ATI: Maternal/Newborn: 4
A nurse is reinforcing teaching with a newborn who is scheduled to undergo a circumcision. Which of the following pieces of information should the nurse include in the teaching? A. "Wash your child's penis with soap starting on day 3 after the circumcision." B. "Apply the diaper loosely over the penis." C. "Your baby's glans penis will be bright red after the circumcision." D. "Remove the yellow exudate that will appear over the glans penis 24 hours following the circumcision."
"Apply the diaper loosely over the penis."
A nurse is caring for a client who reports cramping while trying to breastfeed her newborn. Which of the following instructions should the nurse provide to the client? A. "You might need to walk around to decrease gas." B. "Breastfeeding can cause uterine contractions." C. "We will need to check you for hemorrhaging." D. "You should lie on your side during breastfeeding."
"Breastfeeding can cause uterine contractions."
A nurse is caring for a client who is 32 hours postpartum. The client reports nipple soreness and breast engorgement. Which of the following recommendations should the nurse provide? A. "Call me so I can check your baby's latch the next time you breastfeed." B. "You should reduce the frequency of breastfeeding." C. "Apply expressed breast milk to sore nipples and cover them with nursing pads and a bra." D. "You should apply warm packs to the breasts between nursing sessions."
"Call me so I can check your baby's latch the next time you breastfeed."
A nurse is reinforcing discharge instructions with the parent of a newborn. Which of the following statements should the nurse include? A. "Crib slats should be less than 2.25 inches apart." B. "Share your bed with your baby for the first few weeks." C. "Place your baby on his stomach for naps." D. "You can position your baby's crib next to a heating vent for warmth."
"Crib slats should be less than 2.25 inches apart."
A nurse is collecting data from a client who is at 20 weeks of gestation and reports frequent episodes of indigestion and heartburn. Which of the following instructions should the nurse reinforce with the client? A. "Limit your intake of food twice per day." B. "Decrease your intake of spicy foods." C. "Rest in a supine position for a few minutes after eating." D. "Increase your intake of water and carbonated beverages."
"Decrease your intake of spicy foods."
A nurse is reinforcing teaching with the guardian of a newborn about formula preparation and feeding. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I should use a quick-flow nipple for the first few weeks." B. "I should warm the formula before feeding my newborn." C. "I should use soft bottle nipples to encourage sucking." D. "I should discard any formula left in the bottle after a feeding."
"I should discard any formula left in the bottle after a feeding."
A nurse is reinforcing teaching with a client at 7 weeks of gestation who is experiencing nausea and vomiting. Which of the following client statements indicates to the nurse an understanding of the teaching? A. "I should eat fatty foods to increase my caloric intake." B." I should brush my teeth right after eating." C. "Acupressure bands on my elbow might help me feel better." D. "I should have a small snack before bedtime."
"I should have a small snack before bedtime."
A nurse is reinforcing teaching about home care with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? A. "I should make sure the baby's bath water is between 115 and 120 degrees Fahrenheit." B. "I should let my baby sleep on the sofa until he is old enough to roll over." C. "I should ensure the airbag is functional when my baby is riding in the front sear of a car." D. "I should remove the bumper pad and stuffed toys from my baby's crib."
"I should remove the bumper pad and stuffed toys from my baby's crib."
A nurse is reinforcing with teaching a postpartum client about how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the teaching? A. "I should stop swaddling my baby once she is able to roll over by herself." B. "My baby's legs should be extended straight out when I swaddle her." C. "I should be able to slide just 1 finger between my baby's chest and the swaddled blanket." D. "After swaddling, I should place my baby on her side in her crib or bassinet."
"I should stop swaddling my baby once she is able to roll over by herself."
A nurse is caring for a client who is 6 hours postpartum following a dysfunctional labor. Which of the following statements by the client indicates a possible complication? A. "Suddenly, I seem to be urinating all the time." B. "I am really thirsty and hungry this morning." C. "I think I have changed my pad every 15 minutes." D. "Honestly, I'm so tired I don't want to hold the baby."
"I think I have changed my pad every 15 minutes."
A nurse is reinforcing discharge teaching about circumcision care for the parent of a newborn who has undergone a Gomco clamp procedure. Which of the following statements should the nurse identify as indication that the client understand the instructions? A. "I will apply petroleum jelly to my baby's penis for the first few days." B. "I will use pre-moistened towelettes to clean my baby's penis." C. "I will remove any yellow crusts when I clean my baby's penis." D. "I will wrap my baby's penis in dry gauze until it heals."
"I will apply petroleum jelly to my baby's penis for the first few days."
