ATI Spring NCLEX Week 3

A nurse is reinforcing discharge teaching about circumcision care with the parent of a newborn who has a circumcision using the Plastibell device. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.) A.) "I'll expect the plastic ring to fall off by itself within a week." B.) "I'll apply petroleum jelly to his penis during diaper changes." C.) "I'll wash his penis with warm water and mild soap each day." D.) "I'll call the doctor if I see any bleeding." E.) "I'll make sure his diaper is loose in the front."

A.) "I'll expect the plastic ring to fall off by itself within a week." With the Plastibell procedure, the plastic ring detaches in about 5 to 8 days. D.) "I'll call the doctor if I see any bleeding." The client should report any bleeding to the provider immediately. E.) "I'll make sure his diaper is loose in the front." Applying the diaper loosely prevents pressure over the circumcision area.

A nurse is reinforcing teaching about phenylketonuria (PKU) testing with the parent of a newborn. Which of the following statements by the parent indicates a need for further teaching? A.) "My baby will be placed under special lights if the test is elevated." B.) "My baby must take formula or breast milk before the test is done." C.) "This test checks for a genetic disorder that can be corrected by diet." D.) "Sometimes the test is repeated in the doctor's office at the 2-week check-up."

A.) "My baby will be placed under special lights if the test is elevated." Phototherapy is used to reduce circulating unconjugated bilirubin in infants who have hyperbilirubinemia. Phototherapy for hyperbilirubinemia uses light energy to lower the bilirubin level in the newborn's blood. This would not be appropriate therapy for PKU.

A client is concerned that her newborn has "crossed eyes." Which of the following statements is a therapeutic response by the nurse? A.) "Newborns lack the necessary muscle control to regulate eye movement." B.) "I'll take your baby back to the nursery for an examination." C.) "I will call your provider and report your concerns." D.) "This condition is easily treated by patching your baby's eyes."

A.) "Newborns lack the necessary muscle control to regulate eye movement." Transient strabismus or nystagmus are common until the third or fourth month of life; therefore, the nurse should reassure the client that this is an expected finding.

A nurse is caring for a client who is taking sumatriptan for migraine headaches and reports a positive pregnancy test. Which of the following responses should the nurse make? A.) "You should discuss with your provider other migraine medications that may be safer during pregnancy." B.) "You should decrease your dose by one-half while you are pregnant." C.) Some women do experience a significant decrease or absence of migraines during pregnancy. However, it is also possible for migraine frequency to increase while pregnant. Sumatriptan is a migraine abortive treatment that acts by causing vasoconstriction of cranial arteries. Sumatriptan is a category C medication in pregnancy. Therefore, the client should discuss the use of the medication during pregnancy with her provider. D.) "You should ask your provider for acetaminophen with codeine to take while you're pregnant."

A.) "You should discuss with your provider other migraine medications that may be safer during pregnancy." Sumatriptan is a migraine abortive medication that acts by causing vasoconstriction of cranial arteries. Sumatriptan is a category C medication in pregnancy. Therefore, the client should discuss the use of the medication during pregnancy with her provider.

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby's mouth, which of the following responses by the nurse is appropriate? A.) "You should place your nipple and some of the areola into her mouth." B.) "Babies know instinctively exactly how much of the nipple to take into their mouth." C.) "Your baby's mouth is rather small so she will only take part of the nipple." D.) "Try to place the nipple, the entire areola, and some breast tissue beyond the areola into her mouth."

A.) "You should place your nipple and some of the areola into her mouth." ​Placing the nipple and part of the areola into the baby's mouth will aid in adequately compressing the milk ducts. This placement also decreases stress on the nipple and helps prevent cracking and soreness.

A nurse is caring for a client who has gestational diabetes and reports feeling shaky, sweaty, and having blurred vision. The client's blood glucose level is 48 mg/dL. Which of the following foods should the nurse give to the client? (Select all that apply). A.) 120 mL unsweetened fruit juice B.) 1 tbsp honey C.) 5 hard candies D.) 240 mL regular soda E.) 120 mL milk

A.) 120 mL unsweetened fruit juice It is appropriate for the nurse to give 120 mL of unsweetened fruit juice, which contains 10 to 15 g of simple carbohydrate, to the client to treat hypoglycemia. B.) 1 tbsp honey It is appropriate for the nurse to give 1 tbsp of honey, which contains 10 to 15 g of simple carbohydrates, to the client to treat hypoglycemia. C.) 5 hard candies Five to six hard candies contain 10 to 15 g of simple carbohydrates and are appropriate for the nurse to give to the client to treat hypoglycemia.

A nurse is caring for a client who is 2 hr postpartum. The client has an IV of lactated Ringer's with 25 units of oxytocin infusing and large rubra lochia with a hypotonic uterus. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respirations 18/min. Which of the following prescriptions should the nurse clarify with the provider? A.) Administer methylergonovine 0.2 mg IM now. B.) ​Insert an indwelling urinary catheter. C.) ​Administer oxygen by nonrebreather mask at 5 L/min D.) ​Obtain laboratory study of prothrombin and partial thromboplastin time.

A.) Administer methylergonovine 0.2 mg IM now. Methergine is contraindicated in a client who has a blood pressure greater than 140/90 mm Hg. This prescription requires clarification.

A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to help lessen discomfort during breastfeeding? (Select all that apply.) A.) Apply breast milk to her nipples before each feeding. B.) Alternate breasts at the beginning of each feeding. C.) Let the newborn sleep for long periods so the nipples can heal. D.) Start breastfeeding with the nipple that is most sore. E.) Change the infant's position on the nipples.

A.) Apply breast milk to her nipples before each feeding. This helps moisten the nipples to prepare them for breastfeeding and makes it less painful. B.) Alternate breasts at the beginning of each feeding. Alternating breasts during the early portion of a feeding when the newborn's sucking efforts are strongest helps distribute the nipple soreness more evenly. E.) Change the infant's position on the nipples. Repositioning either the client or the newborn can help alleviate nipple discomfort during feeding.

A nurse is assisting to collect data for a gestational age assessment on a newborn. Which of the following should the nurse check during a neuromuscular assessment? (Select all that apply). A.) Arm recoil B.) Popliteal angle C.) Scarf sign D.) Heel to ear E.) Moro reflex

A.) Arm recoil The nurse should use the Ballard scale when collecting neuromuscular data from a newborn. The nurse should check arm recoil when collecting this data. B.) Popliteal angle The nurse should use the Ballard scale when collecting data for a gestational age assessment on a newborn. The nurse should check the popliteal angle when collecting this data. C.) Scarf sign The nurse should use the Ballard scale when collecting data for a gestational age assessment on a newborn. The nurse should check the scarf sign when collecting this data. D.) Heel to ear The nurse should use the Ballard scale when collecting data for a gestational age assessment on a newborn. The nurse should check the heel to ear when collecting this data.

A nurse is caring for a client following a cesarean birth. The client tells the nurse that she is hungry. Which of the following actions should the nurse take first? A.) Auscultate the client's abdomen. B.) Offer clear liquids. C.) Give the client soda crackers. D.) Check the client's chart for a diet prescription.

A.) Auscultate the client's abdomen. Using the nursing process framework for client care, the nurse should first auscultate the client's abdomen for bowel sounds. During a cesarean birth, the bowel is manipulated, taking 24 to 48 hr before full peristaltic function is restored.

