Custom: Custom: Maternity Practice Questions 4 (Dr. Hernandez)

A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse? "Mongolian spots can be found on the skin of many newborns." "A caput succedaneum occurs due to compression of blood vessels." "This is a cephalhematoma, which can occur spontaneously." "This is erythema toxicum, which is a transient condition."

"A caput succedaneum occurs due to compression of blood vessels." A caput succedaneum is an area of edema on the newborn's occiput, often seen where the cup of the vacuum was applied. It is present at birth and will disappear within 3 to 4 days.

A nurse at a prenatal clinic is caring for a client who is in her first trimester of pregnancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in her life. Which of the following is an appropriate response by the nurse? "Ambivalent feelings are quite common for women early in pregnancy." "Perhaps you should see a counselor to discuss these feelings further." "Have you spoken to your mother about these feelings?" "Don't worry. You will be fine once the baby is born."

"Ambivalent feelings are quite common for women early in pregnancy." This response uses the therapeutic communication technique of providing information while addressing the client's concerns and feelings. This statement is true and gives the client the information she needs; many antepartum women experience similar feelings in early pregnancy.

A charge nurse is supervising a newly licensed nurse provide care for a client who has a PCA pump. Which of the following statements made by the nurse requires further action by the charge nurse? "I discarded the remaining 2 milligrams of morphine from the PCA pump. Please document that you witnessed it." "I noted that my client pushed the PCA button six times in the last hour, and the PCA lockout is set for 10 minutes." "I gave my client a bolus dose of morphine when I initiated the PCA pump." "I told the client's family that they must not push the PCA button for the client."

"I discarded the remaining 2 milligrams of morphine from the PCA pump. Please document that you witnessed it." Two nurses are required to witness the wasting of a narcotic and then sign the narcotic record. The nurse should not ask another nurse to sign the narcotic record if the nurse did not witness wasting the narcotic.

A nurse is providing teaching to a client who has oral candidiasis and a new prescription for nystatin suspension. Which of the following statements by the client indicates an understanding of the teaching? "I will store the medication at room temperature." "I will take the medicine every morning on an empty stomach." "I will spit the medication out after swishing it around my mouth." "I will only need to take this medication for a few days."

"I will store the medication at room temperature." Nystatin oral suspension should be stored at room temperature.

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching? "I'll let my baby drain one breast at each feeding." "I'll try drinking an herbal tea to reduce the engorgement." "I'll apply cold compresses 20 minutes before each feeding." "I'll feed my baby every 2 hours."

"I'll feed my baby every 2 hours." Breast engorgement is relieved by emptying both breasts. The client might be able to accomplish this with more frequent feedings. Otherwise, she can pump her breasts after breastfeeding to ensure optimal emptying.

A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse? "This will determine if there is more than one fetus." "It is useful for estimating fetal age." "It assists in identifying the location of the placenta and fetus." "This is a screening tool for spina bifida."

"It assists in identifying the location of the placenta and fetus." Identifying the positions of the fetus, placenta, and amniotic fluid pockets immediately prior to the amniocentesis increases the safety of this test by assisting with correct placement of the needle.

A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching? "These exercises help prevent constipation." "These exercises help pelvic muscles to stretch during birth." "They can help reduce back aches." "They can prevent further stretch marks."

"These exercises help pelvic muscles to stretch during birth." Kegel exercises improve the strength of perineal muscles, facilitating stretching and contracting during childbirth.

A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make? "What part of the exam makes you most nervous?" "Don't worry, I will be with you during the exam." "All you need to do is relax." "A pelvic exam is required if you want birth control pills."

"What part of the exam makes you most nervous?" This therapeutic response recognizes the client's feelings. It also uses the therapeutic technique of clarification to encourage the client to tell the nurse more about her concerns.

A nurse in a prenatal clinic is completing a skin assessment of a client who is in the second trimester. Which of the following findings should the nurse expect? (Select all that apply.) Eczema Psoriasis Linea nigra Chloasma Striae gravidarum

.Linea nigra is correct. Linea nigra manifests as a line of pigmentation extending from the symphysis pubis to the top of the fundus and is an expected finding during pregnancy. Chloasma is correct. Chloasma, or the mask of pregnancy, manifests as blotchy, brownish hyperpigmentation of the skin over the forehead, nose, and cheeks and is an expected finding during pregnancy. Striae gravidarum is correct. Striae gravidarum, or stretch marks, occur because of the separation of underlying connective tissue on the breasts, thighs, and abdomen. They are an expected finding during pregnancy.

A nurse is preparing to administer vancomycin 500 mg PO daily divided into four equal doses. The amount available is vancomycin 125 mg capsules. How many capsules should the nurse administer with each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

1 capsule

A nurse is preparing to administer digoxin 8 mcg/kg/day PO to divide equally every 12 hr for a preschooler who weighs 33 lb. Available is digoxin elixir 0.05 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

1.2 mL

A nurse is preparing to administer fosamprenavir 1400 mg PO bid. Available is fosamprenavir 700 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2 tabs

A nurse is reviewing contraception options for four clients. The nurse should identify that which of the following clients has a contraindication for receiving oral contraceptives? A 26-year-old client who has migraine headaches at the start of each menstrual cycle A 28-year-old client who has a history of pelvic inflammatory disease A 32-year-old client who has benign breast disease A 38-year-old client who reports smoking one pack of cigarettes every day

A 38-year-old client who reports smoking one pack of cigarettes every day A client who is over the age of 35 and smokes is at increased risk of thromboembolism.

A nurse is instructing a male client about a semen analysis to be done for suspected infertility. Which of the following should be included in the teaching? Abstain from ejaculation for at least 2 to 5 days prior to the test. Refrigerate the specimen after collection. Leave the specimen at room temperature for 3 to 4 hr prior to transport to the laboratory. Collect the specimen using a condom with spermicidal lubricant.