A nurse is reinforcing teaching about mastitis with a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I will limit breastfeeding to 5 minutes per breast." B. "I will not breastfeed if I start to have flu-like symptoms." C. "I will shop for an underwire nursing bra today." D. "I will avoid any of my family members who are ill."
"I will avoid any of my family members who are ill."
A nurse is reinforcing teaching about newborn with the care of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will wash my baby's umbilical cord stump with antibacterial soap." B. "I will cover my baby with a lightweight blanket during nap time. C. "I use a cotton-tipped swab to clean my baby's ear canals." D. "I will place a hate on my baby's head prior to going outside."
"I will place a hate on my baby's head prior to going outside."
A nurse is reinforcing teaching about newborn safety with a client who is postpartum. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will put bumper pads in the crib." B. "I will warm my baby's formula in the microwave on a low-setting." C. "I will place my baby on his stomach to sleep." D. "I will purchase a firm mattress for the crib."
"I will purchase a firm mattress for the crib."
A nurse is talking with a client at 20 weeks of gestation who is scheduled for a sonogram. The client states, "I am here to have my regular prenatal checkup, but I do not want any pictures of my baby." Which of the following responses should the nurse make? A. "Do not worry. We can do the sonogram without showing you the sex of the baby." B. "I would like to hear more about why you do not want the sonogram, including cultural reasons." C. "I think you should reconsider because the sonogram is an important part of the baby's checkup." D. "You have the right to tell the doctor that you do not want the sonogram, including any cultural reasons."
"I would like to hear more about why you do not want the sonogram, including cultural reasons."
A nurse is reinforcing education with a client who is pregnancy about symptoms that should immediately be reported to the provider. Which of the following client responses indicates an understanding of the teaching? A. "I should call my provider if I develop melasma." B. "If I notice that my eyes are puffy, I should call my provider." C. "I should call my provider if I notice that my feet and ankles are swollen." D. "If I notice periodic numbness and tingling in my fingers, I should call my provider."
"If I notice that my eyes are puffy, I should call my provider."
A nurse is talking with a client during her initial prenatal visit. The client reports a history of trisomy 13 syndrome in her family and is concerned her fetus might be at risk. Which of the following statements should the nurse provide? A. "If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder." B. "If the genetic screening shows that your baby has this disorder, I can provide you with information about an abortion clinic." C. "Screening for trisomy 13 syndrome and other chromosomal disorders is done automatically for clients at an increased risk." D. "I can provide you with information about sterilization so that the disorder is not passed to your future children."
"If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder."
A nurse is assisting with the care of a client who has been experiencing mild contractions for a few days. The nurse places an external fetal monitor on the client. The client asks, "What will the monitor show you?" Which of the following responses should the nurse make? A. "It will indicate if you are in active labor." B. "It will measure your heart rate." C. "It indicates if your baby is receiving an adequate amount of oxygen." D. "It indicates the intensity of the contractions you are currently having."
"It indicates if your baby is receiving an adequate amount of oxygen."
A nurse is reinforcing teaching with a group of clients about pregnancy prevention during the postpartum period. Which of the following statements should the nurse include? A. "Non-lactating clients can ovulate immediately after giving birth." B. "Non-lactating clients ovulate in their third month postpartum on average." C. "Lactating clients can ovulate as early as their first month postpartum." D. "Lactating clients ovulate in their sixth month postpartum on average."
"Lactating clients ovulate in their sixth month postpartum on average."
A nurse on a postpartum unit is reinforcing teaching with a client about postpartum blues. Which of the following instructions should the nurse include? A. "Seek immediate assistance for feelings of fatigue." B. "Plan opportunities to get out of the house frequently." C. "You will experience intense fears and anxiety if you have postpartum blues." D. "Most parents feel angry when the baby cries."
"Plan opportunities to get out of the house frequently."
A nurse is reinforcing teaching with a postpartum client about the proper technique for performing Kegel exercises. Which of the following statements should the nurse make? A. "Pretend you are urinating and stop your uterine stream intermittently." B. "You should bear down as if you are passing gas during the exercises." C. "You should feel tightening in the buttocks during the exercises." D. "Each muscle contraction should be held for a minimum of 30 seconds."
"Pretend you are urinating and stop your uterine stream intermittently."
A nurse is reinforcing teaching about toxoplasmosis with a client who is pregnant. Which of the following instructions should the nurse include? A. "To prevent toxoplasmosis, you will need to receive a measles, mumps, and rubella vaccination during your pregnancy." B. "You should avoid gardening during your pregnancy to decrease your risk of contracting toxoplasmosis." C. "You will get a body rash if you are infected with toxoplasmosis." D. "toxoplasmosis is transmitted through a bite from an infected mosquito."
