ATI RN Maternal Newborn Online Practice 2019 - 2023 with NGN

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider? A. BUN 25 mg/dL B. Serum creatinine 0.8 mg/dL C. Urine output of 280 mL within 8 hr D. Urine negative for ketones

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

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

A nurse is assessing a newborn following a circumcision. Which of the following statements should the nurse identify as an indication that the newborn is experiencing pain?

Chin quivering

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.

A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?

Headache that is unrelieved by analgesia

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?

Oligohydramnios

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? A. "I will not gain more than 15 to 20 pounds during my pregnancy." B. "I will likely need to use alternative positions for sexual intercourse." C. "I'm glad I had a breast reduction years ago, so they will not enlarge wi

B. "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. recommended weight gain during pregnancy for a client who has a BMI within the expected reference range is 25 to 35 lb (11.3 to 15.9 kg).

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? A. Hemoglobin 10 g/dL B. WBC count 10,000/mm3 C. Platelets 250,000/mm3 D. Fasting blood glucose 90 mg/dL

A. 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? A. Hypertension B. Hypothermia C. Constipation D. Muscle weakness

A. Hypertension The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension. Not muscle weakness Common S/S Fever. Diarrhea.

A nurse at a provider's office is caring for a client who is 28 years of age. Select the 3 findings that require immediate follow-up. Gravida 3, Para 2, Abortion 1Asthma Pelvic inflammatory disease (PID) Spontaneous vaginal delivery X 2 (hypertension first pregnancy 20 yrs) Voluntary termination (3rd pregnancy) late menses, abdominal pain, and scant dark red vaginal spotting. Reports menstrual period is usually regular and 2 weeks late. Last menstrual period: 2/20/XX. Reports dull abdominal p

Abdomen assessment is correct. The client reports dull abdominal pain and rates it as 2 on 0 to 10 pain scale. The nurse noted right lower quadrant abdominal tenderness during their assessment, which is an unexpected finding that requires immediate follow up. Vaginal spotting is correct. Spotting is defined as a scant amount of vaginal bleeding. The client reports spotting along with a late menstrual period, which are unexpected findings that require immediate follow up. Menstrual period is correct. The client reports a usual regular menstrual period; however, it is currently late by 2 weeks. This is an unexpected finding that requires immediate follow up.

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.

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?

Assist the client to empty her bladder.

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? A. Decreased uterine contractions B. An increase in the client's hemoglobin levels C. A reduction in respiratory distress in the newborn D. Increased production of antibodies in the newborn

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

A 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? A. Client reports nausea B. Urinary output of 40 mL/hr C. Respiratory rate 10/min D. Client reports feeling flushed

C. 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. Nausea is expected adverse effect. Oliguria less than 25 - 30 mL/hr. is a manifestation of Mag toxicity.

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? A. "I should increase my protein intake to 60 grams each day." B. "I should drink 2 liters of water each day." C. "I should increase my overall daily caloric intake by 300 calories." D. "I should take 600 micrograms of folic acid each day."

D. "I should take 600 micrograms of folic acid each day." A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects. Caloric intake increased 340 cal during 2nd trimester & 452 cal during 3rd trimester.

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

D. 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.

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? A. Apply a cool pack for 10 min to the heel prior to the puncture. B. Request a prescription for IM analgesic. C. Use a manual lance blade to pierce the skin. D. Place the newborn skin to skin on the mother's chest.

D. Place the newborn skin to skin on the mother's 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. cool pack will constrict the blood vessels. spring-loaded, automatic puncture device is recommended. pain experienced from a heel stick is too brief

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? A. Singleton pregnancy B. BMI of 20 C. Maternal age 32 years D. Pregestational diabetes mellitus

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

D. 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. Hypoglycemia - hypothermia, poor feeding behaviors, hypotonia

A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?

Have calcium gluconate readily available.

A nurse at a provider's office is caring for a client who is 28 years of age. Complete the following sentence by using the list of options. The nurse should first address the client's ______ followed by the client's ________Select... Day 1, 1000:Temp 37.2° C (98.9° F). HR 90/min. RR 16/min. BP 120/74 mmHg. O297%. Day 1, 1030:Temp 37.2° C (98.9° F). HR 104/min. RR 18/min. BP 116/70 mmHg. O2 97%. Blood: (hCG) 50 IU/L (less than 5 IU/L) (β-hCG) 20,000 IU/L (negative) Hgb 11 g/dL (12 to 16 g/

Heart rate is correct. The nurse should first address the client's heart rate, which is above the expected reference range, to establish a baseline for continued monitoring. Dropdown 2 Vaginal spotting is correct. The nurse should next address the amount and characteristics of the client's vaginal spotting to establish a baseline for continued monitoring.

