KAPLAN OB A NGN

The community nurse is working with women who are formula-feeding their infants and concerned about the high cost of formula. Which statement indicates that the nurse's education session was effective? "I follow the instructions for mixing the powdered formula exactly." "I can reuse one bottle for several feedings." "The mixed formula can warm on the counter for up to 24 hours." "I should use only soy-based formula for the first year."

"I follow the instructions for mixing the powdered formula exactly."

The postnatal nurse is making a newborn visit to parents who are immigrants from another country. The nurse finds the newborn swaddled in a heavy blanket and wearing a knitted cap. The newborn has wet hair and is restless with rapid breathing. Which initial comment from the nurse is most appropriate? "Let me explain the baby's symptoms of being overheated." "Look! Your baby is exhibiting some concerning symptoms." "I want to explain how to dress your baby correctly." "Share with me how babies are cared for in your country."

"Let me explain the baby's symptoms of being overheated."

Which statement, made by the patient is correct concerning the rubella vaccine? "A woman who is labeled as "immune" should receive the vaccine." "Breastfeeding mothers should not receive the vaccine." "The vaccine cannot harm a developing fetus." "Patients should avoid pregnancy for up to four weeks following vaccination."

"Patients should avoid pregnancy for up to four weeks following vaccination."

The nurse is collecting information from a new mother who is bottle-feeding her infant. Which comment, if made by the mother, requires the nurse to provide patient teaching? "Sometimes I will add a little water to the formula if I am running low." "I wish that I had tried breastfeeding because formula is expensive." "At least I get a break every evening when my spouse feeds the baby." "I get frustrated if the last bottle is fed to the baby late at night."

"Sometimes I will add a little water to the formula if I am running low."

A patient has an abnormal MSAFP (maternal serum alpha fetoprotein) test. Which statement indicates that the woman understands the reason for the additional antepartal surveillance test? "The blood test wasn't run correctly, and now we need to have the sonogram." "During the ultrasound we will see the baby's face and can tell if there is a chromosomal abnormality." "The ultrasound will show whether there are abnormalities with the baby's spine." " After the ultrasound, my partner and I can decide how to decorate the nursery."

"The ultrasound will show whether there are abnormalities with the baby's spine."

During the initial assessment of a client who is 8-hours post vaginal delivery, the nurse notes that the perineal pad is completely saturated with lochia. To help determine the significance of this finding, which question should the nurse ask the patient first? "When was the last time you changed your pad?" "Are you having any uterine cramping?" "Have you passed any clots?" "When was the last time you voided?"

"When was the last time you changed your pad?"

A woman telephones the clinic to say that it has been six weeks since her last menstrual period, but that her home pregnancy test was negative today. She asks, "Do you think I could be pregnant?" After determining that the test was performed correctly, what would be the nurse's best reply? "You might be. If you haven't started your period in one week, you should repeat the test and call the clinic again." "Probably not. These tests rarely give a false-negative result." "You may have an ectopic pregnancy. You should be seen by a doctor in the next few days." "You probably are. There are a lot of false-negative results with these tests."

"You might be. If you haven't started your period in one week, you should repeat the test and call the clinic again."

a client reports experiencing weight gain and muscle cramps during the menstrual period. the nurse suggests which measures to the client to alleviate these symptoms? 1. use a mild analgesic, restrict caffeine, exercise moderately 2. avoid analgesics, rest frequently, drink herbal tea 3. restrict fluid intake, exercise moderately, increase caffeine 4. restrict sodium intake avoid exercise use sedatives

1

a primigravida client diagnosed with type 1 DM reviews the insulin regimen with the nurse. the nurse explains which changes in the insulin requirements will occur in pregnancy? 1. insulin requirements will increased during pregnancy and decrease after delivery 2. insulin requirements will decrease during pregnancy and increase after delivery 3. insulin requirements will increase during pregnant and remain increased after delivery 4. insulin requirements decrease during pregnant and remain decreased after delivery

1

the nurse ambulates a postpartum client to the BR for the first time after the client gave birth 3 hours ago. the client reports feeling a sudden gush of bleeding from the vagina while ambulating. which is the most likely cause of the bleeding? 1. lochia has pooled in the clients vagina 2. a cervical tear needs to be repaired 3. the funds is relaxed and requires massaging 4. the client may have bladder distention and needs to void

1

the nurse assesses four newborns, which characteristics noted by the nurse are most common in a preterm infant? 1. red, wrinkled skin, lanugo, hypotonic muscles 2. Veronica caseosa, silky hair, facial edema 3. absent nose bridge, depressed fontanels, absent languo 4. mottled skin, meconium stools, hypertonic muscles