Abstain from ejaculation for at least 2 to 5 days prior to the test. The client should be instructed to abstain from ejaculation for at least 2 to 5 days prior to the te

A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.) Administer magnesium sulfate IV. Provide a dark, quiet environment. Assess respiratory status every 4 hr. Evaluate neurologic status every 8 hr. Ensure that calcium gluconate is readily available.

Administer magnesium sulfate IV is correct. Magnesium sulfate IV is given as a tocolytic medication for preterm labor to relax smooth muscle of the uterus and as a treatment for preeclampsia. The underlying pathophysiology of preeclampsia is vasospasm. The nurse should closely monitor the client for signs of magnesium toxicity, such as loss of patellar reflexes, respiratory depression, cardiac arrhythmias, cardiac arrest, urinary retention, and serum magnesium levels higher than 8 mEq/L. Provide a dark, quiet environment is correct. A dark, quiet environment helps to decrease CNS stimulation, which minimizes the risk of seizures. .Ensure that calcium gluconate is readily available is correct. Calcium gluconate is the antidote for magnesium sulfate and should be readily available when administering magnesium sulfate. The nurse should be prepared to administer the medication in response to manifestations of magnesium toxicity, such as depressed respirations, oliguria, sudden drop in BP, loss of deep-tendon reflexes, and fetal distress.

A nurse is caring for a newborn who is 72 hr old. Vital Signs 0900: Heart rate 160/min Respiratory rate 80/min Temperature 38.1° C (100.6° F) Oxygen saturation 97% 1000: Heart rate 167/min Respiratory rate 72/min Temperature 38°C (100.4°F) Oxygen saturation 97% 1100: Heart rate 174/min Respiratory rate 79/min Temperature 38° C (100.5° F) Oxygen saturation 98% Medical History 0900: A term newborn 37 weeks of gestation is admitted to the newborn nursery following a precipitous vaginal birth. Birthing parent has a history of heroin use during pregnancy and prenatal care beginning at 34 weeks of gestation. Birthing parent and newborn drug screens positive for heroin. Physical Examination 1100: Neonatal Abstinence Scoring System (NAS) Excessive high-pitched cry=2 Sleeps < 2 hr=2 Hyperactive Moro reflex=2 Moderate- severe tremors disturbed=2 Increased muscle tone=2 Fever < 37.2 to 38.2° C (99 to 100.8° F)=1 Excessive sucking=1 Frequent sneezing=1 Frequent yawning=1 Loose stools=2 Poor feeding=2 Respiratory rate > 60/min=1 Mottling=1 NAS score 20 The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions should the nurse anticipate? Se

Administer oral morphine is correct. The nurse should administer oral morphine to assist with decreasing the withdrawal findings in the newborn. The dosage of the medication is adjusted based on the NAS scores of the newborn. Swaddle the newborn is correct. The nurse should swaddle the newborn and reduce the environmental stimuli for newborns with NAS to assist with decreasing the manifestations the newborn is experiencing. Continue NAS scoring as prescribed is correct. The nurse should continue conducting NAS scoring as prescribed in order to evaluate the newborn's clinical findings and status. The score obtained will assist with determining the dosage of morphine to administer.

A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take? Apply an ice pack to the affected area. Offer a warm sitz bath. Provide a squeeze bottle of antiseptic solution. Place a hot pack to the perineum.

Apply an ice pack to the affected area. During the first 24 hr, ice packs and cool water sitz baths are used. They reduce edema and promote comfort. The client may also apply witch hazel compresses to reduce edema. The nurse should instruct the client on the use of prescribed anesthetic creams, sprays, and ointments.

A nurse is reviewing the medical record of a client who reports drinking three to four glasses of wine each night and taking 3,000 mg of acetaminophen daily. Which of the following laboratory values is the priority for the nurse to assess? Amylase Creatinine Aspartate aminotransferase (AST) Antidiuretic hormone (ADH)

Aspartate aminotransferase (AST) The greatest risk to this client is liver injury from the combined adverse effects of alcohol and acetaminophen. Therefore, the priority laboratory value for the nurse to evaluate is AST because an elevated level is an indication of liver damage.

A nurse is caring for a client who has a fungal infection and has a new prescription for amphotericin B. Which of the following laboratory values should the nurse report to the provider before initiating the medication? Sodium 140 mEq/L Potassium 4.5 mEq/L BUN 55 mg/dL Glucose 120 mg/dL

BUN 55 mg/dL This BUN level is above the expected reference range (10-20 mg/dL). Amphotericin B is nephrotoxic and is contraindicated if BUN is > 40mg/dL. The nurse should report this laboratory value to the provider before initiating the medication.

A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care? Position the newborn to promote extension of muscles. Use fingertips when calming the newborn. Cluster the newborn's care activities. Keep the newborn in a well-lit nursery.

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 that promote development.

A nurse is caring for a client who is at 32 weeks of gestation. Medical History 0800: Client admitted to antepartum clinic for management of preeclampsia. Client has been on bedrest for 2 weeks and Labetalol PO 100 mg twice daily. Gravida 3 Para 2 32 weeks of gestation with preeclampsia History of preeclampsia during the last pregnancy Vital Signs 0800: Temperature 36.8° C (98.2° F) Blood pressure 168/108 mmHg Heart rate 87/min Respiratory rate 18/min O2 saturation 97% 0830: Blood pressure 172/104 mm Hg Heart rate 89/min Respiratory rate 16/min O2 saturation 98% 0900: Blood pressure 176/102 mm Hg Heart rate 86 beats/min Respiratory rate 18/min O2 saturation 96% Nurses' Notes 0800: Client awake, alert and oriented x 4. Client reports headache that started 2 days ago. Client reports pain as 6 on a scale of 0 to 10. 0830: Deep tendon reflexes (DTRs) 3+ with a negative clonus (Pitting pedal edema +2 in lower extremities Client reports blurred vision Diagnostic Results Hemoglobin 10 g/dL (> 11g/dL) Hematocrit 34% (>33%) Platelets 120,000 mm3 (150,000 to 400,000 mm3) Creatinine 1.8 mg/dL (0.5 to 1.0 mg/dL) BUN 28 mg/dL (10 to 20 mg/dL) Uric acid 9 mg/dL (2.7 to 7.3 mg/dL) Proteinuria 3+ Whi

