Maternal newborn ati proctored exam FULL ANSWERS
A nurse is caring for a client whose last menstrual period began july 8. Using Nageles rule, the nurse should identify the client's estimated DOB as what?
. april 15
A nurse is caring for a newborn who weighs 4lb. How many kg does the newborn weigh?
1.8
A nurse is assessing a newborn 1 min after birth andnotes a hr of 136/min, resp 36, well flexed extremities, responding to stimuli with a cry, blue hands and feet. What Apgar score should the nurse assign to the newborn?
9
A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication for the use of this medication?
Active genital herpes The use of oxytocin is contraindicated for clients who have an active genital herpes infection. The newborn can acquire the infection as they pass through the birth canal. Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection.
A nurse is discussing epidural anesthesia with a client who is receiving oxytocin for induction of labor. Which of the following statements should the nurse make?
An epidural given too early can prolong labor Clients who receive anesthesia before the active phase of labor usually find the progression of their labor to slow. The medication depresses the central nervous system. Therefore, it will take longer for the cervix to dilate and efface.
A nurse is caring for a client who has a prescription for naloxone. Which of the following is the intended action of the medication in relation to the central nervous system?
Blocks effects of narcotics on the CNS By blocking the effects of narcotics on the CNS, naloxone prevents CNS and respiratory depression in the newborn following delivery.
A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. Which of the following actions should the nurse include in the plan of care?
Check the cervix prior to analgesic administration Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix is dilated. If administered too close to the time of delivery, the analgesic could cause respiratory depression in the newborn.
A nurse administers betamethasone to a client who is at 33 weeks gestation to stimulate fetal lung maturity. Which planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication?
Decreased blood glucose Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery. It is important to assess the newborn's blood glucose level within the first hour following birth and frequently thereafter until blood glucose levels are stable.
A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching?
Do not become pregnant for at least 1 year Hydatidiform moles are uncontrolled growths in the uterus arising from placental or fetal tissue in early pregnancy. There is an increased incidence of choriocarcinoma associated with molar pregnancies. Pregnancy must be avoided for 1 year so the client can be closely monitored for manifestations of this condition.
A nurse is planning care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care?
Ensure the newborns eyes are closed before applying the eye shield Overexposure to the lights during treatment can cause damage to the newborn's corneas. Therefore, the nurse should gently close the newborn's eyes prior to applying the eye shield.
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect?
Exaggerated reflexes A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the central nervous system (CNS). Exaggerated reflexes are indicative of CNS irritability.
A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority?
My heart feels as if it is racing The primary action of terbutaline is to cause bronchodilation and relax smooth muscles. However, an adverse effect is tachycardia. If the pulse is greater than 130/min, the terbutaline needs to be held until the provider is notified.
A nurse is caring for a client who is at 36 weeks of gestation and has preeclampsia. Which of the following findings should the nurse identify as the priority?
Nonreactive nonstress test In a nonreactive nonstress test, there are no accelerations. Absence of FHR accelerations suggests that the fetus might be going into distress.
A nurse is assessing a newborn who is 12 hours old and notes mild jaundice of the face and trunk. Which of the following actions should the nurse take?
Obtain a stat prescription for a bilirubin level Jaundice in the first 24 hr of life is pathologic. The nurse should notify the provider and obtain a stat prescription for a bilirubin level.
A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy?
Pelvic inflammatory disease (PID) An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop there. The most common site is within a fallopian tube, but ectopic pregnancies can occasionally occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, PID places the client at risk for an ectopic pregnancy.
A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving to his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse make?
These feelings are common to expectant fathers in early pregnancy
A nurse is caring for a client who is at 16 weeks of gestation and has severe iron deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication?
Use a 20-guage needle, and administer the medication using the Z track method The nurse should administer iron using the Z-track method to prevent staining of tissue. A 20-gauge needle is the correct size.
A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse provide to the client about the treatment plan?