1

a client is prescribed a colposcopy. the nurse tells the client which information about the purpose of this procedure? 1. magnifies tissues for examination 2. directly examines ovaries, fallopian tubes, uterus, small intestine 3. views structures in pelvic cavity 4. visualizes the bladder

1 NOTE- small amount of bleeding can occur after, notify HCP if heavy bleeding occurs. tests for precancerous lesions of cervix

an abdominal US indicated the placenta is partially covering the cervix. the client is administered to the obstetrics unit and the physician writes several orders. which intervention does the nurse questions? select all that apply 1. vaginal assessment of cervical dilatation 2. type and cross 2 units of packed RBC 3. continuous external fetal monitoring 4. maintain client as NPO 5. encourage activity as tolerated 6. start an IV of D5W at 125 mL/hr 7. insert indwelling urinary catheter

1, 5,

the nurse provides education on increasing dietary iron to a client diagnosed with anemia, the nurse recommends the client to eat which food? (select all that apply) 1. chicken livers 2. pork chop 3. hamburger 4. bananas 5. spinach 6. tofu

1, 5, 6 NOTE- pork is not a concentrated source of iron. hamburger is also not concentrated with iron

the nurse from the NICU meets with the client and partner to explain the challenges and possible care interventions for the baby in the event the child delivered before 36 weeks gestation. which information is correct for the the NICU nurse to discuss with the client? select all that apply 1. the baby might have breathing problems and need supplemental oxygen by cannula 2. the baby might require medications and my need insertion of an umbilical IV line 3. the baby might have trouble staying warm and implementation of kangaroo care will help with thermoregulation 4. the baby may have trouble regulating its glucose so we may give glucose water after every feeding to combat hypoglycemia 5. the baby might become jaundiced and may need phototherapy

1,2,3,5 NOTE- premature birth risk for respiratory issues, feeding issues, thermoregulation, and jaundice.

A nurse is performing an APGAR assessment on a newborn 1 minute after delivery. The newborn has a heart rate of 60 beats/min, presents with complete body cyanosis, exhibits no flexion of extremities (floppy), no response to stimulation and has slow, irregular breathing. What is the newborn's APGAR score?

2

a client comes to the prenatal clinic for the first visit, the nursing history reveal the clients LMP was five months ago and the client is certain of pregnant and reports feeling the baby move. which response by the nurse is best? 1. since you have felt fetal movement I am sure that you are pregnant 2. lie down so that I can listen for FHT with the doppler 3. well collect a urine specimen for testing to confirm that you are pregnant 4. have you noticed feeling more fatigued lately?

2

a client is in active labor. as labor progresses, the client becomes irritable and reports feeling increasingly uncomfortable. the client is 8cm dilated. which action does the nurse take first? 1. contacts the HCP 2. coaches the client in proper breathing and relaxation techniques 3. administers an analgesic 4. removes the fetal monitory to allow the client to move around

2

an infant shows a tendency to bleed two days after birth. the nurse understands this is most likely causes by which reason? 1. hemophilia 2. absence of intestinal bacteria and lack of vitamin K 3. an immature liver that is unstable to synthesize clotting factors 4. delayed produced of RBC

2

the nurse identifies which pregnant woman as most likely to have a problem with rh incompatibility with the fetus? 1. an Rh pos. client who conceived with Rh neg. partner and has two children who are Rh pos. 2. an Rh neg. client who conceived with Rh pos. partner and gave birth 3 years ago to an Rh pos. infant 3. an Rh pos. client who conceived with a Rh pos. partner who previously aborted a fetus at 12 weeks gestation 4 an Rh neg. client who conceived with a Rh neg. partner and never received Rhogam

2

when the nurse accidentallybumps into a newborns bassinet, the newborn jumps and pulls the extremities into the trunk. the nurse identifies the newborn is demonstrating which reflex? 1. tonic neck 2. moro 3. babinski 4. rooting

2

the nurse monitors a client at 30 weeks gestation and the client reports periodic heartburn. it is most important for the nurse to make which recommendation? 1. lie down after eating a meal 2. eat frequent small meals 3. take sodium bicarb as needed 4. sip milk in between meals

2 NOTE- can take OTC antacids but avoid bicarb b/c might interfere with sodium balance as well as aspirin. when the fat from milk is digested it increased the acid in the stomach

a client has a CS. the nurse places the priority on monitoring the client for which potential complication? 1. infection and pain 2. hemorrhage and shock 3. hemorrhage and pain management 4. dehydration and infection

2 NOTE- client is not only obstetrical client but postoperative, observe for patent airway, observe incisional dressing for bleeding and amount of lochia

When using McDonald's Rule to assess a primigravida patient, with a singleton pregnancy, at 28 weeks gestation we expect the measurement to be: At the level of the umbilicus, or 20 cm Two finger breadths below the umbilicus. 28 cm from the symphysis to the top of the fundus 28 cm from the table surface to the highest point on her abdomen while the patient is in a supine position.

