maternity uworld

A 37-weeks-pregnant woman comes to the emergency department with a fractured ankle. Which assessment finding is most concerning and requires the nurse to follow up? 1. Fetal heart rate remains 206/min 2. Fetus kicked 4 times in the past hour 3. Mother reports feeling 2 contractions every hour 4. Mother's hemoglobin is 11 g/dL (110 g/L)

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A client at 38 weeks gestation is brought to the emergency department after a motor vehicle crash. She reports severe, continuous abdominal pain. The nurse notes frequent uterine contractions and mild, dark vaginal bleeding. What actions should the nurse take? Select all that apply. 1. Anticipate emergent cesarean birth 2. Apply continuous external fetal monitoring 3. Assess routine vital signs every 4 hours 4. Draw blood for type and crossmatch 5. Initiate IV access with a 22-gauge catheter

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A client indicates a desire to become pregnant. What are important preconception education topics for the nurse to provide for this client? Select all that apply. 1. Aim for a BMI of <25 kg/m2 2. Avoid alcohol consumption and tobacco products 3. Ensure daily intake of 400-800 mcg of folic acid 4. Obtain testing for rubella immunity 5. Schedule dental wellness appointment

1

A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention? 1. Lochia that soaks a perineal pad every 2 hours 2. Persistent headache with blurred vision 3. Red, painful nipple on one breast 4. Strong-smelling vaginal discharge

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A couple is excited about finding out the sex of their baby during ultrasound at 14 weeks gestation. What is the nurse's best response? 1. "Basic structures of major organs are not yet formed." 2. "External genitalia are not usually visualized until 21-24 weeks." 3. "If the baby is in the right position, the genitalia may be visualized." 4. "Sex cannot be determined until fetal movement is felt."

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A neonate on ventilator support is diagnosed with trisomy 18 (Edwards syndrome). What would be an appropriate action by the nurse? 1. Discuss a plan to decrease ventilator support as the lungs become stronger with the parents 2. Provide parents with information on the medical treatment plan for the neonate 3. Provide the test results to the parents and give them information to read about trisomy 18 4. Request a meeting with the palliative care team and the parents to discuss end-of-life choices

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A nurse is caring for a client who had a vaginal birth 2 hours ago. The client has saturated a perineal pad in 20 minutes. During assessment, the nurse notices that the client has a boggy fundus that is deviated to the right and slightly above the umbilicus. Which intervention should the nurse perform first? 1. Assist client to use the bedpan to void 2. Begin oxytocin IV infusion at 125 milliunits/min 3. Obtain a complete blood count 4. Start oxygen delivery at 10 L/min via nonrebreather facemask

1

The nurse is admitting a client at 41 weeks gestation for induction of labor due to oligohydramnios. Considering the client's indication for induction, what should the nurse anticipate? 1. Additional neonatal personnel present for birth 2. Intermittent fetal monitoring during labor 3. Need for forceps-assisted vaginal birth 4. Need for uterotonic drugs for postpartum hemorrhage

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The nurse is caring for a client who reports severe abdominal pain and vaginal spotting. The client had a positive urine pregnancy test at home, and her last menstrual period was 8 weeks ago. Which client report to the nurse is most concerning? 1. Abdominal pain rated as 8 out of 10 2. History of pelvic inflammatory disease 3. Intermittent nausea and vomiting for the past 7 days 4. Right shoulder pain and dizziness

1

The nurse is counseling a pregnant client who is HIV positive. Which information is appropriate to discuss? 1. Infant should be exclusively breastfed for 6 months to receive maternal antibodies [3%] 2. Infant will not require treatment for HIV after birth [3%] 3. Prescribed antiretroviral therapy should be continued during pregnancy [81%] 4. Tetanus-diphtheria-pertussis vaccine should be avoided until after birth [10%]

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The nurse is performing an assessment on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply. 1. Bright red bleeding from anus 2. Distended abdomen 3. Has not passed stool (meconium) 4. Nonbilious vomiting 5. Refusal to feed

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The nurse is providing education to several first-trimester pregnant clients. Which client requires priority anticipatory teaching? 1. Client who gardens and eats homegrown vegetables 2. Client who has gained 4 lb (1.8 kg) from prepregnancy weight 3. Client who has noticed thin, milky white vaginal discharge 4. Client who practices yoga and swims in a pool 3 times a week

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The nurse receives report on 4 first-trimester pregnant clients. Which client should the nurse assess first? 1. Client with hydatidiform mole reporting dark brown vaginal discharge 2. Client with hyperemesis gravidarum reporting excessive vomiting and weight loss 3. Client with suspected ectopic pregnancy reporting abdominal and shoulder pain 4. Client with threatened miscarriage who says, "I am a Jehovah's Witness."