A nurse is reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply). A.) Blot the perineal area dry after voiding. B.) Clean the perineal area from front to back. C.) Perform hand hygiene before and after voiding. D.) Apply ice packs to the perineal area several times daily. E.) Sit on an inflatable donut to protect the perineum.

A.) Blot the perineal area dry after voiding. The nurse should instruct the client to blot the perineal area dry after voiding. Secretions that are allowed to remain on the perineum can be a medium for bacterial growth, which increases the risk for infection. Therefore, the perineal area should be thoroughly dried by blotting after each void. B.) Clean the perineal area from front to back. The nurse should instruct the client to clean the perineal area from front to back. Cleaning the perineum from front to back decreases the chances of transmitting fecal organisms to other areas, such as the urinary meatus, episiotomy incision, or lacerations resulting from childbirth. C.) Perform hand hygiene before and after voiding. The nurse should instruct the client to perform hand hygiene before and after voiding. Hand hygiene is the primary method of reducing micro-organisms on the hands, thereby reducing the risk of transmission that can lead to infection.

A nurse is assisting with monitoring a client who has preeclampsia and is receiving magnesium sulfate. The client's respiratory rate is 8/min. Which of the following should the nurse administer? A.) Calcium gluconate B.) Flumazenil C.) Naloxone D.) Protamine sulfate

A.) Calcium gluconate The nurse should plan to administer calcium gluconate or calcium chloride as the reversal agent for a client who experiences magnesium sulfate toxicity.

A nurse is caring for a newborn shortly after birth and places the newborn under a radiant warmer. Which of the following potential complications does this action help to prevent? A.) ​Cold stress B.) ​Shivering C.) ​Thermogenesis D.) ​Brown fat production

A.) Cold stress ​Prevention of cold stress is important to decrease metabolic and physiologic demands on the newborn. Cold stress can lead to hypoglycemia and respiratory distress in the newborn.

A nurse is preparing to examine a post-term newborn immediately following delivery. Which of the following findings should she expect to observe? (Select all that apply.) A.) Cracked, peeling skin B.) Moro reflex C.) Abundant lanugo D.) Vernix in the folds and creases E.) Heel to ear maneuverability

A.) Cracked, peeling skin A post-term newborn, born after 42 weeks of gestation, typically has cracked, peeling skin. B.) Moro reflex Reflexes do not change with postmaturity. An intact Moro reflex is an expected finding.

A nurse is assisting in the care of a client who had a vaginal birth 2 hr ago. Which of the following actions should the nurse take? (Select all that apply.) A.) Document fundal height. B.) Massage a firm fundus. C.) Observe the lochia during palpation of fundus. D.) ​Determine whether the fundus is midline. E.) Administer terbutaline if the fundus is boggy.

A.) Document fundal height. The nurse should document the client's fundal height. The nurse should palpate the fundus for location and tone to detect the risk of postpartum hemorrhage. C.) Observe the lochia during palpation of fundus. The nurse should observe the flow of lochia while palpating the fundus. During palpation of the fundus, the nurse should expect an increase in lochia. However, the presence of large clots should alert the nurse to a possible hemorrhage. D.) ​Determine whether the fundus is midline. The nurse should determine whether the fundus is midline, as a full bladder can displace the uterus and cause it to become boggy. If the fundus is not midline, the nurse should have the client empty her bladder then recheck the fundal location. Fundal massage might be needed to increase uterine tone and decrease bleeding.

A nurse is caring for a newborn immediately following delivery. After assuring a patent airway, which of the following actions should be the nurse's priority? A.) Dry the newborn. B.) Administer phytonadione IM. C.) Document the Apgar score. D.) Apply identification bands.

A.) Dry the newborn. Drying the newborn is the priority action the nurse should take. Failure to dry the newborn can result in cold stress, which poses the greatest risk to the infant's safety. Cold stress increases oxygen demand and can result in respiratory distress and hypoglycemia.

A nurse is reinforcing teaching about a biophysical profile with a client who is at 40 weeks of gestation. The nurse should explain that this profile focuses on which of the following parameters? (Select all that apply). A.) Fetal breathing B.) Fetal motion C.) Nuchal translucency D.) Amniotic fluid volume E.) Fetal gender

A.) Fetal breathing A biophysical profile includes evaluation of fetal breathing movements. B.) Fetal motion A biophysical profile includes evaluation of gross body movements of the fetus. D.) Amniotic fluid volume A biophysical profile includes a qualitative evaluation of amniotic fluid volume.

A nurse is caring for a client who is 36 hr postpartum and has a distended bladder. The client reports saturating four perineal pads in the past hour. Which of the following actions should the nurse take? (Select all that apply). A.) Palpate the fundus for location and tone. B.) Check the client's blood pressure and pulse. C.) C. Place the client in reverse Trendelenburg position. D.) Administer intravenous infusion of 0.9% sodium chloride. E.) Look under the client's buttocks.

A.) Palpate the fundus for location and tone. The uterus should be firm and midline and at the appropriate fundal height for the postpartum period. Some causes of a boggy or displaced uterus include a distended bladder, uterine atony, or a retained placenta. B.) Check the client's blood pressure and pulse. The client's vital signs should be carefully monitored for indications of hypovolemic shock due to excessive blood loss. Maternal hemorrhage continues to be the leading cause of maternal mortality. D.) Administer intravenous infusion of 0.9% sodium chloride. Intravenous fluids will help to restore or maintain circulatory blood volume. E.) Look under the client's buttocks. An important nursing action includes monitoring and visualizing the amount of lochia. The nurse should monitor the amount of lochia on the perineal pad and observe for any pooling of lochia under the buttocks. A perineal pad saturated in 15 min or less could be an indication of postpartum hemorrhage.

A nurse is collecting data about reflexes from a newborn. Which of the following actions should the nurse take to elicit the newborn's Moro reflex? A.) Perform a sharp hand clap near the infant. B.) Hold the newborn vertically, allowing one foot to touch the crib surface. C.) Place a finger at the base of the newborn's toes. D.) ​Turn the newborn's head quickly to one side.

A.) Perform a sharp hand clap near the infant. To elicit the Moro reflex, the nurse should perform a sharp hand clap near the newborn. The newborn should exhibit symmetric abduction and extension of the arms, fanning of the fingers with the thumb and forefinger forming a C shape, followed by the arm and hand's return to a relaxed flexion position.

A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse expect to administer? (Select all that apply.) A.) Phytonadione injection B.) Hepatitis B immunization C.) Antibiotic ophthalmic ointment D.) Lidocaine gel to the umbilical stump E.) Haemophilus influenzae type b vaccine (Hib)

A.) Phytonadione injection The nurse should expect to administer phytonadione (vitamin K) IM to the newborn shortly after birth. Phytonadione prevents hemorrhagic disease of the newborn, as vitamin K is not present in the newborn's gastrointestinal tract. Production of vitamin k will begin at about 7 days of age as bacteria begin to form in the intestines. B.) Hepatitis B immunization The nurse should expect to administer a Hepatitis B immunization IM to the newborn shortly after birth. The Hepatitis B immunization should be given to the newborn at birth, 1 month, and 6 months of age. For newborns born to hepatitis-infected mothers, hepatitis B immune globin (HBIG) also should be administered within 12 hr of birth. Parental consent must first be obtained prior to the administration of this immunization. C.) Antibiotic ophthalmic ointment The nurse should expect to administer antibiotic ophthalmic ointment to the newborn shortly after birth. Due to the risk of eye infections to newborns born to women who have vaginal infections (e.g., chlamydia, gonorrhea), the instillation of prophylactic antibiotics is mandatory in the United States. The medication used is dependent upon facility protocols but is usually erythromycin or tetracycline ophthalmic ointment. The ointment is placed in both of the newborn's eyes within 1 to 2 hr after birth.