28 cm from the symphysis to the top of the fundus

the nurse assesses an apical pule on a 8lb 4 oz (3742.14g) newborn. the nurse take which action? 1. places the diaphragm of the stethoscope between the left nipple and sternal notch 2. places the diaphragm of the stethoscope between the 2 and 3 ICS at the left midaxillary line 3. places the bell of the stethoscope at the 4 ICS and the left midclavicular line 4. places the bell of the stethoscope between the 2 and 3 ICS at the LSB

3

the nurse assesses an infant born by VD. at birth the infant is crying and moving all extremities and respiration and pulse rate are good. one minute after birth the baby is noted to have slightly cyanotic extremities. at five minutes the extremities are pink. which is the Apgar score for the baby at one minute and five? 1. 8,9 2. 7,10 3. 9,10 4. 7,9

3

the nurse provides care for a client after an abdominal hysterectomy. the client asks when the indwelling urinary catheter will be removed. which statement by the nurse is most appropriate? 1. you will keep the catheter until you develop a temp 2. you will have the catheter until discharge so that we can measure your output accurately 3. the catheter is removed as soon as you are able to ambulate 4. the catheters will be removed when there is no further bleeding from the bladder

3

the nurse understands which medication is most likely to be prescribed for a client with a diagnosis of gonorrhea? 1. penicillin vaginal suppositories 2. penicillin g benzathine intramuscularly in divided doses once a week 3. ceftriazone IM plus doxycycline for seven days PO 4. ampicillin PO

3

the nurse in the prenatal clinic assesses a client at 31 weeks gestation. the clients BP is 150/96 , serum albumin level is 3g/dL, (30g/L), 3+ protein in urine, the clients face and hands are edematous. which instruction by the nurse is most important? 1. the client should decrease caloric intake 2. the client should eliminate all salt from the diet 3. the client should ensure adequate protein 4. the client should increase the intake of iron

3 NOTE- maintain adequate intake of fluids and protein. proteins restore osmotic pressure

a pregnant civet comes to the clinic. the client questions the nurse about the amount of exercise that is acceptable during pregnancy. which is themes important response by the nurse? 1. you can continue your activities but rest when you get tired 2. you should take a brisk walk daily 3. you can exercise as much as you want but limit household actives 4. what is you usual type of exercise ?

4

the nurse instructs a client how to prevent conception using the basal body temperature method. the nurse explains that during ovulation the basal body temperature will change in which direction? 1. lowers significantly 2. rises significantly 3. is unchanged 4. rises slightly

4

the nurse instructs a client who recently had a modified radical mastectomy. the nurse explains it is very important for the client to exercise the affected arm. which statement by the nurse is the most important reason for the client to exercise the arm? 1. increases muscle strength and diameter 2. maintains body balance 3. limits full range of motion 4.prevents lymphedema

4

the nurse provides a client for a gynecological exam. the nurse explains that a pelvic exam will be performed and a Pap smear obtained. the nurse gives the client which information about the Pap smear? 1. it is taken from exudates of the vagina and cervix 2. it is a sample of tissue used to locate a lesion 3. its an X-ray film taken from various angles 4. it is a scraping of cervix to identify abnormal cells

4

the nurse provides care for a client in labor. the fetus is displaying occasional category 2 fetal heart rate patterns on the monitor. which is the first action for the nurse to perform? 1. immediately call the HCP 2. time the contractions from the beginning of one contraction to the beginning of the next 3. have the client roll onto the ride side and take deep breaths 4 when the fetal HR is baseline perform fetal stimulation to asses for HR acceleration

4

a client in active labor suddenly shouts " I have to push I have to push." the nurse determines the client is 8cm dilated. which action does the nurse take first? 1. instructs the client to take a deep breath and bear down 2. applies pressure to clients funds 3. coaches the client in relation techniques 4. encourages the client to pants with pursed lips

4 NOTE- panting prevents pushing. avoid holding the breath by breathing in and out constantly or by raising the chin and blowing or panting

A nurse recognizes that uterine tachysystole due to oxytocin augmentation requires emergency interventions. What clinical cues would alert the nurse that the client is experiencing uterine tachysystole? Uterine resting tone > 20 m Hg. Uterine contractions lasting 90 seconds and occurring every 3-4 minutes. 6 uterine contractions in a 10 minute period. 2 uterine contractions in 20 minutes.