You and your partner need to take the medication and use a condom during intercourse until cultures are negative Trichomonas vaginalis is the organism that causes the sexually transmitted infection trichomoniasis. Both men and women can be infected with trichomoniasis. Clinical findings include yellowish to greenish, frothy, mucopurulent, copious discharge with an unpleasant odor, as well as itching, burning, or redness of the vulva and vagina. Trichomoniasis can be treated easily with metronidazole. However, for the treatment to work, it is important to make sure both sexual partners receive treatment to prevent reinfection. Instruct the client to use condoms during sexual intercourse while being treated.
A nurse is caring for a client who is at 32 wks gestation and is experiencing preterm labor. What meds should the nurse plan to administer?
betamethasone
A nurse is providing teaching to a client who is at 8 wks gestation about manifestations to report to the provider during pregnancy. What info should the nurse include in the teaching?
blurred or double vision
A nurse is assessing a client who is 34 wks gestation and has mild placental abruption. What finding should the nurse expect?
dark red vaginal bleeding The nurse should expect the client who has a mild placental abruption to have minimal dark red vaginal bleeding.
A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. What action should the nurse take?
obtain blood samples for baseline lab values The nurse should obtain samples of the client's blood for baseline testing of hemoglobin and hematocrit levels.
A nurse is caring for a newborn who is premature in the neonatal ICU. what action should the nurse take to promote development?
position the naked newborn on the parents bare chest
A nurse is caring for a client who has oligohydraminios. What fetal anomalies should the nurse expect?
renal agenesis
A nurse is teaching a client who is at 8 wks gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. What info should the nurse include?
the fibroid can increase the risk for postpartum hemorrhage
A nurse is assessing a client who is at 37 wks gestation and has a suspected pelvic fracture due to blunt abd trauma. What findings should the nurse expect?
uterine contractions The nurse should expect the client to be experiencing uterine contractions due to abdominal trauma.
A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5kg. The amount available is 0.4 mg/ml. how many ml should the nurse administer?
0.25
A nurse is assessing a client who is at 35 weeks of gestation and has mild gestational HTN. What finding should the nurse identify as the priority?
480 mL urine output in 24 hrs When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is 480 mL of urine output in 24 hr because the minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of preeclampsia to preeclampsia with severe features, which requires immediate intervention. Therefore, this is the priority finding.
A nurse is caring for four newborns. Which of the following newborns is at greatest risk for hypoglycemia?
A newborn who is large for gestational age Large for gestational age (LGA) newborns are those newborns whose weight is at or above the 90th percentile. One of the most common etiologies of LGA newborns is a mother who is diabetic. LGA newborns, especially those born to mothers who have diabetes, are at increased risk for hypoglycemia. Other newborns at risk for hypoglycemia are small for gestational age (SGA) newborns (those below the 10th percentile), premature newborns, and newborns who have perinatal hypoxia.
A nurse is assessing a client on the first postpartum day. Findings include fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3 C (99.2 F), and pulse rate 52/min. Which of the following actions should the nurse take?
Ask the client when she last voided Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be found firm at midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void.
A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) Immune Globulin?
At 28 weeks of gestion The nurse should administer Rh(D) Immune Globulin to a client who is pregnant and has Rh-negative blood at 28 weeks of gestation. Rh(D) Immune Globulin consists of passive antibodies against the Rh factor, which will destroy any fetal RBCs in the maternal circulation and block maternal antibody production.
A nurse is teaching a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching?
I should press the button on the handheld marker when my baby moves The purpose of the test is to assess fetal well-being. The client should press the button on the handheld marker when she feels fetal movement.
A nurse is caring for a client who is at 8 weeks of gestation with twins and primigravida. The client states that even though she and her husband planned this pregnancy, she is experiencing many ambivalent feelings about it. Which of the following responses should the nurse make?
These feelings are quite normal at the beginning of pregnancy This client needs reassurance that these feelings are normal and there is no reason for concern.
A nurse is caring for a client whose membranes have ruptured and is in active labor. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first?.
Turn the client onto her left side Late decelerations indicate that the client is experiencing uteroplacental insufficiency. The client might be experiencing pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to the fetus. Turning the client onto her left side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply.
A nurse is assessing a client who is receiving magnesium sulfate as treatment for preeclampsia. Which of the following clinical findings is the nurse's priority?