A nurse on the postpartum unit is planning to delegate client care to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP? A.) Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. B.) ​Observe an area of redness on the breast of a client who is 1 day postpartum.. C.) Check vital signs of a client who is being admitted with gestational hypertension. D.) Assist with changing the perineal pad of a client following delivery.

A.) Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. Providing comfort measures is an appropriate task for the AP since it does not require nursing judgment.

A nurse is reinforcing teaching with a client who is at 15 weeks of gestation and is about to undergo an amniocentesis. The nurse should reinforce that this test can identify which of the following traits or problems? (Select all that apply.) A.) Rh incompatibility B.) Cephalopelvic disproportion C.) Chromosome defects D.) Neural tube defects E.) Fetal gender

A.) Rh incompatibility An amniocentesis can screen for Rh incompatibility prior to birth. C.) Chromosome defects Examination of amniotic fluid yields data about genetic abnormalities, such as hemophilia. D.) Neural tube defects Examination of amniotic fluid yields data about neural tube defects, such as spina bifida. E.) Fetal gender Karyotyping is a process that allows identification of fetal gender with an amniotic fluid sample.

A nurse is collecting data from a newborn who has respiratory distress syndrome and is experiencing respiratory acidosis. Which of the following risk factors predisposes the newborn to respiratory difficulties? A.) Small for gestational age B.) Maternal history of asthma C.) Cesarean birth D.) Ventricular septal defect

A.) Small for gestational age Newborns who are small for gestational age, have a low birth weight, are postterm, have a maternal history of diabetes, and have cord prolapse are at increased risk for respiratory difficulties.

A nurse is collecting data from a newborn who has Trisomy 21. Which of the following findings should the nurse expect? (Select all that apply). A.) Transverse palmar creases B.) Large ears C.) Muscular hypertonicity D.) Protruding tongue E.) Low birth weight

A.) Transverse palmar creases The nurse should expect a newborn who has Trisomy 21 to have a transverse palmar crease. This is a common characteristic associated with this chromosomal abnormality. D.) Protruding tongue The nurse should expect a newborn who has Trisomy 21 to have a protruding tongue. This is a common characteristic associated with this chromosomal abnormality.

A nurse is reinforcing teaching about common discomforts of pregnancy during the first trimester with a client who is pregnant. Which of the following manifestations should the nurse include in the teaching? A.) Urinary urgency B.) Constipation C.) Supine hypotension D.) Heartburn

A.) Urinary urgency Urinary urgency and frequency are common discomforts occurring during the first trimester. Hormones cause vascular engorgement and altered bladder function. Education should also include regular emptying of the bladder, performing Kegel exercises, and limiting fluid intake prior to bedtime.

A nurse working in the newborn nursery is preparing to return a newborn to the mother. Which of the following should the nurse verify? (Select all that apply). A.) Verify the newborn ID band numbers. B.) Verify the newborn's date of birth. C.) Verify the mother's last name. D.) Verify the mother's medical record number. E.) Verify the newborn's gender.

A.) Verify the newborn ID band numbers. Newborn ID bands should be applied immediately after delivery to prevent infant abduction or accidental switching of newborns. One band is applied to the wrist and one band is applied to the ankle of the newborn. Each time the newborn is returned to the mother, the identification band should be verified against the mother's ID band. B.) Verify the newborn's date of birth. The mother and newborn are identified by plastic ID wristbands with permanent locks that must be cut to be removed. The ID band of the newborn includes the date of birth. D.) Verify the mother's medical record number. The newborn's ID band should also include the mother's medical record number. This practice adheres to security protocols safeguarding against infant abduction. E.) Verify the newborn's gender. The ID band of the newborn should include the newborn's gender, date and time of birth, name, and mother's medical record number.

A nurse reinforcing teaching about vitamin K with a client who is postpartum. Which of the following statements should the nurse include? A.) Vitamin K decreases the newborn's risk of hemorrhagic disorders. B.) Vitamin K decreases the newborn's risk of jaundice. C.) Vitamin K decreases the newborn's risk of health care-associated infections. D.) Vitamin K decreases the newborn's risk of complications from the Hepatitis B vaccine.

A.) Vitamin K decreases the newborn's risk of hemorrhagic disorders. Newborns cannot produce vitamin K until about 8 days after birth. It is administered in the delivery suite to prevent hemorrhagic disorders.

A nurse is assisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor. Which of the following findings confirm that the client is in labor? A.) ​Cervical dilation B.) ​Pain just above the navel C.) ​Contractions every 3 to 4 min D.) ​Amniotic fluid in the vaginal vault

A.) ​Cervical dilation Cervical dilation and effacement are indications of true labor.

A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following findings are associated with this diagnosis? (Select all that apply). A.) Coughing B.) Poor suck reflex C.) ​Sunken abdomen D.) Respiratory distress E.) ​Frothy saliva

A.) ​Coughing Coughing, which can be caused by food entering the trachea, is a finding associated with a tracheoesophageal fistula. D.) Respiratory distress Respiratory distress, caused by aspiration during feedings, is a finding associated with a tracheoesophageal fistula. E.) ​Frothy saliva Frothy saliva, caused by food entering the trachea, is a finding associated with a tracheoesophageal fistula.

A nurse is assisting with the care of a client who is in labor and has an external electronic fetal monitor. The nurse observes that the fetal heart rate begins to decelerate after the contraction has started, with the lowest point of the deceleration occurring after the peak of the contraction. Which of the following actions should the nurse take first? A.) ​Place the client in the lateral position. B.) ​Increase the rate of the maintenance IV infusion. C.) ​Elevate the client's legs. D.) ​Administer oxygen using a nonrebreather mask.

A.) ​Place the client in the lateral position. This is a late deceleration and is associated with insufficient placental perfusion. Placing the client in the lateral position is the first action the nurse should take.

A nurse is reinforcing teaching about diaphragms with a client. Which of the following statements by the client indicates an understanding of the teaching? A.) "I will coat the diaphragm with an oil-based lubricant in between uses." B.) "I will leave the diaphragm in for at least 6 hours after vaginal intercourse." C.) "I will avoid using creams or jellies so that the diaphragm will fit snugly." D.) "I will need to get a new diaphragm every year."

B.) "I will leave the diaphragm in for at least 6 hours after vaginal intercourse." The diaphragm must be left in place for 6 to 8 following after vaginal intercourse to be effective. For subsequent vaginal intercourse during this 6 to 8-hr time period, additional spermicidal jelly must be added without disturbing the placement of the diaphragm.

A nurse is caring for client who is at 20 weeks of gestation and tells the nurse that she is concerned that exercising might pose risks to her pregnancy. Which of the following statements should the nurse make? A.) "Be careful about exercises that include stretching." B.) "Moderate exercise can help improve your circulation." C.) "It is a good idea to increase your weight-bearing exercises." D.) "You should rest for 5 minutes following exercise."

