ATI Maternal + newborn practice questions

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? "I should have a goal of maintaining my fasting blood glucose between 100 and 120." "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." "I will continue taking my insulin if I experience nausea and vomiting." "I will ensure that my bedtime snack is high in refined sugar."

"I will continue taking my insulin if I experience nausea and vomiting." The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes.

Fasting blood glucose reference range pregnant client

60 to 105 mg/dL

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.) Cholecystitis Hypertension Human papillomavirus Migraine headaches Anxiety disorder

Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives. Human papillomavirus is incorrect. The presence of human papillomavirus is not a contraindication for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives. Anxiety disorder is incorrect. The presence of an anxiety disorder is not a contraindication for the use of oral contraceptives.

Infant with NAS

Instruct the mother to discontinue breastfeeding is incorrect. The nurse should encourage the mother to continue to breastfeed on demand. Breastfeeding will assist to decrease manifestations of NAS in the newborn. Administer scheduled doses of oral morphine is correct. The nurse should administer scheduled doses of oral morphine to the newborn to decrease manifestations of withdrawal. The dosage of the medication is adjusted based on the NAS score of the newborn. Give a one-time dose of naloxone IM is incorrect. The nurse should not administer naloxone to a newborn who has NAS. It is contraindicated in newborns who are born with opioid dependence because it can increase the severity of withdrawal manifestations and result in seizures. Maintain a low-stimulus environment is correct. Supportive care for a newborn who has NAS includes maintaining a low-stimulus environment to help prevent exacerbation of withdrawal manifestations. Initiate neonatal abstinence syndrome (NAS) scoring is correct. The nurse should initiate NAS scoring to evaluate the severity of the newborn's withdrawal manifestations. The score obtained will be used to evaluate the need to titrate the prescription for the morphine dosage.

A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe? Kleihauer-Betke test Progesterone serum level Lecithin/sphingomyelin (L/S) ratio Maternal Alpha-fetoprotein (AFP)

Kleihauer-Betke test The nurse should expect the provider to prescribe a Kleihauer-Betke test for a client who has suspected placental abruption to determine if fetal blood is in maternal circulation. This test is useful to determine if Rho-(D) immune globulin therapy should be administered to a client who is Rh-negative. explanation for wrong answers: A progesterone serum level helps to determine if a client is pregnant and if the pregnancy is ectopic. Lecithin/sphingomyelin (L/S) ratio is done as a part of an amniocentesis to evaluate fetal lung maturity. Maternal Alpha-fetoprotein (AFP) is a laboratory test used to assess for neural tube defects or chromosome disorders.

A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart? Left upper quadrant Right upper quadrant Left lower quadrant Right lower quadrant

Left lower quadrant

Assessing to report to provider of newborn who is 70 hr old

Respiratory findings is incorrect. The newborn's respiratory rate is within the expected reference range of 30 to 60/min. There is no indication the newborn has an alteration in respiratory status; therefore, this finding does not need to be reported to the provider. Temperature is incorrect. The newborn's temperature is within the expected reference range of 36.5° to 37.5° C (97.7° to 99.5° F). Therefore, this finding does not need to be reported to the provider. Oxygen saturation is incorrect. The newborn's oxygen saturation is within the expected reference range of greater than 94%; therefore, this finding does not need to be reported to the provider. Central nervous system findings is correct. The newborn is displaying inconsolability, high-pitched cry, increased muscle tone, tremors, hyperactive Moro reflex, and excessive sucking. These findings are manifestations of NAS and should be reported to the provider. Gastrointestinal findings is correct. The newborn is displaying poor feeding and loose stools. These findings are manifestations of NAS and should be reported to the provider.

Indications for a cordocentesis

identify fetal blood type and RBC when there is a risk of isoimmune hemolytic anemia.

Platelet expected reference range pregnant client

150,000 to 400,000/mm3

A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity? Calcium gluconate Hydralazine Medroxyprogesterone acetate Methylergonovine

Calcium gluconate The nurse should anticipate administering calcium gluconate if the client develops magnesium toxicity. Calcium gluconate is the antidote.

test that is done as a part of an amniocentesis to evaluate fetal lung maturity.

Lecithin/sphingomyelin (L/S) ratio

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? "I will get injections of the medication once daily until my labor stops." "My blood sugar may be low while I'm on this medication." "I will have blood tests because my potassium might decrease." "My blood pressure may increase while I'm on this medication."

"I will have blood tests because my potassium might decrease."