"You should avoid gardening during your pregnancy to decrease your risk of contracting toxoplasmosis."
A nurse is caring for an adolescent who is in the second trimester of pregnancy. The client states, "I've gotten used to the idea of this pregnancy. It will be fun to have a little baby around the house." Which of the following is the appropriate response by the nurse? A. "Babies are not fun. They're a lot of work." B. "I'm so glad to see you're happy about the baby." C. "How are your parents reacting to the pregnancy?" D. "Tell me how you think your life will be after the baby is born."
"Tell me how you think your life will be after the baby is born."
A nurse is assisting with the care of a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make? A. "This could indicate a possible uterine infection." B. "The bleeding is minimal until I discontinue your IV medication." C. "You might have retained some fragments of your placenta." D. "You will require additional medication to increase your bleeding."
"The bleeding is minimal until I discontinue your IV medication."
A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make? A. "This is an attempt by your body to retain the fluid gained during pregnancy." B. "This is caused by an increase in your estrogen hormonal levels." C. "This is caused by the increased pressure on your veins in your lower legs." D. "This is a source of your fluid loss after delivery."
"This is a source of your fluid loss after delivery."
A nurse is assisting with discussing a nonstress test with a client who is at 39 weeks of gestation. Which of the following statements indicates an understanding of the information? A. "This test will assist in determining if my baby is okay by monitoring the heart rate." B. "This test will determine if chromosomal disorders are present." C. "This test will require me to take a medication that will prompt contractions." D. "This test will use sonar to determine how my baby is doing."
"This test will assist in determining if my baby is okay by monitoring the heart rate."
A nurse is reinforcing teaching with a client about postpartum fatigue. Which of the following statements should the nurse include? A. "Strenuous exercise can help improve your sleep." B. "Try to take naps when your infant is napping." C. "Avoid consuming dairy products such as milk before bedtime." D. "You might want to ask family not to visit until you are more rested."
"Try to take naps when your infant is napping."
A nurse is reinforcing education about continuous heparin therapy with a client who is 18 hr postpartum and has developed a deep vein thrombosis (DVT). Which of the following statements should the nurse include in the teaching? A. "An adverse effect of this medication is drowsiness." B. "This medication will require frequent monitoring of WBC levels." C. "Use a soft toothbrush to gently brush your teeth." D. "Avoid taking acetaminophen while receiving this medication."
"Use a soft toothbrush to gently brush your teeth."
A nurse is reviewing the medical record of a client who is pregnant prior to her first prenatal visit and notes that her pregnancy history is documented as 4, 1, 0, 2, 2. When the client arrives for the visit, which of the following questions should the nurse ask? A. "Were your twins born vaginally or by cesarean." B. "Have you needed counseling to help you cope with the fact that you do not have any living children?" C. "What did your previous provider tell you about the reasons for your preterm births?" D. "Will you have someone to help you care for your 4 children after this baby is born?"
"Were your twins born vaginally or by cesarean."
A nurse is reinforcing teaching with a client who is at 28 weeks of gestation. The client asks, "Is it safe for me to take a 12-hour drive to visit my family?" Which of the following responses should the nurse make? A. "Yes, but avoid using rest-stop bathrooms to reduce your exposure to infection." B. "Yes, but stop and lie down in the back seat if you feel dizzy. Sitting for long periods can put pressure on major blood vessels and make you faint." C. "Yes, but be sure to get out of the car and walk around regularly so you don't develop blood clots in your legs." D. "Yes, but monitor your blood pressure. Remaining in a sitting position during a long car trip can lower your blood pressure."
"Yes, but be sure to get out of the car and walk around regularly so you don't develop blood clots in your legs."
A nurse is caring for a client who in the first trimester of a low-risk pregnancy. The client tells the nurse that she and her partner would like to continue their sexual relationship, but she is afraid it will cause a miscarriage. Which of the following responses should the nurse make? A. "I will talk to your provider about a referral to a sex therapist." B. "You can safely have intercourse as long as you don't feel discomfort." C. "You should try alternative positions for sexual intercourse." D. "You should abstain from intercourse until 6 weeks postpartum."
"You can safely have intercourse as long as you don't feel discomfort."
A nurse is reinforcing teaching with a client who is breastfeeding and has pregestational diabetes controlled with insulin. Which of the following instructions should the nurse include? A. "You have a higher risk for hypoglycemia due to breastfeeding." B. "Reduce your overall carbohydrate intake until you achieve your prepregnancy weight." C. "You will need to take twice the amount of insulin while you breastfeed." D. "You should tailor your mealtimes depending on the needs of your baby."