A nurse is reviewing the provider's prescription in the adolescent's medical chart. The nurse has just reviewed discharge instructions with the adolescent. Which of the following indicates whether the adolescent understands the teaching or requires further education? For each of the statements made by the adolescent, click to specify whether the statement indicates an understanding or requires further education. History and Physical Adolescent is sexually active with two current partners. IUD

Indicates understanding A. "I should continue taking all my medications even if I don't show any symptoms." The nurse instructed the adolescent to complete all of their medications, even if they begin to feel better. B. "If I continue to get this type of infection, it can affect my ability to have kids in the future." The nurse instructed the adolescent that repeated instances of PID can cause infertility. E. "I'm more likely to get a sunburn while taking these medications." The nurse informed the adolescent that they might experience increased sensitivity to sunlight while using doxycycline and that they should use sunscreen and wear protective clothing while taking the medication. Requires further education C. "I should go to the emergency department if my urine turns dark." The nurse informed the adolescent that while taking metronidazole their urine might turn dark, they should not be alarmed because dark urine is an adverse effect of taking this medication. D. "As long as I k

A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan? Monitor the client's blood pressure every hour. Restrict the total hourly intake to 200 mL. Monitor the FHR continuously. Administer protamine sulfate for manifestations of toxicity.

Monitor the FHR continuously. Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The FHR and uterine contractions should be monitored continuously while the client is receiving magnesium sulfate. monitor the client's vital signs, including blood pressure, every 15 to 30 min. client's total hourly intake to no more than 125 mL. calcium gluconate if the client shows manifestations of magnesium sulfate toxicity.

A nurse is reviewing the provider's prescription in the adolescent's medical chart. The nurse is reviewing the provider's prescriptions in the adolescent's medical chart. Complete the following sentence by using the list of options. 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 pai

The nurse should first implement A. Providing education on medications The nurse should first educate the adolescent regarding medications because clients have the right to know the purpose and potential adverse reactions of all prescribed medications before receiving them. An understanding of the prescribed medications will increase the likelihood that the adolescent will adhere to the prescribed therapy. And A. Administering ceftriaxone 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.

A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication fo withdrawal from an SSRI?

Vomiting

A nurse is caring for a newborn. The nurse reviews the assessment findings and determines the findings are consistent with which of the following birth complications? For each assessment finding, click to specify if the findings is consistent with a clavicle fracture or Erb-Duchenne paralysis. Each finding may support more than one condition. Wrist flexion Arm movement Moro reflex Birth history Palmar grasp reflex Crepitus

When analyzing cues clavicle fracture birth of a large for gestational age newborn who had a vacuum assisted Manifestations clavicle fracture include presence of crepitus over the fractured bone with decreased movement and an absent moro reflex in the affected arm. The newborn retains the presence of a palmar grasp reflex. When analyzing cues Erb-Duchenne paralysis result mechanical trauma to the spinal cord during a difficult birth of a large gestational age newborn and during a forceps or vacuum assisted birth. Manifestations of Erb-Duchenne paralysis include a limp arm with absent spontaneous movement and absent moro reflex. The affected shoulder and arm are adducted and internally rotated with the wrist and fingers flexed. This results in a characteristic upwards positioning of the palm towards the back. The palmar grasp reflex is present because the paralysis is limited to the muscles in the upper arm.

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

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

A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching? a. "You will need to drink the glucose solution 2 hours prior to the test." b. "Limit your carbohydrate intake for 3 days prior to the test." c. "A blood glucose of 130 to 140 is considered a positive screening result." d. "You will need to fast for 12 hours prior to the test."

c. "A blood glucose of 130 to 140 is considered a positive screening result." The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, they will need to undergo a 3-hr glucose tolerance test to confirm if they have gestational diabetes mellitus.

A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider? a. Hgb 20 g/dL b. Total bilirubin 5 mg/dL c. Blood glucose 30 mg/dL (30 to 60 mg/dL) d. WBC count 20,000/mm3

c. Blood glucose 30 mg/dL (30 to 60 mg/dL) Newborns less than 24 hr old should have a blood glucose of 40 to 45 mg/dL. A blood glucose level of 30 mg/dL is below the expected reference range for a newborn who is 24 hr old and should be reported to the provider. Hgb range of 14 to 24 g/dL newborn 24 hr. Bilirubin range of 2 to 6 mg/dL for a newborn who is 24 hr. WBC range of 9,000 to 30,000/mm3 for a newborn who is 24 hr.