A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching? "I will not gain more than 15 to 20 pounds during my pregnancy." "I will likely need to use alternative positions for sexual intercourse." "I'm glad I had a breast reduction years ago, so they will not enlarge with my pregnancy." "I'm glad I have a light complexion and will not get any stretch marks."

"I will likely need to use alternative positions for sexual intercourse." The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This client statement indicates that she understands the nurse's teaching about the physiological changes that occur during pregnancy.

A nurse is observing a new parent caring for their crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior? Lays the newborn across their lap and gently sways Places the newborn in the crib in a prone position Offers the newborn a pacifier dipped in formula Prepares a bottle of formula mixed with rice cereal

Lays the newborn across their lap and gently sways This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn. explanation for wrong answers: The parent 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. 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 might become accustomed to it and refuse to take the pacifier in the future without added supplement. 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 is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? Administer antiviral medication. Schedule an ultrasound examination. Administer Haemophilus influenzae type b vaccine. Schedule an indirect Coombs' test.

Schedule an ultrasound examination. The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth.

A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions? Clean newborns diaper area wash the newborns neck by lifting the newborns chin wipe the newborns eyes from the inner canthus outward cleanse the skin around the newborns umbillical cord stump wash the newborns legs and feet

The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus outward using plain water. The nurse should then wash the newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump followed by washing the newborn's legs and feet. The last step of the bath should be to clean the newborn's diaper area.

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

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 nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? Lochia serosa vaginal drainage Vaginal pressure Intermittent vaginal pain Yellow exudate vaginal drainage

Vaginal pressure The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues.

Pregnant client hemoglobin level expected range

greater than 11 g/dL

manifestations of hypoglycemia in newborn

respiratory distress abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures, hypotonia, poor feeding behaviors, hypothermia,

Indications for amniocentesis

to determine lung maturity, detect congenital anomalies, and diagnose fetal hemolytic disease.

The Kleihauer-Betke test

used to determine the amount of fetal blood in the maternal circulation when there is a risk of Rh-isoimmunization.

A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include? "You can resume sexual activity in 1 week." "You won't need to do Kegel exercises since you had a cesarean." "You can still become pregnant if you are breastfeeding." "You are safe to start adding sit-ups to your exercise routine in 2 weeks."

"You can still become pregnant if you are breastfeeding."

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

"You should leave the diaphragm in place for at least 6 hours after intercourse."

A nurse is preparing to administer magnesium sulfate 2 g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

50 mL/hr

level that helps to determine if a client is pregnant and if the pregnancy is ectopic.

A progesterone serum level

Indirect coombs test

An indirect Coombs' test determines whether the client has antibodies to the Rh antigen. The titer determines the prenatal client's sensitization and if there is Rh incompatibility.

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 8 cm and reports back pain. Which of the following actions should the nurse take? Apply sacral counterpressure. Perform transcutaneous electrical nerve stimulation (TENS). Initiate slow-paced breathing. Assist with biofeedback.

Apply sacral counterpressure.

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? BUN 25 mg/dL Serum creatinine 0.8 mg/dL Urine output of 280 mL within 8 hr Urine negative for ketones

BUN 25mg/dL The nurse should report an elevated BUN to the provider since it can indicate dehydration.

Treatment for STIS

Ceftriaxone and doxycycline are correct. Ceftriaxone is an anti-infective used to treat a variety of infections, including gonorrheal infection. Ceftriaxone is administered as a one-time IM injection for the treatment of gonorrhea. The adolescent is exhibiting manifestations of a gonorrheal infection. Therefore, the nurse should anticipate a provider's prescription for ceftriaxone. Doxycycline is an anti-infective used to treat a variety of infections. Doxycycline and ceftriaxone are anti-infectives used in the treatment of mild to moderate PID. The adolescent is exhibiting manifestations of a gonorrheal infection and PID. Therefore, the nurse should anticipate a provider's prescription for doxycycline. Acyclovir, fluconazole, and imiquimod are incorrect. Acyclovir is an antiviral used to treat herpes infections by interfering with the virus' DNA synthesis. The adolescent has no manifestations of genital herpes. Therefore, the nurse should not anticipate a provider's prescription for acyclovir. Fluconazole is an antifungal used to treat various fungal infections, including candidiasis. The adolescent has no manifestations of candidiasis or any fungal infection. Therefore, the nurse should not anticipate a provider's prescription for fluconazole Imiquimod is a topical anti-tumor medication used to treat keratoses, tumors of the skin, and genital warts. The adolescent does not have manifestations of genital warts. Therefore, the nurse should not anticipate a provider's prescription for imiquimod. Administering ceftriaxone is correct. Ceftriaxone is designated as a NOW prescription, which means it should be given within 90 min of the provider writing the prescription. The nurse should administer ceftriaxone after educating the adolescent about the purpose and potential adverse reactions of the medication. Administering metronidazole and educating on condom use is incorrect. The nurse should not administer metronidazole because it is a prescription for the adolescent to begin once discharged, and the prescription will be provided to the adolescent upon discharge; therefore, there is another action that the nurse should take. The nurse should educate the adolescent regarding condom use; however, there is another action that the nurse should take first.

