is assessing a newborn who was born at 26 weeks gestation using the 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 3-4mm buds

a. minimal arm recoil the nurse should expect a newborn that was born at 26 weeks to have decreased muscular tone or minimal arm recoil b. A popliteal angle of 90° is an indicator of physical maturity with increasing gestational age after 26 weeks. c. Creases over the entire sole of a newborn's foot are an indicator of physical maturity with increasing gestational age after 26 weeks. d. Raised areolas with 3 to 4 mm buds is an indicator of physical maturity with increasing gestational age after 26 weeks.

a nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. which of the following cultural practices should the nurse include in plan of care? a. protect head and feet from cold air b. bathe the client within 12 hours following delivery c. ambulate the patient within 24 hr following delivery d. offer the patient a glass of cold milk with her first meal

a. protect head and feet from cold air protecting the client's head and feet from cold air should be included in the plan of care because it is traditional Hispanic practice during the postpartum period. b. Bathing the client within 12 hr following delivery should not be included in the plan of care because traditional Hispanic practices include delaying bathing for 14 days following delivery. c. Ambulating the client within 24 hr following delivery should not be included in the plan of care because traditional Hispanic practices include bed rest for 3 days following delivery. d. Offering the client a glass of cold milk with her first meal should not be included in the plan of care because traditional Hispanic practices include drinking warm beverages following birth.

a nurse is assessing a client who is 30 weeks gestation during a routine prenantal 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+ edema d. hyperpigmentation of the cheeks

a. swelling of the face swelling of the face, sacral area, and hands 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. b. Varicose veins are an expected finding in the third trimester. The increase in hormones during pregnancy causes the relaxation of the smooth muscle of the vascular system, leading to vessel dilation and vasocongestion. Additionally, the weight of the enlarging uterus on the pelvic veins decreases the return of blood from the lower extremities. c. Nonpitting edema of the lower extremities is an expected finding in the third trimester. Warm weather, sitting or standing for prolonged periods of time, and tight clothing can increase edema. d. Hyperpigmentation of the cheeks (melasma), areola, vulva, and linea nigra are expected findings in the third trimester. The anterior pituitary increases the production of melanocyte-stimulating hormone, which leads to hyperpigmentation of the skin.

a nurse is caring for a client and her partner who have experienced a fetal death. which of the following actions should the nurse take? a. take photos of the newborn to give to the parents b. tell the parents that they can consider organ donation c. encourage the parents to avoid allowing older children to visit them in the hospital d. explain to the parents the need to name the newborn

a. take photos of the newborn to give to the parents the nurse should create a memory box that includes mementos of the newborn (ex: photos, ID bands, newborn hat and blanket) b. Organ donation can be considered if a newborn is delivered alive. c. The nurse should encourage the client to allow older children to come to the hospital as a beneficial part of the grieving process. d. The nurse should explain to the client that naming the baby can be helpful during the grieving process, but it is not a requirement.

a nurse is demonstrating to a client how to bathe her newborn. in which order should the nurse perform the following actions a. wipe the newborn's eyes from inner canthus outward b. wash the newborn's legs and feet c. wash the newborn's neck by lifting the newborn's chin d. cleanse the skin around the newborn's umbilical stump e. clean the newborn's diaper area

a. wipe the newborn's eyes from inner canthus outward c. wash the newborn's neck by lifting the newborn's chin d. cleanse the skin around the newborn's umbilical stump b. wash the newborn's legs and feet e. clean the newborn's diaper area The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach.

a nurse is teaching a new mother about newborn safety. which of the following instructions should the nurse include in the teaching? a. you can share your room with your baby for the next few weeks b. cover your baby with a light blanket while she is sleeping c. check the temp of your baby's bath water with your hand d. your baby can nap in her car seat during the daytime

a. you can share your room with your baby for the next few weeks room-sharing is recommended during the first few weeks. this allows the parents to be readily available to the newborn and learn the newborn's cues. however, the nurse should instruct eh parents to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome. b. The nurse should instruct the parents to place the newborn in a sleep sack or a one-piece sleeper. Covering the newborn with a blanket or quilt increases the risk for sudden infant death syndrome. c. The nurse should instruct the parents to check the temperature of the newborn's bath water with their elbow, which is more sensitive to temperature than the hand. The hot water heater should be set at or below 120° F to prevent burns. d. The nurse should instruct the parents to lay the newborn in a bassinet or crib on her back to sleep. Sleeping in a supine position on a firm mattress decreases the risk of sudden infant death syndrome.