"You have a higher risk for hypoglycemia due to breastfeeding."
A nurse is reinforcing teaching about exercise during pregnancy with a client who in in her third trimester. Which of the following statements should the nurse include? A. "Soak in a tub to soothe sore muscles." B. "Relax in a supine position for 10 minutes after your exercise session." C. "It is common to experience dizziness when you exercise during pregnancy." D. "You should be able to carry on a carry on a conversation easily during exercise."
"You should be able to carry on a carry on a conversation easily during exercise."
A nurse is contributing to the plan of care for a client who is at 12 weeks of gestation and has a BMI of 45. Which of the following recommendations should the nurse make for the client regarding weight gain during her pregnancy? A. "You should gain no more than 20 lb during your pregnancy." B. "You should plan to gain between 25 and 35 lb during your pregnancy." C. "You should not plan to gain any weight during pregnancy because you are already well-nourished." D. "Since you have higher energy needs than an average-sized pregnant client, you should plan to gain 45 to 50 lb."
"You should gain no more than 20 lb during your pregnancy."
A nurse is reinforcing teaching about weight gain during pregnancy for a client who is primigravida of normal pre-pregnancy weight. Which of the following statements should the nurse include? A. "You should plan to gain 25 to 35 pounds during your pregnancy." B. "You should plan to gain 11 to 20 pounds during your pregnancy." C. "Because you started pregnancy at a normal BMI and weight, your weight gain is not limited as long as you follow a healthy, balanced diet." D. "Because you are of normal weight prior to pregnancy, you are encouraged to gain 28 to 40 pounds during pregnancy."
"You should plan to gain 25 to 35 pounds during your pregnancy."
A nurse is reinforcing teaching about breastfeeding with a client who is at 32 weeks of gestation. Which of the following responses should the nurse make? A. "You should place plastic-lined breast pads into your bra." B. "You should start pumping your breasts now." C. "You should apply lanolin ointment to your areolas." D. "You should use warm water to wash your nipples."
"You should use warm water to wash your nipples."
A nurse is reinforcing teaching with a client who is breastfeeding. Which of the following pieces of information should the nurse include? A. "You should allow your baby to nurse for a total of 20 min per feeding." B. "Your baby should have 5 wet diapers per day." C. "Your baby should have bursts of 15 sucks or swallows at a time." D. "You can expect your baby to have dark black stools for the first week of life."
"Your baby should have bursts of 15 sucks or swallows at a time."
A nurse is assisting with planning an educational sessions for clients in a childbirth class. Which of the following findings should the nurse plan to instruct the clients to report immediately? A. Vaginal leukorrhea B. Shortness of breath C. Swelling of the face and fingers D. Lower back pain
Swelling of the face and fingers
A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. Which of the following actions should the nurse plan to take when performing a fundal massage? (place them in correct order) A. Position a hand around the top of the client's fundus B. Place a hand just above the client's symphysis pubis C. Ask the client to lie on her back with her knees flexed D. Rotate the upper hand to massage the client's uterus E. Use slight downward pressure to compress the client's fundus
1. Ask the client to lie on her back with her knees flexed 2. Place a hand just above the client's symphysis pubis 3. Position a hand around the top of the client's fundus 4. Rotate the upper hand to massage the client's uterus 5. Use slight downward pressure to compress the client's fundus
A nurse is caring for 4 newborns. Which of the following findings should the nurse report to the provider? A. A 1-hour old newborn who has a blood gluose of 55 mg/dL B. An 8-hour old newborn who has a respiratory rate of 50/min C. A 24 hour old newborn whose chest circumference is 32 cm D. A 12 hour old newborn who has a heart rate of 70/min while sleeping
A 12 hour old newborn who has a heart rate of 70/min while sleeping
A nurse is caring for a client who is pregnant and states she would like to find a midwife with the highest possible level of education. Which of the following should the nurse recommend? A. A community-based midwife B. A certified professional midwife C. A doula D. A certified nurse midwife
A certified nurse midwife
A nurse is caring for several clients. Which of the following clients should the nurse identify as a candidate for oral contraceptives? A. A client who smokes 2 packs of cigarettes per week B. A client who is breastfeeding a 7-month-old infant C. A client who is taking a anticonvulsant medication D. A client who is taking anti-HIV protease inhibitors
A client who is breastfeeding a 7-month-old infant
A nurse is caring for a client in the third trimester of pregnancy who is scheduled to undergo a non-stress test. Which of the following actions should the nurse take prior to the test? A. Ask the client to drink a glass of orange juice B. Prepare the client for a vaginal examination C. Request a serum hemoglobin level D. Obtain a clean-catch urine specimen
