Maternity Practice B

A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of spina bifida occulta?

The nurse should identify this as an image of spina bifida occulta. External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area.

A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? a. "I will eat foods that taste good instead of balancing my meals." b. "I will avoid having a snack before I go to bed each night." c. "I will have a cup of hot tea with each meal." d. "I will eliminate products that contain dairy from my diet."

a. "I will eat foods that taste good instead of balancing my meals." Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet.

A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make? a. "You can miss your period for several other reasons. Describe your typical menstrual cycle." b. "If you have been sexually active and haven't used protection, it is likely that you are pregnant." c. "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" d. "Because you have missed your period, you should try taking a home pregnancy test before you start worrying."

a. "You can miss your period for several other reasons. Describe your typical menstrual cycle." Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions.

A nurse is teaching a new mother about newborn safety. Which of the following instructions should the nurse include in the teaching? a. "You can share your room with your baby for the next few weeks." b. "Cover your baby with a light blanket while sleeping." c. "Check the temperature of your baby's bath water with your hand." d. "Your baby can nap in the car seat during the daytime."

a. "You can share your room with your baby for the next few weeks." The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome.

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching? a. "You should take the medication within 72 hours following unprotected sexual intercourse." b. "You should avoid taking this medication if you are on an oral contraceptive." c. "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test." d. "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it."

a. "You should take the medication within 72 hours following unprotected sexual intercourse." Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse.

A nurse is reviewing the medical record at 1800 for client who is at 34 weeks of gestation. Based on the chart findings and documentation the nursing plan of care should include which of the following actions? a. Administer terbutaline. b. Discuss possible genetic anomalies with the client. c. Administer nalbuphine. d. Discontinue external fetal monitoring.

a. Administer terbutaline. The nurse should administer terbutaline to stop contractions because the laboratory results indicate that the fetus's lungs are not mature enough for birth.

A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take? a. Apply sacral counterpressure. b. Perform transcutaneous electrical nerve stimulation (TENS). c. Initiate slow-paced breathing. d. Assist with biofeedback.

a. Apply sacral counterpressure. The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.

A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider? a. Bilirubin 9 mg/dL b. Hemoglobin 18 g/dL c. Platelets 175,0000/mm3 d. Hematocrit 45%

a. Bilirubin 9 mg/dL A bilirubin level of 9 mg/dL is above the expected reference range for a newborn who is 4 hr old. The expected reference range for a newborn who is less than 24 hr old is 2 to 6 mg/dL. The nurse should report this finding to the provider. This hemoglobin level is within the expected reference range of 14 to 24 g/dL for a newborn and does not require reporting. This platelet count is within the expected reference range of 150,000 to 300,000/mm3 for a newborn and does not require reporting. This hematocrit level is within the expected reference range of 44% to 64% for a newborn and does not require reporting.

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptive? a. Cholecystitis b. Hypertension c. Human papillomavirus d. Migraine headaches e. Anxiety disorder

a. Cholecystitis A history of gallbladder disease is a contraindication for the use of oral contraceptives. b. Hypertension Hypertension is a contraindication for the use of oral contraceptives. d. Migraine headaches A history of migraine headaches is a contraindication for the use of oral contraceptives.

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? a. Cover the newborn's eyes while under the phototherapy light. b. Keep the newborn in a shirt while under the phototherapy light. c. Apply a light moisturizing lotion to the newborn's skin. d. Turn and reposition the newborn every 4 hr while undergoing phototherapy.

a. Cover the newborn's eyes while under the phototherapy light. Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light.

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura. Which of the following findings should the nurse expect? a. Decreased platelet count b. Increased erythrocyte sedimentation rate (ESR) c. Decreased megakaryocytes d. Increased WBC

a. Decreased platelet count A client who has ITP has an autoimmune response that results in a decreased platelet count.

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first? a. Determine respiratory function. b. Increase the IV fluid rate. c. Access emergency medications from cart. d. Collect a maternal blood sample for coagulopathy studies.

a. Determine respiratory function. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation.

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following? a. Emotional lability b. Focusing phase c. Cognitive restructuring d. Couvade syndrome

a. Emotional lability The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.) a. Flaccid uterus b. Cervical laceration c. Excess vaginal bleeding d. Increased afterbirth cramping e. Increased maternal temperature

a. Flaccid uterus Oxytocin increases the contractility of the uterus. c. Excess vaginal bleeding Oxytocin enhances uterine contractility, decreasing vaginal bleeding.