B.) "Moderate exercise can help improve your circulation." ​Improving circulation is one of many benefits of moderate exercise during pregnancy. It can also enhance well-being and promote rest and relaxation. It also improves muscle tone, which might shorten the duration of labor.

A nurse is reinforcing discharge teaching with a client who is 3 days following a cesarean birth. Which of the following client statements indicates that the teaching was effective? (Select all that apply). A.) "I am likely to have a temperature of 38.3° C (101° F) or higher." B.) "My partner and I will use a condom until I can get an intrauterine device." C.) "I will call my provider if I have discharge from my incision." D.) "I should not have unrelieved pain in my abdomen." E.) "I will rest in a recliner until my incision is healed."

B.) "My partner and I will use a condom until I can get an intrauterine device." An intrauterine device (IUD) is usually not inserted until the sixth week postpartum. To prevent infection and allow for healing, women are usually advised to wait 6 weeks prior to resuming sexual activity. However, many women often begin earlier. The client may ovulate prior to that time and should use an alternative form of birth control. C.) "I will call my provider if I have discharge from my incision." Discharge should be reported to the provider. It may indicate infection or failure to heal. Using the REEDA (Redness, Edema, Ecchymosis, Drainage, Approximation) acronym is a good way to remember wound assessment. There should not be any redness, edema, ecchymosis, or drainage and edges should be approximated. D.) "I should not have unrelieved pain in my abdomen." A client will have abdominal pain and tenderness from the surgical procedure. However, this pain should not increase. The nurse should instruct the client to notify the provider if pain or tenderness of the abdominal and pelvic area does not resolve with analgesics. Unrelieved pain could be a sign of infection.

A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make? A.) "This is a Mongolian spot, which is found on many newborns." B.) "This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor." C.) "This is a cephalhematoma, which will resolve on its own in 3 to 5 days." D.) "This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin."

B.) "This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor." A caput succedaneum is an area of edema on the newborn's occiput, often seen where the cup of the vacuum was applied. It resolves within 3 to 4 days and requires no treatment.

A nurse is reinforcing teaching with a client who is pregnant and whose routine diagnostic testing reveals a negative rubella titer. Which of the following statements should the nurse tell the client? A.) "You are immune to rubella." B.) "You will need an immunization following delivery." C.) "I will administer the rubella immunization to you today." D.) "You had the rubella infection as a child."

B.) "You will need an immunization following delivery." The negative rubella titer means that the client is susceptible to the rubella virus and needs to be immunized after delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following the rubella immunization, the client should be cautioned not to conceive for 3 months.

A nurse is working with an assistive personnel (AP) who is pregnant. The nurse is unsure of the AP's immune status. Which of the following clients should the nurse safely assign to the AP? A.) A preschool-age child who has varicella. B.) A toddler who has impetigo. C.) A school-age child who has rubella. D.) A school-age child who has fifth disease with aplastic crisis.

B.) A toddler who has impetigo. Impetigo contagiosa has minimal systemic effects. Therefore, it should be safe for the nurse to assign the AP care of this client.

A nurse is assisting with the care of a client who is in early labor with intact membranes and a temperature of 38.9 C (102 F). After notifying the provider, which of the following actions should the nurse take? A.) Recheck the client's temperature in 2 hr. B.) Administer acetaminophen orally. C.) Administer misoprostol vaginally. D.) Prepare the client for placement of an intrauterine pressure catheter.

B.) Administer acetaminophen orally. The nurse should administer acetaminophen to lower the client's temperature and encourage her to drink sips of water. Acetaminophen is a pregnancy risk category B medication, so it is likely that the provider will prescribe it.

A nurse is assisting with the admission of a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. Incomplete abortion is the initial diagnosis. Which of the following actions should the nurse contribute to the client's plan of care? A.) Administer oxygen via facemask. B.) Determine the amount and type of vaginal bleeding. C.) Instruct the client in appropriate birth control methods. D.) ​Keep the client on bed rest.

B.) Determine the amount and type of vaginal bleeding. Bleeding can continue until the client has expelled all of the products of conception. It is important for the nurse to note the amount and type of bleeding and to monitor the client for indications of excessive blood loss.

A nurse is collecting data from a newborn and finds an apical pulse of 130/min. Which of the following actions should the nurse take? A.) Ask another nurse to verify the heart rate. B.) Document this as an expected finding. C.) Call the neonatologist to assess the newborn. D.) ​Prepare the newborn for transport to the NICU.

B.) Document this as an expected finding. The expected reference range for apical pulse in a newborn is 120 to 160/min. The nurse should document this as an expected finding.

A nurse is collecting data from a client who has a urinary tract infection. Which of the following findings should the nurse expect? (Select all that apply.) A.) Polyuria B.) Dysuria C.) Dependent edema D.) Urinary frequency E.) Hematuria

B.) Dysuria Dysuria, or painful urination, is a clinical finding associated with urinary tract infections. D.) Urinary frequency Urinary frequency is a clinical finding associated with urinary tract infections. E.) Hematuria

A nurse is collecting data from a client who is 3 days postpartum and is breastfeeding. Her fundus is three fingerbreadths below the umbilicus, and her lochia rubra is moderate. Her breasts feel hard and warm. Which of the following recommendations should the nurse give the client? A.) Obtain a prescription for an antibiotic. B.) Express milk from both breasts. C.) Apply a heating pad to her breasts. D.) Wear a nipple shield.

B.) Express milk from both breasts. ​For this postpartum day, the client's fundal location and lochia characteristics are within the expected reference range. The client's manifestations indicate that she is experiencing breast engorgement, an expected finding, as this is the time when the milk "comes in." Frequent breastfeeding and expressing milk from the breasts can help relieve engorgement.

A nurse is reinforcing teaching about immunizations with a woman in her first trimester of pregnancy whose diagnostic testing indicates she does not have an immunity to rubella. The nurse should recommend that the client receive a measles, mumps, rubella (MMR) vaccine at which of the following times? A.) When she does not desire future pregnancies B.) Prior to discharge from the hospital after giving birth C.) Prior to giving birth D.) Two weeks before attempting pregnancy again

B.) Prior to discharge from the hospital after giving birth The nurse should recommend the client receive the MMR vaccine following delivery, so she is protected from contracting rubella then and during any subsequent pregnancies.

A nurse is preparing a sitz bath for a client who is 1 day postpartum. Which of the following actions should the nurse take? A.) Fill the bath ¾ full of water. B.) Set the water temperature to 40° C (104° F). C.) Instruct the client to relax her gluteal muscles when entering the bath. D.) Check on the client every 30 min during the bath.

B.) Set the water temperature to 40° C (104° F). The nurse should ensure that the water temperature of the bath is between 38° to 40.6° C (100.4° to 105.1° F) to prevent injury to the client.

A nurse is reinforcing teaching about crib safety with the parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A.) ​"I will place my baby on his stomach when he is sleeping." B.) ​"I will warm the crib sheets before putting my baby to bed." C.) ​"I should place the crib near a window to provide adequate sunlight and fresh air." D.) ​"I should place my baby's stuffed animals between the mattress and side of the crib."