A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse? a. Acrocyanosis of the extremities b. Murmur at the left sternal border c. Substernal chest retractions while sleeping d. Positive Babinski reflex

c. Substernal chest retractions while sleeping Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This manifestation requires further assessment and intervention by the nurse.

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? A. Monitor the FHR. B. Assess uterine activity. C. Administer oxygen via a nonrebreather mask. D. Start a bolus of IV fluids.

C. 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 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 2 g/hr x 500 mL = 1,000 mL/g/hr 1,000 mL/g/hr / 20g = 50 mL/hr

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? A. Late decelerations B. Moderate variability of the FHR C. Cessation of uterine dilation D. Prolonged active phase of labor

A. 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.

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? A. Lays the newborn across their lap and gently sways B. Places the newborn in the crib in a prone position C. Offers the newborn a pacifier dipped in formula D. Prepares a bottle of formula mixed with rice cereal

A. Lays the newborn across 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.

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

A. Protect the client's head and feet from cold air. Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period. Hispanic practices include delaying bathing for 14 days following birth. practices include bed rest for 3 days following birth. drinking warm beverages following birth.

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

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

B. 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.

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? A. Allow the sibling to hold the newborn during a bath. B. Make sure the sibling kisses the newborn each night. C. Obtain a gift from the newborn to present to the sibling. D. Switch the sibling's room with the nursery.

C. 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.

A nurse is caring for a newborn. 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. Medical History 1600: Apgar Score 9 at 1 min and 9 at 5 min Birth weight 10 lb 6 oz (4706 gm) Gestational age 40 weeks Difficult vaginal birth with shoulder dystocia. Nurses' Notes 1700: Newborn is active and moves all extremities except for right arm. No spontaneous movemen

Indicated A. Educate the parents to begin range of motion exercises on the affected arm after 1 week. 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. B. Assess for grasp reflex in the affected extremity. 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. C. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved by pinning the sleeve to the shirt. Contraindicated D. Instruct parents to limit physical handling for 2 weeks. Parents and guardians should participate in the physical care of their newborn to increase parental-infant attachment. Providing education and practice opportunities

A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?

Transition

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? a. Place the shoulder harness in the slots above the newborn's shoulders. b. Place the retainer clip at the level of the newborn's armpits. c. Place the newborn at a 60° angle in the car seat. d. Place the newborn in a blanket before securing them in the car seat.

b. Place the retainer clip at the level of the newborn's armpits. The nurse should instruct the guardian to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits. place the shoulder harness in the slots that are at or just below the newborn's shoulders. position the newborn at a 45° angle to minimize the risk of airway obstruction from slumping forward. refrain from placing extra padding, including blankets, between the newborn and the straps of the car seat.

A nurse caring for a 28 years old.. Evaluating the client following surgery. Which of the following findings indicate that client experiencing potential complication of surgery requires follow-up? Neuro: Drowsy but easy to arouse. Vital Signs: Temp 35.3° C (95.5° F). HR 60/min RR 16/min. BP 90/60 mmHg. O2 94% (oxygen @2 L/min via nasal cannula). Pain 1/10 pain scale. Integument: Skin cool + moist to touch. Cardio: HR regular. Pedal pulse +1 bilateral. Lungs clear bilateral. RR even non-labored

client's temperature is below indication of hypothermia. oxygen saturation is below can be an indication of decreasing oxygen levels associated with anesthesia. client's blood pressure is below can be a result of anesthesia or the client's low temperature. Require immediate follow-up by the nurse. Neurological findings of drowsiness and easy arousal are expected postoperatively. An integumentary finding of moist, cool skin is unexpected and requires follow up by the nurse. This finding might indicate hypothermia. A cardiopulmonary finding of +1 pedal pulses bilaterally requires follow up by the nurse. This indicates decreased circulation and perfusion.

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? a. "I will receive this medication if my baby is Rh-negative." b. "I will receive this medication when I am in labor." c. "I will need a second dose of this medication when my baby is 6 weeks old." d. "I will need this medication if I have an amniocentesis."

d. "I will need this medication if I have an amniocentesis." 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. Administered at 28 weeks of gestation to clients who are Rh-negative and following the birth of a newborn who is Rh-positive.