A nurse is reviewing the laboratory results for who is at 10 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider? a. Hemoglobin 10 g/dL b. WBC count 15,000/mm3 c. RBC count 5.8 million/mm3 d. Hematocrit 34%

a. Hemoglobin 10 g/dL A hemoglobin level of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this laboratory finding to the provider. This white blood cell count is within the expected reference range of 5,000 to 15,000/mm3 for a client who is pregnant. This finding is does not require reporting. This red blood cell count is within the expected reference range of 5 to 6.25 million/mm3 for a client who is pregnant and does not require reporting. This count increases by 20% to 30% during pregnancy. This hematocrit is within the expected reference range of greater than 33% for a client who is pregnant and does not require reporting.

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following should the nurse expect? a. Jitteriness b. Hypertonia c. Abdominal distention d. Mottling

a. Jitteriness Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia.

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next? a. Massage the client's fundus. b. Insert an indwelling urinary catheter. c. Administer oxygen at 10 L/min. d. Elevate the client's right hip.

a. Massage the client's fundus. The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions.

A nurse is reviewing the medical record of a newly admitted client it was at 32 weeks gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring? a. Oligohydramnios b. Hyperemesis gravidarum c. Leukorrhea d. Periodic tingling of the fingers

a. Oligohydramnios The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.

A nurse is calculating a client's expected date of birth using Naegele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth? a. September 3rd b. September 20th c. August 3rd d. August 20th

a. September 3rd When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.

A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which fo the following findings should the nurse instruct the client to notify the provider? a. Shortness of breath b. Breakthrough bleeding c. Vomiting d. Breast tenderness

a. Shortness of breath The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain.

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? a. Swelling of the face b. Varicose veins in the calves c. Nonpitting 1+ ankle edema d. Hyperpigmentation of the cheeks

a. Swelling of the face Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.

A nurse is teaching a client who is Rh negative about Rh0(D) immune globulin. Which of the following statements by the client indicated understanding of the teaching? a. "I will receive this medication if my baby is Rh-negative." b. "I will receive this medication when I am in labor." c. "I will need a second dose of this medication when my baby is 6 weeks old." d. "I will need this medication if I have an amniocentesis."

b. "I will receive this medication when I am in labor." Rho(D) immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements for the nurse make about the indication for the medication and administration? a. "This medication will stop your labor." b. "This medication stimulates fetal lung maturity." c. "This medication will decrease your risk for uterine infections." d. "This medication will increase your baby's weight."

b. "This medication stimulates fetal lung maturity." The nurse should inform the client that betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of enzymes that release lung surfactant.

A nurse is speaking with a client who is trying to make a decision about tubal ligation. the client asks, "What effects will this procedure have on my sex life?" Which of the following responses should the nurse make? a. "I think that is something you should discuss with your doctor." b. "This procedure should have no effect on your sexual performance or adequacy." c. "You'll be fine. I can't imagine you and your partner will have any problems with sexual function." d. "If this concerns you, perhaps you should reconsider and use another form of contraception."

b. "This procedure should have no effect on your sexual performance or adequacy." The nurse is giving the client the information she is seeking. Sexual function depends on various hormonal and psychological factors. Therefore, tubal occlusion should have no physiological effect on sexual function.

A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statement should the nurse include in the teaching? a. "You should replace the diaphragm every 5 years." b. "You should leave the diaphragm in place for at least 6 hours after intercourse." c. "You should use an oil-based product as a lubricant when inserting the diaphragm." d. "You should insert the diaphragm when your bladder is full."

b. "You should leave the diaphragm in place for at least 6 hours after intercourse." The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy.

A nurse on a antepartum unit is caring for four clients. Which of the following client to the nurse identify as a priority? a. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL b. A client who is at 34 weeks of gestation and reports epigastric pain c. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL d. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria

b. A client who is at 34 weeks of gestation and reports epigastric pain When using the urgent vs nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority.

A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse include in the plan of care for lactation suppression? a. Place warm, moist packs on the breasts. b. Apply cabbage leaves to the breasts. c. Wear a loose-fitting bra. d. Put green tea bags on the breasts.

b. Apply cabbage leaves to the breasts. Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement.

A nurse is preforming a vaginal exam on a client who is in labor and observes the umbilical cord is protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next? a. Place a rolled towel beneath one of the client's hips. b. Apply internal upward pressure to the presenting part using two gloved fingers. c. Administer oxygen to the client via a nonrebreather mask at 10 L/min. d. Increase the IV infusion rate.

b. Apply internal upward pressure to the presenting part using two gloved fingers. Using evidence-based practice, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand.

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? a. Decreased heart rate b. Chin quivering c. Pinpoint pupils d. Slowed respirations

b. Chin quivering Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow.

A nurse is caring for a client who is at 22 weeks of gestation and reports concerns about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take? a. Tell the client to follow up with a dermatologist. b. Explain to the client this is an expected occurrence. c. Explain to the client this is an expected occurrence. d. Inform the client she might have an allergy to her skin care products.

b. Explain to the client this is an expected occurrence. Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery.