B.) ​"I will warm the crib sheets before putting my baby to bed." ​Prewarming crib sheets is an acceptable infant quieting technique. The sheets can be prewarmed with a hot water bottle or heating pad that should be removed before putting the baby to bed. Some babies startle and awaken when placed on a cold sheet.

A nurse in a prenatal clinic overhears a newly licensed nurse discussing conception with a client. Which of the following statements by the newly license nurse requires intervention by the nurse? A.) "Fertilization takes place in the outer third of the fallopian tube." B.) ​"Implantation occurs between two and three weeks after conception." C.) "Sperm remain viable in the woman's reproductive tract for 2 to 3 days." D.) "Bleeding or spotting can accompany implantation."

B.) ​"Implantation occurs between two and three weeks after conception." This statement requires clarification because implantation follows conception within 6 to 10 days.

A nurse is reinforcing teaching about Kegel exercises with a client who is in the third trimester of pregnancy. Which of the following statements by the client indicates an understanding of the teaching? A.) ​"These exercises will help prevent bladder infections." B.) ​"These exercises will help my pelvic muscles stretch when I give birth." C.) ​"These exercises will help lessen my back aches." D.) ​"These exercises will prevent further stretch marks."

B.) ​"These exercises will help my pelvic muscles stretch when I give birth." ​Kegel exercises help strengthen perineal muscles, facilitating stretching and contracting during childbirth.

A nurse is collecting data from an infant who has hydrocephalus. Which of the following findings should the nurse expect? A.) Proteinuria B.) ​Dilated scalp veins C.) ​Hypertension D.) Soft and flat fontanels

B.) ​Dilated scalp veins Manifestations of hydrocephalus in a newborn include dilated scalp veins, separated sutures, and bulging fontanels.

A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client's need to urinate? A.) ​Moderate lochia rubra B.) ​Fundus three fingerbreadths above the umbilicus C.) ​Moderate swelling of the labia D.) ​Blood pressure 130/84 mm Hg

B.) ​Fundus three fingerbreadths above the umbilicus ​A full bladder can raise the level of uterine fundus and deviate it to the side.

A nurse is caring for a client who is postpartum and asks, "When will my breast milk come in?" Which of the following responses should the nurse make? A.) ​Within 2 days after delivery B.) ​In 3 to 5 days after delivery C.) ​In 6 to 8 days after delivery D.) ​In about 10 days after delivery

B.) ​In 3 to 5 days after delivery ​By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milk.

A nurse is assisting with the admission of a client who is in preterm labor at 30 weeks of gestation and has a new prescription for betamethasone. Which of the following statements should the nurse make? A.) "The purpose of this medication is to stop preterm labor contractions." B.) "The purpose of this medication is to halt cervical dilation." C.) "The purpose of this medication is to boost fetal lung maturity." D.) "The purpose of this medication is to increase the fetal heart rate."

C.) "The purpose of this medication is to boost fetal lung maturity." Betamethasone is a glucocorticoid that boosts fetal lung maturity by promoting the release of certain enzymes that help produce surfactant.

A nurse is reinforcing teaching with a newly licensed nurse about the purpose of an indirect Coombs test. Which of the following statements should the nurse include in the teaching? A.) "This test determines if kernicterus will occur in the newborn." B.) "This test detects Rh-negative antibodies in a newborn who is Rh-positive." C.) "This test detects Rh-positive antibodies in the mother's blood." D.) "This test determines the presence of maternal antibodies in the newborn's blood."

C.) "This test detects Rh-positive antibodies in the mother's blood." An indirect Coombs test is performed on the mother's blood to determine if she has developed antibodies to the Rh antigen.

A nurse is reinforcing teaching with a new mother about the purpose of administering vitamin K to her newborn following delivery. The nurse should explain that the purpose of administering vitamin K is to prevent which of the following complications? A.) Infection B.) Potassium deficiency C.) Bleeding D.) Hyperbilirubinemia

C.) Bleeding A newborn is unable to manufacture vitamin K, which is necessary for blood clotting, without intestinal flora. Vitamin K also promotes production of clotting factors II, VII, IX, and X in the liver. Vitamin K is usually produced by day 8; therefore, it is routinely given to newborns to prevent bleeding problems.

A nurse is contributing to the plan of care for a preterm newborn. To help the newborn conserve energy, which of the following actions should the nurse recommend? A.) Place elbow restraints on the newborn. B.) Change the newborn's position every 2 hr. C.) Cluster the newborn's care activities. D.) ​Allow opportunities for newborn massage.

C.) Cluster the newborn's care activities. By clustering activities and organizing care, the nurse prevents excessive interruptions and allows the newborn extended periods of rest and energy conservation.

A nurse is collecting data from a newborn who is 12 hr old. His respiration rate is 44/min, shallow, with periods of apnea lasting up to 5 seconds. Which of the following actions should the nurse take? A.) Activate respiratory arrest procedures. B.) Report the observation to the charge nurse immediately. C.) Continue routine monitoring. D.) Request an order for supplemental oxygen.

C.) Continue routine monitoring. This observation indicates adaptation of the respiratory system to extrauterine life. Continued monitoring is indicated.

A nurse is preparing to administer dinoprostone gel to a client who is pregnant. The client asks the nurse about the purpose of the medication. Which of the following responses should the nurse make? A.) Dinoprostone stimulates uterine contractions. B.) Dinoprostone assists with ending the pregnancy. C.) Dinoprostone promotes softening of the cervix. D.) Dinoprostone relaxes uterine contractions.

C.) Dinoprostone promotes softening of the cervix. Dinoprostone is used to prepare or soften the cervix for the induction of labor in pregnant clients who are at or near term.

A nurse is reinforcing teaching with a client about how to reduce the risk of giving birth to a newborn who has a neural tube defect. Which of the following instructions should the nurse include in the teaching? A.) Avoid consumption of alcohol. B.) Increase intake of iron. C.) Eat foods fortified with folic acid. D.) Avoid the use of aspirin.

C.) Eat foods fortified with folic acid. An increased consumption of folic acid in the 3 months prior to pregnancy, as well as throughout the pregnancy, is associated with a decreased risk of the development of neural tube defects.

A nurse is caring for a client who might have a hydatidiform mole. The nurse should monitor the client for which of the following findings? A.) Fetal heart rate irregularities B.) Whitish vaginal discharge C.) Excessive uterine enlargement D.) Rapidly dropping human chorionic gonadotropin (hCG) levels

C.) Excessive uterine enlargement A hydatidiform mole is a rare tumor that arises from placental tissue and results in a rapidly enlarging uterus.

A nurse is caring for a client who has just learned that she is pregnant. The nurse should reinforce with the client to call her provider if she experiences which of the following manifestations? A.) Decreased energy B.) Urinary frequency C.) Facial edema D.) Mood swings

C.) Facial edema Facial edema is an indication of pregnancy-induced hypertension, which should be reported to the client's provider.

A nurse is collecting data from a newborn who is 48-hr old. Which of the following findings should the nurse report to the provider? A.) Telangiectatic nevi B.) Erythema toxicum C.) Generalized petechiae D.) Mongolian spot

C.) Generalized petechiae Generalized petechiae can indicate a clotting factor deficiency or infection; therefore, the nurse should report these findings to the provider for further evaluation.