A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include? a. Insert the syringe tip before compressing the bulb. b. Suction each of the nares before suctioning the mouth. c. Insert the tip of the syringe into the center of the newborn's mouth. d. Stop suctioning when the newborn's cry sounds clear.

d. Stop suctioning when the newborn's cry sounds clear. The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus. compress the bulb before inserting the syringe tip. suction the mouth before suctioning the nares. insert the tip of the syringe into the side of the newborn's mouth.

A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? A. 2+ deep tendon reflexes B. Proteinuria of 200mg in a 24-hr specimen C. Polyuria D. Blurred vision

D. Blurred vision The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field.

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 will continue taking my insulin if I experience nausea and vomiting."

A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates a understanding of the teaching?

"I will eat foods that taste good instead of balancing my meals."

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?

"You should take the medication within 72 hours following unprotected sexual intercourse."

A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching?

"You will be offered orange juice to drink during the test."

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

A. 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.

A nurse is caring for a client following an aminocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?

Leakage of fluid from the vagina

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?

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 preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)

Flaccid uterus, Excess vaginal bleeding.

A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following actions should the nurse take?

Initiate continuous external fetal monitoring. The nurse should identify that a client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor laboratory values. Also, the nurse should implement interventions to prepare for an emergency birth.

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?

Instruct the client to press the provided button each time fetal movement is detected.

A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients?

Iron

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect?

Jitteriness

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? a. Left upper quadrant b. Right upper quadrant c. Left lower quadrant d. Right lower quadrant

Left lower quadrant. The fetal heart tones of a fetus in the left occiput anterior position are best heard in the left lower quadrant. To Know -The fetal heart tones of a fetus in the left sacrum anterior position are best heard in the left upper quadrant. -The fetal heart tones of a fetus in the right sacrum anterior position are best heard in the right upper quadrant. -The fetal heart tones of a fetus in the right occiput anterior position are best heard in the right lower quadrant.

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider? Hct 39% Serum albumin 4.5 g/dL WBC 9,000/mm3 Platelets 50,000/mm3

Platelets 50,000/mm3 A platelet count of 50,000/mm3 is below the expected reference range (150,000 - 450,000) which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider.

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider? Report of visual disturbances Report of tingling of the fingers Report of urinary frequency Report of leg cramps

Report of visual disturbances Visual disturbances such as blurred vision are a potential prenatal complication associated with hypertension. The nurse should report this finding to the provider so that additional fetal and maternal evaluation can be performed. Tingling or numbness of the fingers is called brachial plexus traction syndrome resulting from drooping of shoulders during pregnancy. Reports of urinary frequency and Leg cramps are common discomfort.

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

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?

Swelling of the face

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

Temperature

A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions? a. Administer terbutaline. b. Discuss possible genetic anomalies with the client. c. Administer nalbuphine. d. Discontinue external fetal monitoring.

a. Administer terbutaline. The nurse should administer terbutaline to stop contractions because the laboratory results indicate that the fetus's lungs are not mature enough for birth. Nalbuphine is an analgesic used for moderate to severe pain.

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 have blood tests because my potassium might decrease." Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr. An adverse effect of terbutaline is hypokalemia. hyperglycemia. hypotension.

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?

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

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration? a. "This medication will stop your labor." b. "This medication stimulates fetal lung maturity." c. "This medication will decrease your risk for uterine infections." d. "This medication will increase your baby's weight."

"This medication stimulates fetal lung maturity." The nurse should inform the client that betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of enzymes that release lung surfactant.

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 ask 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."

A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching?

"You can share your room with your baby for the next few weeks."

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? a. "You should replace the diaphragm every 5 years." b. "You should leave the diaphragm in place for at least 6 hours after intercourse." c. "You should use an oil-based product as a lubricant when inserting the diaphragm." d. "You should insert the diaphragm when your bladder is full."

"You should leave the diaphragm in place for at least 6 hours after intercourse." The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy. Replace the diaphragm every 2 years. avoid using oil-based products because they can weaken the rubber in the diaphragm. have an empty bladder prior to inserting the diaphragm.

A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make?

"Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions."

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.

1. Palpate the fundus to identify the fetal part. 2. Determine the location of the fetal back. 3. Palpate for the fetal part presenting at the inlet. 4. Identify the attitude of the head.

A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?