A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority? a. a client who has gestational diabetes and a fasting blood glucose level of 120mg/dL b. a client who is at 34 weeks of gestation and reports epigastric pain c. a client who is at 28 weeks gestation and has an hgb of 10.4g/dL d. a client who is at 39 weeks of gestation and reports urinary frequency and dysuria

b. a client who is at 34 weeks of gestation and reports epigastric pain epigastric pain is a clinical manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. therefore, the nurse should identify this client as the priority. a. A fasting blood glucose of 120 mg/dL is above the expected reference range for a client who has gestational diabetes. However, this is a non-urgent finding, which means that another client is the nurse's priority. c. This finding is a clinical manifestation of anemia in a client who is pregnant, which is a non-urgent condition. Therefore, another client is the nurse's priority. d. Dysuria can indicate a urinary tract infection, which can cause preterm labor. Dysuria in a client who is at 39 weeks of gestation is a nonurgent condition. Therefore, another client is the nurse's priority.

A nurse on the postpartum unit is caring for a pt. following a cesarean birth. Which of the following assessments is the nurse's priority? a. parent-child attachment b. amount of lochia c. patency of the IV catheter d. quality and quantity of urine

b. amount of lochia when using the ABCs approach to client care, the nurse should place the priority in the immediate postpartum period on assessing the amount of postpartum lochia. the greatest risk to the client is bleeding and postpartum hemorrhage.

a nurse is planning discharge for a client who is 3 days postpartum. which of the following nonpharmacological interventions should the nurse include in the plan of care for lactation suppression? a. place warm, moist packs on the breasts b. apply cabbage leaves to the breasts c. wear a loose fitting bra d. put green tea bags on the breasts

b. apply cabbage leaves to the breasts. plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement. a. The client can use cold compresses to decrease breast discomfort during lactation suppression. c. A tight-fitting bra will provide support to the breasts during engorgement, which can decrease pain. d. Tea bags are used to relieve nipple soreness in breastfeeding clients.

a nurse is assessing a newborn following a circumcision. which of the following findings should the nurse identify as an early indication that the newborn is experiencing pain? a. decrease heart rate b. chin quivering c. pinpoint pupils d. slowed respirations

b. chin quivering behavioral responses to a newborn's pain include facial expressions (ex: chin quivering, grimacing, furrowing of brow) a. The heart rate will increase when a newborn is experiencing pain. c. When experiencing pain, a newborn's pupils typically dilate. d. When experiencing pain, a newborn's respirations are typically rapid and shallow.

a nurse is caring for a client who is pregnant and is at the end of her 1st trimester. the nurse should place the doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones? a. just above the umbilicus b. just above the symphysis pubis c. the right lower quadrant d. the left lower quadrant

b. just above the symphysis pubis at the end of the first trimester of pregnancy. the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. a. The nurse should assess FHTs using the Doppler stethoscope just above the umbilicus if the fetus is in a transverse or breech presentation and the client is at a minimum of 22 weeks of gestation. c. At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse may not hear FHTs in the right lower quadrant. d. At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse may not hear FHTs in the left lower quadrant.

a nurse is caring for a client following an amniocentesis at 18 weeks gestation. which of the following findings should the nurse report to the provider as a potential complication? a. increased fetal movement b. leakage of fluid from the vagina c. upper abdominal discomfort d. urinary frequency

b. leakage of fluid from the vagina leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the doctor. a. Decreased fetal movement is a potential complication that should be reported to the provider. c. Upper abdominal discomfort is not a potential complication associated with an amniocentesis. d. Urinary frequency is not a potential complication associated with an amniocentesis.

a nurse is caring for a postpartum client who is receiving heparin via continuous IV infusion for thrombophlebitis in her left calf. which of the following actions should the nurse take? a. administer aspirin for pain b. maintain the client on bed rest c. massage the affected leg every 12 hour d. apply cold compresses to the affected calf

b. maintain the client on bed rest the client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism a. A client receiving anticoagulant therapy, such as heparin, should not receive aspirin due to the risk of bleeding. c. The nurse should avoid massaging the affected leg to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. d. The nurse should apply warm compresses to the affected area to promote circulation and decrease edema.