Ask the client to drink a glass of orange juice
A nurse is reinforcing teaching with the parent of a newborn about care following circumcision using a Plastibell device. Which of the following pieces of information should the nurse include? A. Apply gentle pressure using sterile gauze if bleeding occurs at the circumcision site B. The plastic rim of the bell will fall off in 2 to 3 days following circumcision C. Use mild soap and water to wash the penis twice each day after circumcision D. Apply petrolatum to the circumcision site after each diaper change
Apply gentle pressure using sterile gauze if bleeding occurs at the circumcision site
A nurse is caring for a client who reports that her last menstrual period (LMP) began on July 8. Based on Naegele's rule, which of the following is the client's expected date of birth (EDB)? A. April 1 B. April 15 C. October 15 D. October 1
April 15
A nurse is planning care for a client who is in labor and is HIV-positive. Which of the following actions should the nurse take after the baby is born? A. Encourage the mother to breastfeed B. Administer the hepatitis B vaccine prior to discharge C. Implement contact and droplet precautions when providing care to the infant D. Collect a cord blood specimen to test for the presence of HIV
Administer the hepatitis B vaccine prior to discharge
A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take? A. Administer vitamin K subcutaneously B. Administer erthromycin eye ointment within 12 hours C. Administer erythomycin eye ointmet from the outer canthus toward the inner canthus D. Administer vitamin K in the newborn's thigh
Administer vitamin K in the newborn's thigh
A nurse is reviewing recent laboratory values during a prenatal visit for a client who is pregnant. The nurse notes a hemoglobin level of 10 g/dL. Which of the following actions should the nurse take? A. Review the medical record for a history of gastric bypass surgery B. Advise the client to start iron and vitamin C supplementation C. Review the medication list to determine if the client is taking an anticonvulsant D. Request an order for sickle cell anemia screening
Advise the client to start iron and vitamin C supplementation
A nurse is collecting data from a newborn who is 12 hours old. Which of the following findings should the nurse report to the provider? A. Apical heart rate of 80/min while crying B. Apneic episode of 10 seconds while sleeping C. Positive Moro reflex D. Vernix caseosa in the skin folds
Apical heart rate of 80/min while crying
A nurse is assisting with amniotomy for a client who is in active labor. Which of the following actions should the nurse take? A. Assess the fetal heart rate before and after the procedure B. Monitor the client's temperature every 4 hours after the procedure C. Medicate the client for pain 30 mintes prior to the procedure D. Perform cervical assessments every 2 hours after the procedure
Assess the fetal heart rate before and after the procedure
A nurse is collecting data from a newborn and notes an axillary temperature of 36 C (96.9 F). Which of the following actions should the nurse take? A. Obtain a rectal temperature B. Assess the newborn's blood glucose level C. Bathe the newborn with warm water D. Position the infant's bassinet in front of a heater vent
Assess the newborn's blood glucose level
A nurse is assisting with the care of a client who is in active labor and receiving an oxytocin infusion. The nurse notes tachysystole with a Category 1 fetal heart rate tracing. Which of the following actions should the nurse take? A. Discontinue oxytocin infusion and apply oxygen B. Increase oxytocin infusion rate by 2 L/min C. Administer terbutaline 0.25 mg subcutaneously D. Assist the client into a side lying position and continue to monitor
Assist the client into a side lying position and continue to monitor
A nurse is caring for a client who is postpartum and reports abdominal pain due to flatus. Which of the following actions should the nurse take? A. Assist the client to ambulate in the hallway B. Encourage the client to increase fiber intake C. Administer a dose of laxative medication to the client D. Increase the client's fluid intake
Assist the client to ambulate in the hallway
A nurse is collecting data from a client who missed 2 menstrual cycles and states that she might be pregnant. Which of the following findings is a positive sign of pregnancy? A. Quickening B. Breast tenderness C. Uterine enlargement D. Auscultation of a fetal heart rate
Auscultation of a fetal heart rate
The parents of a child who has phenylketonuria (PKU) ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inheritance patterns responsible for PKU? A. X-linked recessive B. X-linked dominant C. Autosomal recessive D. Autosomal dominant
Autosomal recessive
A nurse is assisting with the care of an infant who begins displaying manifestations of neonatal abstinence syndrome (NAS). Which of the following actions should the nurse take? A. Swaddle the infant with arms and legs extended B. Administer naloxone IM C. Avoid eye contact during feedings D. Discourage the mother from handling the infant during the withdrawal phase
