MATERNAL NEWBORN PART 1

A nurse is reviewing risk factors for postpartum depression with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Gestational diabetes B. Planned pregnancy C. Being married D. Post-term birth

Correct Answer: A. Gestational diabetes Gestational diabetes increases the risk of postpartum depression. Other risk factors include infertility treatment, pregnancy complications, preterm birth, and a history of mood disorder.

A nurse is assisting with the care of a client who is in the early stage of labor and has preeclampsia with severe features. Which of the following interventions should the nurse perform? A. Assess the fetal heart rate and contractions hourly B. Encourage oral intake of clear, low-sodium fluids C. Instruct the client to ambulate during the early phase of labor D. Implement seizure precautions

Correct Answer: D. Implement seizure precautions The nurse should identify that clients who have preeclampsia with severe features are at risk for seizures. The nurse should keep the side rails of the client's bed up and ensure oxygen and suction are readily available.

A nurse is reinforcing discharge instructions with the parent of a newborn. Which of the following statements should the nurse include? A. "Crib slats should be less than 2.25 inches apart." B. "Share your bed with your baby for the first few weeks." C. "Place your baby on his stomach for naps." D. "You can position your baby's crib next to a heating vent for warmth."

Correct Answer: A. "Crib slats should be less than 2.25 inches apart." Crib slats should be no more than 5.7 cm (2.25 in) apart to prevent injuries due to falls or entrapment of the infant's head between the slats.

A nurse is providing teaching to a client who is 1 hour postpartum about using the perineal squeeze bottle. Which of the following instructions should the nurse include? A. "Fill the perineal bottle with warm water prior to use." B. "Squeeze the perineal bottle while standing up in the bathroom to cleanse the perineum." C. "Only use half of the perineal bottle for cleansing." D. "Wipe the perineum with toilet paper from back to front after using the perineal bottle."

Correct Answer: A. "Fill the perineal bottle with warm water prior to use." The client should fill the squeeze bottle and use the entire contents each time she voids or has a bowel movement to cleanse her perineum. Warm water will promote healing and increase comfort to the perineal area. Cold water will be uncomfortable, and hot water could cause tissue trauma.

A nurse is reinforcing discharge teaching about circumcision care for the parent of a newborn who has undergone a Gomco clamp procedure. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will apply petroleum jelly to my baby's penis for the first few days." B. "I will use pre-moistened towelettes to clean my baby's penis." C. "I will remove any yellow crusts when I clean my baby's penis." D. "I will wrap my baby's penis in dry gauze until it heals."

Correct Answer: A. "I will apply petroleum jelly to my baby's penis for the first few days." The client should apply petrolatum to the penis with each diaper change to protect the incision from contact with urine and feces.

A nurse is talking with a client during her initial prenatal visit. The client reports a history of trisomy 13 syndrome in her family and is concerned her fetus might be at risk. Which of the following statements should the nurse provide? A. "If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder." B. "If the genetic screening shows that your baby has this disorder, I can provide you with information about an abortion clinic." C. "Screening for trisomy 13 syndrome and other chromosomal disorders is done automatically for clients at increased risk." D. "I can provide you with information about sterilization so that the disorder is not passed to your future children."

Correct Answer: A. "If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder." Genetic screening has multiple legal and ethical considerations that must be addressed prior to testing. The client will need to sign an informed consent form prior to the screening.

A nurse is contributing to the plan of care for a client who is at 12 weeks of gestation and has a BMI of 45. Which of the following recommendations should the nurse make for the client regarding weight gain during her pregnancy? A. "You should plan to gain no more than 20 lb during your pregnancy." B. "You should plan to gain between 25 and 35 lb during your pregnancy." C. "You should not plan to gain any weight during your pregnancy because you are already well-nourished." D. "Since you have higher energy needs than an average-sized pregnant client, you should plan to gain 45 to 50 lb."

Correct Answer: A. "You should plan to gain no more than 20 lb during your pregnancy." Women who have a BMI greater than 30 should limit weight gain to 11 to 20 pounds during pregnancy. Excessive weight and weight gain increase the risk of complications during and after pregnancy.

A nurse in a clinic is reinforcing education with a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide? A. "You should slightly increase your exposure to sunlight." B. "You will need extensive dermatological treatment for this condition after you deliver your baby." C. "Your provider will schedule weekly lab testing to monitor your liver function." D. "Your provider will prescribe isotretinoin cream."

Correct Answer: A. "You should slightly increase your exposure to sunlight." Pruritus gravidarum is a condition of pregnancy that causes generalized itching without the presence of a rash. This occurs due to the stretching of the skin. Exposure to sunlight can reduce itching.

A nurse is reinforcing teaching with a client who has active genital herpes simplex virus, type 2. Which of the following statements by the nurse should be included in the teaching? A. "You will have a cesarean birth prior to the onset of labor." B. "Your baby will receive erythromycin eye ointment after birth to treat the infection." C. "You should take oral metronidazole for 7 days prior to 37 weeks of gestation." D. "You should schedule a cesarean birth after your water breaks."

Correct Answer: A. "You will have a cesarean birth prior to the onset of labor." Whenever possible, a 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 reinforcing teaching to a client who is postpartum and has been prescribed warfarin therapy for a deep vein thrombosis. Which of the following instructions should the nurse include? A. "You will need to use a reliable form of contraception while on warfarin therapy." B. "You will need to take a baby aspirin every day while on warfarin therapy." C. "You will need to use formula instead of breast milk while on warfarin therapy." D. "You will need to massage your affected leg 3 times a day while on warfarin therapy."

Correct Answer: A. "You will need to use a reliable form of contraception while on warfarin therapy." Warfarin is teratogenic, and pregnancy should be avoided by using a reliable form of contraception.

A nurse in a provider's office is caring for a client who is in the first trimester of pregnancy. Which of the following psychological tasks should the nurse expect the client to accomplish during this trimester? A. Accepting the pregnancy B. Preparing for the end of pregnancy C. Preparing for parenthood D. Accepting the baby

Correct Answer: A. Accepting the pregnancy Accepting the pregnancy is a psychological task that the client is expected to accomplish during the first trimester.

A nurse is preparing to administer erythromycin ophthalmic ointment 0.5% to a newborn. Which of the following actions should the nurse plan to take? A. Apply the ointment in the lower conjunctival sac of each eye B. Obtain a written consent from the guardian prior to administering the ointment C. Wipe the excess ointment immediately to prevent irritation D. Administer the ointment from the outer canthus of the eye to the inner canthus.

Correct Answer: A. Apply the ointment in the lower conjunctival sac of each eye The nurse should administer the ointment into the lower conjunctival sac by gently squeezing the tube, starting at the inner canthus and moving toward the outer canthus.