a nurse is caring for a client who is at 38 weeks gestation. which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? a. determine progression of dilation and effacement b. perform the Leopold maneuver c. complete a sterile speculum exam d. prepare a nitrazine paper test

b. perform the Leopold maneuver the nurse should perform Leopold maneuver to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer a. The nurse should determine the client's dilation and effacement prior to applying an internal monitor. This action is not required prior to applying an external transducer for fetal monitoring. c. A sterile speculum examination should be performed by the provider and is not required prior to applying an external transducer for fetal monitoring. d. A Nitrazine paper test is performed to assess the components (pH level) of vaginal fluid to determine if the membranes have ruptured. This action is not required prior to applying an external transducer for fetal monitoring.

a nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). which of the following actions should the nurse take? a. administer antiviral medication b. schedule an ultrasound exam c. administer haemophilus influenza type b vaccine d. schedule an indirect coombs' test

b. schedule an ultrasound exam the nurse should schedule serial ultrasound exams to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. a. Currently, there are no antiviral medications available to treat parvovirus B19 infection (fifth disease). c. The haemophilus influenzae type b (HIB) vaccine is given during infancy and childhood to protect against multiple infections caused by haemophilus influenzae type b, not parvovirus B19 (fifth disease). Currently, there are no immunizations to protect against parvovirus B19 (fifth disease). d. An indirect Coombs' test determines whether the client has antibodies to the Rh antigen. The titer determines the mother's sensitization and if there is Rh incompatibility.

a nurse is planning care for a client who is in labor and is to have an amniotomy. which of the following assessments should the nurse identify as the priority? a. O2 saturation b. temperature c. blood pressure d. urinary output

b. temperature the greatest risk for a client following amniotomy is infection. therefore the nurse should identify that the priority assessment is client's temperature. a. Assessing the client's O2 saturation is important during labor. However, another assessment is the nurse's priority. c. Assessing the client's blood pressure is important. However, another assessment is the nurse's priority. d. Assessing the client's urinary output is important during labor. However, another assessment is the nurse's priority.

a nurse is caring for a client who is 36 weeks gestation and has a prescription for an amniocentesis. for which of the following reasons should the nurse prepare the client for an ultrasound? a. to estimate the fetal weight b. to locate a pocket of fluid c. to determine multiparity d. to prescreen for fetal anomalies

b. to locate a pocket of fluid an ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. this decreases the risk of injury to the fetus. a. This is not an indication for an ultrasound prior to an amniocentesis. c. This is not an indication for an ultrasound prior to an amniocentesis. d. This is not an indication for an ultrasound prior to an amniocentesis.

a nurse is providing teaching about family planniong to a client who has a new prescription for a diaphragm. which of the following statements should the nurse include in the teaching? a. you should replace the diaphragm every 5 years b. you should leave the diaphragm in place for at least 6 hours after intercourse c. you should use an oil-based product as a lubricant when inserting the diaphragm d. you should insert the diaphragm when your bladder is full

b. you should leave the diaphragm in place for at least 6 hours after intercourse the client should keep the diaphragm in place for at least 6 hours after intercourse to provide protection against pregnancy. a. The client should replace the diaphragm every 2 yr. c. The client should avoid using oil-based products because they can weaken the rubber. d. The client should have an empty bladder prior to inserting the diaphragm.

a nurse is providing teaching about comfort measures to a client who is breastfeeding and is experiencing engorgement. which of the following nonpharmacological measures should the nurse include in the teaching? a. you may use a breast binder to relieve the discomfort b. you should use cold compresses after each feeding c. you should apply a few drops of colostrum to the nipple following the feeding d. you may place breast shells inside your bra

b. you should use cold compresses after each feeding the nurse should suggest applying cold compresses or ice packs to alleviate the discomforts of engorgement in the client who is breastfeeding. a. The nurse should not suggest the use of a breast binder to treat the discomforts of engorgement for a client who is breastfeeding. A breast binder compresses the breasts and can decrease milk supply. c. Applying drops of colostrum to the nipple following the feeding is helpful for the treatment of sore nipples. d. Breast shells may be worn inside the bra to promote circulation of air and prevent clothing from touching sore nipples.