Avoid eye contact during feedings
A nurse is checking the vital signs of a newborn. Which of the following routes should the nurse use when checking the newborn's temperature? A. Axillary B. Temporal artery C. Oral D. Tympanic
Axillary
A nurse is collecting data from a newborn who has a congenital diaphragmatic hernia. Which of the following findings should the nurse expect? A. Distended abdomen B. Increased blood pressure C. Generalized petechiae D. Barrel-shaped chest
Barrel-shaped chest
A nurse is reinforcing teaching about dietary recommendations to prevent neural tube defects. Which of the following recommendations should the nurse include? A. Take a multivitamin every day B. Decrease consumption of mercury-containing fish C. Increase consumption of dairy products D. Begin taking a folic-acid supplement
Begin taking a folic-acid supplement
A nurse in a prenatal clinic is collecting data from several clients. Which of the following reports is an expected physiological adaptation to pregnancy? A. Spotting with urination B. Breast tenderness C. Thick, white vaginal discharge D. Facial swelling
Breast tenderness
A nurse is assisting the respiratory therapist with obtaining an arterial blood gas (ABG) specimen from a newborn. Which of the following actions should the nurse take? A. Carefully restrain the newborn during the procedure B. Place a warm cloth on the newborn's heel prior to the procedure C. Prepare wet gauze for the newborn's puncture site D. Administer pancuronium to the newborn prior to the procedure
Carefully restrain the newborn during the procedure
A nurse is collecting data from a client who is at 39 weeks of gestation and show manifestations of labor. Which of the following findings should alert the nurse to notify the provider that the client is in true labor? A. Contractions felt in the upper abdomen B. Small amount of bloody discharge C. Contractions occurring every 2 to 10 min D. Changes in cervical dilation or effacement
Changes in cervical dilation or effacement
A nurse is reinforcing teaching with the parents of a newborn about the facility's safety measures. Which of the following pieces of information should the nurse include? A. Expect staff to identify the newborn by verifying the information on the bassinet card B. Check for a photo identification badge before allowing a nurse to remove the newborn from the room C. Place the newborn in the bassinet when the bathroom D. Hold the newborn securely when walking in the hallway
Check for a photo identification badge before allowing a nurse to remove the newborn from the room
A nurse is preparing to provide umbilical cord care for a newborn 12 hours after delivery. Upon inspection, the nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take? A. Check the newborn's heart rate B. Place a pressure dressing on the cord stump C. Administer vitamin K D. Check the integrity of the cord clamp
Check the integrity of the cord clamp
A nurse is assisting with the care of a newborn who is large for gestational age, appears restless, and has tremors. Which of the following actions should the nurse take first? A. Place the newborn under a radiant warmer B. Provide nonnutritive sucking for the newborn C. Check the newborn's blood glucose level D. Swaddle the newborn
Check the newborn's blood glucose level
A nurse is reinforcing teaching with a client at 10 weeks gestation about self-care management for common discomforts in pregnancy. Which of the following instructions should the nurse include? A. Douche every other day to minimize leukorrhea B. Consume frequent snacks to decrease episodes of nausea C. Refrain from scheduling dental procedures until the third trimester D. Decrease fluid intake to reduce urinary frequency
Consume frequent snacks to decrease episodes of nausea
A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 seconds. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? A. Administer oxygen B. Place the newborn in an isolette C. Continue to monitor the newborn routinely D. Check the newborn's blood glucose
Continue to monitor the newborn routinely
A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings is a sign of a potential complication? A. Dark red lochia with small clots B. Deep tendon reflexes 4+ C. Urine output since birth of 3,000 mL D. Soft pink hemorrhoids
Deep tendon reflexes 4+
While assisting with the care of a client in labor, a nurse observes a pattern of early decelerations on the fetal monitor. Which of the following actions should the nurse take?' A. Notify the provider B. Document the findings and continue to monitor C. Administer oxygen to the client via face mask D. Assist with sterile speculum examination
Document the findings and continue to monitor
A nurse is reinforcing teaching about manifestations of postpartum depression with a client. Which of the following findings should the nurse include? A. Episodes of irritability without justification B. Sleeping more than 15 hours per day C. Desire to take care of the newborn with help D. Ability to verbalize negative feelings about the newborn
Episodes of irritability without justification