A nurse is collecting data from a client who is 12 hours postpartum. Which of the following locations should the nurse expect to palpate the client's fundus? A. Approximately 1 cm above the umbilicus B. Approximately 2 cm below the level of the umbilicus C. At the symphysis pubis D. Directly between the symphysis pubis and umbilicus

Correct Answer: A. Approximately 1 cm above the umbilicus The nurse should expect the fundus to be approximately 1 cm above the umbilicus by 12 hours following birth. The fundus should then descend 1 to 2 cm every 24 hrs.

A nurse is preparing to obtain a newborn's temperature. Which of the following methods should the nurse use? A. Axillary B. Temporal C. Tympanic D. Rectal

Correct Answer: A. Axillary An axillary temperature is the most accurate and safe way to obtain a newborn's temperature. The nurse should check the temperature after obtaining respirations and pulse since the baby may cry or struggle when the nurse holds the arm in place.

A nurse is assisting with the care of a client who is experiencing preterm labor. Which of the following medications should the nurse anticipate administering to enhance fetal lung maturation? A. Betamethasone B. Nifedipine C. Indomethacin D. Verapamil

Correct Answer: A. Betamethasone Betamethasone is administered as antenatal glucocorticoid therapy and is given to clients who are experiencing preterm labor to stimulate fetal lung maturation.

A nurse is assisting with the assessment of a 1-day-old newborn. Which of the following findings indicates that the newborn has acrocyanosis? A. Bluish-colored skin B. Pursed lips C. Clenched fists D. Rounded nose

Correct Answer: A. Bluish-colored skin Acrocyanosis is a bluish discoloration of the hands and feet. It is a normal finding in the first 24 hours after birth.

A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. Which of the following actions should the nurse take? A. Encourage the client to frequently change positions. B. Instruct the client to take breaths and hold them for 10 seconds while pushing C. Assess maternal vital signs every 1 hour D. Assist the client to the restroom

Correct Answer: A. Encourage the client to frequently change positions. During the second stage, frequent position changes can promote the descent of the fetus through the birth canal. The nurse should assist the client in finding optimal positions of comfort which allow the client to rest between contractions but also enhances expulsive efforts.

A nurse is reviewing the medical record of a client who has hypertension. The nurse should identify which of the following findings as a contraindication to receiving propranolol? A. Foul-smelling lochia B. Fundus 2 cm above the umbilicus C. Decreased heart rate D. Dysuria

Correct Answer: A. Foul-smelling lochia Endometritis is an infection of the lining of the uterus. Manifestations include a high fever, chills, anorexia, fatigue, pelvic pain, uterine tenderness, and foul-smelling lochia.

A nurse in an antepartum clinic is assisting with the care of a client who is at 24 weeks of gestation. Which of the following findings should the nurse report to the provider? A. Frequent headaches B. Leukorrhea C. Epistaxis D. Periodic numbness of the fingers

Correct Answer: A. Frequent headaches The nurse should report frequent headaches to the provider. Frequent headaches, swelling of the face and fingers, visual disturbances, and epigastric pain are findings associated with preeclampsia.

A nurse is reviewing the medical record of a client who has hypertension. The nurse should identify which of the following findings as a contraindication to receiving propranolol? A. Oxytocin-induced labor B. Oligohydramnios C. Small fetus D. Gravida 1

Correct Answer: A. Oxytocin-induced labor Oxytocin-induced labor can result in a prolonged labor and can be a risk factor for postpartum hemorrhage, Postpartum hemorrhage is the leading cause of maternal mortality and morbidity in the US and worldwide, involving a loss of 500 mL or more of blood after a vaginal delivery and 1000 mL or more after a cesarean birth.

A nurse is caring for a client following a forceps-assisted birth. The nurse should identify which of the following findings as a complication of this procedure? A. Pelvic hematoma B. Retained placenta C. Infertility D. Uterine inversion

Correct Answer: A. Pelvic hematoma Pelvic hematoma is a collection of blood in the connective tissue. Clients experience pain and pressure in the vaginal area. Hematoma is associated with forceps-assisted births, episiotomy, and primigravidity.

A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following interventions should the nurse include in the plan? A. Reposition the newborn every 3 hours B. Apply lotion to the newborn's exposed skin twice daily C. Feed the newborn 1 oz of glucose water every 2 hours D. Dress the newborn in a diaper and a thin cotton t-shirt

Correct Answer: A. Reposition the newborn every 3 hours The nurse should reposition the newborn every 2 to 3 hours during phototherapy to maximize skin exposure to the light.

A nurse in a clinic is caring for a client who is pregnant and reports a last menstrual period (LMP) that began on December 7. Which of the following dates would be the client's estimated date of birth (EDB)? A. September 14 B. September 7 C. March 14 D. March 7

Correct Answer: A. September 14 Naegele's rule involves subtracting 3 months and adding 7 days to the LMP to calculate the EDB. Subtracting 3 months from December (month 12) gives the month of September. Adding 7 days to the seventh day of the month equals 14. Therefore, September 14 is the EDB.

A nurse is assisting with the care of a client in labor who is receiving IV oxytocin. The nurse notes contractions lasting 3 minutes each. What action should the nurse take? A. Stop the oxytocin infusion B. Apply oxygen at 2 L/min via nasal cannula C. Administer methylergonovine intramuscularly D. Prepare for an emergent cesarean birth

Correct Answer: A. Stop the oxytocin infusion A pattern of contractions lasting longer than 2 minutes or more than 5 contractions in a 10-minute period is considered tachysystole. This pattern can result in decreased placental perfusion of oxygen. The appropriate action is to discontinue the oxytocin infusion.

A nurse is collecting data from a client who is at 34 weeks of gestation and has a cardiac disorder. The nurse should notify the provider about which of the following findings? A. The client reports a frequent cough. B. The client reports that none of her shoes fit anymore. C. The client reports a weight gain of 2 lb in a 2-week period. D. The client reports leg cramps in the evening.

Correct Answer: A. The client reports a frequent cough. A frequent cough could be an indication of cardiac decompensation and should be reported to the provider.

A nurse is assisting with the care of a client who is at 32 weeks of gestation and has preeclampsia. Which of the following provider prescriptions should the nurse expect? A. The client should take low-dose aspirin daily. B. The client should check fetal kick counts every other day. C. The client should have her blood pressure measured while standing. D. The client should maintain complete bed rest.

Correct Answer: A. The client should take low-dose aspirin daily. Daily low-dose aspirin has been found to reduce adverse outcomes in preeclampsia. The current recommendation is for low-dose aspirin to be initiated late in the first trimester for clients who have a history of early onset preeclampsia.