6 uterine contractions in a 10 minute period.

One minute after birth a baby girl was assessed to be crying strongly and actively moving her arms and legs. Her heart rate was 110, and her body was pink with bluish hands and feet. She turned away when her nares were suctioned. The nurse assigns an Apgarscore of: 7 9 10 8

9

A patient delivered 30 minutes ago after 16 hours of labor that included 2 hours of pushing. Which 4th stage of labor finding would require further assessment and immediate intervention? A blood soaked perineal pad since the last 15-minute check The patient shivering although she denies feeling cold An edematous perineum despite an ice pack A fundus located at the umbilicus

A blood soaked perineal pad since the last 15-minute check

The nurse knows that in some cases, breastfeeding is not advisable. Which mother should be counseled against breastfeeding? A mother with mastitis A mother who has twins. A mother who is overweight. A mother who is HIV-positive.

A mother who is HIV-positive.

Which of the following patients would be described as multiparous? A patient at 15 weeks' gestation who has never been pregnant before this A patient at 14 weeks' gestation who has a three-year-old daughter and a five year old son at home. A patient at currently at 20 weeks' gestation who had a prior spontaneous loss at 12 weeks A patient currently at 32 weeks' gestation who has a 2 year old at home.

A patient at 14 weeks' gestation who has a three-year-old daughter and a five year old son at home.

Which of the following patients would be considered a primigravida? A patient at currently at 18 weeks' gestation who had a prior spontaneous loss at 12 weeks A patient at 15 weeks' gestation who has never been pregnant before A patient at 14 weeks' gestation who has a three-year-old daughter at home A patient currently at 13 weeks' gestation who had a prior ectopic pregnancy at eight weeks

A patient at 15 weeks' gestation who has never been pregnant before

A sterile vaginal exam is contraindicated in: A patient with placenta previa A patient who is Group B Strep positive A patient in transition A patient with ruptured membranes

A patient with placenta previa

Your G3 P0 patient at 40-weeks gestation is having a prolonged, painful, and anxiety-filled labor. The patient is finally diagnosed with cephalopelvic disproportion (CPD). The nurse should stop and question which of the following contradictory medical orders? Record fetal heart tones every 15-30 minutes Maintain NPO status Add 10 units of oxytocin to IV fluids to augment labor contractions Administer narcotic analgesics as ordered

Add 10 units of oxytocin to IV fluids to augment labor contractions

A patient in labor received an order for epidural anesthesia. To prevent maternal hypotension, which is a common complication associated with this procedure, which action would the nurse perform prior to the procedure? Teach the patient controlled breathing techniques. Administer an amnioinfusion to ensure fetal heart rate variability. Place the patient in a left lateral position. Administer 500-1000 ml of intravenous fluids.

Administer 500-1000 ml of intravenous fluids.

The nurse is caring for a postpartum client in the "taking in" phase. Which intervention is most appropriate for the nurse to implement? Discuss the advantages of breastfeeding over bottle feeding Determine if the client's blood is Rh-negative or Rh-positive Ask the client to demonstrate how to change the infant's diaper. Allow the client to express feelings about the birth of her infant.

Allow the client to express feelings about the birth of her infant.

Which intervention will help decrease perineal edema following a vaginal delivery? Encourage ambulation. Application of a topical anesthetic ointment. Apply ice to the affected area. Assist her with a warm sitz bath.

Apply ice to the affected area.

The home care nurse is assessing the level of a mother's fundus who delivered 3 days ago. Where should the fundus be located? B: 3 cm below the umbilicus C: 6 cm below the umbilicus A: 1 cm above the umbilicus D: at the level of the symphisis

B: 3 cm below the umbilicus

The reality of Domestic (Intimate Partner) Violence is that: Actual battering occurs in a very small percentage of the population. Battered women are emotionally committed to the relationship. Alcohol and drug abuse cause the acute battering incident. Women are protected from violence once they get pregnant.

Battered women are emotionally committed to the relationship.