A nurse is collecting data from a newborn at birth who was delivered at 32 weeks of gestation. Which of the following findings should the nurse anticipate? A. Heel creases over the entire sole of the foot B. Pendulous testes C. Extended extremites D. Leathery cracked skin
Extended extremities
A nurse is assisting with the care of a client who is in active labor and notes early decelerations on the fetal monitor. The nurse should identify that which of the following circumstances can cause early decelerations? A. Cord compression B. Fetal hypoxemia C. Uteroplacental insufficiency D. Fetal head compression
Fetal head compression
A nurse is caring for a newborn who was born to a client with narcotic use disorder. Which of the following nursing actions is contraindicated for the care of the newborn? A. Promoting maternal-newborn bonding B. Tight swaddling of the newborn C. Small, frequent feedings D. Frequent stimulation
Frequent stimulation
The nurse is assisting with the care of a newborn. The nurse should obtain informed consent before taking which of the following actions? A. Administering erythromycin ophthalmic ointment B. Conducting a newborn hearing screening C. Giving the hepatitis B vaccine D. Screening for critical congenital heart disease
Giving the hepatitis B vaccine
A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department? A. Bacterial vaginosis B. Trichomoniasis C. Candidiasis D. Gonorrhea
Gonorrhea
A nurse is reviewing the laboratory report of a newborn who has a blood type of B-negative. The mother's blood type is O-positive. The laboratory results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse anticipate? A. Hyperbilirubinemia B. Central cyanosis C. Intracranial hemorrhage D. Cardiomyopathy
Hyperbilirubinemia
A nurse is assisting with the care of a client who is in the early stage of labor and has preeclampsia with severe features. Which of the following interventions should the nurse perform? A. Assess the getal heart rate and contractions hourly B. Encourage orall intake of clear, low-sodium fluids C. Instruct the client to ambulate during the early phase of labor D. Implement seizure precautions
Implement seizure precautions
A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal findings is a potential risk factor for pathological hyperbilirubinemia? A. Placenta previa B. Multiple gestation C. Infection D. Anemia
Infection
A nurse is assisting with the care of a client in the latent stage of labor who is reporting a pain level of 4 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Encourage the client to use hydrotherapy B. Teach the client biofeedback to control labor pain C. Instruct the client about relaxation breathing techniques D. Administer a benzodiazepine medication
Instruct the client about relaxation breathing techniques
A nurse is reinforcing nutritional teaching with a client who is pregnant. Which of the following nutrients should the nurse instruct the client to increase in her daily diet? A. Iron B. Calcium C. Vitamin E D. Vitamin K
Iron
A nurse is collecting data from a client who is 3 days postpartum. When examining the client's uterus, which of the following techniques should the nurse use? A. Press down and forward with the hand that is placed on the base of the uterus B. Measure the height of the fundus in fingerbreadths in relation to the umbilicus C. Place the client in a semi-Fowler's position prior to checking the uterus D. Massage the fundus with gentle palpation until it becomes soft to touch
Measure the height of the fundus in fingerbreadths in relation to the umbilicus
A nurse is assisting with caring for a client who is at 36 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse identidy as the priority? A. 1+ protenuria B. Blood pressure 140/98 mmHg C. Nonreactive nonstress test D. Fundal height 33 cm
Nonreactive nonstress test
A nurse is using Naegele's rule to determine the estimated date of birth (EDB) for a client whose first day of her last menstrual period was February 2, 2018. The nurse should identify which of the following as the client's EDB? A. November 16, 2018 B. October 19, 2018 C. October 26, 2018 D. November 9, 2018
November 9, 2018
A nurse at a prenatal clinic is collecting data from an adolescent who is pregnant and is visiting the clinic for the first time. Which of the following evaluations is the nurse's prioroty? A. Psychological readiness B. Partner support C. Socioeconomic status D. Nutritional status
Nutritional status
A nurse is caring for a client who is postpartum and has endometritis. Which of the following findings should the nurse report to the provider? A. Foul-smelling lochia B. Uterine pain with palpation C. Temperature 38.1 C (100.6 F) D. Oxygen saturation 93%
Oxygen saturation 93%
A nurse in a clinic is preparing to auscultate fetal heart tones using a Doppler for a client who is pregnant. Which of the following actins should the nurse prepare to take? A. Apply petroleum jelly on the client's abdomen B. Palpate and count the maternal radial pulse while listening to the fetal heart rate C. Place the wand over the fetal chest to hear the fetal heart rate D. Percuss the maternal abdomen to verify the position of the fetus
Palpate and count the maternal radial pulse while listening to the fetal heart rate