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? Cover the newborn's eyes while under the phototherapy light. Keep the newborn in a shirt while under the phototherapy light. Apply a light moisturizing lotion to the newborn's skin. Turn and reposition the newborn every 4 hr while undergoing phototherapy.

Cover the newborn's eyes while under the phototherapy light. Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light.

A nurse is reviewing the prenatal laboratory results for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider? Hemoglobin 10 g/dL WBC count 10,000/mm3 Platelets 250,000/mm3 Fasting blood glucose 90 mg/dL

Hemoglobin 10 g/dL A hemoglobin of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this finding to the provider to obtain a prescription for ferrous iron supplementation because of anemia.

A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication? Hypertension Hypothermia Constipation Muscle weakness

Hypertension The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension.

A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? "I should increase my protein intake to 60 grams each day." "I should drink 2 liters of water each day." "I should increase my overall daily caloric intake by 300 calories." "I should take 600 micrograms of folic acid each day."

I should take 600 mcg of folic acid each day

A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect? Bruising over the buttocks Hard nodules on the roof of the mouth Petechiae over the head Bilateral periauricular papillomas

Petechiae over the head Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck. Wrong answers: A breech birth can cause bruising over the buttocks and swollen genitalia. Inclusion cysts, or whitish hard nodules on the gums or roof of the mouth, can be an expected finding. These are also called Epstein pearls. Bilateral periauricular papillomas are benign skin tags that can be an expected finding.

Which of the following actions are the nurse's priorities? Select the 4 actions that the nurse should take immediately. Exhibit 1: Medical History Gravida 1, Para 0 41 weeks of gestation Induction of labor due to postdates 2: Nurses notes: 1400:Client received epidural anesthesia for reports of a pain level of 7 on a scale of 0 to 10 from uterine contractions. Contractions occurring every 4 to 5 min, lasting 60 seconds, palpate moderate. FHR: Baseline 135/min, average variability, accelerations present, no decelerations noted. Oxytocin infusing at 8 milliunit/min. Rate last increased by 2 milliunits/min at 1330. 1415: Client reports feeling light-headed.Contractions occurring every 4 to 5 min, lasting 60 seconds, palpate moderate FHR: Prolonged deceleration of fetal heart rate to 90/min, minimal variability.

Administer a bolus of IV fluids is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the client's hypotension and fetal bradycardia and minimal variability. The nurse should plan to administer a bolus of IV fluids to increase the client's blood volume and improve uterine and intervillous space blood flow. Reposition the client to their side is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the fetal bradycardia and minimal variability caused by decreased uteroplacental perfusion. The nurse should plan to turn the client to their side to increase cardiac output and improve uterine and intervillous space blood flow. Apply oxygen at 10 to 12 L/min by nonrebreather mask is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the fetal bradycardia and minimal variability caused by decreased uteroplacental perfusion. The nurse should plan to administer oxygen via nonrebreather mask to increase maternal circulating oxygen levels and improve oxygen transfer through the intervillous spaces to the fetus. Elevate the client's legs is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the client's hypotension and fetal bradycardia and minimal variability. Elevating the client's legs will promote blood return to the heart and increase cardiac output. This action will improve uterine and intervillous space blood flow.

A nurse is caring for a client who is at 26 weeks of 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? Monitor the FHR. Assess uterine activity. Administer oxygen via a nonrebreather mask. Start a bolus of IV fluids.

Administer oxygen via a nonrebreather mask. When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask at 10 L/min to ensure adequate oxygenation to the fetus.

A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? Biophysical profile Amniocentesis Cordocentesis Kleihauer-Betke test

Biophysical profile A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound. Wrong answers: An amniocentesis is used to determine lung maturity, detect congenital anomalies, and diagnose fetal hemolytic disease. A cordocentesis is used to identify fetal blood type and RBC when there is a risk of isoimmune hemolytic anemia. 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 in the 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? Emotional lability Focusing phase Cognitive restructuring Couvade syndrome

Emotional lability The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients 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.