A nurse is preparing a client who is pregnant for an ultrasound. Which of the following pieces of information is the most important for the nurse to collect? A. Time of the client's last void B. Who will accompany the client to the ultrasound C. Date of the client's last menstrual period D. Whether the client wants to know the sex of the fetus

Correct Answer: A. Time of the client's last void A client who is pregnant and is undergoing an abdominal ultrasound requires a full bladder for the test to be most accurate. The full bladder helps lift the gravid uterus out of the pelvis during the examination. To determine if the client has a full bladder prior to the ultrasound, the time of the client's last void is the most important information for the nurse to collect.

A nurse is assisting with the care of a newborn who is receiving treatment for jaundice with traditional phototherapy lights. Which of the following interventions should the nurse perform? A. Turn the newborn every 2 hours B. Supplement with 5% glucose water between scheduled feedings C. Dress the infant lightly in a tee shirt and diaper D. Apply lotion to the skin every 4 hours

Correct Answer: A. Turn the newborn every 2 hours Phototherapy lowers serum bilirubin levels by converting bilirubin accumulated in the skin to a form that is excreted in the newborn's urine and stools. The infant must be turned every 2 to 3 hr to maximize skin exposure, which promotes bilirubin breakdown.

A nurse is collecting data from a pregnant client who is at 16 weeks of gestation. Which of the following manifestations should the nurse report to the provider? A. Urinary urgency B. Constipation C. Periodic tingling in fingers D. Pyrosis

Correct Answer: A. Urinary urgency Urinary urgency and frequency can be a common discomfort during the third trimester of pregnancy. However, these symptoms can also indicate a complication of pregnancy like a urinary tract infection, which could cause preterm labor. Therefore, the nurse should report these manifestations to the provider.

A nurse is caring for a client who is in the first trimester of pregnancy and reports daily nausea that interferes with her ability to work. Which of the following dietary supplements should the nurse recommend to help alleviate the client's nausea? A. Vitamin B6 B. Vitamin C C. Vitamin B12 D. Vitamin D

Correct Answer: A. Vitamin B6 Vitamin B6 is essential for carbohydrate, protein, and fat metabolism. Doses of 10 to 25 mg can help alleviate nausea in the first trimester of pregnancy.

A nurse in a prenatal clinic is caring for a client who is within the recommended guideline for weight. The client asks the nurse how much weight she can gain safely during her pregnancy. Which of the following responses should the nurse offer? A. "Your provider can discuss an appropriate amount of weight gain with you." B. "A weight gain of about 25 to 35 pounds is good." C. "If you eat nutritious foods when you feel hungry, the amount of weight gain is insignificant." D. "A weight gain of about 14 pounds each trimester is suggested."

Correct Answer: B. "A weight gain of about 25 to 35 pounds is good." A weight gain of 25 to 35 lb is associated with good fetal outcomes. 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 client who is postpartum and non-lactating. The client reports breast pain. Which of the following statements should the nurse make? A. "Try taking a warm shower." B. "Be sure to wear a well-fitted supportive bra." C. "Expel breast milk using your hand." D. "Avoid laying your newborn on your chest until the pain subsides."

Correct Answer: B. "Be sure to wear a well-fitted supportive bra." The nurse should instruct the client to wear a breast binder and to apply ice packs or cold cabbage leaves to the breasts to suppress milk production. This intervention helps relieve pain in non-lactating mothers.

A nurse is caring for a client who reports cramping while trying to breastfeed her newborn. Which of the following instructions should the nurse provide to the client? A. "You might need to walk around to decrease gas." B. "Breastfeeding can cause uterine contractions." C. "We will need to check you for hemorrhaging." D. "You should lie on your side during breastfeeding."

Correct Answer: B. "Breastfeeding can cause uterine contractions." The nurse should explain to the client that oxytocin is released during breastfeeding, which can cause uterine contractions.

A nurse is reinforcing teaching with a parent about how to care for his newborn's circumcision site. Which of the following client statements indicates an understanding of the teaching? A. "I should clean the circumcision site with half-strength hydrogen peroxide twice a day." B. "I should apply the diaper loosely until the circumcision site is healed." C. "I should notify the doctor if a yellow discharge forms on the head of the penis." D. "Newborns typically do not experience any pain from this procedure."

Correct Answer: B. "I should apply the diaper loosely until the circumcision site is healed." A loosely applied diaper will minimize pressure on the circumcision site, which will help decrease pain in the surgical area.

A nurse is reinforcing education with a client who is pregnant about symptoms that should immediately be reported to the provider. Which of the following client responses indicates an understanding of the teaching? A. "I should call my provider if I develop melasma." B. "If I notice that my eyes are puffy, I should call my provider." C. "I should call my provider if I notice that my feet and ankles are swollen." D. "If I notice periodic numbness and tingling in my fingers, I should call my provider."

Correct Answer: B. "If I notice that my eyes are puffy, I should call my provider." Puffy eyes are associated with facial edema, which is a sign of pregnancy-induced hypertension. This should be reported immediately.

A nurse is reinforcing teaching about nonstress testing with a client who is pregnant. Which of the following pieces of information should the nurse include? A. "This test is an invasive procedure that presents minimal risk to the fetus." B. "If the test is reactive, that means your baby's heart rate is healthy." C. "When your baby moves, the test should record the baby's heart rate decreasing by about 15 beats per minute." D. "The results of the test will be recorded as positive if no fetal movement occurs during the 20-minute testing period."

Correct Answer: B. "If the test is reactive, that means your baby's heart rate is healthy." The fetal heart rate is considered healthy if the results are reactive. A reactive test indicates there are fetal heart rate accelerations associated with fetal movement within the testing period. If the test is nonreactive, fetal health might be affected and further testing might be necessary to evaluate fetal well-being.

A nurse on a postpartum unit is reinforcing teaching with a client about postpartum blues. Which of the following instructions should the nurse include? A. "Seek immediate assistance for feelings of fatigue." B. "Plan opportunities to get out of the house frequently." C. "You will experience intense fears and anxiety if you have postpartum blues." D. "Most parents feel angry when the baby cries."

Correct Answer: B. "Plan opportunities to get out of the house frequently." The nurse should encourage the client to continue to do things for herself to reduce the risk of postpartum blues.

A nurse is caring for a client who is 48 hours postpartum. The client expresses distress about her older children's acceptance of the new baby. Which of the following statements should the nurse make? A. "It would be best if your children met the new baby at home in a familiar setting." B. "Present the older children with a small gift and say it is from the baby." C. "Make sure you are holding the baby when the older children come to visit." D. "Try not to split up the children so no one will feel left out."

Correct Answer: B. "Present the older children with a small gift and say it is from the baby." The nurse should encourage the parents to give the older children a small gift each day they visit. In addition, the parents should state the gift is from the new baby.

A nurse is reinforcing teaching with the parent of a newborn about preventing cold stress. Which of the following statements should the nurse include? A. "Cold stress decreases the newborn's need for oxygen." B. "Skin-to-skin contact with the parent helps provide warmth." C. "The newborn must be air dried to avoid lying in wet clothes." D. "Examinations will be done with the newborn in a room kept at 68° Fahrenheit."

