NCLEX-RN (NEWBORN)

The nurse is caring for a postpartum couplet and notices that the newborn is cyanotic and apneic, with a heart rate of 70/min. The nurse calls for help and begins resuscitation. Which position is appropriate for ventilating the newborn? Before newborn resuscitation

** The nurse should place the infant on the back with the neck slightly extended to promote adequate ventilation. Very slight next extension, otherwise known as neutral or "sniffing" position, ensures a patient airway. ** The nurse may need a blanket or towel roll under the newborn's shoulders to elevate the chest 3/4-1 inch (2-2.5 cm) above the mattress.

The nurse is assessing a 4 day old, term neonate who is breastfed exclusively. Which statement finding should the nurse report to the healthcare provider for further assessment regarding possible formula supplementation? 1. 10% weight loss since birth 2. Cracked, peeling skin 3. Feeds every 2-3 hours 4. Runny, seedy, yellow stools

1. 10% weight loss since birth

The nurse is performing the initial assessment of a newborn. Which finding should the nurse report to the healthcare 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.

1. A sudden jarring of the client's crib does not produce a Moro reflex **Moro reflex (startle reflex) presents age 3-6 months. It is elicited by quickly lowering infant's head relative to the body, simulating a falling sensation. Another response is by sudden loud noises and jarring of the crib.

A nurse is preparing to administer an oxytocin IV infusion to a client for labor induction. The nurse recognizes that an oxytocin infusion may increase the client's risk for which of the following? SATA 1. Abnormal or indeterminate fetal heart rate patterns 2. Delayed breast milk production 3. Placentia previa 4. Postpartum hemorrhage 5. Uterine tachysystole

1. Abnormal or indeterminate fetal heart rate patterns 4. Postpartum hemorrhage 5. Uterine tachysystole **Oxytocin (pitocin) stimulates contraction of the uterine smooth muscle and is used to induce or augment labor and to prevent postpartum hemorrhage

Which assessment finding would the nurse most likely expect to find in a male infant born at 28 weeks gestation? SATA 1. Abundant lanugo on shoulders/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

1. Abundant lanugo on shoulders/back 3. Flat areolae without palpable breast buds 4. Smooth, pink skin with visible veins

The nurse is caring for a client at 39 weeks gestation in active labor who is receiving an oxytocin infusion. The nurse notes persistent late decelerations on the fetal monitor. Which of the following actions should the nurse take? SATA 1. Administer oxygen via a non-rebreather face mask 2. Change maternal position to the left side 3. Discontinue the oxytocin infusion 4. Notify the healthcare provider 5. Perform a nitrazine test

1. Administer oxygen via a non-rebreather face mask 2. Change maternal position to the left side 3. Discontinue the oxytocin infusion 4. Notify the healthcare provider

A nurse is evaluating the fetal monitoring strip of a laboring primigravida at 38 weeks gestation who is receiving an oxytocin infusion and has external fetal monitors and an intrauterine pressure catheter in place. Which of the following interventions should the nurse implement? SATA 1. Administer supplemental oxygen by mask 2. Initiate an IV bolus of 0.9% saline 3. Prepare for amnioinfusion 4. Reposition the client to supine 5. Stop the oxytocin infusion

1. Administer supplemental oxygen by mask 2. Initiate an IV bolus of 0.9% saline 5. Stop the oxytocin infusion

A nurse is caring for a client at 30 weeks gestation who is admitted for preterm labor. Which of the following interventions should the nurse anticipate? SATA 1. Administering IM betamethasone 2. Administering penicillin via IV piggyback 3. Assisting with artificial rupture of membranes 4. Initiating IV magnesium sulfate 5. Obtaining fetal heart tones once per shift

1. Administering IM betamethasone 2. Administering penicillin via IV piggyback 4. Initiating IV magnesium sulfate

A laboring client at 35 weeks gestation comes to the labor and delivery unit with preterm rupture of membranes about "18 hours ago." The client's group B streptococcus status is unknown. What intervention is a priority for this client? 1. Administration of prophylactic antibiotics 2. Assessment of uterine contraction frequency 3. Collection of a clean catch urine specimen 4. Vaginal examination to assess cervical dilation