Urinary output 40ml in 2 hours Urinary output is critical to the excretion of magnesium from the body. The nurse should discontinue the magnesium sulfate if the hourly output is less than 30 mL/hr
A nurse is caring for a client who is pregnant and reports nausea and vomiting. Which of the following instructions should the nurse provide the client?
You should eat some crackers before rising from bed in the morning Morning sickness is caused by the buildup of human chorionic gonadotropin (hCG) in the mother's system. Dry foods eaten before rising in the morning tend to reduce the risk of nausea in clients who are pregnant.
A nurse is teaching a client who has active genital herpes simplex virus, type 2. Which of the following statements should the nurse include in the teaching?
You will have a cesarean birth prior to the onset of labor Whenever possible, the cesarean birth should be scheduled prior to the onset of labor or rupture of membranes to reduce the risk of neonatal transmission of herpes.
A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. What action should the nurse take?
apply pressure to the client's sacral area during contractions
A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bm since delivery. What action should the nurse take?
assist the client to empty her bladder When the client's fundus is deviated to the right or left it can indicate that her bladder is full. The nurse should assist the client to empty her bladder to prevent uterine atony and excessive lochia.
A nurse is caring for a client who is at 38 wks of gestation and reports no fetal movement for 24 hr. What action should the nurse take?
auscultate for a FHR Presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The nurse should auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action.
A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client becomes frightened when she has a gush of dark red blood from her vagina. What following statements should the nurse make?
blood pools in the vagina when you are lying a bed In the early postpartum period, lochia will pool in the vagina when the client is lying in bed and will flow out of the vagina when the client stands up. After the initial gush, the bleeding will slow down to a trickle of bright red lochia.
A nurse is providing teaching to the parents of a newborn about bottle feeding. What instructions should the nurse include?
boil water for powdered formula for 1-2 min The parents should run tap water for 2 min and then boil it for 1 to 2 min before mixing it with the formula to decrease the risk of contamination.
A nurse is caring for a client who is receiving mag sulfate by continuous IV. What meds should the nurse have available at bedside?
calcium gluconate The nurse should have calcium gluconate available to give to a client who is receiving magnesium sulfate by continuous IV infusion in case of magnesium sulfate toxicity. The nurse should monitor the client for a respiratory rate less than or equal to 12/min, muscle weakness, and depressed deep-tendon reflexes.
A nurse is assessing a 12 hr old newborn and notes a resp rate of 44 with shallow respirations and periods of apnea lasting up to 10 seconds. What action should the nurse take?
continue routine monitoring The nurse should continue routine monitoring because the newborn's assessments findings indicate he is adapting to extrauterine life. placing in sidelying or supine
A nurse is caring for a client who is at 35 wks gestation and has severe pre-eclampsia. What assessment provides the most accurate info regarding the client's fluid and electrolyte status.
daily wt
A nurse is assessing a client who is at 12 wks gestation and has hydatidiform mole. What findings should the nurse expect?
dark brown vaginal discharge A hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of the chorionic villi, which gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grapelike clusters.
A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin via continuous IV infusion. The nurse notes that the client is having contractions every 2 min which last 100-110 seconds that the fetal heart rate is reassuring. What action should the nurse take?
decrease the dose of oxytocin by half The nurse should decrease the dose of oxytocin by half because the client is experiencing uterine tachysystole.
A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. What instructions should the nurse include in the teaching?
encourage nonnutritive sucking for pain relief Allowing the newborn to suck on a pacifier is an effective form of nonpharmacological pain management.
A nurse is caring for a newborn directly after birth. What medications should the nurse administer to the newborn within 1-2 hr of delivery?
erythromycin ophthalmic ointment Every newborn born in the United States should receive erythromycin ophthalmic ointment to prevent gonorrheal or chlamydial infections that the newborn can contract during birth.
A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about expected adverse effects. What adverse effects should the nurse include in the teaching?
feeling of warmth The nurse should tell the client to expect the feeling of warmth all over her body while the magnesium sulfate is infusing.
A nurse is planning care for a client who is postpartum and has cardiac disease. For what script should the nurse seek clarification?
monitor clients wt wkly The nurse should weigh the client daily to monitor for fluid overload.
