Ati newborn

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

"Crib slats should be less than 2.25 inches apart." Crib slats should be no more than 5.7 cm (2.25 in) apart to prevent injuries due to falls or entrapment of the infant's head between the slats.

A nurse is administering a rubella immunization to a client who is 2 days postpartum. Which of the following client statements indicates a need for further instruction?

"I can conceive anytime I want after 10 days." A client who receives a rubella immunization should not conceive for at least 1 month after receiving the rubella immunization to prevent injury to the fetus.

A nurse at a prenatal clinic is teaching a client how to perform a kick count. Which of the following statements should the nurse include in the teaching?

"Before bedtime is a good time to start counting the kicks." Peer Comparison Clients should be instructed to perform a kick count, which is the daily fetal movement count (DFMC), before bedtime or after meals for 2 hours, or until 10 movements are counted. Alternatively, the client can count all fetal movements in a 12-hour period each dav until at least 10 movements are counted,

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?

"Call me so I can check your baby's latch the next time you breastfeed." Nipple soreness can be a result of a poor latch. The nurse should observe the next breastfeeding session to offer hands-on advice and assistance to ensure an ideal latch.

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

"I should be careful to avoid becoming pregnant within the next month.! While the chances of fertility in the first 4 weeks postpartum are low, clients who receive a rubella immunization must be additionally careful to avoid pregnancy either through maintaining abstinence or through using an effective contraceptive. The rubella vaccine is a live virus vaccine and can cause birth defects

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

"I'm here for you if you would like to talk.! Peer Comparison This is a therapeutic statement because it acknowledges the client's loss and invites her to share her thoughts and feelings.

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?

"If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder." Genetic screening has multiple legal and ethical considerations that must be addressed prior to testing. The client will need to sign an informed consent form prior to the screening.

A nurse is teaching a sibling class for a group of expectant parents and their older children. Which of the following statements should the nurse include to facilitate sibling adaptation?

"Involve the siblings in decorating your newborn's room.! The parents should involve the siblings as much as possible in preparing for the newborn such as by helping decorate the newborn's room and shopping with the parents for supplies for the newborn.

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

"Losing 2.2 pounds each month would be acceptable." An important postpartum goal is for the client to lose the weight gained during pregnancy. An acceptable amount of weight loss for a client who is lactating is 1 kg (2.2 lb) per month.

A nurse is teaching a client who had a vacuum-assisted vaginal delivery. Which of the following statements should the nurse identify as an indication that the client understands the information?

"My baby has a higher risk of developing jaundice." Peer Comparison A vacuum-assisted birth increases the risk of jaundice as the bruises caused by the device dissipate.

A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of the teaching?

"My baby may sometimes feed every hour for several hours in a row." Cluster feeding is an expected finding for newborns who are breastfeeding. The mother should follow her newborn's cues and feed her 8-12 times per day.

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

"Place ice packs on your breasts." Peer Comparison The nurse should instruct the client to place ice packs on her breasts using a "15 minutes on and 45 minutes off" schedule to decrease swelling of the breast tissue as the body produces milk

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

"The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract

A nurse is performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks what the purpose of the test is. Which of the following responses should the nurse provide?

"This test will help determine if your baby is healthy." This NST is used as a prenatal fetal assessment. It tracks fetal heart rate patterns expected with fetal movement and can help identify fetal distress.

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

"This type of monitoring will allow us to measure the intensity of your contractions." Peer Comparison A tocotransducer can monitor the frequency and duration of contractions, but only an intrauterine pressure catheter can monitor the intensity of contractions.

A nurse is performing a routine prenatal examination of a client who is in the second trimester. The client reports backaches with no other symptoms and refuses medication. Which of the following responses should the nurse make?

"Try pelvic tilt exercises." Backaches are common during the second trimester due to the relaxation of the joints that otherwise stabilize the pelvis and the shift in the client's center of gravity. Pelvic tilt exercises, resting, and sleeping on a firm mattress can help ease this pain.