1. Administration of prophylactic antibiotics

A client, gravida 4 para 3, at 38 weeks gestation arrives in the emergency department with strong contractions that began 1 hour ago. The client is diaphoretic, grunting and yelling loudly that she wants an epidural because she feels the need to push. What priority action should the nurse take? 1. Apply gloves and assess perineal area 2. Initiate large bore IV access 3. Notify anesthesia provider of client's request for epidural 4. Obtain fetal heart tones via doppler

1. Apply gloves and assess perineal area **When a client arrives at the hospital in second stage of labor, the nurse should rapidly assess whether birth is imminent before performing other interventions.

A primi-gravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor? 1. Applying counter pressure to the client's sacrum during contractions 2. Encouraging the client to remain in bed during early labor 3. Positioning the client on the left side with pillows for support 4. Requesting that the nurse anesthetist administer epidural anesthesia

1. Applying counter pressure to the client's sacrum during contractions

A client is admitted to the labor and delivery unit with a diagnosis of severe preeclampsia. IV magnesium sulfate is prescribed. Which nursing measures should the nurse include in this client's plan of care? SATA 1. Assess deep tendon reflexes hourly 2. Ensure availability of calcium gluconate 3. Ensure bright lighting to prevent falls 4. Have supplemental oxygen at bedside 5. Limit visitors to minimize stimulation

1. Assess deep tendon reflexes hourly 2. Ensure availability of calcium gluconate 4. Have supplemental oxygen at bedside 5. Limit visitors to minimize stimulation

The graduate nurse is caring for a laboring client with epidural anesthesia. After the client pushes for 3 hours during the second stage of labor, the healthcare provider decides to use forceps to assist the client to deliver secondary to maternal exhaustion. Which action by the GN requires the nurse preceptor to intervene? 1. Begins to apply fundal pressure when the HCP applies traction to forceps 2. Drains the client's bladder using a catheter before the placement of forceps 3. Notes the exact time the forceps are applied on a card for documentation in the birth record 4. Palpates for contractions and notifies the HCP when they are present

1. Begins to apply fundal pressure when the HCP applies traction to forceps

A nurse is admitting a client at 42 weeks gestation to the labor and delivery unit for induction of labor. What is a predictor of a successful induction? 1. Bishop score of 10 2. Firm and posterior cervix 3. History of precipitous labor 4. Reactive non-stress test

1. Bishop score of 10

The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? SATA 1. Capillary glucose of 60 mg/dL 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

1. Capillary glucose of 60 mg/dL 3. Respirations of 56 breaths per minute 5. White papules on bridge of the nose (Milia) due to plugged sebaceous glands and resolve with treatment

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse? 1. Cessation of contractions and maternal tachycardia 2. Fetal tachycardia with moderate variability 3. Increased anxiety and discomfort with contractions 4. Painful, strong contractions every 3-4 minutes

1. Cessation of contractions and maternal tachycardia

The postpartum nurse is documenting client care at the unit's front desk. During that time, several clients request assistance from the nurse. Which client need should the nurse address first? 1. Client reports that a suspicious visitor is walking up and down the hallway 2. Client reports that her newborn is uncontrollably crying and having difficulty breastfeeding 3. Client who had a cesarean birth 8 hours ago is requesting to ambulate for the first time 4. Client who is receiving IV antibiotics for postpartum endometritis reports that the IV pump is beeping

1. Client reports that a suspicious visitor is walking up and down the hallway

The postpartum nurse is documenting client care at the unit's front desk. During that time, several clients request assistance from the nurse. Which client need should the nurse address first? 1. Client reports that a suspicious visitor is walking up and down the hallway 2. Client reports that her newborn is uncontrollably crying and having difficulty breastfeeding 3. Client who had a cesarean birth 8 hours ago is requesting to ambulate for the first time 4. Client who is receiving IV antibiotics for postpartum endometritis reports that the IV pump is beeping

1. Client reports that a suspicious visitor is walking up and down the hallway Newborns are vulnerable client population and nurses play an important role in establishing a culture of safety and preventing infant abduction. **Safety Measures - matching mother/newborn identification bracelets - newborn security sensors - locked perinatal units - specified uniforms for nursing staff - code pink for infant/child abduction