Correct Answer: B. "Skin-to-skin contact with the parent helps provide warmth." The parent should be encouraged to provide early skin-to-skin contact with the newborn to encourage warmth and reduce cold stress.

A nurse is caring for a client who is at 8 weeks of gestation with twins and is 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 provide? A. "Have you told your husband about these feelings?" B. "These feelings are normal at the beginning of pregnancy." C. "Perhaps you should see a counselor to discuss these feelings." D. "I am concerned about these feelings. Could you explain more?"

Correct Answer: B. "These feelings are normal at the beginning of pregnancy." This client needs reassurance that these feelings are normal and that there is no reason for concern.

A nurse is reinforcing teaching with a client about postpartum fatigue. Which of the following statements should the nurse include? A. "Strenuous exercise can help improve your sleep." B. "Try to take naps when your infant is napping." C. "Avoid consuming dairy products such as milk before bedtime." D. "You might want to ask family not to visit until you are more rested."

Correct Answer: B. "Try to take naps when your infant is napping." The client should be encouraged to sleep while her infant is sleeping. This helps the client replenish energy and decrease fatigue.

A nurse is caring for a client who in the first trimester of a low-risk pregnancy. The client tells the nurse that she and her partner would like to continue their sexual relationship, but she is afraid it will cause a miscarriage. Which of the following responses should the nurse make? A. "I will talk to your provider about a referral to a sex therapist." B. "You can safely have intercourse as long as you don't feel discomfort." C. "You should try alternative positions for sexual intercourse." D. "You should abstain from intercourse until 6 weeks postpartum."

Correct Answer: B. "You can safely have intercourse as long as you don't feel discomfort." The nurse should inform the client that sexual intercourse will not cause a miscarriage. However, the client should report any discomfort experienced during intercourse to the provider so the cause can be identified.

A nurse is reinforcing education with a client who is at 34 weeks of gestation about a non-stress test (NST). Which of the following pieces of information should the nurse include? A. "It will take about 10 minutes to complete the test." B. "You might have to drink orange juice during the test." C. "During the test, you will be asked to massage your nipples." D. "During the test, you will receive a medication to relax your uterus."

Correct Answer: B. "You might have to drink orange juice during the test." An NST monitors for accelerations of the fetal heart rate over a 20-minute period. During this time, the fetus can be asleep and experience hypoactivity. The parent might be asked to drink orange juice during testing to stimulate fetal movements.

A nurse is reinforcing discharge teaching about bathing with the parent of a newborn. Which of the following instructions should the nurse include? A. Shake cornstarch inside the newborn's diaper after bathing B. Clean the newborn's face first using water C. Wash the newborn's umbilical cord with a mild soap D. Avoid massaging the newborn's scalp when washing the hair

Correct Answer: B. Clean the newborn's face first using water The parent should proceed from the cleanest parts of the newborn's body to the most soiled areas. The face should be washed first before the eyes, ears, and nose. The parent should clean the newborn's genital area last.

A nurse is monitoring a newborn for indications of septic shock. Which of the following findings should the nurse expect if the newborn develops this complication? A. Slow respirations B. Decreased blood pressure C. Bradycardia D. Flushed skin

Correct Answer: B. Decreased blood pressure The nurse should monitor the blood pressure of a newborn who is at risk for septic shock and should identify decreased blood pressure as an indication of this complication. Other manifestations include tachypnea, mottled or gray-colored skin, cool extremities, and a rapid pulse.

A nurse is reinforcing teaching with new parents about formula feeding. Which of the following instructions should the nurse include? A. The bedtime bottle can be placed in the crib after the infant is 6 months of age. B. Discard opened cans of formula after 48 hr of refrigeration. C. Powdered and concentrated formula can be reconstituted with tap water from the faucet. D. Bottles and nipples can be hand-washed in hot, soapy water.

Correct Answer: B. Discard opened cans of formula after 48 hr of refrigeration. Opened cans and prepared bottles of formula must be refrigerated and discarded after 48 hours due to the risk of bacterial contamination.

A nurse is assisting with the care of a newborn immediately after birth. The newborn is pink and crying and has a heart rate of 108/min. Which of the following actions should the nurse take? A. Initiate chest compressions B. Dry the newborn on the mother's chest C. Administer epinephrine to the newborn D. Apply an oxygen saturation monitor

Correct Answer: B. Dry the newborn on the mother's chest A newborn who is pink and crying and has a heart rate greater than 100/min is stable and can stay with the mother. The nurse should continue to dry and stimulate the newborn gently and provide warmth by placing the newborn skin-to-skin on the mother's chest.

A nurse is collecting data for 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? A. Administer phytonadione IM B. Obtain a stat prescription for a bilirubin level C. Obtain a bagged urine specimen D. Perform a gestational age assessment

Correct Answer: B. Obtain a stat prescription for a bilirubin level Jaundice in the first 24 hours after birth is pathologic. The nurse should notify the provider and obtain a stat prescription for a bilirubin level.

A nurse in a clinic is preparing to auscultate fetal heart tones using a Doppler for a client who is pregnant. Which of the following actions should the nurse prepare to take? A. Apply petroleum jelly on the client's abdomen B. Palpate and count the maternal radial pulse while listening to the fetal heart rate. C. Place the wand over the fetal chest to hear the fetal heart rate D. Percuss the maternal abdomen to verify the position of the fetus

Correct Answer: B. Palpate and count the maternal radial pulse while listening to the fetal heart rate. The nurse should palpate and count the maternal pulse while listening to the fetal heart rate to validate findings and distinguish the maternal pulse from the fetal heart.

A nurse is assisting with the care of a client who is in labor and has received epidural analgesia. The nurse observes that the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Position the client on her side C. Assist with an examination for cord prolapse D. Provide glucose via oral hydration or IV

Correct Answer: B. Position the client on her side Maternal hypotension is a common cause of late decelerations. Maternal position influences both maternal hypotension and the fetal response to low blood pressure. Positioning the client on her side relieves the pressure of the uterus on the inferior vena cava and improves maternal circulation.

A nurse is reviewing the laboratory values of a client who is pregnant and has a low progesterone level. Which of the following complications should the nurse expect? A. Gestational diabetes B. Preterm labor C. Inadequate milk supply D. Inadequate uterine growth

Correct Answer: B. Preterm labor Progesterone maintains the lining of the uterus, which maintains the pregnancy. It also reduces uterine contractility. A client who has a low progesterone level is at risk for preterm labor.

A nurse is collecting data from a newborn who was born with meconium-stained amniotic fluid. Which of the following findings should the nurse report as an indication of meconium aspiration syndrome? A. High Apgar score B. Rapid respirations C. Flushed skin D. Elevated PO2

Correct Answer: B. Rapid respirations Newborns who have meconium aspiration syndrome are expected to have tachypnea due to the aspiration of meconium-stained amniotic fluid prior to birth. This aspiration can cause tachypnea and other indications of respiratory distress.