a nurse is teaching a client who is in preterm labor about *terbutaline*. which of the following statements by the client indicates an understanding of the teaching? a. "i will get injections of the medication once daily until my labor stops" b. "my blood sugar may be low while I'm on this medication" c. "i will have blood tests because my potassium might decrease" d. "my BP may increase while I'm on this medication"

c. "i will have blood tests because my potassium might decrease" an adverse effect of terbutaline is hypokalemia. *Terbutaline is a medication used to delay preterm labor*. It is in a class of drugs called *betamimetics*, which help prevent & slow contractions of the uterus. *Terbutaline is primarily used when doctors need to delay birth for several hours or days in order to allow the child to mature more before being born* a. Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr. b. An adverse effect of terbutaline is hyperglycemia. d. An adverse effect of terbutaline is hypotension.

a charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following images indicates the first step of Leopold maneuvers? -pictures- a. Hands on either side of baby's head. b. one hand on baby's head. c. Both hands on either side of baby's bottom. d. One hand on baby's back and one hand on baby's front.

c. Both hands on either side of baby's bottom. Evidence-based practice indicates the nurse should perform this step first when performing Leopold maneuvers. During this step, the nurse palpates the client's abdomen with her palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus. a. The nurse should identify this image as the fourth step of Leopold maneuvers. During this step, the nurse faces the client's feet and uses the fingertips to palpate the cephalic prominence. This assessment allows the nurse to determine the attitude of the fetal head. b. The nurse should identify this image as the third step of Leopold maneuvers. During this step, the nurse determines which fetal part is presenting in the pelvic inlet. The nurse gently grasps the lower uterine segment between the thumb and forefingers, pressing in slightly. d. The nurse should identify this image as the second step of Leopold maneuvers. During this step, the nurse uses the palms of her hands to determine the location of the smooth fetal back and the irregularly shaped, smaller fetal parts.

A nurse in an antepartal clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. there are three tabs that contain separate categories of data.) Vital Signs: BP 130/78 mmHg; ~RR 20/min;~ HR 90/min Lab Results: hemoglobin 12 g/dL;~hematocrit 34%; ~1-hr glucose tolerance test 120 mg/dL Progress Note: Fundal height 30 cm~ good fetal movement; not experiencing headache, dizziness, blurred vision, or vaginal bleeding; fetal heart rate 110/min. a. 1 hr glucose tolerance test b. hematocrit c. fundal height measurement d. fetal heart rate (FHR)

c. Fundal height measurement A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider. a. A glucose tolerance test result of 120 mg/dL is within the expected reference range for this client. A value of 130 to 140 mg/dL or greater for a 1-hr glucose tolerance test indicates a positive test result and should be reported to the provider. b. A hematocrit of 34% is within the expected reference range for this client. The level should be greater than 33%. d. This FHR is within the expected reference range of 110/min to 160/min for a client at 26 weeks of gestation.

a nurse for a client who is anemic at 32 weeks gestation and is in preterm labor. the provider prescribed betamethasone 12mg IM. which of the following outcome should the nurse expect? a. decreased uterine contractions b. in increase in the client's hemoglobin levels c. a reduction in respiratory distress in the newborn d.increased production of antibodies in the newborn

c. a reduction in respiratory distress in the newborn betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress. a. This is not an expected outcome of betamethasone. b. This is not an expected outcome of betamethasone. d. This is not an expected outcome of betamethasone.

a nurse is caring for a client who is at 26 weeks gestation and has epilepsy. the nurse enters the room and observes the client having a seizure. after turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure? a. monitor the FHR b. assess uterine activity c. administer oxygen via nonrebreather mask d. start a bolus of IV fluids

c. administer oxygen via nonrebreather mask when using the ABCs approach to the client care, the nurse should take priority on administering oxygen to the client via a nonrebreather mask to ensure adequate oxygenation to the fetus a. The nurse should monitor the FHR to assess fetal well-being. However, this is not the action the nurse should take next. b. The nurse should assess uterine activity for potential complications of the seizure. However, this is not the action the nurse should take next. d. The nurse should start IV fluids following the seizure to ensure adequate hydration. However, this is not the action the nurse should take next.