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The nurse reviews the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has an increased risk of postpartum hemorrhage? 1. Infant birth weight of 9 lb 2 oz (4139 g) 2. Labor and birth without pain medication 3. Labor that lasted 8 hours 4. Third stage of labor lasting 20 minutes

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The nurse has received report on 4 clients. Which client should the nurse assess first? 1. Client, gravida 5, para 5, post vaginal delivery who is soaking a perineal pad every hour 2. Client post cesarean delivery who has deep venous thrombosis and is receiving enoxaparin 3. Client post cesarean delivery who has fever with a red and swollen breast 4. Client post vaginal delivery who has mild cramping and foul-smelling lochia

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The nurse performing an initial newborn assessment after birth observes a bluish discoloration of the hands and feet. The trunk has a pink color. What is the nurse's initial action? 1. Apply oxygen and count respirations 2. Assess heart sounds for a murmur 3. Observe for expiratory grunting 4. Place infant skin-to-skin with mother

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A client is at 20 weeks gestation. The client reports having to "run to the bathroom all the time," "it hurts to pee," and my urine "smells bad." Which statement by the nurse is the most appropriate? 1. "Drink cranberry juice to relieve the symptoms." 2. "Make sure to wipe from the front to the back after voiding." 3. "Most women have urinary frequency at this stage and it is normal." 4. "You may need to be checked for a urinary tract infection."

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The nurse is providing nutrition counseling during a preconception visit to a client who does not eat green vegetables. In addition to a daily prenatal vitamin, which foods can the client add to the daily diet to decrease the risk of neural tube defects? Select all that apply. 1. Black beans and rice 2. Fortified breakfast cereal and milk 3. Medium baked sweet potato 4. Peanut butter on whole wheat toast 5. Raw carrots with cheese dip

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The nurse performs initial assessments of four clients in a prenatal clinic. Which client findings are abnormal and require further assessment? 1. Client at 9 weeks gestation with a normal BMI and a weight gain of 2 lb (1 kg) from pre-pregnancy weight 2. Client at 15 weeks gestation with headaches relieved by acetaminophen 3. Client at 19 weeks gestation with bleeding gums after brushing and flossing teeth 4. Client at 20 weeks gestation with an increase in diastolic blood pressure of 15 mm Hg since last visit

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A client denies illicit drug use but has some suspicious behaviors. The client's neonate has a low birth weight. What other signs would lead the nurse to suspect neonatal abstinence syndrome? Select all that apply. 1. Irritability and restlessness 2. Meconium ileus and floppy tone 3. Microencephaly and cleft palate 4. Poor feeding and loose stools 5. Stuffy nose and frequent sneezing

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The nurse is teaching about prevention of sudden infant death syndrome (SIDS) to a group of parents with newborns. Which recommendations does the nurse suggest for SIDS prevention? Select all that apply. 1. Breastfeeding 2. Co-sleeping in parent's bed 3. Side-lying sleeping position 4. Smoking cessation by parents 5. Up-to-date vaccinations

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The nurse is teaching the mother of a newborn about gastroesophageal reflux. What does the nurse suggest to help prevent reflux? Select all that apply. 1. Burp during and after feeds 2. Engage baby in active play after the feeding 3. Feed baby in side-lying position 4. Hold baby upright 20-30 minutes after each feeding 5. Offer smaller but more frequent feeds 6. Place baby on tummy after feeding

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The nurse is caring for a baby born at 30 weeks gestation and diagnosed with necrotizing enterocolitis. Which nursing action should be implemented? 1. Encourage parents to increase skin-to-skin care 2. Measure abdominal girth daily 3. Measure rectal temperature every 3-4 hours 4. Position client on side and check diaper for stool

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When assessing newborns, the nursery nurse should report which findings to the health care provider? Select all that apply. 1. Chest wall retractions 2. Desquamation of the feet 3. Head circumference of 13 in (33 cm) 4. Jaundiced appearance 5. Not voiding in 24 hours

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Within thirty seconds after birth, an unresponsive and limp newborn is placed on the warmer in the "sniffing" position. The nurse clears the airway, dries, and stimulates the newborn. At 1 minute of life, the newborn has shallow, gasping respirations with a heart rate of 62/min. What action should the nurse take? 1. Administer epinephrine 2. Begin positive pressure ventilation 3. Continue stimulating the newborn 4. Start chest compressions