A woman is menstruating. If hormonal studies were to be done at this time, which of the following hormonal levels would the nurse expect to see? Both estrogen and progesterone are low Both estrogen and progesterone are high Estrogen is low and progesterone is high Estrogen is high and progesterone is low

Both estrogen and progesterone are low

A nurse is assessing a client 24 hours after delivery. Which of the following signs/symptoms should the nurse expect to see? Diuresis Cracked nipples Lochia alba discharge Tachycardia

Diuresis

A nurse is caring for a newborn immediately after delivery. The baby's skin is still wet from amniotic fluid. The nurse understands that the baby is at risk for which type of heat loss if not dried promptly? Evaporation Radiation Convection Conduction

Evaporation

A woman who is 10-weeks pregnant dies from a head injury in an automobile accident. Her death would be recorded as a maternal mortality statistic. True False

False

A patient who is at 42 weeks' gestation is concerned when the clinician decides to induce labor. Which reason does the nurse explain as the most important need for this procedure? Fetal hypoxia due to placental insufficiency Risk of hypoglycemia due to macrosomia Likelihood of meconium aspiration Risk of hypothermia due to loss of fetal subcutaneous fat

Fetal hypoxia due to placental insufficiency

The nurse knows that a lecithin/sphingomyelin (L/S) ratio finding of 1:1 on amniotic fluid means which of the following? The fetus is an infant of a diabetic mother. The fetus is small for gestational age. Fetal lungs are still immature. Fetal lungs are mature.

Fetal lungs are still immature. (nondiabetic baby is 2:1, diabetic is 3:1)

A pregnant patient presents to the emergency department with vaginal bleeding. Which sign best suggests placenta abruption? Maternal bradycardia Painless, bright red bleeding History of 2nd trimester bleeding. Hard, rigid uterus

Hard, rigid uterus

A newborn born to a woman infected with hepatitis B should receive? Hepatitis B vaccine at birth Hepatitis B immune globulin (HBIg) within 12 hours of birth as well as the hepatitis B vaccine Hepatitis B immune globulin (HBIg) at birth and forego the hepatitis B vaccine Hepatitis B immune globulin (HBIg) within 48 hours of birth as well as the hepatitis B vaccine

Hepatitis B immune globulin (HBIg) within 12 hours of birth as well as the hepatitis B vaccine

The nurse teaches a fertility client that fertilization of the ovum usually occurs: On the first day of the menstrual cycle In the upper portion of the uterus In the distal third of the fallopian tube Before ovulation

In the distal third of the fallopian tube

The legal concept that protects a patient's right to autonomy and self-determination by specifying that no action may be taken, nor procedure or treatment given, without that person's prior understanding and freely given permission is called: Justice Beneficience Informed Consent Autonomy

Informed Consent

A nurse is caring for a newborn who was born to a mother with poorly controlled gestational diabetes. The newborn is jittery, irritable, and has a weak, high-pitched cry. The nurse tests the newborn's blood glucose level and finds it to be 35 mg/dL. Which of the following interventions should the nurse implement first? Initiate breastfeeding or provide a formula feed. Administer a bolus of 10% dextrose IV. Prepare the newborn for immediate transfer to the neonatal intensive care unit (NICU). Nothing. This is a normal glucose level for a newborn.

Initiate breastfeeding or provide a formula feed.

Which of the following is a function of the fluid filled amniotic sac? It furnishes the basic germinal matrix layers for fetal development It provides a medium for fetal movement It supplies fetal metabolic and nutrient support It secretes hormones to maintain pregnancy

It provides a medium for fetal movement

The postpartum nurse is admitting a 3-day-old infant from home for hyperbilirubinemia. Which of the following does the nurse know to be true? Select all that apply. Jaundice affects approximately two-thirds of term infants during the first week of life. Jaundice progresses in a direction from head to lower extremities. Infection can be a cause of hyperbilirubinemia. Jaundice reliably indicates a clinically significant bilirubin level. Jaundice that occurs at 20 hours of age is considered physiological.

Jaundice affects approximately two-thirds of term infants during the first week of life. Jaundice progresses in a direction from head to lower extremities. Infection can be a cause of hyperbilirubinemia.

A Moro reflex is the single best assessment of neurologic ability in a newborn. Unit protocols should specify which action for eliciting a Moro reflex? Stroke the sole of the foot and look for the toes to fan out. Lift her head while she is supine and allow it to fall back 1 inch. Vigourously shake the newborn's bassinette until she responds by flailing her arms out. Turn her onto her abdomen and see if she can turn her head.

Lift her head while she is supine and allow it to fall back 1 inch.