Collecting a urine specimen for culture and sensitivity is nonessential. The nurse should collect a urine specimen for culture and sensitivity if the client presents with manifestations of a UTI. Administer magnesium sulfate 4 g IV bolus is anticipated. This client is preeclamptic and has manifestations of CNS irritability including 3+ deep tendon reflexes, headache, and blurred vision. These manifestations place the client at a greater risk for seizure activity; therefore, the provider should prescribe a magnesium sulfate 4 g IV bolus, followed by a 2 g/hr maintenance dose. Tell the client to lie in a supine position is contraindicated. The nurse should encourage the client to lay in a side-lying position. A side-lying position increases uteroplacental blood flow and decreases blood pressure. Monitor blood pressure and respiratory status every 15 min is anticipated. To evaluate the effectiveness of therapy the nurse should anticipate the provider to prescribe monitoring the client's blood pressure every 15 to 30 min.

A nurse is providing teaching to a client who has renal failure and an elevated phosphorous level. The provider instructed the client to take aluminum hydroxide 300 mg PO three times daily. For which of the following adverse effects should the nurse inform the client? Constipation Metallic taste Headache Muscle spasms

Constipation Constipation is a common side effect of aluminum-based antacids. The nurse should instruct the client to increase fiber intake and that stool softeners or laxatives may be needed.

A nurse receives report about a client who is in labor and is having contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? Contractions that last for 60 seconds each with a 4-min rest between contractions A contraction that lasts 4 min followed by a period of relaxation Contractions that last for 60 seconds each with a 3-min rest between contractions Contractions that last 45 seconds each with a 3-min rest between contractions

Contractions that last for 60 seconds each with a 3-min rest between contractions A contraction interval indicates how often a uterine contraction occurs. The nurse should measure the interval from the beginning of one contraction to the beginning of the next contraction. A contraction lasting 60 seconds with a relaxation period of 3 min is equivalent to contractions every 4 min.

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia? 1+ pitting sacral edema 3+ protein in the urine Blood pressure 148/98 mm Hg Deep tendon reflexes of +1

Deep tendon reflexes of +1 Deep tendon reflexes of +1 are decreased. In a client who has preeclampsia, the nurse should expect to find an increased, rather than a decreased, deep tendon reflex.

A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find? Over-riding suture lines Dilated scalp veins Hypertension A backward sloping appearance of the forehead.

Dilated scalp veins Manifestations of hydrocephalus in newborns include dilated scalp veins, separated sutures, and, in late infancy, frontal enlargement.

A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention? Decreased urge to void Increased urine output Displaced fundus from the midline Fundal height below the umbilicus

Displaced fundus from the midline A distended bladder can cause uterine atony and lateral displacement of the fundus from the midline of the lower abdomen, usually to the right. This requires immediate intervention because the distended bladder pushes the uterus up and to the side, which prevents it from contracting firmly. Uterine atony results from the inability of the uterine muscle to contract adequately after birth. This can lead to postpartum hemorrhage

A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications? Anaphylactoid syndrome of pregnancy Disseminated intravascular coagulation Preeclampsia Puerperal infection

Disseminated intravascular coagulation Clinical manifestations of disseminated intravascular coagulation (DIC) include oozing from intravenous access and venipuncture sites; petechiae, especially under the site of the blood pressure cuff; spontaneous bleeding from the gums and nose; other signs of bruising; and hematuria.

A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest? Flex her knee while resting. Massage the area. Elevate her leg. Apply cold compresses.

Elevate her leg. The client should elevate her leg to encourage venous return and to relieve pain

A nurse is caring for a client who is pregnant. 1100: Temperature 37.2° C (98.9° F) Pulse rate 80/min Respiratory rate 16/min Blood Pressure 136/79 mm Hg 1200: Pulse rate 90/min Respiratory rate 20/min Blood Pressure 134/82 mm Hg 1100: Gravida 4 Para 3 32 weeks of gestation BMI 32 History of two newborns weighing over 4.5 kg (10 lb) Family history of type one diabetes mellitus (maternal) Fetal heart tones 140/min via doppler 1115: Fasting blood glucose 138 mg/dL (60 to 105 mg/dL) 1200: Fasting blood glucose 142 mg/dL (60 to 105 mg/dL) 1200: HbA1c 12 % (less than 6.5%) 1220: Urinalysis Appearance: clear Color: amber yellow pH: 8.0 (4.6 to 8.0) Positive urine glucose (expected negative) 3+ ketones (expected negative) Urine specific gravity 1.020 (1.005 to 1.030) Contacted the provider to notify of client's status. Which of the following provider prescriptions should the nurse plan to implement? Select the 3 actions the nurse should plan to take. Encourage the client to limit carbohydrate intake to 40% of their daily calories. Instruct the client to check a random blood glucose level once daily. Anticipate a prescription for metformin. Conduct a non-stress test twice per week. Tell the c

Encourage the client to limit carbohydrate intake to 40% of their daily calories is correct. The nurse should encourage the client to limit carbohydrate intake to 33% to 40% of daily calorie intake. This can prevent excessive weight gain and post-meal hyperglycemia. Anticipate a prescription for metformin is correct. The nurse should anticipate a prescription for metformin. Oral hypoglycemic therapy is frequently prescribed. Metformin and glyburide are commonly used for glucose control for clients who have gestational diabetes mellitus. Conduct a non-stress test twice per week is correct. The nurse should conduct a non-stress test twice per week beginning at 32 weeks of gestation to assess for fetal well-being.

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first? Evaluate the firmness of the uterus. Initiate oxygen therapy by nonrebreather mask. Administer oxytocin infusion. Obtain a type and crossmatch.

Evaluate the firmness of the uterus. The first action the nurse should take using the nursing process is to assess the client. A blood pressure of 60/50 mm Hg can indicate postpartum hemorrhage; therefore, the first action the nurse should take is to evaluate the firmness of the uterus to determine if there is uterine atony.