A nurse is teaching a client who is breastfeeding about strategies for preventing mastitis. Which of the following instructions should the nurse include?

"Use your finger to release suction after feeding." Releasing the newborn's grasp on the nipple with a finger before removing the newborn from the breast helps prevent injury to the nipples, which can lead to mastitis.

A nurse is providing counseling for a couple experiencing infertility issues. Which of the following statements by the nurse is appropriate?

"You might want to join our support group for couples who are experiencing similar problems." An invitation to join a support group will promote emotional, social, and spiritual growth. Many positive results from peer support can occur.

A nurse is teaching a client who is pregnant about toxoplasmosis. Which of the following instructions should the nurse include?

"You should avoid gardening during your pregnancy to decrease your risk of contracting toxoplasmosis." Toxoplasmosis infection is potentially teratogenic to the fetus. It can be transmitted through contact with cat feces, which can be found in garden areas. It can also be transmitted through contact with uncooked meat.

A nurse is caring for a pregnant client who reports nausea and vomiting. Which of the following instructions should the nurse share with the client?

"You should eat some crackers before rising from bed in the morning." Morning sickness is caused by the buildup of human chorionic gonadotropin (hG) in the mother's system. Dry foods eaten before rising in the morning tend to reduce the risk of nausea in clients who are pregnant.

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

"You should slightly increase your exposure to sunlight." Pruritus gravidarum is a condition of pregnancy that causes generalized itching without the presence of a rash. This occurs due to the stretching of the skin. Exposure to sunlight can reduce itching.

A nurse is caring for a client who is at 26 weeks gestation and reports constipation. Which of the following responses by the nurse is appropriate?

"You should walk for at least 30 min every day" The nurse should encourage the client to participate in moderate physical activity, such as walking or swimming, every day. This activity increases intestinal peristalsis, which will help alleviate constipation.

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

Give oxygen at 10 L/min via face mask The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to administer oxygen to help stabilize the client's respiratory status.

A nurse is providing teaching about calcium intake to a client who is breastfeeding. Which of the following is the recommended daily calcium intake for a client who is breastfeeding?

1,000 mg Peer Comparison The nurse should instruct the client that 1,000 mg of calcium is recommended for women age 19 and older, as well as those who are lactating. This amount of calcium is sufficient to meet the needs of the client and the infant because additional calcium is absorbed from the intestines during this time.

A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority?

480 mL urine output in 24 hr Peer Comparison When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is 480 m L of urine output in 24 hr because the minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of preeclampsia to preeclampsia with severe features, which requires immediate intervention. Therefore, this is the priority finding.

A community health nurse is planning care for 4 high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first?

A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy The nurse should apply the safety and risk-reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to the client's safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. An elevated bilirubin level can lead to kernicterus; therefore, it is imperative for the nurse initiate phototherapy immediately to help prevent this dangerous outcome.

A nurse is assisting with fetal heart monitoring during labor for a client who is at 40 weeks of gestation. The nurse should identify that which of the following findings on the fetal monitoring tracing requires intervention?

A fetal heart rate of 180/min for 15 minutes Peer Comparisol A heart rate of more than 160/min for 10 minutes or longer is considered fetal tachycardia, which can indicate fetal hypoxemia; therefore, this finding requires intervention by the nurse.

A nurse is caring for a client who is 12 hr postpartum. Which of the following interventions should the nurse implement? (Click on "Figure/Media" above the question for additional information about the client)

Administer ferrous sulfate orally The nurse should administer ferrous sulfate orally for a client who has a hemoglobin level of =10.5 g/dL.

A nurse is planning care for a client who is at 35 weeks gestation. Which of the following laboratory tests should the nurse obtain?

Group B streptococcus ß-hemolytic The nurse should obtain a vaginal/anal group B streptococcus ß-hemolytic (GBS) culture at 35 to 37 weeks gestation to screen for infection. Prophylactic antibiotics should be given during labor to clients who are positive for GBS.