A client is expecting her second baby. She states that her last menstrual period (LMP) started on June 20. Using Nagele's rule what is her due date (EDD)? Mar 27 April 13 Mar 23 April 27

Mar 27

A nurse is evaluating a newborn for jaundice 48 hours after birth. The bilirubin level is 9 mg/dL. The baby is nursing well and appears healthy. The nurse recognizes these characteristics are consistent with which type of jaundice? Physiological jaundice Pathological jaundice Breast milk jaundice Kernicterus

Physiological jaundice

A nurse is caring for a neonate diagnosed with neonatal abstinence syndrome (NAS). Which of the following nursing actions would be most appropriate for this newborn? Providing small, frequent feedings as the newborn may have a high-caloric need and difficulty feeding. Avoiding any physical contact with the newborn to prevent overstimulation. Keeping the newborn in a bright, noisy environment to distract from withdrawal symptoms. Limiting swaddling and skin-to-skin contact to prevent dependency on comfort measures.

Providing small, frequent feedings as the newborn may have a high-caloric need and difficulty feeding.

One presumptive, or subjective, change of pregnancy is: Hearing the baby's heart rate Chadwicks sign Quickening Positive home pregnancy test

Quickening

All of the following are true regarding a Non-Stress Test (NST) except: Gestational age is known to affect results. Evidence of accelerations implies an intact CNS. Requires three contractions in 10 minutes. Requires at least two accelerations within 20 minutes.

Requires three contractions in 10 minutes.

The nurse begins a prenatal assessment on a 32-year-old multigravida at 20 weeks' gestation and then notifies the healthcare provider of which concerning vital sign? Pulse 88/minute Temperature 37.4°C (99.3°F) Blood pressure 118/82 m m H g Respirations 30/minute

Respirations 30/minute

Which of the following findings on a newborn nursing assessment would warrant a call to the newborn's pediatrician? Presence of milia on the nose Newborn's breast tissue slightly engorged Respiratory rate of 75 breaths per minute Overriding cranial sutures

Respiratory rate of 75 breaths per minute

Which of the following would be expected findings and complications for a neonate who is large for gestational age (LGA)? (Select all that apply) Shoulder dystocia Hypogylcemia Loose skin due to a lack of subcutaneous fat Large anterior fontanel

Shoulder dystocia Hypogylcemia

Which of the following findings is expected on an assessment of a term newborn? extended posture at rest. Abundant lanugo over his entire body The ability to move his elbow past his sternum Testes descended into the scrotum

Testes descended into the scrotum

Which of the following are true statements regarding the infant mortality rate? (Select all that apply). The U.S. infant mortality rate is concerning when compared to other industrialized countries. The infant mortality rate is the number of deaths of children under the age of 2 years per 100,000 live births. The infant mortality rate is the number of deaths of infants under the age of 1 year per 1000 live births. The U.S. infant mortality rate is calculated based on the number of preterm births per year. The U.S. infant mortality rate varies widely when based on the race of the mother.

The U.S. infant mortality rate is concerning when compared to other industrialized countries. The infant mortality rate is the number of deaths of infants under the age of 1 year per 1000 live births. The U.S. infant mortality rate varies widely when based on the race of the mother.

Which statement is true regarding the cycle of Intimate Partner Violence? The batterer often feels remorse during the tension building phase. The acute battering incident, or explosion phase, often finds the victim hopeful that the relationship will get better. The acute battering incident, or explosion phase, is often triggered by an external event, such as job loss. The tension building phase typically lasts a few hours.

The acute battering incident, or explosion phase, is often triggered by an external event, such as job loss.

The nursing instructor is explaining to a group of students how the neonate transitions to extrauterine life. Which changes regarding the respiratory and cardiovascular systems are correct? Select all that apply. The first breaths the infant takes after birth help to inflate the lungs and decrease pulmonary vascular resistance. With the clamping of the umbilical cord, the blood flow through the ductus venosus ceases, leading to its closure. The baby's first breaths stimulate the production of surfactant in the lungs. The pulmonary vessels constrict after birth to shunt blood away from the lungs.

The first breaths the infant takes after birth help to inflate the lungs and decrease pulmonary vascular resistance. With the clamping of the umbilical cord, the blood flow through the ductus venosus ceases, leading to its closure.

A nurse is assessing a preterm newborn who was born 6 hours ago. Which of the following findings should alert the nurse to the possibility of Respiratory Distress Syndrome (RDS)? The newborn is grunting, has nasal flaring, and intercostal retractions. The newborn has a strong, lusty cry and is active. The newborn has yellowing of the skin and sclerae. The newborn's blood glucose is 40 mg/dL.