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The nurse is documenting assessments of pregnant clients in the antepartum unit. Which client's assessment findings are most important to report to the health care provider? 1. Client at 28 weeks gestation with an asymptomatic systolic murmur 2. Client at 34 weeks gestation with 1+ edema of bilateral lower extremities 3. Client at 35 weeks gestation with painful genital lesions 4. Client at 39 weeks gestation with brownish, mucoid vaginal discharge

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A client at 39 weeks gestation with preeclampsia has a blood pressure of 170/100 mm Hg, 2+ proteinuria, and moderate peripheral edema. Immediately after hospital admission, she develops seizures and uterine contractions. Magnesium sulfate is prescribed. Which finding indicates that the drug has achieved the desired therapeutic effect? 1. Blood pressure <130/80 mm Hg 2. Seizure activity stops 3. Urine has 1+ protein 4. Uterine contractions stop

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A 28-year-old client is admitted to the labor and delivery unit for severe preeclampsia. She is started on IV magnesium sulfate. Which signs indicate that the client has developed magnesium sulfate toxicity? Select all that apply. 1. 0/4 patellar reflex 2. Blood pressure is 156/84 mm Hg 3. Client voided 600 mL in 8 hours 4. Respirations are 10/min 5. Serum magnesium level is 5 mEq/L (2.5 mmol/L)

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A client comes to the clinic indicating that a home pregnancy test was positive. The client's last menstrual period was September 7. Today is December 7. Which are true statements for this client? Select all that apply. 1. According to Naegele's rule, the expected date of delivery is June 14 2. Detection of the fetal heart rate via Doppler is possible 3. Fundal height should be 24 cm above the symphysis pubis 4. The client should be feeling fetal movement 5. Urinary frequency is a common symptom

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A client postpartum 3 days scheduled for discharge today was given education about diaper changes yesterday. The client says to the nurse, "I'm so glad you are here. I think my baby has a dirty diaper. I can't change it as well as you can. Will you change my baby's diaper for me?" What is the nurse's best response? 1. Reassure the mother that it takes time to learn how to care for a baby while quickly changing the diaper 2. Suggest that the mother change the diaper as the nurse watches 3. Tell the mother that it is time to take over changing the baby's diaper as she will have to do it once discharged 4. Tell the mother that the nurse will change the baby's diaper while she watches

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A full-term newborn of a mother with gestational diabetes is slightly jittery with a blood glucose level of 45 mg/dL (2.2 mmol/L). What is the nurse's first action? 1. Administer oral glucose 2. Feed the newborn 3. Notify the pediatrician 4. Warm the room

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A nurse is teaching a client about formula preparation for a newborn. Which statements by the client indicate proper understanding? Select all that apply. 1. "I can add water to the formula if my baby wants to eat more frequently." 2. "I must wash the top of the concentrated formula can before opening it." 3. "I shouldn't heat formula in the microwave for more than 1 minute." 4. "If my baby does not finish the bottle, the leftover milk should be refrigerated." 5. "Prepared formula should be kept in the refrigerator and discarded after 48 hours."

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A pregnant client arrives in the labor and delivery unit with mild contractions and brisk, painless vaginal bleeding. The client received no prenatal care and reports being "about 7-8 months." Which actions should the nurse anticipate? Select all that apply. 1. Blood draw for type and screen 2. Electronic fetal monitoring 3. Initiation of 2 large-bore IV catheters 4. Pad counts to assess bleeding 5. Vaginal examination for cervical dilation

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A pregnant client comes in for a routine first prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. Where would the nurse expect to palpate the uterine fundus in this client? 1. 12 cm above the umbilicus 2. At the level of the umbilicus 3. Halfway between the symphysis pubis and the umbilicus 4. Just above the symphysis pubis

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A pregnant client provides the following obstetric history to the nurse at the first prenatal visit: Elective abortion at age 17; a 5-year-old daughter born at 40 weeks gestation; and 3-year-old twin boys born at 34 weeks gestation. Using the GTPAL system, which option is correct? 1. G3, T1, P1, A1, L3 2. G3, T1, P2, A1, L3 3. G4, T1, P1, A1, L3 4. G4, T1, P2, A1, L3