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

Abundant lanugo Newborns who are premature have abundant lanugo (fine hair), especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinna, and forehead.

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

Administer immune globulin to the client to prevent fetal isoimmunization Because the client is Rh-negative, Rh immune globulin is administered after the procedure to prevent fetal isoimmunization or help ensure maternal antibodies will not form against any placental red blood cells that might have accidentally been released into the maternal bloodstream during the procedure.

A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take?

Administer vitamin K in the newborn's thigh The nurse should administer vitamin K in the vasts lateralis muscle in the newborn's thigh.

A nurse is assessing a pregnant client at 26 weeks of gestation who reports an episode of dizziness after lying on her back on the couch. Which of the following actions should the nurse take?

Advise the client to lie on her side Peer Comparison SO ATTA Dizziness after a pregnant client lies flat on her back is a sign of supine hypotension, which is caused by compression of the vena cava from the weight of the pregnant uterus. Pregnant women should be advised to avoid lying in a supine position

A nurse is caring for a client who delivered a stillborn child. Which of the following actions should the nurse take?

Allow the parents to keep the child in their room for as long as they wish The parents should have unrestricted access to the child's body. This time allows them to process the traumatic event. Evidence shows that the risk of infection caused by having a deceased body in the room is minimal. Most parents will be ready to say goodbye to the body when it begins to show obvious signs of deterioration.

A nurse is assessing a female client 24 hr after delivery and notes the fundus is 2 cm above the umbilicus. Which of the following actions should the nurse take?

Ambulate the client to the bathroom Peer Comparison An increased fundal height in the postpartum period is a sign of a non-contracted uterus, which increases the risk for hemorrhage. The most common postpartum cause of an elevated tundal height is an over-distended bladder.

A nurse is caring for a client who is in labor. The client asks the nurse, "Why are you pressing on my abdomen?" Which of the following responses should the nurse make?

I can determine the position or your baby. Peer Comparison Palpation of the abdomen can determine which fetal part is in the uterine fundus and where the back of the fetus is. Palpating the lower abdomen will help determine whether the retuss head is down or it another extremity is the presenting part

While caring for a client who is in active labor, a nurse notes late decelerations on the fetal monitor. Which of the following actions should the nurse take?

Apply oxygen at 10 L/min via nonrebreather face mask Late decelerations are caused by uteroplacental insufficiency and require intervention to increase oxygen flow to the fetus. Administering oxygen to the client will increase the amount of oxygen available to the fetus.

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

Apply pressure to the client's sacral area during contractions The nurse should provide counter-pressure to the sacral area with a palm or a firm object, such as a tennis ball, during contractions. Counter-pressure lifts the fetal head away from the sacral nerves, which decreases pain.

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

Ask the client when she last voided Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be firm at the midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void.

A nurse is caring for a client who is at 38 weeks gestation and reports no fetal movement for the past 24 hr. Which of the following actions should the nurse take?

Auscultate for a fetal heart rate The presence of a fetal heart rate is a reassuring manifestation of fetal wellbeing. The nurse should auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action.

A nurse is assessing a client who missed 2 menstrual cycles and reports that she might be pregnant. Which of the following findings is a positive sign of pregnancy?

Auscultation of a fetal heart rate The auscultation of a fetal heart rate is a conclusive sign of pregnancy.

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

Autosomal recessive PKU is inherited by autosomal-recessive gene patterns. In these types of disorders, neither parent may actually have the disorder, but both mother and father must carry and contribute a variant gene for it to occur. Other autosomal-recessive disorders are cystic fibrosis and sickle cell anemia.

A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving this vaccine?

Baker S yeast Peer Comparison An allergy to baker's yeast is a contraindication to receiving the hepatitis B vaccine. The nurse should notify the client's provider.

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

Blurred or double vision A client who is pregnant should report experiencing blurred or double vision, as these could be a manifestation of gestational hypertension or preeclampsia.