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which uterine assessment finding requires an intervention by the nurse? 1. Contraction duration of 95 seconds 2. Contraction frequency of every 3 minutes 3. Contraction intensity of 45 mmHg 4. Uterine resting tone of 10mmHg

1. Contraction duration of 95 seconds **Normal contractions during 1st stage of labor Duration: - lasts 45-80 seconds - shouldn't exceed 90 seconds Frequency: - 2-5 contractions every 10 mins - should not occur more than 2 min Intensity: - strength of contraction at its peak - 25-50 mmHg - should not exceed 80 Resting Tone: - tension in the uterine muscle between contractions - allows fetal oxygenation between contractions - average 10 mmHg - should not exceed 20 mmHg

A nulliparous client asks about being in "real" labor. The nurse should teach that which signs are most indicative of true labor? SATA 1. Contractions that increase infrequency 2. Contractions that lessen after resting 3. Increased blood tinged, mucoid vaginal discharge 4. Pain in lower back that moves to lower abdomen 5. Progressive cervical effacement and dilation

1. Contractions that increase infrequency 4. Pain in lower back that moves to lower abdomen 5. Progressive cervical effacement and dilation

The nurse is performing telephone triage with a client at 38 weeks gestation who thinks she may be in labor. Which questions would help the nurse determine whether the client is in labor? SATA 1. Do you feel like the contractions are getting stronger 2. Does anything you do make the pain better 3. Have you lost your mucous plug 4. How frequent are the contractions 5. Where do you feel the contraction pain most

1. Do you feel like the contractions are getting stronger 2. Does anything you do make the pain better 4. How frequent are the contractions 5. Where do you feel the contraction pain most

The nurse is caring for a 6 hour old, full term newborn of a mother with gestational diabetes. A bedside capillary blood glucose measurement reveals that the newborn's blood glucose level is 45 mg/dL. The newborn is asymptomatic. What is the nurse's first action? 1. Feed the newborn 2. Notify the healthcare provider 3. Place the newborn under a radiant warmer 4. Prepare to administer IV glucose

1. Feed the newborn A normal blood glucose is (40-60) A low blood glucose is (less than 40-45) Feeding and keeping the newborn warm via skin to skin contact is priority. **Hypoglycemia S/S poor feeding, jitteriness, and irritability. They will require IV glucose administration

The nurse is caring for a 2 week old client who has Tetralogy of Fallot. Which assessment finding is a priority to report to the healthcare provider? 1. Hemoglobin level of 24.9 2. Murmur noted on heart auscultation 3. Newborn becomes fatigued during feeding 4. Newborn has gained 0.6 lb since birth

1. Hemoglobin level of 24.9 Tetralogy of Fallot is a cyanotic cardiac defect, where experience chronic hypoxemia due to decreased pulmonary blood flow and circulation of poorly oxygenated blood. Hemoglobin more than 22 or hematocrit more than 65% are priority from increased circulatory viscosity increasing the risk for thrombus formation and stroke.

The nurse is participating in an obstetrical emergency simulation in which a client is hemorrhaging after birth due to uterine inversion. When describing interventions, which statement by the nurse indicates a need for further education? 1. I will administer a rapid infusion of IV oxytocin before the inverted uterus is corrected 2. I will establish a second IV line with an 18 gauge catheter 3. I will initiate serial blood pressure monitoring every 3-5 minutes 4. I will notify anesthesia and operating room staff of the client's condition immediately

1. I will administer a rapid infusion of IV oxytocin before the inverted uterus is corrected ** Uterine inversion is rare, obstetrical emergency that occurs after birth when the uterine fundus collapses (partially/completely) causing a sudden hemorrhage, severe pelvic pain and hypovolemic shock.