A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take? a. Restrict hourly fluid intake to 150 mL/hr. b. Have calcium gluconate readily available. c. Assess deep tendon reflexes every 6 hr. d. Monitor intake and output every 4 hr.

b. Have calcium gluconate readily available. The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity.

A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)? a. Just above the umbilicus b. Just above the symphysis pubis c. The right lower quadrant d. The left lower quadrant

b. Just above the symphysis pubis At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis.

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication? a. Increased fetal movement b. Leakage of fluid from the vagina c. Upper abdominal discomfort d. Urinary frequency

b. Leakage of fluid from the vagina Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider.

A nures is providing discharge teaching to the parents of newborn about car seat safety. Which of the following instructions should the nurse include? a. Place the shoulder harness in the slots above the newborn's shoulders. b. Place the retainer clip at the level of the newborn's armpits. c. Place the newborn at a 60° angle in the car seat. d. Place the newborn in a blanket before securing them in the car seat.

b. Place the retainer clip at the level of the newborn's armpits. The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits.

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority? a. O2 saturation b. Temperature c. Blood pressure d. Urinary output

b. Temperature The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.

A nurse is caring for a client who is in labor and reports increasing rectal pressure. She has experience contractions 2 to 3 minutes apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to nine centimeters. The nurse should identify that the client is in which of the following phases of Labor? a. Active b. Transition c. Latent d. Descent

b. Transition The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds. The active phase of labor is characterized by a cervical dilatation of 4 to 7 cm and contractions every 3 to 5 min, each lasting 40 to 70 seconds. The latent phase of labor is characterized by cervical dilation of 0 to 3 cm and contractions every 5 to 30 min, each lasting 30 to 45 seconds. The descent phase of labor is characterized by active pushing with contractions every 1 to 2 min, each lasting for 90 seconds.

A nurse is caring for a newborn who was transferred to the nursery 30 min after delivery. Which of the following actions should the nurse take first? a. Confirm the newborn's Apgar score. b. Verify the newborn's identification. c. Administer vitamin K to the newborn. d. Determine obstetrical risk factors.

b. Verify the newborn's identification. When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery.

A nurse is teaching a client who is at 24 weeks of gestation regarding a one hour glucose tolerance test. Which of the following statements should the nurse include in the teaching? a. "You will need to drink the glucose solution 2 hours prior to the test." b. "Limit your carbohydrate intake for 3 days prior to the test." c. "A blood glucose of 130 to 140 is considered a positive screening result." d. "You will need to fast for 12 hours prior to the test."

c. "A blood glucose of 130 to 140 is considered a positive screening result." The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus.

A nurse is teaching a client who has pregestational type 1 DM about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. "I should have a goal of maintaining my fasting blood glucose between 100 and 120." b. "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." c. "I will continue taking my insulin if I experience nausea and vomiting." d. "I will ensure that my bedtime snack is high in refined sugar.

c. "I will continue taking my insulin if I experience nausea and vomiting." The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes.

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? a. "I will get injections of the medication once daily until my labor stops." b. "My blood sugar may be low while I'm on this medication." c. "I will have blood tests because my potassium might decrease." d. "My blood pressure may increase while I'm on this medication."

c. "I will have blood tests because my potassium might decrease." An adverse effect of terbutaline is hypokalemia.

A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching? a. "You will receive IV fluids prior to this test." b. "The procedure will take approximately 10 to 15 minutes." c. "You will be offered orange juice to drink during the test." d. "You will need to sign an informed consent form each time you have this test."

c. "You will be offered orange juice to drink during the test." A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate fetal movements during the procedure, helping to obtain results.

A nurse is assessing a client who gave birth vaginally 12 hours ago and palpate her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform? a. Reassess the client in 2 hr. b. Administer simethicone. c. Assist the client to empty her bladder. d. Instruct the client to lie on her right side.

c. Assist the client to empty her bladder. The nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage.

A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? a. Percutaneous umbilical blood sampling b. Amnioinfusion c. Biophysical profile (BPP) d. Chorionic villus sampling (CVS)

c. Biophysical profile (BPP) The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli.

A nurse is reviewing the laboratory report of a newborn he was 24 hours old. Which of the following results should the nurse expect to report to the provider? a. Hgb 20 g/dL b. Total bilirubin 5 mg/dL c. Blood glucose 30 mg/dL d. WBC count 20,000/mm3

c. Blood glucose 30 mg/dL Newborns less than 24 hr old should have a blood glucose of 40 to 45 mg/dL. A blood glucose level of 30 mg/dL is below the expected reference range for a newborn who is 24 hr old and should be reported to the provider.