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Exhibit The nurse assesses a newborn with skin discoloration in the lumbar area, as shown in the exhibit. What would be an appropriate action for the nurse to complete? Click the exhibit button for additional information. 1. Assess the infant's hemoglobin, hematocrit, and platelet levels 2. Measure and document the size and location of the markings 3. Notify the health care provider of the markings immediately 4. Review the delivery record for evidence of a traumatic birth

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The clinic nurse is collecting data on a pregnant client in the first trimester. Which finding is most concerning and warrants priority intervention? 1. Client has not been taking prenatal vitamins 2. Client is taking lisinopril to control hypertension 3. Client reports a whitish vaginal discharge 4. Client reports mild cramping pain in the lower abdomen

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The initial prenatal laboratory screening results of a client at 12 weeks gestation indicate a rubella titer status of nonimmune. What will the nurse anticipate as the plan of care for this client? 1. Administer measles-mumps-rubella (MMR) vaccine now 2. Administer MMR vaccine immediately postpartum 3. Administer MMR vaccine in the third trimester [ 4. An MMR vaccine is not indicated for this client

2

The nurse is caring for a client in the first trimester during an initial prenatal clinic visit. Based on the information provided by the client, which factor places the client at an increased risk for preterm labor? 1. Age 25 2. Periodontal disease 3. Vegetarian diet 4. White ethnicity

2

The nurse is preparing a nutritional teaching plan for a client planning to become pregnant. Which foods would best prevent neural tube defects? 1. Calcium-rich snacks 2. Fortified cereals 3. Organ meats 4. Wild salmon

2

The nurse is preparing to assess a client visiting the women's health clinic. The client's obstetric history is documented as G5T1P2A1L2. Which interpretation of this notation is correct? 1. The client had 1 birth at 37 wk 0 d gestation or beyond 2. The client had 3 births between 20 wk 0 d and 36 wk 6 d gestation 3. The client has 3 currently living children 4. The client is currently not pregnant

2

The nurse is teaching a client, gravida 1 para 0, at 8 weeks gestation about expected weight gain in pregnancy. The client's prepregnancy BMI is 21 kg/m2. Which statement made by the client indicates an understanding about weight gain? 1. "I should gain 10-15 lb (4.5-6.8 kg) during the first trimester." 2. "I should gain a total of about 30 lb (13.6 kg) during my pregnancy." 3. "I should gain no more than 0.5 lb (0.2 kg) per week during the third trimester." 4. "If I gain <20 lb (9.1 kg) during pregnancy, it will be easier to lose weight postpartum."

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Which finding is most important for the nurse to report to the health care provider? 1. 24 weeks gestation, hemoglobin is 9 g/dL (90 g/L) 2. 24 weeks gestation, 1-hour (50 g) oral glucose screen is 120 mg/dL (6.7 mmol/L) 3. 27 weeks gestation, vaginal secretion is pH 5 4. 36 weeks gestation, white blood cell count is 13,000/mm3 (13.0 x 109/L)

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A pregnant client at 30 weeks gestation comes to the prenatal clinic. Which vaccines may be administered safely at this prenatal visit? Select all that apply. 1. Influenza injection 2. Influenza nasal spray 3. Measles, mumps, and rubella 4. Tetanus, diphtheria, and pertussis 5. Varicella

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After giving birth to a full-term neonate, the client informs the nurse that she has been taking hydrocodone on a regular basis for several years. What should the nurse plan as part of the neonate's care? 1. Feed newborn while swaddled 2. Keep newborn close to the nurse's station 3. Position newborn supine after feeding 4. Stimulate newborn with light regularly

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The nurse is performing a postpartum assessment 12 hours after the prolonged vaginal delivery of a term infant. Which assessment findings should be reported to the health care provider? 1. Complaints of discomfort during fundal palpation 2. Foul-smelling lochia 3. Oral temperature 100.1 F (37.8 C) 4. White blood cell (WBC) count 24,000/mm3 (24.0 x 109/L)

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A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply. 1. Blood pressure 82/64 mm Hg 2. Crackles on auscultation 3. Distended jugular veins 4. Pulse 120/min 5. Shoulder pain

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A client in the postpartum unit has a temperature of 100.9 F (38.3 C) and tachycardia on the second day following a cesarean delivery. Examination shows uterine tenderness, fundus +2 above the umbilicus, moderate lochia rubra with a foul smell, and chills. Which prescription should the nurse implement first? 1. Acetaminophen 500 mg, 2 tablets orally for fever 2. Clindamycin and gentamicin, first dose 3. Insertion of saline IV lock 4. Serum laboratory draws for blood culture and sensitivity