A client without prenatal care gives birth to a newborn at term gestation. The client denies opioid or other illicit drug use during pregnancy. When monitoring the newborn, which of the following signs would indicate neonatal abstinence syndrome to the nurse? SATA 1. Irritability and restlessness 2. Meconium ileus and floppy muscle tone 3. Microcephaly and cleft palate 4. Nasal congestion and frequent sneezing 5. Poor feeding and loose stools

1. Irritability and restlessness 4. Nasal congestion and frequent sneezing 5. Poor feeding and loose stools

The nurse is caring for an exclusively breastfed, small for gestational age, term newborn at 6 hours of life. The newborn has a capillary blood glucose of 30 mg/dL and is asymptomatic. Which action is most appropriate for the nurse to take at this time? 1. Administer IV glucose 2. Allow the newborn to breastfeed 3. Obtain a prescription for formula supplementation 4. Wait for plasma blood sample to confirm BG prior to feeding

2. Allow the newborn to breastfeed **Initially treating with feeding is a simple, non-invasive method of increasing and stabilizing blood glucose. ** Normal Blood Glucose (40-45) IV glucose is indicated for newborns who do NOT tolerate oral feedings or are symptomatic (lethargic, jittery) or whose BG does not increase with feeding.

A nurse is preparing to administer oxytocin to induce labor in a pregnant client at term gestation. Which of the following nursing actions are appropriate during oxytocin infusion? SATA 1. Administer oxytocin through the primary IV line 2. Assess the uterine contraction pattern 3. Initiate continuous fetal heart rate monitoring 4. Place IV oxytocin on an electronic infusion pump 5. Titrate oxytocin to achieve cervical dilation of 1 cm every 2 hours

2. Assess the uterine contraction pattern 3. Initiate continuous fetal heart rate monitoring 4. Place IV oxytocin on an electronic infusion pump

A pregnant client comes to the labor and delivery unit stating, "My water just broke at home." On assessment of the client's perineal area, the nurse visualizes a loop of umbilical cord protruding from the vagina. Which nursing intervention would be appropriate? 1. Apply suprapubic pressure 2. Assist the client to the knee-chest position 3. Perform Leopold maneuvers 4. Perform the McRoberts maneuver

2. Assist the client to the knee-chest position ** Assist the client on their hands and knees with the buttocks elevated above the head (knee-chest position) The nurse may use a sterile gloved hand to life the presenting part off the cord.

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

2. Begin positive pressure ventilation (PPV) **Positive pressure ventilation is started if heart rate is less than 100/min Compressions are started if the newborns heart rate remains less than 60/min after at least 30 minutes of quality PPV

An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? SATA 1. Angle bottle up and toward cleft 2. Burping the infant often 3. Feeding in an upright position 4. Feeding slowly over 45 minutes or more 5. Using a specialty bottle or nipple

2. Burping the infant often 3. Feeding in an upright position 5. Using a specialty bottle or nipple ** A child with a cleft palate is at risk for aspiration and inadequate nutrition due to eating and feeding difficulty. ** pointing bottle down, away from cleft to prevent formula from flowing back into the nose area.

A pregnant client admitted for induction of labor is receiving an oxytocin infusion. The baseline fetal heart rate is 140/min and the strip is shown. What is the nurse's best course of action? 1. Apply oxygen 10L/min face mask 2. Continue to monitor the client 3. Discontinue oxytocin infusion 4. Notify the healthcare provider

2. Continue to monitor the client **moderate variability refers to fluctuations in the baseline heart rate between 6-25/min. It is considered normal and indicates fetus is healthy,

The nurse is performing the initial assessment of a newborn. Which of the following findings should the nurse report to the health care provider? SATA 1. Cyanosis of the hands and feet 2. Decreased muscle tone 3. Heart rate of 150/min 4. Sacral dimple with a 0.4 inch skin tag 5. Single artery in the umbilical cord

2. Decreased muscle tone 4. Sacral dimple with a 0.4 inch skin tag 5. Single artery in the umbilical cord

A graduate nurse is caring for a client at 39 weeks gestation who is receiving an oxytocin infusion. Oxytocin is infusing at 20 mU/min. Based on the electronic fetal monitoring strip, which action by the graduate nurse would cause the registered nurse to intervene? 1. Administer oxygen by face mask at 10 L/min 2. Decreases oxytocin to 10mU/min 3. Notifies the healthcare provider 4. Repositions the client in left lateral position

2. Decreases oxytocin to 10mU/min

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

2. Distended abdomen 3. Has not passed stool (meconium) 5. Refusal to feed Hirschsprung disease occurs when a child is born with lack of specialized nerve cells in sections of the distal large intestine. This causes no peristalsis and stool is not passed. **The patient has a distended abdomen that will not pass meconium, difficulty with feeding and often vomit green bile.