A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take? Tell the client to follow up with a dermatologist. Explain to the client this is an expected occurrence. Instruct the client to increase her intake of vitamin D. Inform the client she might have an allergy to her skin care products.

Explain to the client this is an expected occurrence. Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery.

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? Maintain the client NPO throughout the procedure. Place the client in a supine position. Instruct the client to massage the abdomen to stimulate fetal movement. Instruct the client to press the provided button each time fetal movement is detected.

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 nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? Acrocyanosis Transient strabismus Jaundice Caput succedaneum

Jaundice Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider.

laboratory test used to assess for neural tube defects or chromosome disorders.

Maternal Alpha-fetoprotein (AFP)

A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? Reports increased urinary output Diaphoresis Reports blurred vision Shallow respirations

Reports increased urinary output Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain, constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations include weak rapid pulse, fruity breath odor, urine positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL.

A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? Hypertonia Increased feeding Hyperthermia Respiratory distress

Respiratory distress Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.

A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which of the following findings should the nurse instruct the client to notify the provider? Shortness of breath Breakthrough bleeding Vomiting Breast tenderness

Shortness of breath The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain.

Which of the following findings should the nurse report to the provider? Select the 3 findings that should be reported: -Uterine contractions? -Fetal heart rate? -Gestational age? -Vaginal examination? -Maternal blood pressure? Vital Signs: 0900: Temperature 36.6° C (97.9° F) Heart rate 88/min Respiratory rate 18/min Blood pressure 130/70 mm Hg Oxygen saturation 97% on room air 1000: Heart rate 76/min Respiratory rate 20/min Blood pressure 138/68 mm Hg Oxygen saturation 98% on room air Medical History: 0900:Gravida 3, Para 2 32 weeks of gestation Client reports cramping and lower back pain that started this morning. Client denies leaking fluid. Nurses' Notes 0900:Client placed on electronic fetal monitor. Client reports pain as 4 on a scale of 0 to 10. 1000: FHR assessment 150/min. Average variability. No decelerations. Spontaneous accelerations noted.Uterine contractions occurring every 2 min, lasting 40 to 60 seconds in duration. Palpate as moderate intensity.Vaginal examination performed. Cervix is 2 cm dilated and 50% effaced.

Uterine contractions is correct. The client is experiencing regular uterine contractions and cervical change, which are indicators of preterm labor; therefore, the nurse should notify the provider about this finding. Gestational age is correct. The client is at 32 weeks of gestation and is experiencing regular uterine contractions and cervical dilation, which indicates that the client is in preterm labor; therefore, the nurse should notify the provider about this finding. Vaginal examination is correct. The client's cervix is dilated to 2 cm and is 50% effaced, which indicate the client is in preterm labor; therefore, the nurse should notify the provider about this finding.

A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? Blood pressure 136/88 mm Hg Report of insomnia Weight gain of 2.2 kg (4.8 lb) Report of Braxton Hicks contractions

Weight gain of 2.2kg (4.8lbs) A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider.

A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching? "I will receive this medication if my baby is Rh-negative." "I will receive this medication when I am in labor." "I will need a second dose of this medication when my baby is 6 weeks old." "I will need this medication if I have an amniocentesis."

"I will need this medication if I have an amniocentesis." Rho(D) 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 nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the f"You will need to drink the glucose solution 2 hours prior to the test." "Limit your carbohydrate intake for 3 days prior to the test." "A blood glucose of 130 to 140 is considered a positive screening result." "You will need to fast for 12 hours prior to the test." ollowing statements should the nurse include in the teaching?

"You will need to drink the glucose solution 2 hours prior to the test." "Limit your carbohydrate intake for 3 days prior to the test." "A blood glucose of 130 to 140 is considered a positive screening result." "You will need to fast for 12 hours prior to the test."

A nurse is providing teaching about nonpharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items? Cold cabbage leaves Purified lanolin cream A snug-fitting support bra Breast shells

Cold cabbage leaves The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement. The nurse should instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the application for two to three sessions as needed. More frequent applications could decrease the client's milk supply.

A nurse in an antepartum 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? Exhibit 1: Blood pressure 130/78 mm HgRespiratory rate 20/minHeart rate 90/min 2: Hemoglobin 12 g/dL Hematocrit 34%1-hr glucose tolerance test 120 mg/dL 3: Fundal height 30 cmGood fetal movementNot experiencing headache, dizziness, blurred vision, or vaginal bleedingFetal heart rate 110/min 1-hr glucose tolerance test Hematocrit Fundal height measurement Fetal heart rate (FHR)

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 nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider? Late decelerations Moderate variability of the FHR Cessation of uterine dilation Prolonged active phase of labor

Late decelerations Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider.