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A nurse is caring for a pregnant client at 27 weeks gestation after a motor vehicle collision with side airbag deployment. The client's blood type is O negative. Which laboratory test should the nurse anticipate? 1. Group B streptococcal culture 2. Indirect Coombs test 3. Rubella immunity titer 4. Serum alpha-fetoprotein

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A nurse is caring for a pregnant client who has hyperemesis gravidarum. Which findings should the nurse anticipate? 1. Blood pressure of 160/94 mm Hg 2. Large amounts of urine protein 3. Positive urine ketones (moderate) 4. Potassium of 3.2 mEq/L (3.2 mmol/L) 5. Pulse rate of 106/min

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A nurse is providing care to a group of postpartum clients. Which client comment should prompt further investigation? 1. "I feel so exhausted that I started taking naps when the baby sleeps." 2. "I have trouble sleeping well at night because I worry that I won't hear the baby cry." 3. "My aunt has come over every day to care for the baby because the baby's cries bother me." 4. "My spouse thinks that I have been more emotional since I had the baby last week."

3

A pregnant client in the first trimester tells the clinic nurse she will be traveling to an area with a known Zika virus outbreak and expresses concern regarding disease transmission. Which statement by the nurse is most appropriate? 1. "If you experience Zika symptoms, notify your health care provider." 2. "Take precautions against mosquito bites throughout the trip." 3. "You are not far enough along for the Zika virus to affect your baby." 4. "You should consider postponing your trip until after you have the baby."

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Exhibit The nurse reviews laboratory test results for a pregnant client at 32 weeks gestation. What is the nurse's best action based on these results? Click on the exhibit button for additional information. 1. Complete the client assessment and documentation 2. Draw another sample for repeat complete blood count 3. Prepare for transfusion of packed red blood cells 4. Request a prescription for iron supplementation

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The nurse and unlicensed assistive personnel (UAP) are performing rounds on their clients. The nurse notes that a 2-hour post vaginal delivery client has saturated the peripad with rubra drainage. What should the nurse do next? 1. Have the UAP change the client's peripad 2. Immediately assess the client's fundus 3. Obtain a stat hemoglobin and hematocrit 4. Tell the UAP to increase the IV line to 150 mL/hr

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The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply. 1. One artery and one vein in the umbilical cord 2. Plantar creases up the entire sole 3. Skin on the nose blanches to a yellowish hue 4. Toes fan outward when the lateral sole surface is stroked 5. White pearl-like cysts on gum margins

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The nurse is performing an assessment on a neonate shortly after delivery. The nurse is most concerned about which assessment finding? 1. Bilateral rales found on lung auscultation 2. Dullness over bladder found on percussion 3. Ptosis of right eyelid found on facial inspection 4. Single testicle found on genital palpation

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The postpartum nurse is assessing a client who gave birth by cesarean section 5 hours ago and is requesting pain medication. The client appears restless, has a heart rate of 110/min, and admits to recent onset of anxiety. What priority action should the nurse take? 1. Assess for lower extremity warmth and redness 2. Instruct the client in relaxation breathing techniques 3. Obtain oxygen saturation reading by pulse oximeter 4. Offer the client prescribed PRN pain medication

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The registered nurse is teaching a class of expectant parents about infant safety. Which statement by a class participant indicates a need for further instruction? 1. "I will make sure there is a firm mattress in the crib." 2. "I will put my baby to bed with a pacifier." 3. "I will tie bumper pads to the sides of the crib to protect my baby's head." 4. "I will use a sleeping sack or a thin tucked blanket to cover my baby."

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Which client in a prenatal clinic should the nurse assess first? 1. Client at 11 weeks gestation with backache and pelvic pressure 2. Client at 16 weeks gestation with earache and sinus congestion 3. Client at 27 weeks gestation with headache and facial edema 4. Client at 37 weeks gestation with white vaginal discharge and urinary frequency

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A 14-year-old client confides to the school nurse that she is about 22 weeks pregnant and has not had prenatal care. Which topics are most important and priorities for the nurse to discuss with the client in anticipation of referral for prenatal care? Select all that apply. 1. Adoption planning 2. Family and social support 3. Future education plans 4. Nutrition and prenatal vitamins 5. Sexual abuse

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A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)? 1. Hemoglobin and hematocrit levels 2. Human chorionic gonadotropin level 3. Serum folate level 4. White blood cell count