The labor and delivery nurse is performing a vaginal examination to assess for cervical dilation and effacement. While palpating the presenting fetal part, the nurse feels a diamond-shaped structure that feels soft in the middle. What is the nurse's best action? 1. Document fetal presentation as breech 2. Document fetal presentation as cephalic 3. Elevate the fetal presenting part away from the prolapsed cord 4. Request that the health care provider confirm fetal presentation

2. Document fetal presentation as cephalic ** A diamond-shaped anterior fontanelle of the fetal head, is cephalic "head down" presentation. ** In breech presentation, the fetal buttocks, legs or feet may be palpated.

A nurse is participating in an obstetrical emergency stimulation in which the healthcare provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? SATA 1. Assist maternal pushing efforts by applying fundal pressure during each contraction 2. Document the time the fetal head was born 3. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubic 4. Prepare for a forceps assisted birth 5. Request additional assistance from other nurses immediately

2. Document the time the fetal head was born 3. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubic (McRobert's maneuver) 5. Request additional assistance from other nurses immediately

The precepting nurse is supervising a new obstetric nurse performing a labor admission assessment on a client with suspected spontaneous rupture of membranes. Which action by the new nurse would cause the precepting nurse to intervene? 1. Documenting a positive nitrazine test result when the test strip turns blue 2. Donning nonsterile gloves and using soluble gel for vaginal examination 3. Palpating the client's abdomen before applying external fetal monitors 4. Providing the client with a variety of clear liquids to drink

2. Donning non-sterile gloves and using soluble gel for vaginal examination ** The nurse should use a sterile glove during vaginal examination in the presence of ruptured membranes to prevent infection. Using non-sterile gloves increases the risk of infection in the laboring client or fetus.

The nurse has received report for a term newborn after a vaginal birth. Maternal history includes diagnosis of gestational diabetes at 25 weeks gestation and poorly controlled blood glucose during pregnancy. When assessing the newborn, which finding should the nurse most likely expect? 1. Delayed meconium passage 2. Elevated hematocrit level 3. Shrill cry and frequent yawning 4. Smooth philtrum and thin upper lip

2. Elevated hematocrit level Poorly controlled maternal diabetes negatively effects fetal growth and oxygenation

A client at 38 weeks gestation is in latent labor with ruptured membranes and is receiving an oxytocin infusion for labor augmentation. The client is requesting IV pain medication. When administering an IV narcotic during labor, which nursing action is appropriate? 1. Discontinue the oxytocin infusion prior to giving the medication 2. Give the medication slowly during the peak of the next contraction 3. Hold until contractions are occurring at least every 4 minutes for an hour 4. Withdraw 5 mL of lactated ringers from the IV tubing to dilute the medication

2. Give the medication slowly during the peak of the next contraction ** The administration of IV narcotics (nalbuphine, butorphanol, meperidine) during the peak of contractions that can help decrease sedation of the fetus

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

2. Measure abdominal girth daily **Necrotizing enterocolitis occurs in preterm infants secondary to gastrointestinal and immunologic immaturity. Due to underdeveloped intestine and gut immunity. Clients are placed supine and undiapered Clients are NPO and receive nasogastric suction to decompress the stomach and intestines.

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

2. Measure and document the size and location of the markings ** Mongolian spots are usually bluish gray and fade over the first 1-2 years of life. They are often misidentified as bruises and it is important for nurse to measure and document area for reference during future health assessments.

The nurse is performing an assessment on a 39 week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? SATA 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

2. Plantar creases up the entire sole 4. Toes fan outward when the lateral sole surface is stroked 5. White pearl like cysts on gum margins ** The cord should be opaque/whitish with two arteries and one vein covered with Wharton's jelly. The presence of one umbilical artery and vein is associated with heart or kidney malformation.