A nurse is caring for a newly admitted newborn who is large for gestational age. After 30 minutes, the newborn becomes jittery and lethargic with hypotonic muscles and a cry that is different from the time of admission. Which of the following actions should the nurse take? A. Perform a heel stick to check the newborn's glucose level B. Obtain a prescription for serum substance screening C. Provide a feeding of sterile water D. Screen the newborn for phenylketonuria (PKU)
Perform a heel stick to check the newborn's glucose level
A nurse is discussing the expected changes of pregnancy with a client who is at 8 weeks of gestation. Which of the following findings should the nurse tell the client to report to the provider during the first trimester? A. Breast tenderness B. Urinary frequency C. Persistent vomiting D. No fetal movement
Persistent vomiting
A nurse is assisting with the care of a newborn who has hyperbilirubinemia and is scheduled to receive phototherapy. Which of the following actions should the nurse take? A. Place an opaque mask over the newborn's eyes B. Apply lotion to the newborn's skin twice daily C. Dress the newborn in a diaper and t-shirt D. Check the newborn's temperature twice daily
Place an opaque mask over the newborn's eyes
A nurse is reviewing the laboratory values of a client who is pregnant and has a low progesterone level. Which of the following complications should the nurse expect? A. Gestational diabetes B. Preterm labor C. Inadequate milk supply D. Inadequate uterine growth
Preterm labor
A nurse is assisting with the care of a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication from the oxygen therapy? A. Atelectasis B. Retinopathy C. Interstitial emphysema D. Necrotizing enterocolitis
Retinopathy
A nurse is reinforcing teaching with a client who is postpartum and has a hearing impairment. Which of the following techniques should the nurse use? A. Raise voice volume B. Stand in front of a light or window C. Sit at the client's eye level D. Ask client to read educational material after the teaching
Sit at the client's eye level
A nurse is reinforcing teaching about parental attachment with a client who is postpartum. Which of the following client behaviors indicates an understanding of the teaching? A. The client primarily touches the newborn with her fingertips B. The client does not critique the newborn's features and body parts C. The client has given the newborn a name D. The client is quiet with a blank facial expression
The client has given the newborn a name
A nurse is assisting with the care of a client who is at 32 weeks of gestation and has preeclampsia. Which of the following provider prescription should the nurse expect? A. The client should take low-dose aspirin daily B. The client should check fetal kick counts every other day. C. The client should have her blood pressure measured while standing D. The client should maintain complete bed rest
The client should take low-dose aspirin daily
The nurse is collecting data about the reflex responses of a newborn. Which of the following findings should the nurse expect when assessing the Moro reflex? A. Abduction and extension of the arms are asymmetric B. The opposite leg reflexes while a leg is extended and the sole of the foot is stimulated C. Toes hyperextend with dorsiflexion of the great toe D. The legs move in a similar pattern of response to the arms
The legs move in a similar pattern of response to the arms
A nurse is collecting data from a newborn. Which of the following locations should the nurse palpate to check the anterior fontanel? (PICTURE OF BABY'S HEAD)
The nurse should palpate the anterior fontanel on the top of the newborn's head where the sagittal, coronal, and frontal sutures meet. This area is about 5 cm (1.97 inches) and diamond shaped. A
A nurse is collecting data from a male newborn. Which of the following findings should the nurse report to the provider? A. Superficial cracking and peeling are evident on the skin of the hands and feet. B. The palmar grasp occurs spontaneously when the newborn is sucking. C. The bulge of the testes is palpable in the inguinal canal D. There is decreased abdominal movement with breathing
There is decreased abdominal movement with breathing
A nurse is collecting data from a client who is receiving morphine via a patient-controlled analgesia (PCA) pump following a cesarean birth. Which of the findings should the nurse report to the provider? A. Respiratory rate 14/min B. Temperature 37.* C (100 F) C. Dizziness upon rising D. Urine output 20 mL/hr
Urine output 20 mL/hr
A nurse is preparing to perform a heel stick on a newborn. Which of the following actions should the nurse take? A. Don sterile gloves prior to puncturing the newborn's heel B. Puncture the center aspect of the newborn's heel C. Elevate the newborn's heel prior to the procedure D. Warm the heel with a warm washcloth prior to the procedure
Warm the heel with a warm washcloth prior to the procedure
A nurse in antepartum clinic is collecting data from a client who is 2 weeks postpartum and reports vaginal discharge. Which of the following discharge characteristics should the nurse expect? A. Dark red uterine discharge B. Pinkish-brown vaginal discharge C. Yellowish-white uterine discharge D. Bright red vaginal discharge
Yellowish-white uterine discharge