A nurse is teaching a client who is at 12 wks gestation about manifestations of potential complications that she should report to her provider. What info should the nurse include in the teaching?
swelling of the face
A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. What action should the nurse take?
use photometer to monitor the lamp's energy The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective.
A nurse in a prenatal clinic is caring for a client who is within the recommended guidelines for weight. The client asks the nurse how much weight is safe for her to gain during her pregnancy. Which of the following responses should the nurse make?
A weight gain of about 25-35 pounds is good A weight gain of 25 to 35 lb is associated with good fetal outcome. A gain of 4 lb in the first trimester and 12 lb each for the second and third trimester is recommended.
A nurse is caring for a newborn who has irregular respirations of 52/minute with several periods of apnea lasting approximately 5 seconds. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take?
Continue to routinely monitor the newborn
A nurse is caring for a newborn who was born to a client who has a narcotic use disorder. Which of the following nursing actions should the nurse identify as a contraindication for the care of the newborn?
Frequent stimulation This newborn needs a quiet, calm environment with minimal stimulation to promote rest and reduce stress. A stimulating environment can trigger irritability and hyperactive behaviors.
A nurse is planning care for a client who is at 35 weeks of gestation. Which of the following laboratory tests should the nurse obtain?
Group B streptococcus B-hemolytic The nurse should obtain a vaginal/anal group B streptococcus ß-hemolytic (GBS) culture at 35 to 37 weeks of gestation to screen for infection. Prophylactic antibiotics should be given during labor to the client who is positive for GBS.
A nurse is caring for a client who is 2 hours postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse take first?
Massage the fundus The primary cause of early postpartum bleeding is uterine atony manifested by a relaxed, boggy uterus. Thus, the greatest risk for the client is hemorrhage. The nurse should massage the client's fundus first.
A nurse is caring for a client who desires an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for the use of this device?
Menorrhagia An IUD is a small plastic or copper device placed inside the uterus that changes the uterine environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia, severe dysmenorrhea, or history of ectopic pregnancy.
A nurse is caring for a client who is receiving oxytocin for induction of labor. Which of the following actions should the nurse take?
Perform continuous fetal heart rate monitoring When oxytocin is administered to an antepartum client, the fetal monitor must be used to continuously monitor the fetal heart rate and maternal contractions.
A nurse is reviewing the med record of a client who is at 39 wks gestation and has polyhydramnios. What finding should the nurse expect?
fetal GI anomaly Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurologic disorders are expected findings for a fetus experiencing the effects of polyhydramnios.
A nurse is reviewing lab results for a client who is at 37 wks gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic strep, and has a blood type O neg. What action should the nurse take?
instruct the client to obtain a rubella immunization after delivery
A nurse is providing teaching to a client who is planning to breastfeed her newborn. What statement by the client indicates an understanding of the teaching?
it is normal for my baby to sometimes feed every hr for several hours in a row Cluster feeding is an expected finding for newborns who are breastfeeding. The mother should follow her newborn's cues and feed her 8 to 12 times per day.
A nurse is teaching a client who is at 30 wks gestation about warning signs of complications that she should report to her provider. What finding should the nurse include in the teaching?
vaginal bleeding Vaginal bleeding can be an abnormal finding during pregnancy that might indicate a complication such as placental abruption, placenta previa, or preterm labor.
A nurse is caring for a client who is to receive a continuous IV infusion of oxytocin following a vaginal birth. What assessment findings should the nurse monitor to evaluate the effectiveness of the med?
fundal consistency Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective.
A nurse is assessing a newborn 1 hr after birth. What assessment findings should the nurse report to the provider?
jaundice of the sclera If the newborn has jaundice within the first 24 hr of life, this can indicate a potential pathological process such as hemolytic disease. Pathologic jaundice can result in high levels of bilirubin that can cause damage to the neonatal brain.
A nurse is assessing a newborn for congenital hip dysplasia. What finding should the nurse expect?
limited abduction of one hip A newborn who has congenital hip dysplasia can have limited abduction because the head of the femur might have slipped out of the acetabulum. asymmetrical gluteal folds
A nurse is caring for a client who has a soft uterus and increased lochia. What meds should the nurse plan to administer to promote uterine contractions?
methylergonovine The nurse should administer methylergonovine, an ergot alkaloid, which promotes uterine contractions.