A Client who is at 34 weeks of gestation and reports epigastric pain

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? A. "I can administer oxytocin 4 hours after the insertion of the medication." B. "You will need a full bladder prior to the insertion of the medication." C. "Remain in a side-lying position for 15 minutes after the medication is inserted." D. "An antacid will be given 20 minutes prior to the insertion

A. "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 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? A. Biophysical profile B. Amniocentesis C. Cordocentesis D. Kleihauer-Betke test

A. 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.

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? A. Calcium gluconate B. Hydralazine C. Medroxyprogesterone acetate D. Methylergonovine

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

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? A. Depression B. Polyuria C. Hypotension D. Urticaria

A. 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.

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? A. Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. B. Wrap the visible cord tightly with sterile, dry gauze. C. Apply oxygen to the client at 2 L/min via nasal cannula. D. Place the client in the lithotomy position and apply fundal pressur

A. 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.

A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider? A. Substernal retractions B. Acrocyanosis C. Overlapping suture lines D. Head circumference 33 cm (13 in)

A. Substernal retractions The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea and manifestations of neonatal infection or respiratory distress in the newborn.

A nurse is caring for a client who is pregnant in an antepartum clinic. Which of the following findings should the nurse report to the provider? Select the 3 findings that should be reported. 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,

A. Uterine contractions 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. C. Gestational age 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. D. Vaginal examination 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 caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take? A. Administer aspirin for pain B. Maintain the client on bed rest C. Massage the affected leg ever 12 hr. D. Apply cold compresses to the affected cald

B. Maintain the client on bed rest The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended.

A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority? A. Check the client's capillary refill B. Massage the client's fundus C. Insert an indwelling urinary catheter for the client D. Prepare the client for a blood transfusion

B. Massage the client's fundus. Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood loss

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? A. B. C. D.

C. 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 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? A. "My sister will be able to carry my baby from the nursery to my room when she arrives." B. "The nurse will match my wrist band to my baby's crib card when they bring him to me." C. "The person who comes to take my baby's pictures will be wearing a photo identification badge." D. "My baby doesn't n

C. "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.

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? A. "You can resume sexual activity in 1 week." B. "You won't need to do Kegel exercises since you had a cesarean." C. "You can still become pregnant if you are breastfeeding." D. "You are safe to start adding sit-ups to your exercise routine in 2 weeks."

C. "You can still become pregnant if you are breastfeeding." The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding.

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

C. 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.

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? A. Fentanyl B. Butorphanol C. Naloxone D. Meperidine

C. 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.

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? A. Perform Nitrazine testing. B. Assess the fluid. C. Check cervical dilation. D. Begin FHR monitoring.

D. 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.

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?

Decreased platelet count

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?

Determine respiratory function.

A nurse at a provider's office is caring for a client who is 28 years of age. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. After reviewing the client's current assessment findings, the nurse should identify that the client is experiencing ______. late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal

Ectopic pregnancy is correct. The client reports late menses, abdominal pain, and scant dark red vaginal spotting. The assessment findings reveal right lower quadrant abdominal tenderness and scant dark red vaginal spotting on perineal pad, which are associated with ectopic pregnancy. The client also has a history of PID, which is a risk factor for ectopic pregnancy. Right lower quadrant abdominal tenderness is correct. The assessment findings reveal right lower quadrant abdominal tenderness and scant dark red vaginal spotting, which are findings associated with ectopic pregnancy.

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

A nurse is performing a physical assessment of a newborn. Which of the following clinical finding should the nurse expect? Heart rate 154/min Axillary temperature 36° C (96.8° F) Respiratory rate 58/min Length 43 cm (16.9 in) Weight 2,600 g (5 lb 12 oz)

Heart rate 154/min is correct. range for a newborn's heart rate is from 110/min to 160/min while awake. Respiratory rate 58/min is correct. range for a newborn's respiratory rate is from 30/min to 60/min. Weight 2.6 kg (5 lb 12 oz) is correct. range for a newborn's weight is from 2,500 to 4,000 g (5.5 lb to 8.8 lb). Axillary temperature 36° C (96.8° F) is incorrect. A healthy newborn's temperature averages 37° C (98.6° F), with a range of 36.5° to 37.5° C (97.7° to 99.5° F). Length 43 cm (16.9 in) is incorrect. The expected reference range for a newborn's length is from 45 to 55 cm (17.7 to 21.7 in).

The nurse is reviewing laboratory results in the adolescent's medical record. The nurse is reviewing the adolescent's medical record. Which of the following conditions is the client most likely developing? Complete the following sentence by using the list of options. 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 "

The adolescent is most likely developing A. Pelvic inflammatory disease 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 As evidenced by C. C-reactive protein The adolescent's C-reactive protein is elevated, which is a manifestation of PID.