A nurse is caring for a client who is at 36 weeks of gestation Provider's Prescriptions Day 1: 1330: Admit to antepartum unit for blood pressure monitoring Apply external electronic fetal monitor (EFM) Monitor BP and deep tendon reflexes every hour Notify provider for systolic BP greater than 160 and/or diastolic BP greater than 110 Obtain CBC, BUN, Creatinine, PTT, fibrinogen, and liver enzymes Repeat lab work in 24 hr Notify provider if client's condition worsens or of changes in fetal status 1515: Start a 4 g magnesium sulfate bolus and infuse over 20 min. After infusing the magnesium sulfate bolus, infuse magnesium sulfate at a rate of 2 g per hr. Nurses' Notes Day 1: 1400: Client received to unit . BP readings in clinic were 156/90 mm Hg and 154/92 mm Hg. Reported headache, heartburn, and edema in the hands for the last several days. Continues to report headache and epigastric pain. Rates pain with headache as a 4 on a 0 to 10 pain scale. EFM applied. 1430: Lab drawn. Urine dipstick 2 + protein. FHR130s with moderate variability and accelerations present. Occasional contraction observed on electronic fetal monitor. Denies pain with contractions 1515: Provider notified of changes i

Fetal heart rate and variability indicates that the client's condition has declined. On day 1, the FHR was in the 130s with moderate variability and accelerations were present. This is a category 1 fetal heart rate tracing indicating fetal well-being. On day 2, the FHR was in the 120s with minimal variability and no accelerations were observed. This is a category 2 fetal heart rate tracing indicating that the condition of the fetus is declining. Headache indicates that the client's condition has improved. On day 1, the client reported a headache with a rating of an 8 on a 0 to 10 pain scale. On day 2, the client rated the pain as a 2 on a 0 to 10 pain scale, indicating that the cerebral manifestations associated with preeclampsia are improving. Epigastric discomfort indicates that the client's condition has improved. On day 1, the client reported epigastric pain. On day 2 the client denied that epigastric pain was present. The absence of epigastric pain indicates that the hepatic manifestations associated with preeclampsia are improving. Urine dipstick indicates no change in the client's condition. The urine dipstick result was a 2 + on day 1 as well as day 2, which is an indicator that the client's kidney function has not changed. Patellar reflexes are an indication that the client's condition is worsening. On day 1, the client had 3 + patellar reflexes with no clonus. On day 2, the client had 4 + patellar reflexes with clonus present. This is an indication that the client's CNS manifestations associated with preeclampsia are worsening and that the client's risk for seizure activity is increasing. Edema is an indicator that the client's condition is improving. On day 1, the client had facial edema and 3 + pitting edema in the lower extremities. On day 2, the client's lower extremity edema had decreased to 2 + pitting. This is an indicator that the client's kidney function is improving. Liver function tests are an indicator that the client's condition has declined. The client's liver function test values increased from day 1 to day 2. This is an indicator that the client's hepatic manifestations of preeclampsia are worsening.

A nurse is caring for a newborn who is 70 hr old. Medical History 0900: Term newborn who is 38 weeks of gestation is admitted to the newborn nursery following a spontaneous vaginal birth. Birthing parent has a history of heroin use during pregnancy. Birthing parent and newborn drug screens positive for heroin. Vital Signs 0900: Heart rate 168/min Respiratory rate 84/min Temperature 38°C (100.4°F) Oxygen saturation 96% 1000: Heart rate 172/min Respiratory rate 72/min Oxygen saturation 97% 1100: Heart rate 184/min Respiratory rate 80/min Oxygen saturation 97% Physical Examination 1100: NAS Scoring System Excessive high- pitched cry=2 Sleeps < 3 hr=3 Hyperactive Moro reflex=2 Moderate-severe tremors disturbed=2 Loose stools=2 Fever < (37.2 to 38.2°C) =1 Excessive sucking=1 Frequent sneezing=1 Respirations >60=1 Mottling=1 NAS score 16 Diagnostic Results Urine drug screen + heroin A nurse reviews the assessment finding and determines the finding are consistent with which of the following complications? For each assessment finding, click to specify if the finding is consistent with hypoglycemia or neonatal abstinence syndrome (NAS). Each finding may support more than one disease process.

Gastrointestinal assessment is consistent with NAS. Newborns who have NAS might exhibit loose and/or watery stools. Jitteriness is consistent with hypoglycemia and NAS. This newborn is experiencing jitteriness, which is a manifestation of both NAS and hypoglycemia. The newborn who has NAS frequently experience tremors when disturbed or undisturbed. Temperature is consistent with NAS. This newborn has a temperature of 38°C (100.4°F) which is above the expected reference range. An increased temperature is a manifestation of NAS. Newborns who are hypoglycemia experience a decrease in temperature, not an increase. Skin color is consistent with NAS. Mottling is a vasomotor disturbance that is frequently seen in newborns who have NAS. Newborns who are hypoglycemic might experience cyanosis, not mottling

A nurse in the labor and delivery unit is caring for a client who is pregnant. 0900: Gravida 4 Para 3 31 weeks of gestation FHT 140/min Client reports cramping and low back pain that started last night. 0900: Temperature 36.9° C (98.4° F) Pulse rate 87/min Respiratory rate 20/min Blood Pressure 129/70 mm Hg Oxygen saturation 98% 1000: Pulse rate 86/min Respiratory rate 18/min Blood Pressure 130/76 mm Hg Oxygen saturation 97% 0900: Client placed on external electronic fetal monitor. Fetal heart tones (FHT) 160/min. Client reports pain as 6 on a scale of 0 to 10. Reports needing pain medicine. Vaginal examination 2 cm, 80% effaced, -1 station Uterine contractions every 2 to 4 min, lasting 60 to 80 seconds , noted on fetal monitor tracing. 1000: FHT 158/min. Uterine contractions every 2 min, lasting 80 seconds in duration, noted on fetal monitor tracing. Provider notified of client status, prescriptions received. The nurse is contacting the provider regarding the client's status. Which of the following findings should the nurse report to the provider? Select the 4 findings the nurse should report. Gestational age Vaginal examination Uterine contractions Birthing parent's blood pressure B

Gestational age is correct. The client's gestational age is 31 weeks of gestation which is preterm.. Based on other assessment data collected, the nurse should report this finding to the provider. Vaginal examination is correct. The client's cervix is dilated and effaced, which are findings of preterm labor. Therefore, the nurse should report this finding to the provider. Uterine contractions is correct. The client is experiencing regular uterine contractions that are increasing in frequency and duration. This is a manifestation of preterm labor. The nurse should report this finding to the provider. Birthing parent's report of pain is correct. The client is reporting pain and requesting pain medication. The nurse should report this finding to the provider.