A nurse is caring for a client who had a cesarean birth 36 hours ago and is experiencing pain due to gas. Which of the following strategies should the nurse recommend? A. Sip a carbonated beverage throughout the day B. Rock in a rocking chair C. Lie flat in bed with the legs extended D. Use a straw when drinking fluids

Correct Answer: B. Rock in a rocking chair The nurse should recommend that the client rocks in a rocking chair, ambulates in the hallways, and lies on her left side to assist with intestinal motility and to expel flatulence.

A nurse is reinforcing teaching about newborn skin care with a group of new parents. Which of the following instructions should the nurse include? A. Gently retract the foreskin to wash the glans with soap and water B. Sponge-bathe the newborn every other day C. Use an antimicrobial soap for bathing D. Bathe the newborn with water at a temperature between 46° and 49°C (115° and 120°F)

Correct Answer: B. Sponge-bathe the newborn every other day Daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The parents should sponge-bathe the infant until the cord stump has detached and the area has healed.

A nurse in a provider's office is reviewing the medical record of a client who is at 28 weeks of gestation. The nurse should identify that prophylactic administration of Rh immune globulin is contraindicated for which of the following findings? A. The client is a Jehovah's Witness. B. The client has Rh-positive blood. C. The client had an external cephalic version. D. The client is currently pregnant with fraternal twins.

Correct Answer: B. The client has Rh-positive blood. The nurse should identify that administration of Rh immune globulin is contraindicated for clients who have Rh-positive blood or for clients who have Rh-negative blood and have been previously sensitized.

The nurse is reinforcing discharge teaching with the guardians of a newborn about how to use a bulb syringe. Which of the following statements by a guardian indicates an understanding of the teaching? A. "I should insert the bulb syringe deep in the back of the baby's mouth to obtain mucus." B. "I should place the tip in the baby's nose first and then the mouth." C. "I should insert the bulb syringe at the corners of the baby's mouth to suction the cheek pockets." D. "I should place the bulb tip in the baby's mouth before squeezing the bulb."

Correct Answer: C. "I should insert the bulb syringe at the corners of the baby's mouth to suction the cheek pockets." The tip of the bulb syringe should be inserted into the corner of the mouth, and secretions should be suctioned from the pockets of the cheeks. The guardians should avoid inserting the bulb syringe tip into the middle of the mouth because it can cause the child to gag.

A nurse is reinforcing teaching with a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching? A. "I know not to eat anything after midnight." B. "I will have medication given to me to cause contractions." C. "I should press the button on the handheld marker when my baby moves." D. "I will have to stimulate my breast to cause contractions."

Correct Answer: C. "I should press the button on the handheld marker when my baby moves." The purpose of a nonstress test is to assess fetal wellbeing. The client should press the button on the handheld marker when she feels fetal movement.

A nurse is caring for a newborn who has a prescription for phototherapy. The mother asks why the newborn needs to lay under a special light. Which of the following responses should the nurse make? A. "The light helps your baby maintain his body temperature." B. "The light helps your baby establish a regular sleeping pattern." C. "The light will help lower your baby's bilirubin level." D. "The light will help regulate your baby's blood sugar."

Correct Answer: C. "The light will help lower your baby's bilirubin level." Jaundice is caused by the breakdown of red blood cells, which release bilirubin. A newborn's immature liver is unable to filter and excrete the bilirubin efficiently, leading to accumulation of bilirubin in the tissues. The ultraviolet light in phototherapy assists in breaking down the bilirubin so that it can be excreted in the urine and feces.

A nurse is caring for a client who had pelvic measurements recorded by the provider. The client asks, "Since my pelvis is gynecoid, will I be able to deliver vaginally?" Which of the following responses should the nurse make? A. "The shape of your pelvis will make vaginal childbirth difficult, but it is still possible." B. "The shape of your pelvis will require a cesarean delivery." C. "The shape of your pelvis is ideal for vaginal childbirth." D. "The shape of your pelvis will change as you near delivery, and the provider will determine if vaginal delivery is possible."

Correct Answer: C. "The shape of your pelvis is ideal for vaginal childbirth." The nurse should inform the client that a gynecoid pelvis is well-rounded with a wide pubic arch. This is ideal for vaginal childbirth.

A nurse is caring for a client who is at 28 weeks of gestation. The client asks, "Why do people say I should not lie on my back while I'm pregnant?" Which of the following responses should the nurse make? A. "When you lie on your back, your blood pressure increases." B. "When you lie on your back, your pulse increases." C. "When you lie on your back, your uterus compresses your vena cava." D. "When you lie on your back, you reduce your chance of developing hemorrhoids."

Correct Answer: C. "When you lie on your back, your uterus compresses your vena cava." The nurse should inform the client that during the second half of pregnancy, the uterus compresses the vena cava when lying supine. This compression results in a blood pressure drop and maternal bradycardia, ultimately causing syncope.

A nurse is reinforcing teaching with a client who is at 28 weeks of gestation. The client asks, "Is it safe for me to take a 12-hour drive to visit my family?" Which of the following responses should the nurse make? A. "Yes, but avoid using rest-stop bathrooms to reduce your exposure to infection." B. "Yes, but stop and lie down in the back seat if you feel dizzy. Sitting for long periods can put pressure on major blood vessels and make you faint." C. "Yes, but be sure to get out of the car and walk around regularly so you don't develop blood clots in your legs." D. "Yes, but monitor your blood pressure. Remaining in a sitting position during a long car trip can lower your blood pressure."

Correct Answer: C. "Yes, but be sure to get out of the car and walk around regularly so you don't develop blood clots in your legs." Pregnancy is a hypercoagulable state in which women are at an increased risk of thromboembolic disease. Regular activity will decrease the risk of developing thrombophlebitis.

A nurse in an outpatient setting is reinforcing education with a client who is pregnant. Which of the following statements should the nurse include in the teaching? A. "During the last trimester, you should sleep mainly on your back." B. "During the second trimester of pregnancy, you will notice increased urinary frequency and urgency." C. "You will probably first notice your baby moving when you are around 20 weeks of gestation." D. "You should plan to gain 40 to 45 lb during your pregnancy."

Correct Answer: C. "You will probably first notice your baby moving when you are around 20 weeks of gestation." Fetal movement is typically noted by a pregnant client at 18 to 20 weeks of gestation. Multiparous clients might notice the movement earlier.

A nurse is reinforcing teaching with a postpartum client who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching? A. "You should supplement your baby with formula until you notice that your breasts become firm and full." B. "You should adhere to a schedule when feeding your baby to ensure she is getting enough to eat." C. "Your milk supply will noticeably increase in volume around the third or fourth day after delivery." D. "It is typical for your nipples to hurt for the first few weeks while you are breastfeeding."