A nurse is providing discharge teaching to a client who is postpartum. For which of the following manifestations should the nurse instruct the client to monitor and report to the provider? a. Persistent abdominal striae b. Temperature 37.8° C (100° F) c. Unilateral breast pain d. Brownish-red discharge on day 5

Unilateral breast pain Sudden onset of chills, fever, malaise, body aches, headaches, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this manifestation to the provider.

A nurse at a provider's office is caring for a client who is 28 years of age. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Transvaginal ultrasound Meperidine IM Repeat quantitative β-hCG level Methotrexate IM Blood typing

Transvaginal ultrasound is indicated. The nurse should anticipate a prescription for a transvaginal ultrasound. A transvaginal ultrasound is useful in determining the location of the ectopic pregnancy. Repeat quantitative β-hCG level is anticipated. The quantitative β-hCG level should be repeated within 48 hr to see if the level has changed from last recording. If increased levels are identified with no intrauterine pregnancy on ultrasound, this is indicative of ectopic pregnancy. Methotrexate IM is anticipated. The nurse should anticipate a prescription for methotrexate IM administration to prevent further embryonic cell reproduction. Blood typing is anticipated. anticipate potential surgical intervention for the client; therefore, blood typing is indicated. Meperidine IM is contraindicated. Clients who receive methotrexate for an ectopic pregnancy should not take analgesics stronger than acetaminophen, because these medications can mask the manifestations of tubal rupture.

A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

Verify the newborn's identification.

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 Migraine headaches

A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)? a. Just above the umbilicus b. Just above the symphysis pubis c. The right lower quadrant d. The left lower quadrant

b. Just above the symphysis pubis At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis.

A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client ask, "What effects will this procedure have on my sex life?" Which of the following responses should the nurse make? "I think that is something you should discuss with your doctor." "This procedure should have no effect on your sexual performance or adequacy." "You'll be fine. I can't imagine you and your partner will have any problems with sexual function." "If this concerns you, perhaps you shou

"This procedure should have no effect on your sexual performance or adequacy." The nurse is giving the client the information they are seeking. Sexual function depends on various hormonal and psychological factors. Therefore, tubal occlusion should have no physiological effect on sexual function.

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

A. 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.

A nurse in a clinic is caring for a 16-year-old adolescent. Which of the following findings should the nurse report to the provider? Select all that apply. 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. Repor

A. Abdominal assessment Abdominal tenderness with palpation is not an expected finding with an abdominal assessment; therefore, the nurse should report this finding to the provider. B. Vaginal discharge 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. D. Temperature 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. E. Dyspareunia Dyspareunia is painful intercourse, which can be associated with STIs; therefore, the nurse should report this finding to the provider. F. Condom usage Sexual activity without the use of condoms increases the risk of contracting STIs; therefore, the nurse should report this finding to the provider.

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? A. Abruptio placenta B. Placenta previa C. Preeclampsia D. Maternal bradycardia

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

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? A. Cold cabbage leaves B. Purified lanolin cream C. A snug-fitting support bra D. Breast shells

A. 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. Purified lanolin cream & breast shells - sore nipples

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? A. Kleihauer-Betke test B. Progesterone serum level C. Lecithin/sphingomyelin (L/S) ratio D. Maternal Alpha-fetoprotein (AFP)

A. 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. Progesterone: confirm pregnancy and if ectopic L/S ratio: part of amniocentesis to evaluate fetal lung maturity Maternal AFP: neural tube defects or chromosome disorder.

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? A. Minimal arm recoil B. Popliteal angle of 90° C. Creases over the entire foot sole D. Raised areolas with 3 to 4 mm buds

A. 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 3 days postpartum. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Medical History Gravida 1, Para 138 weeks of gestation Forceps-assisted birth following failed vacuum-assisted attempt. 3rd degree laceration with a repair Amniotic membranes ruptured

Action to Take A. Plan to administer IV antibiotics. C. Obtain a culture of vaginal fluid using a sterile swab. Potential Condition A. Endometritis Parameter to Monitor D. Lochia amount and odor E. Temperature 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 caring for a client who is pregnant. Which of the following actions are the nurse's priorities? Select the 4 actions that the nurse should take immediately. Assess cervical dilation. Administer a bolus of IV fluids. Insert an indwelling urinary catheter. Reposition the client to their side. Apply oxygen at 10 to 12 L/min by nonrebreather mask. Elevate the client's legs. Evaluate the client's pain level.