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following? Hyperinsulinemia Increased deposits of fat in the chest and shoulder area Brachial plexus injury Increased blood viscosity

Hyperinsulinemia High levels of maternal glucose increase the production of fetal insulin. High fetal insulin levels interfere with the production of surfactant.

A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn's chest circumference? Sternal notch Nipple line Xiphoid process Fifth intercostal space

Nipple line The nurse should measure the newborn's chest circumference at the nipple line.

A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis? Moderate amount of dark red lochia with a bloody odor A localized area of breast tenderness Pelvic pain Hematuria

Pelvic pain Indications of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain.

A nurse is caring for a client who is 42 weeks of gestation. Medical History 0500: 29-year-old client, Gravida 2 Para 1, admitted this morning for induction of labor Had an uncomplicated spontaneous vaginal birth 3 years ago of a 7 lb 4 oz infant. Client has no outstanding medical, social, or surgical history. Plan is to induce labor using oxytocin. Nurses Notes 0600: Arrives to unit ambulatory and stable. Verbalizes is here for induction of labor due to gestational age. Electronic fetal monitor applied. Fetal heart rate 142/min. Abdomen gravid and soft to palpation. Denies having contractions, vaginal bleeding, or rupture of membranes. IV infusion of dextrose 5% lactated Ringer's at 125 mL/hr initiated. Sterile vaginal examination performed. Cervix 2 cm dilated, 50%, effaced, soft and anterior. 0630: Fetal heart rate 140 to 145/min with moderate variability. Accelerations present. Rare contraction observed on electronic fetal monitor. Oxytocin initiated at 1 mu/min per secondary infusion in lowest port of primary line. 0900: Pitocin infusing at 11 mu/min. Category 3 fetal heart rate tracing observed. Vital Signs 0600: Temperature 36.8º C (98.2º F)Heart rate 98/minRespiratory rate 18/mi

Place the client in a side-lying position is correct. This client has a category 3 fetal heart rate tracing indicating absent baseline variability and either late or recurrent variable decelerations. These findings are consistent with manifestations associated with fetal hypoxia. Placing the client is a side-lying position increases maternal oxygenation and cardiac output, which increases blood flow and oxygenation to the fetus. Initiate bolus of primary IV fluids is correct. This client has a category 3 fetal heart rate tracing indicating absent baseline variability and either late, or recurrent variable decelerations. These findings are consistent with manifestations associated with fetal hypoxia. Initiating a bolus of the primary IV fluids increases the client's blood volume, which increases oxygenation and cardiac output thereby increasing blood flow and oxygenation to the fetus. Perform sterile vaginal examination is correct. This client has a category 3 fetal heart rate tracing indicating absent baseline variability and either late or recurrent variable decelerations. These findings are consistent with findings associated with fetal hypoxia and could be caused by a prolapsed umbilical cord. Therefore, the nurse should perform a SVE to assess for the presence of a hidden prolapsed umbilical cord.

A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first? Place the client in the lateral position. Increase the rate of maintenance IV infusion. Elevate the client's legs. Administer oxygen using a nonrebreather mask.

Place the client in the lateral position. This is a late deceleration and is associated with fetal hypoxemia due to insufficient placental perfusion. Placing the client in the lateral position is the first action the nurse should take.

A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care? Obtain rectal temperatures. Place the newborn in the prone position. Cover the lesion with a dry dressing. Apply snug, clean diapers.

Place the newborn in the prone position. Placing the newborn in the prone position prevents trauma to the lesion. The newborn's knees should be assessed for evidence of skin breakdown.

A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider? Poor sucking Blue coloring of the hands and feet Soft, edematous area on the scalp Facial edema

Poor sucking Vacuum-assisted birth involves attaching a vacuum cup to the fetal head and using negative pressure to assist in the birth of the head, placing the newborn at risk for a subdural hematoma. The nurse should report manifestations of cerebral irritation, such as listlessness and poor sucking to the provider.

A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action? Examination to determine cervical status A magnesium sulfate infusion Initiation of pushing Preparation for cesarean birth

Preparation for cesarean birth A cesarean birth is indicated for all clients who have a confirmed placenta previa.

A nurse is caring for a client who is breastfeeding her newborn and asks the nurse about the changes she should make in her diet. Which of the following dietary changes should the nurse suggest? Increase her caloric intake by 600 kcal/day. Increase her fluid intake to 2.5 L/day. Reduce her intake of iron. Avoid shellfish.

Reduce her intake of iron. Recommendations for some nutrients, such as iron and folic acid, are less during lactation than during pregnancy. Because maternal blood volume decreases after childbirth, the client's need for these nutrients also diminishes.