Asessment findings for exams

Pelvic inflammatory disease is correct. Pelvic inflammatory disease (PID) is an infection that involves the pelvic reproductive organs. There are several causative agents that lead to infection, including Neisseria gonorrhoeae and C. trachomatis. PID occurs as a result from untreated infections ascending from the vagina.. Manifestations include fever, increased C-reactive protein, nausea, and vomiting; therefore, the nurse should suspect the adolescent is developing PID Ectopic pregnancy is incorrect. Ectopic pregnancy is characterized by lower abdominal pain on one side, vaginal spotting or bleeding, and a delayed menstrual period. The adolescent reports having a normal menstrual period 3 weeks ago. The beta hCG test was negative and there are no other indications that the adolescent has an ectopic pregnancy; therefore, there is another condition the adolescent is most likely developing. Pyelonephritis is incorrect. Pyelonephritis is an inflammation of the upper urinary tract and kidneys and usually develops following a bladder infection. It is characterized by fever, flank pain, dysuria, and urgency. The adolescent's urinalysis has a negative leukocyte esterase and an absence of white blood cells and bacteria. These findings do not indicate the presence of a bladder infection; therefore, there is another condition the adolescent is most likely developing C-reactive protein is correct. The adolescent's C-reactive protein is elevated, which is a manifestation of PID. Beta hCG level is incorrect. The beta hCG test was negative and there are no other indications the adolescent has an ectopic pregnancy; therefore, there is another condition the adolescent is most likely developing Urinalysis is incorrect. The adolescent's urinalysis has a negative leukocyte esterase and an absence of white blood cells and nitrites. These findings do not indicate the presence of a bladder infection; therefore, there is another condition the adolescent is most likely developing.

A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? Apply a cool pack for 10 min to the heel prior to the puncture. Request a prescription for IM analgesic. Use a manual lance blade to pierce the skin. Place the newborn skin to skin on the mother's chest.

Place the newborn skin to skin on the mothers chest Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure.

A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include? Place the shoulder harness in the slots above the newborn's shoulders. Place the retainer clip at the level of the newborn's armpits. Place the newborn at a 60° angle in the car seat. Place the newborn in a blanket before securing them in the car seat.

Place the retainer clip at the level of the newborn's armpits. The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits.

A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? Determine progression of dilatation and effacement. Perform Leopold maneuvers. Complete a sterile speculum exam. Prepare a Nitrazine paper test.

Preform Leopold maneuvers The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer.

A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia? Singleton pregnancy BMI of 20 Maternal age 32 years Pregestational diabetes mellitus

Pregestational diabetes mellitus Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis.

A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching? "Obtain an informed consent prior to obtaining the specimen." "Collect at least 1 milliliter of urine for the test." "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." "Premature newborns may have false negative tests due to immature development of liver enzymes."

"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 hr prior to testing. Wrong answers: 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. Premature newborns have a delayed development of liver enzymes which can cause a false positive result. The nurse should collect a capillary blood sample via heel stick for the newborn screening. Urine is not collected for this test.

A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? "I can administer oxytocin 4 hours after the insertion of the medication." "You will need a full bladder prior to the insertion of the medication." "Remain in a side-lying position for 15 minutes after the medication is inserted." "An antacid will be given 20 minutes prior to the insertion of the medication."

"I can administer oxytocin 4 hours after the insertion of the medication." The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor.

A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make? "The nurse will carry your newborn to the nursery for procedures." "We will document the relationship of visitors in your medical record." "Your baby will stay in the nursery while you are asleep." "Staff members who take care of your baby will be wearing a photo identification badge."

"Staff members who take care of your baby will be wearing a photo identification badge."

A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching? "My sister will be able to carry my baby from the nursery to my room when she arrives." "The nurse will match my wrist band to my baby's crib card when they bring him to me." "The person who comes to take my baby's pictures will be wearing a photo identification badge." "My baby doesn't need to wear the electronic security bracelet when he's in my room."

"The person who comes to take my baby's pictures will be wearing a photo identification badge." All personnel working on the unit should be wearing a photo identification badge. The nurse should instruct the parent to never allow anyone who is not wearing an identification badge to come in contact with the newborn. explanation for wrong answers: The newborn should wear the electronic security bracelet at all times. The bracelet is set to alarm if anyone removes the bracelet or if the newborn is brought near an exit door. The nurse will match the newborn's identification number with the parent's identification number when they bring the newborn to the parent's room. A newborn should always be transported in a bassinet when outside the parent's room.