The newborn is grunting, has nasal flaring, and intercostal retractions.

A nurse is performing a vaginal exam on a client who is being evaluated in triage for possible labor. The client's contractions are every 3 to 4 minutes, 60 to 70 seconds in duration and moderate by palpation. Her cervical exam in the office is illustrated on the far left. Her current exam is illustrated on the far right. What conclusions should the nurse draw from the illustration on the right? The woman is completely dilated but not effaced. The woman is almost completely dilated and is completely effaced. The woman is completely effaced but minimally dilated. The woman is not dilated or effaced.

The woman is completely effaced but minimally dilated.

A mother who is breastfeeding her 10 day old baby expresses concern about whether her infant is getting enough milk. Which concrete indicator does the nurse provide to the mother? There are at least eight wet diapers and several stools per day. The mother is physically and emotionally comfortable during feedings. The newborn suckles and the mother can hear or see swallowing. The newborn spontaneously releases the grip on the breast when satiated.

There are at least eight wet diapers and several stools per day.

A patient is scheduled for a contraction stress test (CST) at 36 weeks gestation. The nurse is aware that successful testing is dependent on which factor? If the mother is not overly tired or anxious If the fetus is in an awake cycle and actively moving Whether uterine contractions can be stimulated Whether braxton-hicks contractions are occurring

Whether uterine contractions can be stimulated

A client who is gravida 2, para 1 is admitted in labor. Her cervix is 100% effaced and she is dilated to 6 cm. The presenting part is vertex and at -2 station. The nurse is aware that the fetus' head is: below the ischial spines. above the ischial spines. visible at the vaginal opening. in a malposition.

above the ischial spines.

A patient who is havingTRUE labor most likely would have: (Select all that apply.) pain in the abdomen that does not radiate an increase in the intensity and frequency of contractions contractions that lessen with rest and warm tub baths contractions that do not intensify while walking progressive cervical effacement and dilatation

an increase in the intensity and frequency of contractions contractions that do not intensify while walking progressive cervical effacement and dilatation

the nurse asses the clients vital signs. the client has sudden increased vaginal bleeding and dropping baseline in FHT with late decelerations noted. the nurse immediately (applies oxygen by mask at 5L.min, encourages slow deep breathing, prepares to intubate the client). it is a priority for the nurse to (move the client to hands/knees, turn the client onto the left side, place the client in semi-fowler position). the nurse will (change the IV fluids to 0.45% NS, increase the IV rate to wide open, slow the IV to keep vein open). the nurse ensures the (amount of bleeding is measured, client is unaware of changes, partner is removed from room).

applies oxygen by mask at 5L.min turn the client onto the left side increase the IV rate to wide open amount of bleeding is measured NOTE- side lying position increased placental blood and oxygenation to the fetus with late decelerations. increasing the IV rate to wide open supports maternal blood volume in the presence of bleeding

When preparing for and performing an assessment of the postpartum patient, the nurse would: ask the patient to void before assessing the uterus defer patient teaching to another time inform the patient's visitors that the exam will be brief; then start by exposing only the patient's abdomen wear gloves only if she sees visible blood on the patient

ask the patient to void before assessing the uterus

A woman is admitted in labor. She is 6 cm dilated, -2 station, with intact membranes. Her membranes rupture spontaneously. What would the nurse's initial response be? notify the physician cleanse her perineum and assist her to change her pads administer oxygen at two liters per minute assess the fetal heart rate

assess the fetal heart rate

The nurse begins an assessment of the postpartum patient. After introductions, the patient states that she "feels lots of blood coming out" and shows the nurse her peri-pad that has moderate lochia rubra with several small clots. Which of the following nursing actions should the nurse perform first? assess the fundus and bladder status reassess her baseline vital signs and blood pressure contact the provider immediately increase the Pitocin (oxytocin) infusion to stop the bleeding

assess the fundus and bladder status

A primigravida with Type 1 diabetes is at her first prenatal visit. Anticipating future changes in her insulin needs during pregnancy, the nurse explains that based on her blood glucose levels she should expect to increase her insulin dosage: in the next few weeks immediately following delivery prior to delivery by the end of the second trimester

by the end of the second trimester

State nurse practice acts define the legal scope of nursing practice. How can the policies of an institution influence nursing practice? The institution: cannot restrict nurses from performing acts that are allowed by the state nurse practice act. can either restrict or expand the limits of the practice act . can develop policies that expand the scope of nursing practice beyond the state nurse practice act. can restrict nurses from performing acts that are allowed by the state nurse practice act.