a nurse is assessing a client who gave birth vaginally 12 hours ago and palpates her uterus to the right above the umbilicus. which of the following interventions should the nurse perform? a. reassess the client in 2 hours b. administer simethicone c. assist the client to empty her bladder d. instruct the client to lie on her right side

c. assist the client to empty her bladder the nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. this can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage. a. The nurse should assess the client more frequently after birth to determine the position of the uterus and to intervene as soon as possible if necessary. b. The nurse should administer simethicone to reduce bloating, discomfort, or pain caused by excessive gas. d. Lying on her right side will not resolve the client's displaced uterus.

a nurse is reviewing the medical record of a client who is one day postpartum. the client had a vaginal birth with a 4th degree perineal laceration. the nurse should contact the provider regarding which of the following prescriptions? a. docusate sodium 100mg PO TID b. sitz bath 2-3 times per day PRN pain c. bisacodyl rectal suppository daily PRN constipation d. ibuprofen 600mg PO Q 6hours PRN pain

c. bisacodyl rectal suppository daily PRN constipation the nurse should NOT administer a rectal suppository or enema to a client who has a 4th degree perineal laceration. these can cause separation of the suture line, bleeding, or infection a. Docusate sodium is a stool softener that is often prescribed following birth. The client should take a stool softener until the perineum is healed. Hard stool can separate the suture line between the vagina and rectum, leading to bleeding and infection. b. A sitz bath filled with warm water is soothing to the perineum. The warm water also increases blood flow to the tissues, promoting healing. The nurse should encourage the client to use a sitz bath two to three times per day, or as often as needed, to decrease perineal pain. d. Ibuprofen is a nonsteroidal, anti-inflammatory medication that is used to decrease pain and swelling. The client who has a fourth-degree perineal laceration will likely receive scheduled ibuprofen as well as an opioid analgesic as needed for breakthrough pain.

a nurse is teaching a newly licensed nurse about the collecting a specimen for the universal newborn screening. which of the following statements should the nurse include in the teaching? a. obtain an informed consent prior to obtaining the specimen b. collect at least 1ml of urine for the test c. ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen d. premature newborns may have false negative test due to immature development of liver enzymes

c. ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen the nurse should ensure that the newborn has been receiving regular feedings for at least 24 hours prior to testing. a. The universal newborn screening is mandated by law for all newborns. Therefore, the nurse does not need to obtain informed consent prior to obtaining the specimen. b. The nurse should collect a capillary blood sample via heel stick for the newborn screening. Urine is not collected for this test. d. Premature newborns have a delayed development of liver enzymes which can cause a false positive result.

a nurse is reviewing the laboratory report of a client who is 24 hours postpartum following a vaginal delivery. which of the following laboratory results should the nurse identify as an indication of a postpartum infection? a. platelets 300,000 b. WBC 9,000 c. erythrocyte sedimentation rate (ESR) 26 c-reactive protein 0.8

c. erythrocyte sedimentation rate (ESR) 26 the nurse should realize that this value exceeds the expected reference range for a postpartum client and indicates infection. *normal range is 0-22* a. This value is within the expected reference range for a postpartum client and does not indicate an infection. b. This value is within the expected reference range for a postpartum client and does not indicate an infection. d. This value is within the expected reference range for a postpartum client and does not indicate an infection.

a nurse is assessing a client who is in labor and notes early decelerations on the fetal monitor. which of the following findings should the nurse identify as a possible cause of the early decelerations? a. prolapsed umbilical cord b. placenta previa c. fetal head compression d. maternal hypotension

c. fetal head compression the nurse should identify fetal head compression as a likely cause of the early decelerations on the fetal monitor. early decelerations are an expected fetal pattern caused by fetal head compression due to uterine contractions, fundal pressure, and vaginal exams. a. A prolapsed umbilical cord would cause variable decelerations, rather than early, because of the compression on the umbilical cord. b. Placenta previa would cause late decelerations, rather than early, because of the disruption of oxygen to the fetus. d. Maternal hypotension would cause late decelerations, rather than early, because of the disruption of oxygen to the fetus.