A nurse in a prenatal clinic is performing telephone triage for several clients. Which of the following client reports should the nurse identify as an expected physiological adaptation to pregnancy?

Breast tenderness Peer Comparison Breast tenderness is common during the first and third trimesters of pregnancy. The nurse should explain that this is expected and that the client should wear a well-fitting, supportive bra to help alleviate the tenderness.

A nurse is teaching about mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching?

I will avoid any of my family members who are ill." The client should avoid ill family members to decrease the risk of mastitis. While the causative organisms of mastitis tend to be bacterial, exposure to viral illnesses can compromise the immune system and leave the client vulnerable to mastitis.

A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer?

Calcium gluconate The nurse should discontinue the magnesium sulfate infusion immediately and prepare to administer calcium gluconate IV to reverse the effects of magnesium sulfate and to prevent cardiac and respiratory arrest

A nurse is providing teaching about the selection of commercial formula to the guardian of a newborn. Which of the following pieces of information should the nurse include?

Cow's milk-based formula is recommended for healthy newborns. Peer Comparisor The nurse should identify that cow's milk-based formulas are similar to human breast milk and are recommended for newborns and infants unless prescribed otherwise by the provider. Certain conditions that might indicate a need to switch to an alternate formula include galactosemia, a congenital lactase deficiency, and immunoglobulin E allergies.

A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication to the use of this medication?

D. Active genital herpes The use of oxytocin is contraindicated for clients who have an active genital herpes infection. The newborn can acquire the infection while passing through the birth canal. Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection.

A nurse is caring for a preterm infant in the NICU. Which of the following actions by the nurse will promote the infant's optimal development?

D. Reducing ambient noise and lighting Minimizing light and noise stimuli in the nursery is an important aspect of promoting optimal development. Lighting should be dimmed at night, and blankets should be placed over the incubators during the daylight hours. Noise levels should always be kept to a minimum.

A nurse is assessing a client who is at 26 weeks of gestation and has mild preeclampsia. Which of the following findings should the nurse report to the provider?

Deep tendon reflexes 4+ Peer Comparison Hyperactive deep tendon reflexes demonstrate a progression from mild preeclampsia to severe gestational hypertension or preeclampsia with severe features. This finding indicates the need for hospitalization and treatment with magnesium sulfate to prevent eclamptic seizures.

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

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

A nurse is planning care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care?

Ensure the newborn's eyes are closed before applying the eye shield Overexposure to the lights during treatment can cause damage to the newborn's corneas. Therefore, the nurse should gently close the newborn's eyes prior to applying the eye shield.

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect?

Exaggerated reflexes A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the central nervous system (CNS). Exaggerated reflexes are indicative of CNS irritability.

A nurse is assessing the respiratory status of a newborn who was born 2 hours ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress?

Expiratory grunting Expiratory grunting is an indication of respiratory distress that is caused by narrowing of the bronchi. The nurse should report this finding to the provider.

A nurse is assessing a newborn at birth who was delivered at 32 weeks gestation. Which of the following findings should the nurse anticipate?

Extended extremities An infant born at 32 weeks gestation has poorlv developed muscle tone and is unable to maintain the flexed position seen in infants born at Tull term

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

Fetal asphyxia Oxytocin may cause tachysystole, which can lead to uteroplacental insufficiency. Inadequate oxygen transfer to the placenta will result in fetal asphyxia.

A nurse in labor and delivery is teaching a newly licensed nurse about performing the McRoberts maneuver to relieve shoulder dystocia. Which of the following pieces of information should the nurse include?

Flex the client's legs apart and raise her knees to her abdomen Peer Comparisor The McRoberts maneuver includes helping the client flex her knees apart, which rotates the pubic bone anteriorly. This movement releases the anterior shoulder, but the nurse should not apply pressure directly to the anterior shoulder during this maneuver. This maneuver can be used for clients with or without epidural anesthesia

A nurse is caring for a newborn who was born to a client with a narcotic use disorder. Which of the following nursing actions is contraindicated in the care of this newborn?