can restrict nurses from performing acts that are allowed by the state nurse practice act.

client is a G4 T1 P0 A2 L1 with history of 2 elective abortions. client has received no prenatal care and is uncertain about her estimated date of conception. client believes that she conceived while breastfeeding her last child; estimates current gestation is 32 weeks. a moderate amount of bright red vaginal blood is noted. client is crying loudly and asking for someone to call her partner. states " I do not understand why im bleeding. nothing hurts at all." FH tones at 148 bpm with fetal activity palpable externally. abdominal ultrasound complete. client transported to obstetrics unit.

client has received no prenatal care and is uncertain about her estimated date of conception. current gestation is 32 weeks moderate amount of bright red vaginal blood nothing hurts at all NOTE- birth of fetus prior to 36 weeks places fetus at risk for respiratory issues, LBW, thermoregulation challenges. the client is likely exhibiting placenta prevue as evidence day painless vaginal bleeding

When a breech presentation is suspected during the intrapartum period, a priority nursing intervention is to diligently observe the client for signs of: a precipitous delivery hip dysplasia labor progression cord prolapse

cord prolapse

The nurse understands that early fetal heart rate decelerations are a result of vagal nerve stimulation and are commonly caused by: fetal head compression fetal cord prolapse deterioration of placental perfusion fetal hypoxia

fetal hypoxia

The student nurse notices that the newborn has the ability to ignore the constant crying of the other newborns in the newborn nursery. The nursing instructor explains that this newborn behavior is known as: elf-quieting behavior orientation active-alert state habituation

habituation

Assessment of a primigravida client in labor who has had no analgesia or anesthesia reveals complete (100%) cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which behavior during this phase of labor? feelings of relief excitement loss of control numbness of legs

loss of control

Immediately following the injection of epidural anesthesia, the most important nursing intervention is to monitor: contractions. maternal blood pressure. intravenous infusion rate. urinary output.

maternal blood pressure.

To prevent sudden infant death syndrome (SIDS), the nurse encourages the parents of a term infant to place the infant in which sleeping position? on the back on the parent's bed swaddled in an infant swing on the side with a positioning device

on the back

The nurse is planning care for a newborn. Which of the following nursing interventions would best protect the newborn from conductive heat loss? placing the newborn away from air currents increasing the room temperature drying the newborn thoroughly pre-warming the examination table

pre-warming the examination table

The ductus arteriosus is the shunt from the: right atrium to the left atrium pulmonary vein to the descending aorta pulmonary artery to the aorta carotid to the inferior vena cava

pulmonary artery to the aorta

Transitional physiology involves a change in the circulation pattern at birth. The placenta blood flow ceases and the lungs become the organ of gas exchange. Which of the following occur as part of this transition: (Select all that apply) pulmonary vascular resistance decreases the systemic vascular resistance decreases the lungs expand the ductus arteriosus and the foramen ovale remain open to facilitate circulation

pulmonary vascular resistance decreases the lungs expand

Match the following findings to the correct newborn reflex (2 points; each answer worth 0.5): Options: startle/moro, babinski, rooting, palmar grasp When the newborn's cheek is stroked, they turn their head toward the stroked side and open their mouth. When the newborn's foot is stroked upward, the toes spread out and then curl in. When the newborn's hand is stroked, the fingers close into a fist. When the newborn is startled, they throw back their head, extend their arms and legs, and then quickly close their arms and legs.

rooting babinski palmar grasp startle/moro

Which of the following statements does the nurse include in teaching a pregnant woman about dilation of the cervix? dilation comes before effacement in the first time pregnancy the cervix shortens during the second stage of labor bearing down efforts by the woman will aid dilation the cervical opening widens during the first stage of labor

the cervical opening widens during the first stage of labor

The nurse is caring for a laboring patient. To identify the duration of a contraction, the nurse should: time from the beginning of one contraction to the beginning of the next contraction time from the beginning of one contraction to the completion of the same contraction time from the beginning of one contraction to the peak of the same contraction palpate the uterus at the peak of a contraction for the intensity

time from the beginning of one contraction to the completion of the same contraction

A women at 38-weeks gestation has been diagnosed with preeclampsia. Intravenous Magnesium Sulfate is administered. What is the primary reason for administering magnesium sulfate in this situation? to reduce platelet aggregation to improve renal blood flow to decrease blood pressure to prevent seizures

to prevent seizures