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? "You can miss your period for several other reasons. Describe your typical menstrual cycle." "If you have been sexually active and haven't used protection, it is likely that you are pregnant." "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" "Because you have missed your period, you should try taking a home pregnancy test before you start worrying."

"You can miss your period for several other reasons. Describe your typical menstrual cycle."

WBC count reference range pregnant client

5,000-15,000/mm3

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first? A client who is at 11 weeks of gestation and reports abdominal cramping A client who is at 15 weeks of gestation and reports tingling and numbness in right hand A client who is at 20 weeks of gestation and reports constipation for the past 4 days A client who is at 8 weeks of gestation and reports having three bloody noses in the past week

A client who is at 11 weeks of gestation and reports abdominal cramping When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of 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. explanation for wrong answers: 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. Therefore, there is another client that the provider should see first. Constipation is nonurgent because it is a common discomfort related to pregnancy for a client who is at 20 weeks of gestation. Therefore, there is another client that the provider should see first. Epistaxis is nonurgent because it is a common discomfort related to pregnancy for a client who is at 8 weeks of gestation. Therefore, there is another client that the provider should see first.

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? A newborn who is 26 hr old and has erythema toxicum on his face A newborn who is 32 hr old and has not passed a meconium stool A newborn who is 12 hr old and has pink-tinged urine A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)

A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F) An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider. explanation for wrong answers: Pink-tinged urine is an indication of uric acid crystals and is an expected finding for a newborn during the first week following birth. A newborn should pass the first meconium stool within the first 24 to 48 hr following birth. Failure to pass a meconium stool can indicate a bowel obstruction or congenital disorder. This finding is within the expected reference range. Erythema toxicum is a transient rash that can appear anywhere on a newborn's body during the first 24 to 72 hr following birth and can last up to 3 weeks. This finding requires no treatment.

A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect? Decreased uterine contractions An increase in the client's hemoglobin levels A reduction in respiratory distress in the newborn Increased production of antibodies in the newborn

A reduction in respiratory distress in the newborn Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress.

Which of the following findings should the nurse report to the provider? Select all that apply. -Abdominal assessment -Vaginal discharge -Heart rate -Temperature -Dyspareunia -Condom usage A nurse in a clinic is caring for a 16-year-old adolescent: History and Physical Adolescent is sexually active with two current partners. IUD in place Reports not using condoms during sexual activity. History of type 1 diabetes mellitus Nurses' Notes 1300:Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours.Reports painful urination and pain during sexual intercourse with minimal vaginal itching.Tenderness with palpation to lower abdomen, guarding abdomen observed. Greenish vaginal discharge observed. Reports last menstrual period was 3 weeks ago as normal period lasted 4 days. Vital Signs 1300:Blood pressure 118/72 mm Hg Heart rate 100/min Respiratory rate 20/min Temperature 38.3° C (101° F) Provider Prescriptions 1300:Standing prescriptions for clients who present with abdominal pain: Obtain laboratory tests: Urinalysis Cervical culture C-reactive protein Beta hCG

Abdominal assessment is correct. Abdominal tenderness with palpation is not an expected finding with an abdominal assessment; therefore, the nurse should report this finding to the provider. Vaginal discharge is correct. Greenish vaginal discharge indicates that the adolescent has an infection, which is not an expected finding; therefore, the nurse should report this finding to the provider. Temperature is correct. The client's temperature of 38.3° C (101° F) is above the expected reference range. An elevated temperature could signal infection or inflammation; therefore, the nurse should report this finding to the provider. Dyspareunia is correct. Dyspareunia is painful intercourse, which can be associated with STIs; therefore, the nurse should report this finding to the provider. Condom usage is correct. Sexual activity without the use of condoms increases the risk of contracting STIs; therefore, the nurse should report this finding to the provider.

Assessment findings for STIS and associated symptoms

Abdominal pain is consistent with gonorrhea. Gonorrhea can present with reports of acute or chronic lower abdominal pain. Greenish discharge is consistent with trichomoniasis and gonorrhea. Green-yellow discharge can occur in both trichomoniasis and gonorrhea. Candidiasis causes thick, white, lumpy discharge. Diabetes is consistent with candidiasis. Diabetes is a predisposing factor for yeast infections because high glucose levels provide an environment with enough glucose to allow the growth of yeast. Pain on urination is consistent with trichomoniasis, gonorrhea, and candidiasis. Dysuria is a manifestation of trichomoniasis, gonorrhea, and candidiasis and can be the result of urine flowing over an irritated and inflamed vulva and surrounding skin. Absence of condom use is consistent with trichomoniasis and gonorrhea. Sexual activity without the use of a condom can result in the transmission of STIs. Candidiasis is a vaginal infection that is not sexually transmitted.