A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following treatments should the infant receive? A.) Hepatitis B immune globulin at 1 week followed by the hepatitis B vaccine monthly for 6 months B.) The hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen C.) Hepatitis B immune globulin and the hepatitis B vaccine within 12 hr of birth D.) The hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days

C.) Hepatitis B immune globulin and the hepatitis B vaccine within 12 hr of birth ​A newborn whose mother is positive for the hepatitis B surface antigen should receive both the hepatitis B vaccine and the hepatitis B immune globulin within 12 hr of birth.

A nurse is collecting data from a client who is at 18 weeks of gestation and tells the nurse that she felt light fluttering in her stomach the previous day. The nurse should use which of the following terms to document this finding? A.) Ballottement B.) Lightening C.) Quickening D.) Chloasma

C.) Quickening ​Clients often describe quickening as a fluttering sensation they first perceive as early as the 14th week of gestation. It reflects fetal movement.

A nurse is reinforcing teaching with a parent about using an iron fortified formula to feed her newborn. Which of the following information should the nurse include in the teaching? A.) Iron will facilitate eyesight development. B.) Iron will facilitate bone growth. C.) The newborn's iron source will start to deplete. D.) Newborns do not metabolize iron adequately.

C.) The newborn's iron source will start to deplete. Iron sources deplete and need to be supplemented in newborns.

A nurse is assisting with a community program to educate adolescents about contraception. After the class, a 15-year-old girl asks the nurse which method is best for her to use. Which of the following statements is an appropriate nursing response? A.) ​"You are so young. Are you sure you are ready for the responsibilities of a sexual relationship?" B.) ​"Because of your age, we need your parents' consent for an examination, and then we'll talk." C.) ​"Before I can help you with that question, I need to know more about your sexual activity." D.) ​"The doctor can best help you with that after your physical examination."

C.) ​"Before I can help you with that question, I need to know more about your sexual activity." ​Effective consultation with a client about the best form of birth control for her requires further data collection about the frequency of intercourse, number of partners, and her own motivation and reliability.

A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following statements is an appropriate response by the nurse? A.) ​"You may carry your grandchild to the room." B.) ​"You can push the baby to the room in a wheeled bassinet." C.) ​"Have the mother call and I will take the baby to the room." D.) ​"If you show me your photo identification, you can take the infant."

C.) ​"Have the mother call and I will take the baby to the room." ​Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel verify before permitting an infant to leave the nursery.

A nurse is caring for a client who is postpartum. The client states, "I am concerned about my baby's hearing because my mother was born deaf." Which of the following statements should the nurse make? A.) ​"There is no need to worry about that. Most forms of hearing loss are not inherited." B.) ​"Look at how she looks as you when you speak. That's a good sign." C.) ​"We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." D.) ​"The best way to determine if your baby can hear is to clap your hands loudly and see if she startles."

C.) ​"We do routine hearing screenings on newborns. You'll know the results before you leave the hospital." ​Most states mandate hearing screening for all newborns. The two tests in use do not diagnose hearing loss, but determine whether a newborn requires further evaluation.

A nurse is assisting with the care of a client who is multigravida and in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following is the appropriate nursing response? A.) Assist the client into a comfortable position. B.) Assess the perineum for signs of crowning. C.) ​Have the client pant during the next few contractions. D.) Help the client to the bathroom to empty her bladder.

C.) ​Have the client pant during the next few contractions. ​Panting is fast, continuous, shallow breathing. It helps a client in labor refrain from pushing before her cervix reaches full dilation.

A nurse is preparing to administer methylergonovine IM for a client who had a vaginal delivery earlier that day, The nurse should explain to the client that this medication will help prevent which of the following? A.) ​Postpartum infection B.) ​Hypertension C.) ​Postpartum hemorrhage D.) ​Thromboembolic events

C.) ​Postpartum hemorrhage ​Methylergonovine is an oxytocic. It causes uterine contractions to help control postpartum bleeding.

A nurse is caring for a client who is postpartum and is breastfeeding her infant. Which of the following findings indicates mastitis? A.) ​Swelling in both breasts B.) ​Cracked and bleeding nipples C.) ​Red and painful area in one breast D.) Increase in breast milk

C.) ​Red and painful area in one breast ​Mastitis often appears as a red, hard, and painful area. Although mastitis can occur in both breasts, it is usually unilateral. After delivery, the nurse should monitor the client's breasts for signs of mastitis and reinforce instruction about breast self-examination.

A nurse is reinforcing teaching with a newly licensed nurse about the administration of depot medroxyprogesterone. Which of the following instructions should the nurse include in the teaching? A.) "Administer depot medroxyprogesterone every 6 to 8 weeks." B.) "Initiate depot medroxyprogesterone 14 days after the client's first day of her menstrual cycle." C.) "Massage the site after you administer the medication." D.) "Give the medication intramuscularly."

D.) "Give the medication intramuscularly." The nurse can administer depot medroxyprogesterone subcutaneously or intramuscularly.

A nurse is reinforcing nutrition teaching with a client during the first prenatal visit. Which of the following statements by that client indicates an understanding of the teaching? A.) "I will switch to drinking whole milk." B.) "I can have 4 oz of white wine daily." C.) "I can consume 600 milligrams of caffeine daily." D.) "I can eat 12 to 18 ounces of albacore tuna weekly."

D.) "I can eat 12 to 18 ounces of albacore tuna weekly." Women should be instructed to limit their intake of commercially caught "white tuna" or albacore tuna and tuna steaks to 6 ounces per week because they contain high levels of mercury.

A nurse in a provider"s office is collecting data from a female client in her third trimester of pregnancy. The client describes actions she took to obtain relief from a headache which lasted all day. Which of the following client statements should the nurse identify as the priority? A.) "I ignored the headache pain and just kept on going." B.) "I skipped lunch and took 1000 mg of acetaminophen with sips of water." C.) "I drank three 8-ounce cups of coffee with extra sugar and cream." D.) "I took 400 mg of ibuprofen with a diet soda."

D.) "I took 400 mg of ibuprofen with a diet soda." Taking a non-steroidal anti-inflammatory drug (NSAID) during pregnancy indicates the greatest risk is injury to the fetus. Ibuprofen is a category C medication during the first two trimesters of pregnancy, and contraindicated (category D) during the 3rd trimester. NSAIDs inhibit prostaglandin synthesis, which is required to maintain patency of the ductus arteriosus for the fetus and maintain fetal circulation. NSAIDs can also cause blood dyscrasias and increase bleeding time, both of which can harm the mother and fetus.

A nurse is caring for a female client who is scheduled to have a pelvic examination. The client tells the nurse, "I'm really nervous because I've never had a pelvic exam before." Which of the following is an appropriate therapeutic response by the nurse? A.) "A pelvic exam is required if you want birth control pills." B.) "Don't worry, I will stay in there with you for the exam." C.) "All you need to do is relax during the exam." D.) "Tell me more about your concerns."

D.) "Tell me more about your concerns." This therapeutic response is an open-ended statement and encourages the client to tell the nurse more about her concerns.

A nurse is reinforcing teaching with a client who has genital herpes. Which of the following client statements should the nurse identify as understand of the teaching? A.) "I am not contagious if no lesions are present." B.) "The provider can do weekly treatment to remove the lesions." C.) "I should use condoms during the prodromal phase of infection." D.) "The lesions can spread to other areas of my body."