Frequent stimulation This newborn needs a quiet, calm environment with minimal stimulation to promote rest and reduce stress. A stimulating environment can trigger irritability and hyperactive behaviors.

A nurse is caring for a client who is scheduled to receive a continuous IV infusion of oxytocin following a vaginal birth. Which of the following assessment findings should the nurse monitor to evaluate the effectiveness of the medication?

Fundal consistency Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective.

A nurse is caring for a client who is pregnant and has a rupture of membranes. The nurse notes the presence of meconium-stained fluid. Which of the following actions should the nurse take?

Gather equipment for neonatal resuscitation Peer Comparison Meconium-stained amniotic fluid can cause neonatal meconium aspiration syndrome. The nurse should gather equipment for neonatal resuscitation.

A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should the charge nurse include in the teaching?

Impaired placental perfusion Maternal hypotension can occur in 10% to 30% of women who receive epidural or spinal anesthesia. This can result in decreased blood flow to the placenta and impair the delivery of oxygen to the fetus

A nurse is assessing a newborn. Which of the following findings should the nurse identify as an indication of recent maternal heroin use?

Incessant crying Manifestations of neonatal abstinence syndrome due to maternal heroin use include incessant crying, jitteriness, hyperactivity, poor feeding, tachycardia, and frequent yawning and sneezing.

A nurse is caring for a term newborn 90 minutes after a scheduled cesarean birth. The newborn's 1-minute Apgar score was 9. The newborn's heart rate is 120/min, and his respiratory rate is 70/min. There are no indications of retractions, grunting, or nasal flaring. Which of the following actions should the nurse Take?

Initiate close observation of the newborn for indications of respiratory distress Peer Comparison The newborn has manifestations of transient tachypnea of the newborn (TTN). This condition is thought to be a result of an incomplete clearance of fluid from the lungs at birth. Newborns born by cesarean are more likely to have TN because the thoracic cavity is not compressed as in a vaginal birth. It usually resolves spontaneously, and close observation of the newborn is indicated

A nurse is assessing a newborn 1 hr after birth. Which of the following findings should the nurse report to the provider?

Jaundice of the sclera If the newborn has jaundice within the first 24 hours of life, this can indicate a potentially pathological process such as hemolytic disease, Pathological jaundice can result in high levels of bilirubin, which can damage the neonatal brain.

A nurse in a clinic is assessing a client who is at 13 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse identify as the priority?

Ketones 2+ The greatest risk to this client is malnutrition that poses a serious risk to the developing fetus. Ketonuria indicates that the client's body is breaking down fat and protein stores for energy and cannot provide the fetus with essential nutrients. Therefore, this is the priority finding, and the nurse should report it to the provider immediately.

A nurse is planning care for a client who is scheduled to have prostaglandin E2 gel inserted for cervical ripening. Which of the following actions should the nurse take?

Maintain the client in a side-lying position for 30 min after insertion Peer Comparison The client should maintain a side-lying or supine position with a lateral tilt for 30 to 40 minutes after the insertion of the medication to allow the gel to stay in contact with the cervix.

A nurse is caring for a client who just had a spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and a prolapsed umbilical cord. Which of the following actions should the nurse take first?

Manually apply upward pressure intravaginally on the presenting part The greatest risk to this client is fetal CNS injury or death from fetal hypoxia due to cord compression. Therefore, the first action the nurse should take is to insert a gloved hand into the vagina and apply upward pressure to the presenting part to move it away from the cord.

A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions?

Methylergonovine The nurse should administer methylergonovine, an ergot alkaloid, which promotes uterine contractions.

A nurse is planning care for a client who is postpartum and has cardiac disease. For which of the following prescriptions should the nurse seek clarification?