Administer a bolus of IV fluids. 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. 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. 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 mini Elevate

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.) A. Yellow sclera B. Acrocyanosis C. Posterior fontanel larger than the anterior fontanel D. Positive Babinski reflex E. Two umbilical arteries visible

B. Acrocyanosis 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. D. Positive Babinski reflex 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. E. Two umbilical arteries visible The nurse should observe two arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly.

A nurse is caring for a newborn who is 72 hr old. The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions regarding the newborn should the nurse anticipate? Select all that apply. Medical History Newborn delivered by repeat cesarean birth at 40 weeks of gestation.Birth weight 7 lb 12 oz (3,515 g)Apgar scores 8 at 1 min and 9 at 5 minMaternal history of methadone use during pregnancy. Vital Signs 0700: Heart rate 156/min, Respiratory

B. Administer scheduled doses of oral morphine. 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. D. Maintain a low-stimulus environment. Supportive care for a newborn who has NAS includes maintaining a low-stimulus environment to help prevent exacerbation of withdrawal manifestations. E. Initiate neonatal abstinence sydrome (NAS) scoring. 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 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? A. Determine progression of dilatation and effacement. B. Perform Leopold maneuvers. C. Complete a sterile speculum exam. D. Prepare a Nitrazine paper test.

B. Perform 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 is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? A. Administer antiviral medication. B. Schedule an ultrasound examination. C. Administer Haemophilus influenzae type b vaccine. D. Schedule an indirect Coombs' test.

B. 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 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? A. To estimate the fetal weight B. To locate a pocket of fluid C. To determine multiparity D. To prescreen for fetal anomalies

B. To locate a pocket of fluid An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus.

A 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? A. "Obtain an informed consent prior to obtaining the specimen." B. "Collect at least 1 milliliter of urine for the test." C. "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." D. "Premature newborns may have false negative tests due to immature development of liver

C. "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr. prior to testing. The universal newborn screening is mandated by law for all newborns no consent is needed. A capillary blood sample via heel stick for the newborn screening. Urine is not collected for this test. Premature newborns have a delayed development of liver enzymes which can cause a false positive result.

The nurse is reviewing laboratory results in the adolescent's medical record. The nurse is planning care for the adolescent. Which of the following prescriptions should the nurse expect the provider to prescribe? Drag words from the choices below to fill in each blank in the following sentence. 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: Adm

C. Ceftriaxone & E. Doxycycline 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.

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? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Graphic Record​ Blood pressure 130/78 mm Hg, Respiratory rate 20/min, Heart rate 90/min Diagnostic Results​ Hemoglobin 12 g/dL, Hematocrit 34

C. Fundal height measurement A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider.

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

C. 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.

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? A. Feed the newborn 1 oz of water every 4 hr. B. Apply lotion to the newborn's skin three times per day. C. Remove all clothing from the newborn except the diaper. D. Discontinue therapy if the newborn develops a rash.

C. Remove all clothing from the newborn except the diaper. The nurse should remove all 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 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? A. Blood pressure 136/88 mm Hg B. Report of insomnia C. Weight gain of 2.2 kg (4.8 lb) D. Report of Braxton Hicks contractions

C. Weight gain of 2.2 kg (4.8 lb) 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 demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) A. Clean the newborn's diaper area. B. Wash the newborn's neck by lifting the newborn's chin. C. Wipe the newborn's eyes from the inner canthus outward. D. Cleanse the skin around the newborn's umbilical cord stump. E. Wash the newborn's legs and feet.

C. Wipe the newborn's eyes from the inner canthus outward. B. Wash the newborn's neck by lifting the newborn's chin. D. Cleanse the skin around the newborn's umbilical cord stump. E. Wash the newborn's legs and feet. A. Clean the newborn's diaper area. The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. 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 newborn who is 70 hr old. Which of the following findings should the nurse report to the provider? Select all that apply. Medical History Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth weight 7 lb 12 oz (3,515 g) Apgar scores 8 at 1 min and 9 at 5 min Maternal history of methadone use during pregnancy. Vital Signs 0700: Heart rate 156/minRespiratory rate 58/minTemperature 37.2° C (98.9° F) Oxygen saturation 98% on room air 1100: Heart rat

D. Central nervous system findings 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. E. Gastrointestinal findings The newborn is displaying poor feeding and loose stools. These findings are manifestations of NAS and should be reported to the provider.