D.) "The lesions can spread to other areas of my body." Herpes simplex lesions can spread through autoinoculation, when a client touches an active lesion then touches another area of the body. Therefore, the nurses should identify this statement as understanding of the teaching.

A nurse is reviewing contraception options for four clients. The nurse should identify which of the following clients as having a contraindication to oral contraceptives? A.) A 15-year old client who has acne B.) A client who has a hematocrit of 39% C.) A client who has a menstrual cycle every 14 days D.) A client who has a blood pressure of 140/90 mm Hg

D.) A client who has a blood pressure of 140/90 mm Hg Oral contraceptives are contraindicated for individuals who have hypertension, especially if it is not controlled by medication. High doses of estrogen and progestin in oral contraceptives are associated with risk for stroke, myocardial infarction, hypertension, and thromboembolism. Clients who have hypertension are already at an increased risk for a thromboembolic event.

A nurse is assisting with the admission of a client who is Hispanic to the labor and delivery unit. Which of the following practices should the nurse anticipate while caring for this client? A.) Absence of family members during labor B.) Request to drink cold fluids immediately after delivery C.) Practice of maternal fasting following the birth D.) Desire to delay breastfeeding for several days

D.) Desire to delay breastfeeding for several days Hispanic beliefs may include delaying breastfeeding until breast milk is present. The nurse can provide education and should remain nonjudgmental. The newborn can drink formula until the mother chooses to begin breastfeeding.

A nurse is assisting in the care of a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take? A.) Instruct the client to apply mineral oil to the nipples after each feeding. B.) Encourage the client to keep the nipples covered when not breastfeeding. C.) Instruct the client to limit feedings to 10 min on each breast. D.) Encourage the client to change the newborn's position with each feeding.

D.) Encourage the client to change the newborn's position with each feeding. ​The nurse should encourage the client to reposition the newborn for each feeding to decrease nipple soreness. The client should also ensure the newborn's mouth is wide open prior to latching on to the breast.

A nurse is caring for a client who is requesting to go to the bathroom immediately after a vaginal birth. Which of the following actions should the nurse take? A.) Assist the client to the bathroom using a wheelchair. B.) Advise the client to remain in bed for the next few hours. C.) Inform the client that she can go to the bathroom whenever needed. D.) Evaluate the side effects of analgesia used during labor.

D.) Evaluate the side effects of analgesia used during labor. It is necessary to collect data on the client for side effects from analgesia prior to ambulation. The effects of narcotic analgesia as well as epidural or general anesthesia should be evaluated to prevent falls. The client should be able to raise her legs, flex her knees, and lift her buttocks off the bed. Sensation in the feet and legs should be present with no "tingling". Often, it will take several hours for the anesthetic effects to disappear.

A nurse is reinforcing teaching with the parents of a newborn about caring for the umbilical cord stump. Which of the following instructions should the nurse include? A.) Wash the cord daily with mild soap and water. B.) ​Cover the cord with the diaper. C.) ​Wrap the cord in petroleum jelly gauze. D.) Give the newborn a sponge bath until the cord stump falls off.

D.) Give the newborn a sponge bath until the cord stump falls off. ​The nurse should instruct the parents to give the newborn a sponge bath until the stump falls off.Immersing the umbilical cord stump in water might delay the process of drying, separation, and healing.

A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication? A.) Chills shortly following delivery B.) ​Fundus at umbilicus level C.) ​Urinary output 3,000 mL/12 hr D.) Heart rate 110/min

D.) Heart rate 110/min A rapid or increasing heart rate can be a sign of fluid volume depletion related to hemorrhage. The nurse should further evaluate the client for postpartum hemorrhage.

A nurse is reinforcing teaching with a client who is being fitted for a contraceptive diaphragm. Which of the following information should the nurse include? A.) Replace the device once per year. B.) Replace the device every 3 years C.) Replace the device after a urinary tract infection. D.) Replace the device after a 20% weight loss.

D.) Replace the device after a 20% weight loss. It is important for the device to fit appropriately in the vaginal vault in order to provide adequate contraceptive protection. The client should replace the diaphragm after a 20% weight loss or gain.

A nurse is observing a new mother bathe her newborn for the first time. Which of the following actions by the mother requires the nurse to intervene? A.) The mother provides a sponge bath using mild soap. B.) The mother cleans the umbilical cord with sterile water. C.) The mother leaves the crust on the circumcision site. D.) The mother sprinkles powder on the perineal area.

D.) The mother sprinkles powder on the perineal area. Powder, can be aspirated and cause inflammation and respiratory complications. Lotions or oils should not be used, because they can provide a medium for bacterial growth.

A nurse is assisting in the care of a newborn following birth. At 1 min after birth, the nurse notes the following: heart rate 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. What should the nurse document as the newborn's 1-min Apgar score?

6

A nurse is collecting data from a newborn. Which of the following anatomical landmarks should the nurse use to measure chest circumference? A.) ​Sternal notch B.) ​Nipple line C.) ​Lower ribcage border D.) ​Axillae

B.) Nipple line ​The nurse should measure the chest circumference at the nipple line.

A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings should the nurse expect? A.) Well rounded abdomen B.) Decreased circulating RBC C.) Blood glucose instability D.) Retinopathy

C.) Blood glucose instability Decreased glycogen storage and less gluconeogenesis put newborns who are SGA at high risk for hypoglycemia.

A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about her newborn's hydration. Which of the following nursing observations is appropriate to use in evaluating the adequacy of the newborn's hydration? A.) The fit of the newborn's clothes B.) How often the newborn cries C.) The newborn's skin turgor D.) The number of wet diapers per day

D.) The number of wet diapers per day The easiest and most reliable method to evaluate hydration is urinary output. Six to eight wet diapers per day is generally considered adequate.

A nurse is preparing to administer vitamin K 1 mg IM to a newborn. Available is vitamin K injection 1 mg/0.5 mL. How many mL should the nurse administer per dose?

0.5 mL

A nurse is assisting in the care of a newborn immediately after birth. At 5 min after birth, the newborn has acrocyanosis, flexed extremities, a grimace when suctioned, a heart rate of 130/min, and a lusty cry with tactile stimulation. What should the nurse document as the newborn's 5-min Apgar score?

8

A nurse is caring for a newborn who is formula fed. The newborn takes 0.5 oz of formula at 0800, 1 oz at 1100, 0.5 oz at 1300, 0.5 oz at 1600, and 0.5 oz at 1830. How many mL of formula should the nurse record as the client's intake for the shift?

90 mL

A nurse is reinforcing teaching with a client about checking her basal temperature to identify when ovulation occurs. The nurse should instruct the client to check her temperature at which of the following times? A.) Every morning before arising B.) Only on days 13 to 17 of her menstrual cycle C.) 1 hr after vaginal intercourse D.) Immediately after getting into bed at night

A.) Every morning before arising The nurse should instruct the client to measure her temperature every morning throughout her menstrual cycle, upon waking, before getting out of bed. Activity or movement can raise body temperature slightly and provide inaccurate results. The client should use a special thermometer that is accurate to the tenth of a degree.