a nurse is caring for a client who is 35 weeks gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. which of the following actions should the nurse take? a. give the client orange juice b. elevate the client's legs c. have the client change position d. establish IV access

c. have the client change position having the client change position is an appropriate intervention for a variable deceleration to relieve umbilical cord compression a. Giving the client orange juice is not an appropriate intervention for a variable deceleration in the FHR. b. Elevating the client's legs is an acceptable intervention for late decelerations associated with maternal hypotension. d. Establishing IV access is not indicated at this time.

a nurse is teaching a client who is 35 weeks gestation about clinical 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 contractions

c. headache that is unrelieved by analgesia a headache that is unrelieved by analgesia may indicate preeclampsia and should be reported to the provider. a. Shortness of breath is related to the enlarging uterus interfering with the expansion of the diaphragm and is an expected clinical manifestation at 35 weeks of gestation. b. Swelling of feet and ankles is due to the enlarging uterus interfering with blood return to the heart and is an expected clinical manifestation at 35 weeks of gestation. d. Braxton Hicks contractions are an indication that the uterus is preparing for labor and is an expected clinical manifestation at 35 weeks of gestation.

a nurse is assessing a newborn 12 hours after birth. which of the following manifestations should the nurse report to the provider? a. acrocyanosis b. transient strabismus c. jaudice d. caput succedaneum

c. jaundice jaundice occurring within the first 24 hours of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. the nurse should report this manifestation to the provider. a. Acrocyanosis is a bluish discoloration of the hands and feet and is an expected finding in a newborn 12 hr after birth. b. Transient strabismus is a normal variation in the newborn's eyes that can persist until 4 months of age. d. Caput succedaneum is a benign, edematous area of the scalp and is commonly found on the occiput.

a staff nurse on an obstetric unit is caring for a client who is scheduled for an induced abortion. the staff nurse informs the nurse manager that she has a moral issue with the client's decision. which of the following actions should the nurse manager take? a. inform the staff nurse that she is required to care for the client b. advise the staff nurse that she will likely receive disciplinary action c. reassign the client to another staff nurse d. advise the staff nurse to transfer to another unit

c. reassign the client to another staff nurse the nurse manager should take into account the staff nurse's moral beliefs and recognize that she also has rights and responsibilities concerning the care of the client who is undergoing induced abortion. therefore, the nurse manager should reassigns the care of the client to another staff nurse. a. The nurse manager should take into account the staff nurse's moral beliefs and recognize that she also has rights and responsibilities concerning the care of a client who is undergoing an induced abortion. b. There are no grounds for bringing disciplinary action against the staff nurse. The nurse manager should take into account the staff nurse's moral beliefs and recognize that it is not warranted to take disciplinary actions unless the staff nurse clearly abandons the client. d. It is not legal or ethical to advise the staff nurse to transfer off the unit to work on another unit due to a moral issue. The nurse manager should take into account the staff nurse's moral beliefs and recognize that she also has rights and responsibilities concerning the care of a client who is undergoing an induced abortion.

a nurse is developing a plan of care for a newborn who is to undergo photo-therapy for hyperbilirubinemia. which of the following actions should the nurse include in the plan? a. feed the newborn 1 oz of water every 4 hours b. apply lotion to the newborn's skin 3 times per day c. remove all clothing form the newborn except the diaper d. discontinue therapy if the newborn develops a rash

c. remove all clothing from the newborn except the diaper the nurse should remove all of the newborn's clothing except the diaper while under photo-therapy. maximum ski exposure to the ultraviolet light is needed to break down the excess bilirubin. a. The nurse should not feed the newborn any water or glucose water. Hydration can be maintained through regular breastfeeding or formula feeding. Water and glucose water do not increase the excretion rate of bilirubin or provide nutritional value. b. The nurse should not apply lotion or creams to a newborn who is undergoing phototherapy. Lotions and creams can absorb heat and lead to burns. d. The nurse should not discontinue phototherapy if the newborn develops a rash. A temporary, fine rash can occur during therapy. This rash requires no treatment.