A nurse is caring for a newborn 1 hr following birth Medical History 1000: 39-week gestation Emergency cesarean birth for abruptio placenta and non-reassuring fetal heart rate Apgar 5 at 1 min, 8 at 5 min Positive pressure ventilation given for 1 min followed by free flow oxygen Vital Signs 1000: Temperature: 36.6° C (97.9° F) Axillary Heart rate: 180/min Respiratory rate: 80 /min Oxygen saturation 96% 1030: Temperature: 36.6° C (97.9° F) Axillary Heart rate: 188/min Respiratory rate: 84/min Oxygen saturation 97% Diagnostic Results 1030: Hemoglobin: 9 g/dL (14 to 24 g/dL) Hematocrit: 35% (44 to 64%) Platelet count: 210,000/mm3 (150,000 to 300,000 mm3) White blood cells: 9,500/mm3 (9,000 to 30,000/mm3) Serum glucose: 130 mg/dL (40 to 45 mg/dL) Nurses' Notes 1000: Newborn placed on radiate warmer. Color consistent with newborn's genetic background. Acrocyanosis present. Mild grunting, nasal flaring, and intermittent retractions noted. Select the 5 findings the nurse should report to the provider. Respiratory assessment Temperature Serum glucose Hemoglobin Hematocrit White blood cells Heart rate

Respiratory assessment is correct. The newborn is exhibiting tachypnea, grunting, nasal flaring, and intermittent retractions, which are all findings associated with respiratory distress syndrome. Therefore, the nurse should report these findings to the provider. Serum glucose is correct. The newborn's serum glucose is above the expected reference range. Therefore, the nurse should report this finding to the provider. Hematocrit is correct. The newborn's hematocrit is 35%, which is below the expected reference range. Therefore, the nurse should report this finding to the provider. Hemoglobin is correct. The newborn's hemoglobin is 9 g/dL which is below the expected reference range, Therefore, the nurse should report this finding to the provider. Heart rate is correct. The newborn is exhibiting tachycardia, which might require interventions. Therefore, the nurse should report this finding to the provider.

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus? 3 cm above the umbilicus Slightly above the umbilicus Slightly below the umbilicus 3 cm below the umbilicus

Slightly above the umbilicus At 22 weeks of gestation, the fundal height should be just above the level of the umbilicus. The distance in centimeters from the symphysis pubis to the top of the fundus is a gross estimate of the weeks of gestation.

A nurse is providing instruction to a new nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia? Furosemide Hydrochlorothiazide Metolazone Spironolactone

Spironolactone Spironolactone is a potassium-sparing diuretic. It blocks the effects of aldosterone in the renal tubules, causing a loss of sodium and water and the retention of potassium. The possible adverse reactions include hyperkalemia and hyponatremia.

A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what to do when her newborn cries persistently. Which of the following strategies should the nurse suggest? (Select all that apply.) Take the newborn for a ride in the car. Keep the newborn in the center of a large crib. Carry the newborn in a front or back pack. Swaddle the newborn in a receiving blanket. Allow the newborn to continue crying.

Take the newborn for a ride in the car is correct. Movement and rhythmic noise are soothing to newborns. .Carry the newborn in a front or back pack is correct. Carrying the newborn in a front or back carrier provides the comfort of close contact and gentle movement that is soothing to newborns. Swaddle the newborn in a receiving blanket is correct. Swaddling simulates the intrauterine environment, position-wise, and provides security to the newborn.

A nurse is caring for a client who is in labor. Medical History Gravida 2, Para 1 34 weeks of gestation Uncomplicated pregnancy Previous spontaneous vaginal birth History of migraine headaches Nurses' Notes 0800: Client reports increased clear vaginal discharge for the past 12 hr. Denies cramping or contractions. Confirms fetal movement is present and unchanged. Moderate amount of clear drainage present on the client's peri pad. Bilateral lower extremity non-pitting edema noted. Deep tendon reflexes 2+. Client reports a migraine headache that started a few hours ago. Reports pain as 4 on a scale of 0 to 10. External fetal monitor applied. 0900: Fetal heart rate 132/min. Moderate variability. Spontaneous accelerations present. No decelerations observed. No contractions noted. Vital Signs 0800: Temperature 36.7° C (98° F) Heart rate 88/min Respiratory rate 18/min Blood pressure 114/68 mm Hg Pulse oximeter 98% Diagnostic Results 0900: Speculum examination by provider Cervix closed Clear fluid noted in vagina. Ph 7.0. Microscopic examination of vaginal fluid sample demonstrates crystallized ferning pattern. Preterm premature rupture of membranes confirmed. Drag 1 parameter and 1 complica

Temperature is correct. A client who has preterm premature rupture of membranes without the presence of contractions is at risk for developing a bacterial infection within the uterus. Chorioamnionitis occurs most often following the rupture of the amniotic membranes, which allows bacteria from the vagina to ascend into the amniotic cavity. Manifestations of chorioamnionitis include an elevated temperature, foul-smelling vaginal discharge, and maternal and/or fetal tachycardia. Chorioamnionitis is correct. A client who has preterm premature rupture of membranes without the presence of contractions is at risk for developing a bacterial infection within the uterus. Chorioamnionitis occurs most often following the rupture of the amniotic membranes, which allows bacteria from the vagina to ascend into the amniotic cavity. Manifestations of chorioamnionitis include an elevated temperature, foul-smelling vaginal discharge, and maternal and/or fetal tachycardia.

A home health nurse is assessing an older adult client who reports falling a couple of times over the past week. Which of the following findings should the nurse suspect is contributing to the client's falls? The client takes alprazolam. The client has a nonslip bath mat in his shower. The client uses a raised toilet seat. The client wears fitted slippers.

The client takes alprazolam. Alprazolam is a CNS depressant that can cause dizziness and orthostatic hypotension, which can cause the client to lose his balance and fall.