A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? Abruptio placenta Placenta previa Preeclampsia Maternal bradycardia

Abruptio placenta Cocaine use increases the risk for vasoconstriction and possible abruptio placenta.

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurse's priority? Perform Nitrazine testing. Assess the fluid. Check cervical dilation. Begin FHR monitoring.

Begin FHR monitoring. The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take. explanation for wrong answers: The nurse should perform a Nitrazine test to determine the pH of the fluid. An alkaline pH can indicate rupture of membranes. However, this is not the first action the nurse should take. The nurse should observe the characteristics of the fluid to document color, odor, and amount. However, this is not the first action the nurse should take. The nurse should check the client's cervical dilation to assess progress of labor. However, this is not the first action the nurse should take.

A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider? Bilirubin 9 mg/dL Hemoglobin 18 g/dL Platelets 175,0000/mm3 Hematocrit 45%

Bilirubin 9 mg/dL A bilirubin level of 9 mg/dL is above the expected reference range for a newborn who is 4 hr old. The expected reference range for a newborn who is less than 24 hr old is 2 to 6 mg/dL. The nurse should report this finding to the provider.

A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? Depression Polyuria Hypotension Urticaria

Depression The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness.

Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's palsy) paralysis. Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn. Educate the parents to begin range of motion exercises on the affected arm after 1 week. Assess for grasp reflex in the affected extremity. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. Instruct parents to limit physical handling for 2 weeks.

Educate the parents to begin range of motion exercises on the affected arm after 1 week is indicated. Passive ROM exercises of the arm are indicated to restore function of the extremity. The initiation of these exercises is delayed for approximately 1 week to prevent additional injury to the brachial plexus. Assess for grasp reflex in the affected extremity is indicated. With Erb-Duchenne paralysis, only the upper arm is affected. The function of the wrists and fingers should be unaffected; the nurse should assess for a palmar grasp reflex. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt is indicated. Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved by pinning the sleeve to the shirt. Instruct parents to limit physical handling for 2 weeks is contraindicated. Parents and guardians should participate in the physical care of their newborn to increase parental-infant attachment. Providing education and practice opportunities for the parents will decrease their fears of injuring the newborn and increase confidence and bonding.

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?

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 the 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 nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? Deep tendon reflexes 4+ Fundal height 14 cm Urine protein 2+ FHR 152/min

FHR 152/min The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse.

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take? Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. Wrap the visible cord tightly with sterile, dry gauze. Apply oxygen to the client at 2 L/min via nasal cannula. Place the client in the lithotomy position and apply fundal pressure.

Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. The nurse should quickly apply gloves and insert two fingers into the vagina toward the cervix, exerting upward pressure onto the presenting part to relieve umbilical cord compression and increase oxygenation to the fetus. explanation for wrong answers: The nurse should wrap the visible cord with a loose sterile towel saturated with warm 0.9% sodium chloride solution, rather than with sterile, dry gauze. The nurse should apply oxygen to the client at 8 to 10 L/min via nonbreather mask. The nurse should place the client into a modified Sims position, knee-chest position, or extreme Trendelenburg to attempt to relieve the compression of the umbilical cord.

A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? Minimal arm recoil Popliteal angle of 90° Creases over the entire foot sole Raised areolas with 3 to 4 mm buds

Minimal arm recoil The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil.

A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure? Check the client's temperature. Observe for uterine contractions. Administer Rho(D) immune globulin. Monitor the FHR.

Monitor the FHR. The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis. wrong answers: The nurse should administer Rho(D) immune globulin following an amniocentesis to prevent Rh sensitization. However, this is not the priority nursing intervention. The nurse should observe for uterine contractions to identify preterm labor following an amniocentesis. However, this is not the priority nursing intervention. The nurse should check the client's temperature to monitor for infection following an amniocentesis. However, this is not the priority nursing intervention.

A nurse is assessing a client who is receiving morphine via IV bolus for pain following a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the following medications should the nurse administer? Fentanyl Butorphanol Naloxone Meperidine

Naloxone Morphine is a common opioid analgesic used for postoperative pain management that can cause central nervous system depression and can cause respiratory depression. The nurse should administer naloxone, an opioid antagonist, to reverse the opioid-induced respiratory depression in the client. Wrong answers: The nurse should administer meperidine to the client for the relief of severe, persistent pain. An adverse effect of this medication is respiratory depression. The nurse should administer butorphanol to the client for the relief of labor pain and severe postoperative pain after cesarean birth. An adverse effect of this medication is respiratory depression. The nurse should administer fentanyl to the client for the relief of severe, recurrent, or persistent pain during labor. Fentanyl is most commonly administered via PCA pump or epidural, alone or with a local anesthetic agent. An adverse effect of this medication is respiratory depression.