A nurse is caring for a client who is at 32 weeks of gestation and has hyperthyroidism. For which of the following clinical findings should the nurse monitor and report to the provider? (Select all that apply). A.) Fever B.) Tachycardia C.) Vomiting D.) Hypertension E.) Restlessness

A.) Fever Fever is a clinical manifestation of thyroid storm, a complication of hyperthyroidism, which can occur in response to stresses such as birth, surgery, or infection. The nurse should report this finding to the provider. B.) Tachycardia Tachycardia is a clinical manifestation of thyroid storm, a complication of hyperthyroidism, which can occur in response to stresses such as birth, surgery, or infection. The nurse should report this finding to the provider. C.) Vomiting Vomiting is a clinical manifestation of thyroid storm, a complication of hyperthyroidism, which can occur in response to stresses such as birth, surgery, or infection. The nurse should report this finding to the provider. E.) Restlessness Restlessness is a clinical manifestation of thyroid storm, a complication of hyperthyroidism, which can occur in response to stresses such as birth, surgery, or infection. The nurse should report this finding.

A nurse is reinforcing teaching about strategies to calm a newborn with a client who is postpartum. Which of the following suggestions should the nurse make? (Select all that apply.) A.) ​Take the newborn for a ride in the car. B.) ​Keep the newborn in the center of a large crib. C.) ​Carry the newborn in a front or back pack. D.) ​Swaddle the newborn in a receiving blanket. E.) Allow the newborn to continue crying until she falls asleep.

A.) ​Take the newborn for a ride in the car. Movement and rhythmic noise are soothing to newborns. C.) ​Carry the newborn in a front or back pack. This provides the comfort of close contact and gentle movement. D.) ​Swaddle the newborn in a receiving blanket. This simulates the intrauterine environment, position-wise, and provides security to the newborn.

A nurse is assisting with the monitoring of a client who is in the first stage of labor, with an external fetal monitor in place and IV fluids infusing. Which of the following factors will cause variable decelerations in the fetal heart rate? A.) ​Umbilical cord compression B.) ​Uteroplacental insufficiency C.) ​Maternal opioid administration D.) ​Fetal head compression

A.) ​Umbilical cord compression ​Variable decelerations are drops in the fetal heart rate with an abrupt onset followed by a return to baseline. Variable decelerations coincide with cord compression.

A nurse is preparing to administer vitamin K IM to a newborn. Into which of the following muscles should the nurse inject the medication? A.) ​Vastus lateralis B.) ​Ventrogluteal C.) ​Dorsogluteal D.) ​Deltoid

A.) ​Vastus lateralis ​The nurse should administer vitamin K, or phytonadione (AquaMEPHYTON), into the vastus lateralis muscle in the thigh. This medication prevents and treats hemorrhagic disease of the newborn, as newborns are born with vitamin K deficiency.

A nurse is assisting with the care of a client who presents to a labor and delivery unit with rapidly progressing labor. Which of the following actions is the priority for the nurse to take? A.) ​Cutting the umbilical cord B.) ​Supporting the infant during the birth C.) ​Preventing the perineum from tearing D.) ​Promoting delivery of the placenta

B.) ​Supporting the infant during the birth The most important intervention is preventing injury to the infant during the delivery, which is achieved by supporting the infant during birth. Fetal complications from precipitous labor include hypoxia, caused by decreased periods of uterine relaxation between contractions. A change in pressure from a rapid delivery of the fetal head can cause neurologic damage, such as increased intracranial pressure and dural or subdural tearing. Rapid birth can also cause maternal injury, such as vaginal or perineal lacerations. Precipitous labor is defined as labor that lasts less than 3 hr from the onset of contractions to the time of birth. Precipitous labor can result from hypertonic uterine contractions, which can increase the risk for abruptio placentae.

A nurse is reinforcing teaching with a client who is postpartum about bathing her newborn. Which of the following statements by the client indicates a need for further teaching? A.) "I will use mild soap." B.) "I will use a basin during bathing." C.) "Baby powder will help prevent a diaper rash." D.) "I will test the water on my wrist for temperature before bathing."

C.) "Baby powder will help prevent a diaper rash." ​This statement requires the nurse to clarify instruction on newborn care. Lotions, creams, oils, or powders can alter a newborn's skin and provide a medium for bacterial growth or cause an allergic response. Powders can be inhaled, leading to respiratory distress.

A nurse is reinforcing teaching with a client who is pregnant and has a new prescription for ferrous sulfate due to iron-deficiency anemia. The nurse should instruct the client to take this medication with which of the following? A.) Milk B.) Orange juice C.) Scrambled eggs D.) A high-fiber meal

B.) Orange juice Orange juice and other vitamin C-rich foods and beverages enhance iron absorption.

A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborn's umbilical cord? A.) One artery and one vein B.) Two arteries and one vein C.) Two veins and one artery D.) Two arteries and two veins

B.) Two arteries and one vein. The vein carries oxygenated blood to the fetus, and the two arteries carries unoxygenated blood back to the placenta.

A nurse is caring for a client who is at 28 weeks of gestation and has received terbutaline. Which of the following findings should the nurse expect? A.) ​Fetal heart rate 100/min B.) Weakened uterine contractions C.) Enhanced fetal lung surfactant D.) ​Maternal glucose 63 mL/dL

B.) Weakened uterine contractions ​Terbutaline is a beta2-adrenergic agonist that acts to relax the uterus. Terbutaline is used to stop a contraction pattern in a client who is at preterm gestation.

A nurse is reinforcing teaching about formula feeding to a group of parents of newborns. Which of the following statements by one of the parents indicates a need for further teaching? A.) ​"I will give formula to my baby at room temperature." B.) ​"I will ensure my baby's feedings last 10 to 15 minutes." C.) ​"I will burp my baby half way through each feeding." D.) ​"I will watch for signs my baby is full and stop the feeding."

B.) ​"I will ensure my baby's feedings last 10 to 15 minutes." The parent should allow the feeding to last 20 to 30 minutes.

A nurse is assisting with the care of a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain? A.) Administering prescribed analgesic medication B.) ​Encouraging the client to rest between contractions C.) Massaging the client's back D.) ​Turning the client onto her left side

C.) Massaging the client's back ​The gate control theory is based on the concept of preventing the transmission of pain signals to the brain by using distraction techniques. Massaging the client's back is a distraction technique.

A charge nurse observes a newly licensed nurse checking fetal heart tones (FHT) for a client who is at 12 weeks of gestation. Which of the following actions by the nurse indicates a need for intervention by the charge nurse? A.) Places a pillow under the client's head B.) Counts the fetal heart rate for a full minute C.) Auscultates slightly above the symphysis pubis D.) Listens with a fetoscope

D.) Listens with a fetoscope ​The charge nurse should intervene if the nurse uses a fetoscope to check FHT on a client who is at 12 weeks of gestation. A fetoscope will not be able to detect FHT this early in the pregnancy. The nurse should use a Doppler or ultrasound stethoscope.

A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect? A.) Uterine enlargement greater than expected for gestational age B.) Copious vaginal bleeding C.) Severe nausea and vomiting D.) Pelvic pain

D.) Pelvic pain The client will experience a dull to colicky pain at the beginning, progressing to a sharp, stabbing pain as the tube stretches.

A nurse is collecting data from a newborn immediately after delivery by a client who was at 42 weeks of gestation. Which of the following findings should the nurse expect? A.) ​Copious vernix B.) ​Scant scalp hair C.) ​Increased subcutaneous fat D.) ​Dry, cracked skin

D.) ​Dry, cracked skin ​Newborns who are postmature have dry, cracked skin that feels like parchment paper.