A nurse is caring for a 36-hr-old newborn in the neonatal intensive care unit (NICU) born at 34 weeks of gestation. 0800: Assessment reveals skin tone consistent with genetic background, no cyanosis. Skin is warm and dry to touch. Lungs sounds clear bilateral, but an extra heart sound that was not present at birth. Tachycardia and tachypnea noted that was not present at last assessment. Newborn fed by parent and consumed 20 mL of breast milk via bottle. Apgar at birth 36 hr ago was 7 at 1 minute and 8 at 5 minutes. Newborn was admitted to the NICU following a vaginal delivery. Maternal history includes prenatal care that consisted of consumption of iron supplements and folic acid supplements. Vital Signs Heart rate: 168/min Temperature: 37.2° C (99° F) axillary Respiratory rate: 60/min Oxygen saturation: 90% on room air. Physical Examination • Color pink, warm, and dry • In flexed position, moves extremities symmetrical • Alert but quiet • Eyes clean and dry • Airway patent, no retractions or nasal flaring noted • Respiratory rate 72/min, lungs clear bilaterally • Murmur noted • Abdomen soft with no distention noted, bowel sounds active in all four quadrants • Light colored urine no

The nurse should administer oxygen as prescribed because the newborn might be experiencing patent ductus arteriosus. Respiratory support is needed because the ductus arteriosus might have re-opened due to low oxygen levels; therefore, the newborn requires oxygen. The nurse should restrict fluids to decrease cardiovascular volume overload. The nurse should monitor arterial blood gases because the amount of respiratory support needed will be based on the blood gases. The blood gases are also significant because they might show metabolic acidosis. The nurse should monitor fluid balance to ensure fluid overload does not occur.

A nurse is caring for a client who is at 34 weeks of gestation and has preeclampsia. Vital Signs Temperature 37.2° C (98.9° F)Blood pressure 160/105 mm HgHeart rate 89/minRespiratory rate 20/minO2 saturation 97% Medical History Client admitted to antepartum unit following home interventions for management of preeclampsia, which included bedrest for 3 weeks and labetalol 100 mg PO twice daily.Gravida 4 Para 334 weeks of gestation with preeclampsiaHistory of preeclampsia x 2 previous pregnanciesPreexisting diabetes mellitus diet controlledBMI 30 Diagnostic Results Hemoglobin 11 g/dL (greater than 11 g/dL)Hematocrit 35% ( greater than 33%)Platelets 98,000/mm3 (150,000 to 400,000/mm3)Creatinine 1.5 mg/dL (0.5 to 1.0 mg/dL)BUN 30 mg/dL (10 to 20 mg/dL)Uric Acid 10 mg/dL (2.7 to 7.3 mg/dL)Proteinuria 3+ Nurses' Notes Client awake, alert and oriented x 4. Reports headache that started yesterday with pain as 7 on a scale of 0 to 10. Deep tendon reflexes 3+ with a negative clonus. Pitting pedal edema +3 and +3 in lower extremities. Client also reports dizziness and blurred vision. A nurse is reviewing the client's electronic medical record. For each potential provider's prescription, click to

The nurse should anticipate the provide to prescribe monitoring the client's blood pressure every 15 to 30 min. The nurse should collect a urine specimen for culture and sensitivity if the client presents with manifestations of a UTI. The nurse should determine that collecting a urine specimen for culture and sensitivity is non-essential for a client who has preeclampsia. The nurse should anticipate the provider to prescribe dim lighting to decrease environmental stimuli. The nurse should recognize that a prescription to encourage the client to lay in a supine position is contraindicated. The nurse should encourage the client to lay in a side-lying position. The nurse should anticipate the provider restricting hourly fluid intake to 125 mL/hr. The nurse should anticipate the provider to prescribe a loading dose of magnesium sulfate 4 g IV bolus, following by 2 g/hr maintenance dose.

A nurse is caring for a newborn. Nurses Notes Newborn delivered via cesarean birth approximately 1 hr ago. Apgar scores 8 and 9. Vitamin K administered in left vastus lateralis. Weight 4337 grams (9 lb 9 oz), length 52 cm (20.5 in). Gestational age assessment of 39 weeks. Large for gestational age. Newborn noted to be jittery and have decreased muscle tone. Vital Signs Heart rate: 170/min apical Respiratory rate: 68/min auscultation Temperature: 36.1° C (96.9° F) axillary Diagnostic Results Type: O Rh: Positive Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the newborn's progress.

The nurse should place the newborn under a radiant warmer and check the newborn's capillary blood glucose level because the newborn is most likely experiencing hypoglycemia as evidenced by the newborn's jitteriness, decreased temperature, and hypotonia. The nurse should monitor the newborn's body temperature and for seizure activity because hypoglycemia can lead to respiratory distress, apnea, temperature instability, and seizures.

A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make? The presenting part is 1 cm above the ischial spines. The presenting part is 1 cm below the ischial spines. The cervix is 1 cm dilated. The cervix is effaced 1 cm.

The presenting part is 1 cm above the ischial spines. Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is minus (-) 1, then the presenting part is 1 cm above the ischial spines.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and undergoing a contraction stress test. The test results are negative. Which of the following interpretations of this finding should the nurse make? There is evidence of cervical incompetence. There is no evidence of two or more accelerations in fetal heart rate in 20 min. There is no evidence of uteroplacental insufficiency. There are less than 3 uterine contractions in a 10-min period.

There is no evidence of uteroplacental insufficiency. A contraction stress test determines how well the fetus tolerates the stress of uterine contractions. A test is negative when there are at least 3 uterine contractions in a 10-min period with no late or significant variable decelerations during electronic fetal monitoring. Uteroplacental insufficiency produces late decelerations.

A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? Two veins and one artery One artery and one vein Two arteries and one vein Two arteries and two veins

Two arteries and one vein The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta.

A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles? Vastus lateralis Ventrogluteal Dorsogluteal Deltoid

Vastus lateralis The nurse should administer vitamin K, or phytonadione, 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 caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make? "Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." "I will call the provider to get a prescription for discontinuing the IV heparin today." "Both heparin and warfarin work together to dissolve the clots." "The IV heparin increases the effects of the warfarin and decreases the length of your hospital stay."

Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level." Heparin and warfarin are both anticoagulants that decrease the clotting ability of the blood and help prevent thrombosis formation in the blood vessels. However, these medications work in different ways to achieve therapeutic coagulation and must be given together until therapeutic levels of anticoagulation can be achieved by warfarin alone, which is usually within 1 to 5 days. When the client's PT and INR are within therapeutic range, the heparin can be discontinued.