a nurse is teaching a new mother about steps the nurses will take to promote the security and safety of the newborn. which of the following statements should the nurse make? a. "we will prevent unidentified visitors from entering the unit" b. "we will document the relationship of visitors in your medical record" c. "your baby will stay in the nursery while you are asleep" d. "staff members who take care of your baby will be wearing a photo ID badge"

d. "staff members who take care of your baby will be wearing a photo ID badge" the nurse should teach the client that all staff members that care for newborns are required to wear a photo ID badge so that the client will be reassured of her newborn's safety. a. The nurse should teach the client that visitors are allowed to enter the unit without identifying themselves. However, visitors must provide the name of the client they are visiting. b. The nurse should teach the mother that clients are allowed to have anyone visit them on the unit. There is no documentation of a visitor's relationship to the client entered into the medical record. c. The nurse should teach the mother to place the baby in the bassinet on the side of the bed furthest from the door while she is sleeping.

a nurse is teaching a client who is at 8 weeks gestation about exercise. which of the following instructions should the nurse include in the teaching? a. "you should increase weight-bearing exercises as your pregnancy progresses" b. "you should lie on your back to rest for 5 minutes after exercising" c. "you should take your pulse every 20 minutes while your are exercising" d. "you should exercise for 30 minutes each day"

d. "you should exercise for 30 minutes each day" the nurse should instruct the client to engage in 30 minutes of moderate exercise every day to improve muscle tone throughout pregnancy a. The nurse should instruct to client to decrease, rather than increase, weight-bearing exercises as the pregnancy progresses. b. The nurse should instruct the client to rest in a lateral position for 10 min following exercise.. c. The nurse should instruct the client to take her pulse every 10 to 15 min during exercise, rather than every 20 min.

a client who is 34 week gestation asks the nurse how will she know when she is in labor and should go to the hospital. which of the following responses should the nurse make? a. "you will feel the contractions primarily in your upper abdomen" b. "you will feel extremely fatigued when your labor starts" c. "your breasts will begin to excrete colostrum" d. "you will notice blood-tinged discharge from your vagina"

d. "you will notice blood-tinged discharge from your vagina" the nurse should inform the client that a sign of true labor is the *bloody show*, which is a blood-tinged discharge from the vagina that occurs when the cervix begins to efface and dilate. this is an indication that the client should go to the hospital a. Contractions during true labor are usually felt in the lower abdomen, not the upper abdomen. b. True labor is usually preceded by a burst of energy, not extreme fatigue. c. The breasts begin producing and excreting colostrum as early as 16 weeks of gestation. Therefore, this does not indicate the onset of labor.

a nurse is caring for a client who is in active labor and has no cervical changes in the last 4 hours. which of the following statements should the nurse make? a. "let me help you into a comfortable pushing position so you can begin bearing down" b. "I am going to call the doctor to get you a prescription for medication to ripen your cervix" c. " I will give you some IV pain medication to strengthen your contraction" d. "your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions

d. "your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, which will identify whether or not the contractions are adequate for progression of labor a. The nurse should not instruct the client to start bearing down until the second stage of labor. b. A cervical ripening agent is not used during the active stage of labor. c. Administering IV pain medication can decrease the intensity of uterine contractions.

a nurse is performing a routine assessment on a client who is 18 weeks gestation. which of the following findings should the nurse expect? a. deep tendon reflexes 4+ b. fundal height 14 cm c. urine protein 2+ d. FHR 152/min

d. FHR 152/min the expected range for the FHR is 110-160. the FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks gestation. therefore this is an expected finding by the nurse a. Deep tendon reflexes (DTRs) are an indication of the balance between the cerebral cortex and spinal cord. The nurse should expect the client's DTR to be 2+. Therefore, a DTR of 4+ indicates hyperreflexia. b. From gestational weeks 18 to 32, the height of the fundus is approximately equal to the number of weeks of gestation plus or minus 2 cm. Therefore, the nurse should expect the fundal height for this client should be 16 to 20 cm. c. A urine protein concentration of 2+ is an indication of preeclampsia and should be investigated further. Therefore, the nurse should expect the urine protein for this client to be less than 1+.