Correct Answer: C. "Your milk supply will noticeably increase in volume around the third or fourth day after delivery." As the colostrum transitions to mature breast milk, the volume of milk produced will also increase. Typically, the postpartum client will notice that 72 to 96 hours after delivery her breasts feel fuller and firmer and that milk is leaking from her nipples.

A nurse is collecting data from a client who delivered vaginally 8 hours ago. The nurse notes that the client's fundus is 2 fingerbreadths above the umbilicus and has shifted to the left, and there is a large amount of lochia rubra on the perineal pad. Which of the following actions should the nurse take first? A. Administer analgesia B. Administer carboprost IM C. Assist the client to the toilet D. Obtain a blood specimen to test Hct and Hgb levels

Correct Answer: C. Assist the client to the toilet Evidence-based practice indicates that the nurse should first help the client empty her bladder. Displacement of the fundus to the left indicates that the cause of the excessive bleeding is uterine atony due to bladder distention, so this action is the nurse's priority.

A nurse is assisting with the care of a newborn who is large for gestational age, appears restless, and has tremors. Which of the following actions should the nurse take first? A. Place the newborn under a radiant warmer B. Provide nonnutritive sucking for the newborn C. Check the newborn's blood glucose level D. Swaddle the newborn

Correct Answer: C. Check the newborn's blood glucose level The nurse should identify that newborns who are large for gestational age are at an increased risk of hypoglycemia. Therefore, the first action the nurse should take when using the nursing process is to check the newborn's blood glucose level.

A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 seconds. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? A. Administer oxygen B. Place the newborn in an isolette C. Continue to monitor the newborn routinely D. Check the newborn's blood glucose

Correct Answer: C. Continue to monitor the newborn routinely This newborn is exhibiting a normal respiratory rate and rhythm. No additional measures are needed at this time.

A nurse is collecting data from a newborn at birth who was delivered at 32 weeks of gestation. Which of the following findings should the nurse anticipate? A. Heel creases over the entire sole of the foot B. Pendulous testes C. Extended extremities D. Leathery cracked skin

Correct Answer: C. Extended extremities An infant born at 32 weeks of gestation has poorly developed muscle tone and is unable to maintain the flexed position seen in an infant who was born at full term.

A nurse is assisting with the care of a newborn. The nurse should obtain informed consent before taking which of the following actions? A. Administering erythromycin ophthalmic ointment B. Conducting a newborn hearing screening C. Giving the hepatitis B vaccine D. Screening for critical congenital heart disease

Correct Answer: C. Giving the hepatitis B vaccine The nurse must obtain informed consent from the newborn's guardian before administering the hepatitis B vaccine.

A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. Tinnitus B. Numbness in the hand C. Headache D. Nasal stuffiness interfering with sleep

Correct Answer: C. Headache This is a complication that requires further evaluation. Postpartum-onset preeclampsia can cause headaches. Also, if the client was given epidural or spinal anesthesia, cerebral spinal fluid leakage must be ruled out. The nurse should report this finding to the provider.

A nurse at a prenatal clinic is collecting data from an adult client who had genital cutting performed as a child as part of her cultural practices. The nurse notes the client's clitoris and labia minora were removed, and she has scarring in the vaginal area. Which of the following actions should the nurse take? A. Report the findings to the local authorities B. Ask the client who performed the cutting C. Inform the client that giving birth vaginally might not be possible D. Prepare the client for the increased risk of spontaneous abortion

Correct Answer: C. Inform the client that giving birth vaginally might not be possible The nurse should recognize that female genital cutting is done in early adolescence as a part of some religious and cultural practices. The scarring that can result from this practice may necessitate a cesarean delivery.

A nurse is collecting data from a newborn. For which of the following findings should the nurse notify the provider? A. Heart rate 136/min B. Acrocyanosis C. Mottling D. Respiratory rate 60/min

Correct Answer: C. Mottling The nurse should report mottling to the provider as an indication of hypothermia or respiratory distress.

A nurse is collecting data from a 7-month-old infant during a well-child visit and notes the presence of a full Moro reflex. For which of the following should the nurse screen the infant? A. Congenital heart disease B. Hearing loss C. Neurological disorder D. Amblyopia

Correct Answer: C. Neurological disorder The Moro reflex, also known as the startle reflex, is elicited by striking the surface next to the newborn to startle him/her. A classic pattern of abduction and extension of the arms that follows is expected. This reflex should be gone by 4 months of age; its presence after 4 months of age is associated with the presence of a neurological disorder.

A nurse is caring for a client who is postpartum. The client suddenly appears restless and reports an inability to catch her breath. Which of the following actions should the nurse take? A. Evaluate vital sign trends, focusing on blood pressure history B. Review admission laboratory values, specifically hematocrit C. Notify the unit charge nurse and the rapid response team D. Ask the client about pain, urination, and lochia characteristics

Correct Answer: C. Notify the unit charge nurse and the rapid response team This client requires an emergency response. A sudden onset of air hunger can be related to hemorrhage or pulmonary embolism, which are medical emergencies that can lead to cardiopulmonary arrest if they are not managed aggressively.

A nurse is reinforcing teaching with the guardian of a newborn about car seat safety. Which of the following pieces of information should the nurse include? A. Position the child's car seat forward-facing at 1 year of age B. Place the retainer clip 2 inches above the newborn's umbilicus C. Place the shoulder harness in the slots that are level with the newborn's shoulders D. Position the newborn's car seat at a 20° angle in the vehicle

Correct Answer: C. Place the shoulder harness in the slots that are level with the newborn's shoulders The guardian should place the shoulder harness in the slots that are level or slightly below the newborn's shoulders to ensure the child is restrained in the event of an accident.

A nurse is reinforcing teaching about parental attachment with a client who is postpartum. Which of the following client behaviors indicates an understanding of the teaching? A. The client primarily touches the newborn with her fingertips. B. The client does not critique the newborn's features and body parts. C. The client has given the newborn a name. D. The client is quiet with a blank facial expression.

Correct Answer: C. The client has given the newborn a name. A parent who names the newborn and incorporates the newborn into the family helps facilitate parental attachment.

A nurse is reinforcing discharge teaching with a client about breastfeeding her newborn. Which of the following pieces of information should the nurse include? A. Milk should replace the colostrum in 12 to 14 days. B. The newborn should have 3 to 4 wet diapers each day. C. The newborn should appear satisfied after each feeding. D. The client's breasts should feel firm after each feeding.

Correct Answer: C. The newborn should appear satisfied after each feeding. The nurse should inform the client that the newborn should appear satisfied and content after feedings. A newborn who continues to show hunger indications (e.g. rooting, sucking on the hands, or crying) might not be effectively emptying the breasts during feedings.