A nurse is caring for a client who believes she may be pregnant. What finding should the nurse identify as a positive sign of pregnancy? a. palpable fetal movement
palpable fetal movement
A nurse is reviewing the medical record of a client who is at 33 wks gestation and has placenta previa and bleeding. What scripts should the nurse clarify with the provider?
perform a vaginal exam When a client has a placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta and increased bleeding.
A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. What instructions should the nurse include in the teaching?
place ice packs on your breasts The nurse should instruct the client to place ice packs on her breasts using a 15 min on and 45 min off schedule, to decrease swelling of the breast tissue as the body produces milk.
A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and slightly blue What action should the nurse take?
place the naked newborn on the mothers bare chest and cover both with a blanket Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding.
A nurse is caring for a newborn immediately following delivery. What actions should the nurse take first?
place the newborn directly on the client's chest the greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client's chest will help maintain the newborn's temperature.
A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor. What action should the nurse take?
prepare equipment needed for newborn resuscitation The nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.
A nurse is caring for a postpartum client 8hrs after delivery. What factors place the client at risk for uterine atony? select all
prolonged labor Prolonged labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus from contracting. mag sulfate infusion Magnesium sulfate is a smooth muscle relaxant and can prevent adequate contraction of the uterus. distended bladder After birth, clients can experience a decreased urge to void due to birth-induced trauma, increased bladder capacity, and anesthetics, which can result in a distended bladder. The distended bladder displaces the uterus and can prevent adequate contraction of the uterus.
A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For what finding should the nurse monitor to identify a cervical laceration?
slow trickle of bright vaginal bleeding and a firm fundus The nurse should monitor for bright red bleeding as a slow trickle, oozing or outright bleeding,and a firm fundus to identify a cervical laceration.
A nurse is assessing a newborn who was born at 39 wks gestation. What finding should the nurse expect?
symmetric rib cage A newborn who is born at 39 weeks of gestation is full-term and should have normal, smooth skin with good turgor and the presence of subcutaneous fat pockets. A postmature newborn, greater than 42 weeks of gestation, will have dry, cracked skin with a wrinkled appearance.
A nurse is assessing a 2 day old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. What pieces of info should the nurse provide to the mother when she inquires about the finding?
this will resolve within 3-6 wks without treatment
A nurse is testing the reflexes of a newborn to assess neurologic maturity. What reflexes is the nurse assessing when she quickly and gently turns the newborn's head to one side?
tonic neck To elicit the tonic neck reflex, the nurse should quickly and gently turn the newborn's head to one side when he is sleeping or falling asleep. The newborn's arm and leg should extend outward to the same side that the nurse turned his head while the opposite arm and leg flex. This reflex persists for about 3 to 4 months.
A nurse is assessing a client who is at 35 wks gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. What finding should the nurse report to the provider?
urinary output 20 mL/hr The nurse should report a urinary output of 20 mL/hr because this can indicate inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary output can also indicate a decrease in renal perfusion secondary to a worsening of the client's pre-eclampsia.
A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that what lab test will be used to confirm her pregnancy?
urine test for presence of HCG
A nurse is caring for a client who is at 37 wks gestation and is undergoing a nonstress test. The FHR is 130 without accelerations for the past 10 min. What action should the nurse take?
use vibroacoustic stim on the client's abd for 3 seconds The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR.
A nurse is caring for a client who is at 39 wks gestation and is in the active phase of labor. The nurse observes late decels in the FHR. What finding should the nurse identify as the cause of late decels?
uteroplacental insufficiency
A nurse is teaching a client who is at 12 wks gestation and has HIV. What statement should the nurse include in the teaching?
you should continue to take zidovudine throughout the pregnancy -can be transmitted through breastfeeding -she can continue to have sex The nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmission of HIV to her newborn.
A nurse is caring for a client who is at 26 wks gestation and reports constipation. What responses by the nurse is appropriate?
you should walk for at least 30 minutes q day The nurse should encourage the client to participate in moderate physical activity, such as walking or swimming, every day. This activity increases intestinal peristalsis, which will help alleviate constipation.