A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider? Sedation Increased appetite White coating in the mouth Dry oral mucous membranes

White coating in the mouth Fluticasone/salmeterol is an inhaled glucocorticoid and long acting beta2 adrenergic agonist combination inhalation medication that is used for daily management of asthma. It is not a rescue medication. An adverse effect of the medication is oropharyngeal candidiasis. The nurse should instruct the client to gargle after each use, use a spacer to reduce the amount of drug in the mouth and throat, and report any white patches inside the mouth or on the tongue to the provider.

A nurse is caring for a newborn who is 8 hr old. Diagnostic Results 0900: ABO/Rh: A positive Coombs test, indirect: positive (negative) Total bilirubin 6.2 mg/dL (1.0 to 12.0 mg/dL) Urine toxicology screen: positive for cocaine and marijuana (negative) Medical History Spontaneous vaginal birth Pregnancy complicated by maternal history of illicit drug use Apgar scores: 7 at 1 min; 8 at 5 min Birth weight 2,948 gm (6 lb 8 oz) Gestational age: 38 weeks Maternal prenatal laboratory results: ABO/Rh: O positive Urine toxicology screen: positive for cocaine and marijuana (negative) Nurses Notes 0800: Newborn is alert and active with a strong cry. Skin color is consistent with the newborn's genetic background. Respirations are easy and unlabored. Anterior fontanel even and soft. Molding of skull noted. Generalized edematous area noted on occiput. Newborn is breastfeeding vigorously every 2 to 4 hr. No void or stool noted since birth. Vital Signs 0800 : Axillary temperature 37.1° C (98.8° F) Heart rate 132/min Respiratory rate 52/min Based on the information in the newborn's medical record, the nurse determines that the newborn is at risk for developing which of the following complication

e. Jaundice is correct. A positive Coombs test indicates the presence of anti-A and anti-B maternal antibodies within the newborn's blood. These antibodies will result in an accelerated destruction of the newborn's type A blood cells. The by-product of red blood cell hemolysis is bilirubin. The accelerated breakdown of the red blood cells can lead to excess bilirubin accumulating within the newborn's skin, mucus membranes, and sclera, resulting in a yellow discoloration known as jaundice. The nurse should continue to monitor the newborn's bilirubin levels. Dropdown 2 Anemia is correct. A positive Coombs test indicates the presence of anti-A and anti-B maternal antibodies within the newborn's blood. These antibodies will cause an accelerated destruction of the newborn's type A blood cells. The accelerated hemolysis can result in anemia.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following? Fetal lung maturity Location of the placenta Viability of the fetus The biparietal diameter

location of the placenta Painless, spontaneous vaginal bleeding might indicate that the client has placenta previa. Placenta previa is a condition in which the placenta is implanted low in the uterus, sometimes to the point of covering the cervical os. As the cervix effaces, the client begins to bleed. The ultrasound will show the location of the placenta and help to determine what sort of delivery the client requires and how emergent it is.

A nurse is caring for a client who is 42 weeks of gestation. Medical History 29-year-old client admitted this morning for induction of labor. Gravida 2 Para 1. Had an uncomplicated spontaneous vaginal birth 3 years ago of a 7 lb 4 oz infant. Client has no outstanding medical, social, or surgical history. Plan is to induce labor using oxytocin Nurses' Notes 0600: Client arrives to unit ambulatory and stable. Verbalizes is here for induction of labor due to gestational age. Electronic fetal monitor applied. Fetal heart rate 142/min. Abdomen gravid and soft to palpation. Denies having contractions, vaginal bleeding, or rupture of membranes. IV infusion of dextrose 5% lactated ringer's at 125 mL/hr initiated. Sterile vaginal examination performed. Cervix 2 cm dilated, 50% effaced, soft and anterior, -1 station 0630: Fetal heart rate 140 to 145/min with moderate variability. Accelerations present. Rare contraction observed on electronic fetal monitor. Oxytocin initiated at 1 mu/min per secondary infusion in lowest port of primary line. 0900: Pitocin infusing at 11 mu/min. Category 3 fetal heart rate tracing observed. Vital Signs Temperature 36.8°C (98.2°F) Heart rate 98/min Respiratory rate

ncrease the oxytocin infusion to 13 mu/min is contraindicated. This client has a category 3 fetal heart rate tracing indicating absent baseline variability and either late, or recurrent variable decelerations. Increasing the oxytocin infusion would likely cause a further decline in fetal well-being. Therefore, the nurse should stop the infusion of oxytocin, not increase the rate of infusion. Place client in a side-lying position is anticipated. This client has a category 3 fetal heart rate tracing indicating absent baseline variability and either late, or recurrent variable decelerations. These findings are consistent with manifestations associated with fetal hypoxia. Placing the client is a side-lying position increases client oxygenation and cardiac output, thereby increasing blood flow and oxygenation to the fetus. Initiate bolus of primary IV fluids is anticipated. This client has a category 3 fetal heart rate tracing indicating absent baseline variability and either late, or recurrent variable decelerations. These findings are consistent with manifestations associated with fetal hypoxia. Initiating a bolus of the primary IV fluids increases the client's blood volume which increases their oxygenation and cardiac output, thereby increasing blood flow and oxygenation to the fetus. Apply oxygen at 10 L/min via venturi mask is contraindicated. The nurse should apply oxygen at 10 L/min via a nonrebreather mask, not a venturi mask. A nonrebreather mask will provide the client with a greater concentration of oxygen than the venturi mask, thereby increasing the amount of oxygen received by the fetus. Perform sterile vaginal examination (SVE) is anticipated. This client has a category 3 fetal heart rate tracing indicating absent baseline variability and either late, or recurrent variable decelerations. These findings are consistent with findings associated with fetal hypoxia and could be caused by a prolapsed umbilical cord; therefore, the nurse should perform a SVE to assess for the presence of a hidden prolapsed umbilical cord. Assign a Bishop score is nonessential. A Bishop score is used to assess the cervix prior to induction of labor to determine the likelihood of a vaginal delivery. The Bishop score should h