A nurse in an antepartum clinic is collecting data from a client who is 2 weeks postpartum and reports vaginal discharge. Which of the following discharge characteristics should the nurse expect? A. Dark red uterine discharge B. Pinkish-brown vaginal discharge C. Yellowish-white uterine discharge D. Bright red vaginal discharge

Correct Answer: C. Yellowish-white uterine discharge Lochia alba is yellow to white uterine discharge. This is present about 10 to 14 days following birth and can persist up to 8 weeks. Lochia alba consists of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria.

A nurse is reinforcing teaching with a client about nutrition during pregnancy. Which of the following instructions should the nurse include in the teaching? A. "Plan to double your normal caloric intake during the last trimester of pregnancy." B. "Expect to gain 10 to 15 lb during pregnancy." C. "Restrict your intake of sodium throughout pregnancy." D. "Do not eat swordfish, shark, or king mackerel while you are pregnant." Check Answer Question Feedback Show Explanation Grade Pause Previous

Correct Answer: D. "Do not eat swordfish, shark, or king mackerel while you are pregnant." These fish have high levels of mercury which can harm the developing nervous system of the fetus. Consumption of food with high levels of mercury should be avoided prior to conception and until the cessation of breastfeeding.

A nurse is caring for a client who has a BMI of 22.6 and expresses concern about weight gain during pregnancy. Which of the following responses should the nurse make? A. "You're eating for 2, so you should double your caloric intake." B. "You'll lose weight easily after the birth of your baby." C. "Plan to gain a total of 15 to 20 pounds during pregnancy." D. "Gaining weight will promote a healthy pregnancy."

Correct Answer: D. "Gaining weight will promote a healthy pregnancy." A weight gain of 11.3 to 15.9 kg (25 to 35 lb) during pregnancy is essential for supporting the growth and development of the fetus. Limiting caloric intake can result in using fat stores for energy and developing ketonemia, which is a risk factor for preterm labor.

A nurse in an antepartum clinic is reinforcing teaching about recommended weight gain with a client who is at 12 weeks of gestation. The client has a documented prepregnancy BMI of 32. Which of the following client statements indicates an understanding of the teaching? A. "I should limit my weight gain to 40 pounds during pregnancy." B. "I should limit my weight gain to 35 pounds during pregnancy." C. "I should limit my weight gain to 25 pounds during pregnancy." D. "I should limit my weight gain to 20 pounds during pregnancy."

Correct Answer: D. "I should limit my weight gain to 20 pounds during pregnancy." Clients who have a prepregnancy BMI over 30 are considered to be obese and should plan to limit their weight gain to 5 to 9.1 kg (11 to 20 lb) during pregnancy.

A nurse is reinforcing discharge teaching with the parents of a newborn about home safety. Which of the following parent responses indicates an understanding of the instructions? A. "I should attach a soft bumper pad to the rails on the inside of my baby's crib." B. "I should place my baby in an infant carrier on the sofa for daytime napping." C. "I should change the smoke detector batteries in my baby's room once a year." D. "I should use my elbow to check the temperature of my baby's bath water."

Correct Answer: D. "I should use my elbow to check the temperature of my baby's bath water." The nurse should instruct the parents to test the temperature of the water using their own elbow before placing the newborn in the bath. This prevents chilling or scalding of the newborn's skin.

A nurse is reinforcing teaching about mastitis with a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I will limit breastfeeding to 5 minutes per breast." B. "I will not breastfeed if I start to have flu-like symptoms." C. "I will shop for an underwire nursing bra today." D. "I will avoid any of my family members who are ill."

Correct Answer: D. "I will avoid any of my family members who are ill." The client should avoid ill family members to decrease the risk of mastitis. While the causative organisms of mastitis tend to be bacterial, exposure to viral illnesses can compromise the immune system and leave the client vulnerable to mastitis.

A nurse is assisting with the care of a client who is in labor. The client asks the nurse, "Why is the other nurse pressing on my abdomen?" Which of the following responses should the nurse make? A. "To determine your baby's heart rate" B. "To determine if you have sufficient fluid around your baby" C. "To make sure your baby moves with stimulation" D. "To determine the position of your baby"

Correct Answer: D. "To determine the position of your baby" Palpation of the abdomen can determine which fetal part is in the uterine fundus and where the back of the fetus is. Palpating the lower abdomen will help determine whether the fetus's head is down or if another extremity is the presenting part.

A nurse is reinforcing teaching about exercise during pregnancy with a client who is in her third trimester. Which of the following statements should the nurse include? A. "Soak in a hot tub to soothe sore muscles." B. "Relax in a supine position for 10 minutes after your exercise session." C. "It is common to experience dizziness when you exercise during pregnancy." D. "You should be able to carry on a conversation easily during exercise."

Correct Answer: D. "You should be able to carry on a conversation easily during exercise." A client who is pregnant should moderate her exercise intensity to where she is able to carry on a conversation easily. If she is unable to talk easily, she should reduce the intensity of her workout.

A nurse is reinforcing teaching about breastfeeding with a client who is at 32 weeks of gestation. Which of the following responses should the nurse make? A. "You should place plastic-lined breast pads into your bra." B. "You should start pumping your breasts now." C. "You should apply lanolin ointment to your areolas." D. "You should use warm water to wash your nipples."

Correct Answer: D. "You should use warm water to wash your nipples." Colostrum can dry on the nipples and create blockages. Warm water can be used to remove the dried colostrum gently.

A nurse is assisting with the care of a client who is in active labor and receiving an oxytocin infusion. The nurse notes tachysystole with a Category 1 fetal heart-rate tracing. Which of the following actions should the nurse take? A. Discontinue oxytocin infusion and apply oxygen B. Increase oxytocin infusion rate by 2 mu/min C. Administer terbutaline 0.25 mg subcutaneously D. Assist the client into a side-lying position and continue to monitor

Correct Answer: D. Assist the client into a side-lying position and continue to monitor A Category 1 fetal heart rate tracing is an expected finding and does not represent fetal distress. The nurse should assist the client into a side-lying position to optimize uteroplacental perfusion and continue to monitor the tracing for another 10 minutes to determine whether tachysystole resolves.

A nurse is reviewing the plan of care before assuming the care of a newborn who is prescribed a hepatitis B vaccine, vitamin K, and an antiretroviral regimen. The plan of care indicates the newborn's mother is HIV-positive and plans to breastfeed. Which of the following findings should the nurse address with the newborn's interdisciplinary team? A. Hepatitis B vaccine B. Antiretroviral regimen C. Vitamin K D. Breastfeeding

Correct Answer: D. Breastfeeding In areas with access to nutritious infant formula and clean water, breastfeeding by mothers who are HIV-positive is not recommended because HIV can be transmitted through breast milk. HIV is a contraindication to breastfeeding and requires discussion with the newborn's interdisciplinary team.