Monitor the client's weight weekly The nurse should weigh the client daily to monitor for fluid overload.

A nurse is assessing a 7-month-old infant during a well-child visit and notes the presence of a full Moro reflex. For which of the following conditions should the nurse screen the infant?

Neurological disorder Peer Comparison The Moro reflex, also known as the startle reflex, is elicited by striking the surface next to the newborn to startle him/her. A classic pattern of abduction and extension of the arms is expected. This reflex should be gone by 4 months of age; its presence after 4 months of age is associated with a neurological disorder.

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?

November 9, 2018 This would be the correct EDB because Naegele's rule involves counting backward 3 calendar months from the first day of the client's last menstrual period and then adding 7 days.

A nurse is caring for a client who is nulliparous and experiencing hypertonic uterine dysfunction. An assessment indicates 3 cm dilation. Which of the following actions should the nurse take?

Offer the client hydrotherapy Peer Comparison Therapeutic rest measures should be initiated for a client who has hypertonic uterine dysfunction. Therapeutic rest can include hydrotherapy and analgesia to relieve pain. Decreasing uterine contractions and helping the client relax and sleep will help prevent early exhaustion.

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

Painless, bright red bleeding Placenta previa is the placement of the placenta low in the uterus. Depending on the severity, manifestations include bright red vaginal bleeding and a fundal height higher than expected for the gestational age. The presenting part is higher due to the placenta taking up space inside the lower part of the uterus.

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

Palpating the client's fundus The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. A precipitous delivery follows a labor of 3 hours. Regardless of the cause of the rapid delivery, uterine atony can result, causing postpartum hemorrhage. The nurse should palpate the fundus and massage as needed to monitor for and reduce the risk of hemorrhage.

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

Pelvic inflammatory disease (PID) An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and the placenta, and the fetus begin to develop in this area. The most common site is within a fallopian tube, but ectopic pregnancies can occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, PID places the client at risk of an ectopic pregnancy.

A nurse is teaching the guardian of a newborn about car seat safety. Which of the following pieces of information should the nurse include?

Place the shoulder harness in the slots that are level with the newborn's shoulders The guardian should place the shoulder harness in the slots that are level or slightly below the newborn's shoulders to ensure the child is restrained in the event of an accident.

A nurse is assessing a client who is in the first stage of labor and has preeclampsia. Which of the following findings should the nurse expect?

Proteinuria The nurse should expect a client with preeclampsia to have proteinuria and impaired kidney function.

A nurse is caring for a client who is receiving IV oxytocin for the induction of labor and notes repetitive early decelerations on the electronic fetal heart rate (FHR) tracing. Which of the following actions should the nurse take?

Re-evaluate the FHR tracing in 15 minutes Early decelerations are a result of the compression of the fetal head during contractions. They are benign and require no specific intervention. The nurse should reassess the FHR and contraction pattern in 15 minutes due to the infusion of oxytocin.

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

Renal agenesis Oligohydramnios is a volume of amniotic fluid that is -300 mL during the third trimester of pregnancy. This occurs when there is a renal system dysfunction or obstructive uropathy. The absence of fetal kidneys will cause oligohydramnios.

A nurse is caring for a client who is in labor and has fetal heart tracings of variable decelerations. Which of the following actions should the nurse take?

Reposition the client from side to side Variable decelerations are caused by cord compression. Changing the client from side to side or assisting her into a knee-chest position might relieve cord compression and improve the variable decelerations.

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication of the oxygen therapy?

Retinopathy Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. It is a disorder of retinal blood vessel development in premature newborns. In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fills the back of the eye. This condition can reduce vision or result in complete blindness.

A nurse is planning care for a client who is postpartum. Which of the following strategies should the nurse include in the plan to prevent bladder distention?

Run water in the sink while the client sits on the toilet Running water in the sink, placing the client's hand in warm water, and using a squeeze bottle to run water over the client's perineum can assist with spontaneous voiding.

A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration?