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member? Allow the sibling to hold the newborn during a bath. Make sure the sibling kisses the newborn each night. Obtain a gift from the newborn to present to the sibling. Switch the sibling's room with the nursery.

Obtain a gift from the newborn to present to the sibling. Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that they understand their role in the family. Wrong answers: Switching the sibling's room with the newborn's room might cause jealousy of the newborn or cause the sibling to feel that the newborn is taking their belongings. Forcing interactions between the sibling and the adoptive newborn can cause anger on the part of the sibling. It is more important to allow feelings to evolve naturally as the family unit bonds. Allowing the sibling to hold the newborn during a bath is not an appropriate activity for a school-age child because of the safety risk. However, the parents could let the sibling assist with other things in regard to caring for the newborn.

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? (Select all that apply.) Yellow sclera Acrocyanosis Posterior fontanel larger than the anterior fontanel Positive Babinski reflex Two umbilical arteries visible

Positive Babinski reflex is correct. Newborns should exhibit a positive Babinski sign following birth. The nurse should stroke the newborn's foot upward from the heel to the toes. The toes should hyperextend, and dorsal flexion of the big toe should occur. The absence of this finding requires neurological evaluation. The Babinski reflex is no longer present after 1 year of age. Acrocyanosis is correct. Acrocyanosis is an expected finding for at least the first 24 hr following birth. Poor peripheral perfusion leads to bluish discoloration in the newborn's hands and feet. Two umbilical arteries visible is correct. The nurse should observe two arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly. explanation for wrong answers: Posterior fontanel larger than the anterior fontanel is incorrect. The posterior fontanel is located on the back of the newborn's head and is a small triangular shape. The anterior fontanel is diamond shaped and approximately 5 cm (2 in) long. It is located on the top of the newborn's head and is larger than the posterior fontanel. Posterior fontanel larger than the anterior fontanel is incorrect. The posterior fontanel is located on the back of the newborn's head and is a small triangular shape. The anterior fontanel is diamond shaped and approximately 5 cm (2 in) long. It is located on the top of the newborn's head and is larger than the posterior fontanel. Yellow sclera is incorrect. Yellow sclera is an indication of hyperbilirubinemia and is not an expected manifestation.

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 the plan of care? Protect the client's head and feet from cold air. Bathe the client within 12 hr following birth. Ambulate the client within 24 hr following birth. Offer the client a glass of cold milk with her first meal.

Protect clients head and feed from cold air Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period.

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? Feed the newborn 1 oz of water every 4 hr. Apply lotion to the newborn's skin three times per day. Remove all clothing from the newborn except the diaper. Discontinue therapy if the newborn develops a rash.

Remove all clothing from the newborn except the diaper. The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin.

A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? Client reports nausea Urinary output of 40 mL/hr Respiratory rate 10/min Client reports feeling flushed

Respiratory rate 10/min The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available. explanation for wrong answers: Flushing and feeling hot is an expected adverse effect of magnesium sulfate. The nurse should reassure the client and provide comfort measures. Oliguria is a manifestation of magnesium toxicity. The nurse should report a urinary output of less than 25 to 30 mL/hr to the provider. Nausea is an expected adverse effect of magnesium sulfate. The nurse should reassure the client and provide comfort measures.

Patient with endometritis

The nurse should plan to obtain a culture of vaginal fluid and to administer IV antibiotics because the client is most likely experiencing endometritis as evidenced by increased pelvic pain, pressure and tenderness, fever, and foul-smelling vaginal discharge. The client had an increased risk of developing endometritis due to the history of anemia, gestational diabetes, operative vaginal birth, and prolonged rupture of membranes. The nurse should plan to monitor the client's temperature and the amount and odor of the lochia. Clients who have endometritis have an increased risk of hemorrhage. A decrease of foul-smelling lochia and fever indicate progression toward resolution of the infection.

A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take? Verify that the parent's identification band matches the newborn's identification band. Scan the newborn's identification band to verify their identity. Check the newborn's security tag number to ensure it matches the newborn's medical record. Match the newborn's date and time of birth to the information in the parent's medical record.

Verify that the parent's identification band matches the newborn's identification band. The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the information on the parent's identification band to the information on the newborn's identification band.