A nurse is teaching a client who is at 10 wks gestation about an abd. ultrasound in the first trimester. What info should the nurse include in the teaching?
you will need to have a full bladder during the ultrasound MY ANSWER The nurse should tell the client that a full bladder helps to lift the gravid uterus out of the pelvis during the examination. Therefore, it is important to ensure that the client has a full bladder to obtain the most accurate image of the fetus.
A nurse receives report on a client who is in labor and is experiencing contractions 4 minutes apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?
Contractions that last for 60 seconds each with a 3-minute rest between contractions A contraction interval is how often a uterine contraction occurs. The nurse will 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 a client who is in labor and has an epidural for pain relief. Which of the following is a complication from the epidural block?
Hypotension Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of epidural anesthesia in order to decrease the likelihood of this complication.
A nurse is administering a rubella immunization to a client who is 2 days postpartum. What statement indicates to the nurse the client needs further instruction?
I can conceive anytime i want after 10 days A client who receives a rubella immunization should not conceive for at least 1 month after receiving the rubella immunization to prevent injury to the fetus.
A nurse is teaching a client who is at 13 wks gestation about the treatment of incompetent cervix with cervical cerclage. What statement by the client indicates an understanding of teaching?
I should go to the hospital if I think I may be in labor Cervical cerclage prevents premature opening of the cervix during pregnancy. The client should immediately go to a facility for evaluation if she experiences any manifestations of labor while the cerclage is in place. If the client experiences preterm uterine contractions she might require tocolytic therapy.
A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching?
I should replace my diaphragm every 2 years The diaphragm is a flexible rubber cup that is filled with spermicide and is inserted over the cervix prior to intercourse. The diaphragm is a prescribed device fitted by the provider. It should be replaced every 2 years.
A nurse is providing teaching to the parents of a newborn about home safety. What statement by the parents indicates an understanding of the teaching?
I will place my baby on his back when it is time for him to sleep
A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication?
IV narcotics administered to the mother during labor The nurse should administer naloxone to reverse respiratory depression due to acute narcotic toxicity, which can result from IV narcotics administration during labor.
A nurse in an antepartum clinic answers a phone call from a client who is at 37 weeks of gestation and reports, "I become very dizzy while lying in bed this morning, but the feeling went away when I turned on my side." Which of the following actions should the nurse take?
Instruct the client about vena cava syndrome and measures to prevent it This is the typical finding of vena cava syndrome, or hypotension that occurs in clients who are pregnant upon assuming a supine position. It is caused by compression of the inferior vena cava by the gravid uterus with a consequent reduction in venous return. A side lying position promotes uterine perfusion and fetoplacental oxygenation.
A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy?
Respiratory depression Magnesium sulfate can cause respiratory and neuromuscular depression in the newborn. The nurse should monitor the newborn for clinical manifestations of respiratory depression.
A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication from the oxygen therapy?
Retinopathy Oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. It is a disorder of retinal blood vessel development in the premature newborn. In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel that fills the back of the eye. It can reduce vision or result in complete blindness.
A nurse is caring for a client who is in labor. A vaginal examination reveals the following information: 2cm, 50%, +1, right occiput anterior. Based on this information, which of the following position should the nurse document in the medical record?
Vertex ROA describes the relationship of the presenting part of the fetus to the client's pelvis. In this case, the occipital bone is the presenting part and is located anteriorly in the client's right side. Based on the presentation of the fetus, the position is vertex.
A nurse is caring for a client who is in labor. The client questions the application of an internal fetal scalp monitor. Which of the following responses should the nurse make?
We need to observe your baby more closely The client has asked an information-seeking question. This therapeutic response provides information to the client in an honest, nonthreatening manner. The use of an internal fetal scalp monitor, or an internal spiral electrode, provides a more accurate assessment of fetal well-being during labor.
A nurse is caring for a newborn who is premature at 30 wks gestation. What finding should the nurse expect?
abundant lanugo Newborns who are premature have abundant lanugo, fine hair, especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pinnas, and forehead.
A nurse is caring for a client who reports intestinal gas pain following a c-section. What action should the nurse take?
assist the client to ambulate in the hallway Walking can help stimulate peristalsis, which will promote expulsion of gas.