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? A. Deep tendon reflexes 4+ B. Fundal height 14 cm C. Urine protein 2+ D. FHR 152/min

D. FHR 152/min The expected range for the FHR is 110/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 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? A. Check the client's temperature. B. Observe for uterine contractions. C. Administer Rho(D) immune globulin. D. Monitor the FHR.

D. 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.

A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? a. Discuss contraceptive options with the client and their partner. b. Repeat information to ensure client understanding. c. Listen to the client and their partner as they reflect upon the birth experience. d. Demonstrate to the client how to perform a newborn bath.

Demonstrate to the client how to perform a newborn bath. Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new guardian moves from being passively dependent to taking a stronger interest in their new role as a guardian. They are now focusing on the care of thier newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new guardian confidence and promote maternal adjustment.

A nurse at a provider's office is caring for a client who is 28 years of age. The nurse is preparing the client for surgery which actions the nurse take?SATA. a. Ensure the client is NPO prior to surgery. b. Administer Rho(D) immune globulin prior surgery. c. Prepare administer AB positive blood products. d. Insert an 18-gauge peripheral IV prior to surgery. e. Explain the surgical procedure to the client. f. Obtain a complete blood count. g. Verify a consent form is signed by the client.

Inform the client to be NPO prior to surgery is correct. prevent aspiration Insert an 18-gauge peripheral IV prior to surgery is correct. larger bore IV such as an 18- or 20-gauge Obtain a complete blood count is correct. obtain CBC to establish baseline data Verify a consent form is signed by the client is correct. Administer Rho(D) immune globulin prior to surgery is incorrect. administer Rho D immune globulin after surgery Prepare to administer AB positive blood products if needed is incorrect. only administer O or B negative blood products Explain the surgical procedure to the client is incorrect. provider is responsible

A nurse in a clinic is caring for a 16-year-old adolescent. Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding, click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process. History and Physical ​Adolescent is sexually active with two current partners. IUD in place Reports not using condoms during sexual

Trichomoniasis B. Greenish discharge Green-yellow discharge can occur in both trichomoniasis and gonorrhea. Candidiasis causes thick, white, lumpy discharge. D. Pain on urination 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. E. Absence of condom use 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. Gonorrhea A. Abdominal pain Gonorrhea can present with reports of acute or chronic lower abdominal pain. B. Greenish discharge Green-yellow discharge can occur in both trichomoniasis and gonorrhea. Candidiasis causes thick, white, lumpy discharge. D. Pain on urination 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. E. Absence of condom use Sexual

A nurse is caring for a client who is pregnant. Which of the following findings should the nurse report to the provider? Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Vital Signs 0900: Temperature 38.3° C (101° F) Pulse rate 89/min Respiratory rate 20/min Blood pressure 128/70 mm Hg Oxygen saturation 98% Nurse's Notes 0900: Client reports, "I've been cramping and had low back pain since yesterday. It burns when I urinate

When recognizing cues the nurse should report the client's temperature, which is above the expected reference range, and the burning upon urination to the provider. These are manifestation of an infection. The nurse should also report the client's statement of "cramping and lower back pain", the frequency and duration of the uterine contractions, and cervical dilation and effacement. These findings in a client who is less than 37 weeks gestation are all manifestations of preterm labor.

A nurse is caring for a client who is in labor. A nurse reviews the most recent assessment findings. What actions should the nurse take? Apply oxygen at 10 L by nonrebreather mask. Discontinue the magnesium infusion. Request a prescription for an amnioinfusion. Administer calcium gluconate. Collect a specimen for a fetal fibronectin test. Infuse a 500 mL bolus of lactated Ringer's. Decrease the rate of the oxytocin infusion.

When taking action the nurse should discontinue the magnesium infusion, administer calcium gluconate, and apply oxygen at 10L by nonrebreather mask. The client is exhibiting signs of magnesium toxicity. The client's urine output is less than 25 to 30 mL/hr. Decreased renal function can lead to inadequate clearance of the magnesium. Other manifestations of magnesium toxicity the client is experiencing include decreased level of consciousness, decreased respiratory rate and absent deep tendon reflexes. Calcium gluconate is the antidote for magnesium sulfate toxicity and should be administered to prevent a cardiac arrest. The client's pulse oximeter reading is < 95%. Low circulating levels of maternal oxygen can lead to fetal distress.

A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of spina bifida occulta?

spina bifida Occulta mildest type of spina bifida. It is sometimes called "hidden" spina bifida. With it, there is a small gap in the spine, but no opening or sac on the back. External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area.