The nurse is performing an APGAR assessment on a newborn client at 1 minute of life. The newborn is completely blue, has a heart rate of 110/min and is emitting a weak cry. Active movement and flexion of extremities are noted and the newborn grimaces when nares are suctioned. Which APGAR score should the nurse assign this newborn? 1. APGAR score of 4 2. APGAR score of 5 3. APGAR score of 6 4. APGAR score of 8

3. APGAR score of 6 A (Appearance) - Blue/Pale 0 - Body Pink Extremity Blue 1 - Completely Pink 2 P (Pulse) - Absent 0 - <100/min 1 - >100/min 2 G (Grimace) - Absent 0 - Grimace/Whimper 1 - Cough/sneeze/cry 2 A (Activity/Muscle tone) - Limp 0 - Some flexion 1 - Active/Spontaneous 2 R (Respiratory effort) - Absent 0 - Slow, weak cry 1 - Regular, good cry 2

The nurse receives report for a client at 36 weeks gestation who is being transferred to the unit for labor induction from a rural health care facility with an intrauterine fetal demise of unknown duration. Which intervention is most important when receiving care of the client? 1. Apply tocodynamometer and evaluate current contraction pattern 2. Ask the client about the family's desire for speaking with a chaplain 3. Draw coagulation tests, fibrinogen and complete blood count with platelets 4. Initiate oxytocin prescription to begin induction of labor

3. Draw coagulation tests, fibrinogen and complete blood count with platelets Pregnant client with placental abruption and intrauterine fetal demise is at risk for disseminated intravascular coagulation. Thromboplastin from the retained dead fetus activates the clotting cascade followed by consumption of clotting factors and platelets that leads quickly to life threatening external/internal bleeding

Following the precipitous birth of a term newborn, what is the best action by the nurse while awaiting expulsion of the placenta and arrival of the healthcare provider? 1. Clean the perineal area 2. Gently pull on the cord 3. Keep the infant warm 4. Massage the fundus

3. Keep the infant warm ** Precipitous birth occurs when delivery takes place <3 hours after the onset of contractions. The nurse should prevent newborn cold stress by promptly drying and placing the newborn on the mother's abdomen for skin to skin contact

A client in active labor who received an epidural 20 minutes ago reports feeling nauseated and lightheaded. Which action should the nurse perform first? 1. Administer IV ondansetron 2. Apply oxygen via face mask 3. Obtain blood pressure 4. Perform vaginal examination

3. Obtain blood pressure

The nurse reviews the laboratory results of a laboring client who is requesting epidural anesthesia. Which value is the priority to report to the anesthesia provider prior to epidural placement? Patient Vitals Blood group: O Rh factor: Negative Hematocrit: 32% Hemoglobin:10 WBCs: 15,000 Platelets 90,000 1. Blood type and Rh 2. Hemoglobin 3. Platelet count 4. White blood cell count

3. Platelet count Normal Hgb: more than 11 Hct: more than 33 RBCs: 5.00-6.25 WBCs: 5,000-15,000 Platelets: 150,000-400,000

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

3. Provides supplemental formula feedings until improved breastfeeding occurs

The nurse is assisting with a vaginal birth at term gestation. Which newborn assessment finding is most important for the nurse to follow up? 1. Edema of the scalp crossing the suture line 2. Flat, bluish discolored area on the buttocks 3. Small tuft of hair at the base of the spine 4. White, waxy substance in the axillae and labial folds

3. Small tuft of hair at the base of the spine ** Spina bifida, is a neural tube defect occurs when the spinal vertebrae does NOT close during fetal development that potentially allows spinal cord contents to protrude through the opening.