a nurse is caring for a full-term newborn immediately following birth. which of the following actions should the nurse take first? a. assign apgar score to the newborn b. weigh the newborn c. place identification bracelets on the newborn d. dry the newborn

d. dry the newborn when using the urgent vs. non-urgent approach to client care, the nurse should determine that the greatest risk to the newborn is cold stress. therefore, the first action the nurse should take immediately after birth is to dry the newborn. a. The nurse should obtain Apgar scores at 1 and 5 min after birth. Therefore, this is not the first action the nurse should take. b. The nurse should obtain the newborn's weight shortly after birth to obtain a baseline. However, this is not the first action the nurse should take. c. The nurse should place identification bracelets on the newborn shortly after birth. However, this is not the first action the nurse should take.

a nurse is teaching a client who is pregnant about managing n/v. which of the following instructions should the nurse include in the teaching? a.brush your teeth immediately after eating b. eat foods served at a warm temp c. drink a glass of water with each meal d. eat high carb foods

d. eat high carb foods the nurse should instruct the client to eat high carb foods (for example, toast, potatoes, and rice) to decrease n/v. the nurse should also instruct the client to avoid spicy, fatty, or fried foods. a. The nurse should instruct the client to avoid brushing her teeth after eating to prevent triggering the gag reflex, which can cause vomiting. b. The nurse should instruct the client to eat foods at cool temperatures to avoid exacerbating nausea and vomiting. c. The nurse should instruct the client to drink fluids between meals rather than during meals to avoid exacerbating nausea and vomiting.

a nurse is teaching a client who is 10 weeks 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 60g each day b. i should drink 2 L of water each day c. i should increase my overall daily caloric intake by 300 calories d. i should take 600mcg of folic acid each day

d. i should take 600mcg of folic acid each day a client who is pregnant should increase her folic acid intake to 600mcg daily. folic acid assists with preventing neural tube defects a. A client who is pregnant should increase her protein intake to 71 g each day during the second and third trimesters. b. A client who is pregnant should consume 3 L of water each day. c. A client who is pregnant should increase her caloric intake by 300 to 340 cal during the second trimester and by 452 cal during the third trimester.

a nurse is teaching a client who id Rh negative about Rh immune globulin. which of the following statements by the client indicates understanding of the teaching? a. i will receive this medication if my baby is Rh negative b. i will receive this medication when i am in labor c. i will need a second dose of this medication when my baby is 6 weeks old d. i will need this medication if i have an amniocentesis

d. i will need this medication if i have an amniocentesis Rh immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation. a. Rho(D) immune globulin is administered to a mother who is Rh-negative and gives birth to an Rh-positive newborn. Therefore, this statement does not indicate an understanding of the teaching. b. Rho(D) immune globulin is administered at 28 weeks of gestation or after birth if the newborn is Rh-positive. Therefore, this statement does not indicate an understanding of the teaching. c. Rho(D) immune globulin is administered at 28 weeks of gestation to mothers who are Rh-negative and following the birth of a newborn who is Rh-positive. Therefore, this statement does not indicate an understanding of the teaching.

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 fetal movement may not be evident on the fetal monitor and tracing. instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted. a. There is no indication for the client to be NPO. Sometimes, clients are encouraged to drink liquids to promote adequate hydration. b. The client should be placed in a semi-Fowler's or sitting position and tilted to the right or left to promote uterine perfusion and prevent supine hypotension. c. Massaging the abdomen does not stimulate fetal movement.

a nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. which of the following laboratory results should the nurse report to the provider? a. hct 39% b. serum albumin 4.5 g/dL c. WBC 9,000/mm3 d. platelets 50,000/mm3

d. platelets 50,000/mm3 a platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. the nurse should report this result to the provider a. An Hct of 39% is within the expected reference range and is not indicative of a postpartum complication. b. A serum albumin level of 4.5 g/dL is within the expected reference range. This finding is consistent with mild preeclampsia and does not indicate a worsening of the condition. c. A WBC of 9,000/mm3 is within the expected reference range.

a nurse is assessing the newborn of a client who took a SSRI during pregnancy. which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? a. large for gestational age b. hyperglycemia c. bradypnea d. vomiting

d. vomiting expected clinical manifestation associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. these manifestations typically last 2 days a. Low birth weight is an expected clinical manifestation of fetal exposure to SSRIs. b. Hypoglycemia is an expected clinical manifestation of fetal exposure to SSRIs. c. Tachypnea is an expected clinical manifestation of fetal exposure to SSRIs.