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A client at 39 weeks gestation is brought to the emergency department after a motor vehicle crash. The client, who is secured supine on a backboard, suddenly becomes pale with a blood pressure of 88/50 mm Hg. What action should the nurse take first? 1. Administer normal saline fluid bolus 2. Assess cervix for presenting part 3. Obtain fetal heart rate 4. Turn client laterally

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A client who is 8 weeks pregnant reports morning sickness. What is the most appropriate response by the nurse? 1. Advise the client to consume hot, versus cold, foods 2. Instruct the client to drink 2 glasses of water with each meal 3. Suggest the client consume high-protein snacks on awakening 4. Tell the client that morning sickness should pass in a few weeks

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A client with diabetes visits the clinic reporting breast tenderness, vaginal discharge, and urinary frequency. Which action is most important for the nurse to perform? 1. Ask if the client performs breast self-exams 2. Ask the client about characteristics of vaginal discharge 3. Assess the date of the client's last menstrual period 4. Review the client's home blood sugar logs

4

A nurse is measuring a uterine fundal height for a client who is at 36 weeks gestation in supine position. The client suddenly reports dizziness and the nurse observes pallor and damp, cool skin. What should the nurse do first? 1. Assess fetal heart rate and pattern [5%] 2. Assess heart and lung sounds [2%] 3. Notify the health care provider (HCP) immediately [1%] 4. Reposition the client into a lateral position [90%]

4

A nurse is teaching a client about breastfeeding. Which statement by the client indicates correct understanding of the teaching? 1. "If I need to reposition the baby's latch, I will use my finger to break the suction first." 2. "I will feed the baby for about 5-10 minutes on each breast." 3. "I will hold the baby on the back with the head turned toward my breast." 4. "The baby should grasp only the nipple without the areola in its mouth."

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The nurse is assisting with a vaginal delivery of a full-term infant. Which assessment finding of the newborn is most important for the nurse to follow-up? 1. Flat bluish discolored area on the buttocks 2. Localized soft tissue edema of the scalp 3. Small amount whitish substance in axilla 4. Tuft of hair at the base of the spine

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The nurse is caring for a group of 1-day-old clients in the newborn nursery. Which finding requires immediate attention? 1. Abdominal breathing with 15-second pauses in a sleeping newborn 2. Apical pulse of 190/min in a newborn who is crying 3. Heart murmur in a newborn who is feeding appropriately 4. Respirations of 68/min with grunting in a newborn post cesarean birth

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The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply. 1. Capillary glucose of 60 mg/dL (3.3 mmol/L) 2. Holosystolic murmur auscultated at fourth intercostal space 3. Respirations of 56 breaths per minute 4. Single transverse crease across palm of the hand 5. White papules on bridge of the nose

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The nurse is observing a student nurse care for a mother who has been unsuccessful with breastfeeding her newborn infant. Which action by the student would require the nurse to intervene? 1. Assesses the baby's position and sucking behavior during breastfeeding 2. Demonstrates to the mother how to use an electric breast pump 3. Provides supplemental formula feedings until improved breastfeeding occurs 4. Shows the mother how to hand express breast milk

4

The nurse is performing the initial assessment of a newborn. Which finding should the nurse report to the health care provider? 1. A sudden jarring of the client's crib does not produce a Moro reflex. 2. The client has swollen labia and a thin, white vaginal discharge. 3. The posterior fontanel is triangular and smaller than the anterior fontanel. 4. There are pearly, white pinpoint papules on the client's face and nose.

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When triaging 4 pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first? 1. First-trimester client reporting frequent nausea and vomiting 2. Second-trimester client with dysuria and urinary frequency 3. Second-trimester client with obesity reporting decrease in fetal movement 4. Third-trimester client with right upper quadrant pain and nausea

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Which assessment findings would the nurse most likely expect to find in a male infant born at 28 weeks gestation? Select all that apply. 1. Abundant lanugo on shoulders and back 2. Deep creases and peeling skin on soles of feet 3. Flat areolae without palpable breast buds 4. Smooth, pink skin with visible veins 5. Testes completely descended into the scrotum

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A nurse is teaching the parent how to care for a newly circumcised newborn. Which statement by the parent indicates that further teaching is needed? 1. "Discharge and odor indicate infection of the circumcision site." 2. "I will clean the area with alcohol-based wipes or soap water." 3. "Infant crying during petrolatum gauze changes is expected." 4. "The diaper should be changed at least every 4 hours."

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