Slow trickle of bright vaginal bleeding and a firm fundus Peer Comparisol The nurse should monitor for bright red bleeding in the form of a slow trickle, oozing or outright bleeding, and a firm fundus to identify a cervical laceration.

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

Slow-paced breathing Peer Comparison Slow-paced breathing is an easy technique for the client to learn quickly and practice immediately. It provides distraction, which can help reduce the perception of pain. The pattern is In-2-3-4/Out-2-3-4/In-2-3-4/Out-2-3-4. Repeating this cycle slows the client's breathing to about half of its usual rate. which can help relax the client and improve oxygenation.

A nurse is caring for a client who is in labor and is receiving IV oxytocin. The nurse notes contractions lasting 3 min each. What action should the nurse take?

Stop the oxytocin infusion A pattern of contractions lasting longer than 2 minutes or of more than 5 contractions in a 10-minute period is considered tachysystole. This pattern can decrease the placental perfusion of oxygen. The appropriate action is to discontinue the oxytocin infusion.

A nurse is planning educational sessions for clients in a childbirth class. Which of the following findings should the nurse plan to instruct the clients to report immediately?

Swelling of the face and fingers Peer Comparison Swelling of the face, fingers, or area over the sacrum is an indication of hypertensive disorders such as eclampsia. The nurse should ensure these educational sessions include instructing clients about reporting such indications to their provider immediately.

A nurse is assessing the Moro response of a newborn. Which of the following findings should the nurse expect?

The legs move in a similar pattern of response to the arms. Symmetric movement of the arms and legs is an expected finding when assessing the Moro reflex. If the arms move up, the legs are expected to move up as well.

A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord?

They can cause delayed cord separation. Peer Comparison There is no evidence that antimicrobial preparations are of any benefit in the process of the drying and detachment of the umbilical cord stump. Keeping the cord moist with any kind of preparation prevents drying and separation and also increases the risk for infection.

A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding?

This will resolve in 3 to 6 weeks Without treatment. Peer Comparison This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum. It will resolve within 2 to 6 Weeks

A nurse is caring for a newborn who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect and report to the provider?

Tremors Newborns who have neonatal abstinence syndrome can have tremors, tachypnea, nasal flaring, apnea, retractions, incessant crying, frequent yawning and sneezing, mottling of the skin, excessive sucking, vomiting, and fevers.

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

Urine output 20 mL/hr Opioid analgesics such as morphine can cause urinary retention. The client should have a urinary output of at least 30 mL/hr. The nurse should report this finding to the provider.

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

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

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

Uterine tone The uterus will be relaxed, soft, and painless if the bleeding is caused by placenta previa. With abruptio placenta, the uterus will be firm and board-like, and the client will complain of pain.

A nurse is teaching a client who is at 30 weeks gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching?

Vaginal bleeding Vaginal bleeding can be an abnormal finding during pregnancy indicating a complication such as placental abruption, placenta previa, or preterm labor.

A nurse is caring for a client who is in labor. A vaginal examination reveals the following findings: 2 cm, 50%, +1, right occiput anterior (ROA). Based on this information, which of the following fetal positions should the nurse document in the medical record?

Vertex ROA describes the relationship of the presenting part of the fetus to the client's pelvis. In this case, the occipital bone is the presenting part and is located anteriorly on the client's right side. Based on the presentation of the fetus, the position is vertex.

A nurse is providing teaching about newborn baths to a client who is 2 days postpartum. Which of the following pieces of information should the nurse include?

Wash the newborn's face with plain warm water The parent should wash the newborn's face with plain warm water. Soap can irritate the eyes and skin.

A nurse is determining an Apgar score for a newborn who was born 1 minute ago. For which of the following findings should the nurse assign a score of 13

Weak cry The nurse should assign a score of 1 to a newborn who has a slow, weak cry.

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

will place my baby on his back when putting him to sleep." Newborns should always sleep on the back to prevent sudden infant death syndrome.