A nurse is teaching a client who is at 35 weeks of gestation about clinical manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include? a. Shortness of breath when climbing stairs b. Swelling of feet and ankles at the end of the day c. Headache that is unrelieved by analgesia d. Braxton Hicks contractions

c. Headache that is unrelieved by analgesia A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider.

A nurse at a women's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase your daily intake of which of the following nutrients? a. Calcium b. Vitamin E c. Iron d. Vitamin D

c. Iron The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old.

A nurse is assessing fetal heart tones for a client who is pregnant the nurse is determined the fetal position as left occipital anterior. To which of the following areas of the clients abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity to the fetal heart? a. Left upper quadrant b. Right upper quadrant c. Left lower quadrant d. Right lower quadrant

c. Left lower quadrant The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant.

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care? a. Place the client in a supine position for 30 min following the first dose of anesthetic solution. b. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution. c. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. d. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution.

c. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution.

A nurse is preparing to perform Leopold Maneuvers for a client. Identify the sequence the nurse should follow. a. Determine the location of the fetal back. b. Identify the attitude of the head. c. Palpate the fundus to identify the fetal part. d. Palpate for the fetal part presenting at the inlet.

c. Palpate the fundus to identify the fetal part. a. Determine the location of the fetal back. d. Palpate for the fetal part presenting at the inlet. b. Identify the attitude of the head. The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? a. Acrocyanosis of the extremities b. Murmur at the left sternal border c. Substernal chest retractions while sleeping d. Positive Babinski reflex

c. Substernal chest retractions while sleeping Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This manifestation requires further assessment and intervention by the nurse.

A nurse is providing discharge teaching to a client who has postpartum. For which of the following manifestation should the nurse instruct the client to monitor and report to the provider? a. Persistent abdominal striae b. Temperature 37.8° C (100° F) c. Unilateral breast pain d. Brownish-red discharge on day 5

c. Unilateral breast pain Sudden onset of chills, fever, malaise, body aches, headaches, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this manifestation to the provider.

A nurse is teaching a new mother about steps the nurses will take to promote the security and safety of the newborn. Which of the following statements should the nurse make? a. "The nurse will carry your newborn to the nursery for procedures." b. "We will document the relationship of visitors in your medical record." c. "Your baby will stay in the nursery while you are asleep." d. "Staff members who take care of your baby will be wearing a photo identification badge."

d. "Staff members who take care of your baby will be wearing a photo identification badge." The nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs.

A nurse is caring for a client who is in active labor and has no cervical change in the last four hours. Which of the following statement should the nurse make? a. "Let me help you into a comfortable pushing position so you can begin bearing down." b. "I am going to call the doctor to get a prescription for medication to ripen your cervix." c. "I will give you some IV pain medicine to strengthen your contractions." d. "Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions."

d. "Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions." Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, frequency, and duration which will identify whether the contractions are adequate for progression of labor.

A nurse is planning care for a client who is two hours postpartum. Which of the following intervention should the nurse plan to implement during the taking hold phase of postpartum behavioral adjustment? a. Discuss contraceptive options with the client and her partner. b. Repeat information to ensure client understanding. c. Listen to the client and her partner as they reflect upon the birth experience. d. Demonstrate to the client how to perform a newborn bath.

d. Demonstrate to the client how to perform a newborn bath. Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new parent moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new parent confidence and promote maternal adjustment.

A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following actions should the nurse take? a. Perform a vaginal exam to determine cervical dilation every 2 hr. b. Instruct the client to ambulate in the hallway once every 4 hr. c. Administer betamethasone to the client via IM injection. d. Initiate continuous external fetal monitoring.

d. Initiate continuous external fetal monitoring. The nurse should identify that a client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor laboratory values. Also, the nurse should implement interventions to prepare for an emergency birth.

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care? a. Maintain the client NPO throughout the procedure. b. Place the client in a supine position. c. Instruct the client to massage the abdomen to stimulate fetal movement. d. Instruct the client to press the provided button each time fetal movement is detected.

d. Instruct the client to press the provided button each time fetal movement is detected. Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.

A nurse is reviewing the medical record of a client who has postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider? a. Hct 39% b. Serum albumin 4.5 g/dL c. WBC 9,000/mm3 d. Platelets 50,000/mm3

d. Platelets 50,000/mm3 A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider.

A nurse is teaching a new mother how to use a bulb syringe to suction her newborn secretions. Which of the following instructions should the nurse include? a. Insert the syringe tip before compressing the bulb. b. Suction each of the nares before suctioning the mouth. c. Insert the tip of the syringe into the center of the newborn's mouth. d. Stop suctioning when the newborn's cry sounds clear.

d. Stop suctioning when the newborn's cry sounds clear. The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus.

A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? a. Large for gestational age b. Hyperglycemia c. Bradypnea d. Vomiting

d. Vomiting Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.