A newborn client is seen in the emergency department for vomiting. Which assessment finding indicates a possible emergency? 1. Frequent vomiting since birth 2. Tiny blood streaks in the vomit 3. Vomit that is green 4. Vomiting through the nose

3. Vomit that is green Bile that is made by the liver is green and is released into the duodenum on eating to aid digestion. When there is obstruction in the intestine and stool cannot pass, it may come back up as green vomit. ** A bowel obstruction is an emergency that can lead to bowel rupture, peritonitis and sepsis

A laboring client reports feeling the need to have a bowel movement and begins vomiting. The nurse notes that the client's legs are trembling. What cervical examination finding would the nurse most expect this client to have? 1. 2 cm dilated, 50% effaced, -2 station 2. 6 cm dilated, 70% effaced, -1 station 3. 7 cm dilated, 80% effaced, 0 station 4. 8 cm dilated, 100% effaced, +1 station

4. 8 cm dilated, 100% effaced, +1 station **The end of the first stage of labor (8-10 cm dilation) is "transition phase" This period is often by perineal/rectal pressure due to fetal descent, which the client may perceive as an urge to have a bowel movement. Stage 1 - Latent 0-3 cm dilated - Active 4-7 cm dilated - Transient 8-10 cm dilated Stage 2 - Patient is 10 cm dilated, and complete cervical dilation to birth Stage 3 - Birth of the baby to expulsion of placenta Stage 4 - It is 1-4 hours after birth, maternal physiologic readjustment

The 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 allow my baby to sleep with a pacifier 2. I will dress my baby in a sleep sack to prevent my baby from getting cold 3. I will make sure there is a firm mattress in the crib 4. I will tie bumper pads to the sides of the crib to protect my baby's head

4. I will tie bumper pads to the sides of the crib to protect my baby's head **Sudden Infant death syndrome is the leading cause of death among infants age 1 month to 1 year. Nurses should inform caregivers about ways to reduce risk of SIDS - Place infant on back to sleep - Avoid soft objects (stuffed animals) Nothing in bed with the infant is safest - Avoiding bumper pads - Maintain a smoke free environment - Avoiding overheating - Breastfeeding and ensuring immunizations are updated

Four clients in labor are requesting pain relief. The nurse understandings that which client can safely receive a dose of IV butorphanol tartrate, an opioid agonist-antagonist, at this time? 1. Multipara at 6 cm dilation with recent heroin use 2. Multipara at 9 cm dilation with an urge to push 3. Nullipara at 3 cm dilation desiring to ambulate 4. Nullipara at 7 cm dilation moaning with contractions

4. Nullipara at 7 cm dilation moaning with contractions

The nurse performing an initial newborn assessment observes a bluish discoloration of the hands and feet. The trunk has a pink color. Which action by the nurse is appropriate? 1. Apply blow by oxygen and count respirations 2. Auscultate heart sounds for a murmur 3. Observe the newborn for expiratory grunting 4. Place the newborn skin to skin with the mother

4. Place the newborn skin to skin with the mother

A client in labor has reached 8 cm dilation, is fully effaced and feels an urge to push. The nurse observes thick, blood tinged mucus during the vaginal examination. What is the nurse's best action? 1. Administer prescribed IV meperidine for pain relief 2. Encourage client to bear down with spontaneous urges to push 3. Place client in the lithotomy position in preparation for birth 4. Provide encouragement and coaching breathing techniques

4. Provide encouragement and coaching breathing techniques **A bloody show (mucus and pink/dark brown blood) is commonly observed during the the transition in the first stage of labor.

A laboring client, gravida 3 para 2, is admitted to the labor unit reporting severe perineal pressure and urgently requesting pain relief. The client's cervix is 10 cm dilated and 100% effaced, with the fetal head at 0 station. Which pain management technique is most appropriate for this client's report of perineal pressure? 1. Epidural anesthesia 2. Hydrotherapy 3. IV narcotics 4. Pudendal nerve block

4. Pudendal nerve block **PNB infiltrates local anesthesia into the areas surrounding the pudendal nerves that innervate the lower vagina, perineum and vulva. ** When birth is imminent a pudendal block provides the best pain relief with the least maternal/newborn side effects and should be administered quickly.