A nurse is assisting with the care of a newborn immediately following birth. Which of the following actions should the nurse take first? A. Weigh the newborn B. Instill erythromycin ophthalmic ointment in the newborn's eyes C. Administer vitamin K to the newborn D. Dry the newborn

Correct Answer: D. Dry the newborn The greatest risk to the newborn immediately after birth is heat loss, which can cause cold stress, respiratory distress, and hypoglycemia. Therefore, the first action the nurse should take is to dry the newborn to prevent heat loss from evaporation.

A nurse is reinforcing education with a client who is of childbearing age. The nurse should state that which of the following structures expels the mature ovum? A. Blastocyst B. Fallopian tube C. Corpus luteum D. Graafian follicle

Correct Answer: D. Graafian follicle The Graafian follicle expels the mature ovum.

A nurse is caring for a client who is 24 years old and at 13 weeks of gestation. The client's history includes a BMI of 31 prior to pregnancy, a prior post-term delivery, and a newborn birth weight of 4,167.38 g (9 lb 3 oz). Which of the following laboratory values should the nurse expect to collect? A. Maternal serum alpha-fetoprotein B. Pregnancy-associated plasma protein A C. Chorionic villus sampling D. HbA1c

Correct Answer: D. HbA1c HbA1c measures average plasma glucose concentration over the 12 weeks preceding the test. A female client whose BMI is >30 and who has a history of delivering a baby weighing over 4,082.33 grams (9 lb) is at risk for impaired glucose metabolism and should be screened at the end of the first trimester.

A nurse is caring for a client who is 3 days postpartum and has chosen to bottle feed the newborn. During examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take? A. Encourage the client to pump the breasts. B. Instruct the client to take a warm shower twice per day. C. Tell the client to massage the breasts. D. Instruct the client to apply cold compresses.

Correct Answer: D. Instruct the client to apply cold compresses. To help relieve breast engorgement, the client should apply cold compresses for about 15 min every hour. The client can also try applying fresh, cold cabbage leaves to the breasts.

A nurse is reviewing the fetal heart tracings for a client in labor and notes variable decelerations. Which of the following actions should the nurse take? A. Request a prescription for oxytocin B. Administer oxygen at 2 L/min via nasal cannula C. Prepare for the insertion of an intrauterine balloon D. Reposition the client from side to side

Correct Answer: D. Reposition the client from side to side Variable decelerations are caused by cord compression. Changing the client from side to side or assisting her into a knee-chest position might relieve cord compression and improve the variable decelerations.

A nurse in a prenatal clinic is preparing to check a client's blood pressure. Which of the following actions should the nurse plan to take? A. Ensure the client's feet are dangling B. Place the client's arm across her abdomen with her hand in her lap C. Allow the client to sit quietly for 2 to 3 minutes before checking her blood pressure D. Select a cuff that covers about 80% of the client's upper arm

Correct Answer: D. Select a cuff that covers about 80% of the client's upper arm The nurse should select a blood pressure cuff that covers about 80% of the client's upper arm or that is about 1.5 times the length of the client's upper arm in order to obtain an accurate blood pressure measurement.

A nurse is reinforcing teaching with the parent of a premature infant on interventions to promote optimal development. Which of the following actions should the nurse instruct the parent to take? A. Maintain bright lighting to enable close observation of the infant at all times B. Place the infant in the prone position with arms and legs extended C. Rouse the infant every 1 to 2 hr to provide auditory and visual stimulation D. Teach the parent to provide kangaroo care for the infant

Correct Answer: D. Teach the parent to provide kangaroo care for the infant Studies show that premature infants who are held skin-to-skin (i.e. given kangaroo care) demonstrate improved thermostability, oxygen saturation, interest in feeding, and maintenance of an organized, relaxed state.

A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. The client's temperature measures 101.9°F (38.8°C) 3 hours following delivery. B. Lochia is red with small clots and mucus 2 days after delivery. C. Client reports abdominal pain 48 hours after delivery when the newborn is breastfeeding. D. The fundus feels soft and is a fingerbreadth below the umbilicus 72 hours after delivery.

Correct Answer: D. The fundus feels soft and is a fingerbreadth below the umbilicus 72 hours after delivery. The fundus will rise to the height of the umbilicus about 1 hour after delivery and remains there for about 24 hours. It should decrease by 1 fingerbreadth per day and become more firm. A soft fundus on day 3 that has not dropped could indicate uterine atony and should be reported to the provider.

The nurse is collecting data about the reflex responses of a newborn. Which of the following findings should the nurse expect when assessing the Moro reflex? A. Abduction and extension of the arms are asymmetric. B. The opposite leg flexes while a leg is extended and the sole of the foot is stimulated. C. Toes hyperextend with dorsiflexion of the great toe. D. The legs move in a similar pattern of response to the arms.

Correct Answer: D. The legs move in a similar pattern of response to the arms. Symmetric movement of the arms and legs is an expected finding when assessing the Moro reflex. If the arms move up, the legs are expected to move up as well.

A nurse is reinforcing teaching about nutritional requirements during lactation for a client who is planning to breastfeed her newborn. Which of the following nutrients should nurse recommend the client increase during lactation? A. Calcium B. Iron C. Vitamin D D. Vitamin C

Correct Answer: D. Vitamin C The nurse should recommend the client increase her vitamin C intake during lactation to 115 to 120 mg per day.

A nurse is preparing to administer vitamin K IM to a newborn. Which of the following actions should the nurse plan to take? A. Identify the injection site on the dorsogluteal muscle B. Apply sterile gloves prior to administration C. Insert the needle at a 30° angle D. Withdraw the needle quickly after administration

Correct Answer: D. Withdraw the needle quickly after administration The nurse should withdraw the needle quickly and place a dry gauze pad over the site. The nurse should then apply gentle pressure to minimize pain and bleeding at the site.

A nurse collecting data from a full-term newborn who is demonstrating the Moro reflex. Which of the following movements are expected responses to this reflex? (Select all that apply.) A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward C. Arms and legs adducting D. Arms falling backward after startling E. Head turning to the right

Correct Answers: A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward These are expected components of the Moro reflex. This response is present at birth and absent by 6 months of age in neurologically intact infants.

A nurse is assisting with the care of a client who is 8 hours postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider? (Select all that apply.) A. Massage the fundus B. Give oxygen at 2 L/min via nasal cannula C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30°

Correct Answers: A. Massage the fundus C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30° The nurse should massage the fundus to expel clots and assist the uterus to contract. Also, the nurse should add oxytocin to the intravenous drip and insert an indwelling urinary catheter to monitor urinary output and perfusion to the kidney. Finally, the nurse should place the client in a lateral position with her legs elevated 30°.