The labor and delivery charge nurse receives report on several clients. Which task is appropriate for the nurse to delegate to the unlicensed assistive personnel? 1. Assist a client to the restroom 1 hour after a vaginal birth with regional anesthesia 2. Check the perineal pad of a client who is in triage with possible rupture of membranes 3. Obtain vital signs on a newborn who is skin to skin with the mother 1 hour after birth 4. Reposition an unmedicated client who is in active labor onto a birthing ball

4. Reposition an unmedicated client who is in active labor onto a birthing ball

The labor and delivery nurse is receiving report for a pregnant client who is having a scheduled cesarean birth for placenta accreta. Which information is priority for the nurse to ascertain? 1. The client has a history of three previous cesarean births 2. The client has a signed consent form for a cesarean hysterectomy 3. The client has removed all metal jewelry and contact lenses 4. The client has two 18 gauge IVs and a blood type and crossmatch

4. The client has two 18 gauge IVs and a blood type and crossmatch Placenta accreta is an abnormal placental adherence which the placenta implants directly in the myometrium rather than the endometrium. ** A cesarean birth before term gestation at a facility with resources (blood products, intensive care unit) is recommended. **A major complication of placental accreta is life-threatening hemorrhage which occurs during the attempt of placental separation. **At least 2 large bore IVs and blood type and crossmatch is priority in case of a blood transfusion is necessary.

The nurse is performing an assessment on a 24 hour old male who was born breech via vaginal birth at 36 weeks gestation. Which assessment finding requires immediate evaluation by the healthcare provider? 1. Foreskin adheres to the glans penis 2. Scrotum is mildly edematous 3. Testes are palpated in the inguinal canal 4. Two wet diapers are noted since birth but no meconium

4. Two wet diapers are noted since birth but no meconium **Imperforate anus is a congenital malformation of the anorectal opening that prevents normal stool passage. If there is no stool noted within 24 hours of birth, the nurse should request immediate evaluation of the newborn for correction of defect.

The nurse is monitoring a client who is 6 cm dilated with recurrent variable decelerations on the fetal heart rate monitor. The HCP places an intrauterine pressure catheter and prescribes an amnioinfusion. After the amnioinfusion bolus is complete, which assessment finding should the nurse report to the HCP immediately? 1. Cervic is 8 cm dilated and 100% effaced with fetal presenting part at +1 station 2. Contractions are every 3 mins and 60-80 seconds each 3. FHR baseline is 155/min with early decelerations and moderate variability 4. Uterine resting tone baseline has increased to 45 mmHg and perineal pads are dry

4. Uterine resting tone baseline has increased to 45 mmHg and perineal pads are dry ** An amnioinfusion is a transvaginal infusion of isotonic fluids through an intrauterine pressure catheter to compensate for low amniotic fluid in the uterus.

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate? 1. Cervical lacerations 2. Inversion of the uterus 3. Uterine atony 4. Vaginal hematoma

4. Vaginal hematoma ** A vaginal hematoma forms when trauma to the tissues of the perineum occurs during delivery.

What is an appropriate nursing intervention after the birth of a newborn with anencephaly? 1. Instruct the parents that visitors should be restricted 2. Provide information to the parents about genetic counseling 3. Refer the parents to a perinatal loss support group 4. Wrap the newborn in warm blankets for the parents to hold

4. Wrap the newborn in warm blankets for the parents to hold **Anencephaly is a severe neural tube defect resulting in little to no brain tissue or skull formation in utero. ** Many are stillborn and those born alive are not compatible with life. Providing comfort care for the newborn and emotional support for the family is priority at the time of birth. ** Providing a therapeutic environment for grieving parents and providing newborn comfort such as warmth and oxygen

A graduate nurse is reinforcing education to a pregnant client with Hepatitis B who expresses concern about transmitting the virus to the newborn after birth. Which statement about newborn care made by the graduate nurse should cause the precepting nurse to intervene? 1. IM injections will be given after the newborn's bath to reduce exposure to bodily fluids during needle sticks 2. The newborn will receive both the Hep B vaccination and Hep B immune globulin injection after birth 3. You may safely initiate skin to skin contact after birth which promotes bonding and keeps the newborn warm 4. You will need to formula feed your newborn to reduce the risk of transmitting the virus via breast milk

4. You will need to formula feed your newborn to reduce the risk of transmitting the virus via breast milk Hep B virus infection is a bloodborne disease that poses an infection risk to the newborn because of exposure to maternal blood and bodily fluids during birth. ** It is not contraindicated to breastfed the newborn however Hep B immune globulin and vaccine should be administered to the newborn within 12 hours of birth.