OB Exam 4

d. Betamethasone Rationale: a. Calcium gluconate is administered as an antidote for magnesium sulfate toxicity. b. Indomethacin is an NSAID used to suppress preterm labor by blocking prostaglandin production. c. Nifedipine is a calcium channel blocker used to suppress uterine contractions. d. Betamethasone is a glucocorticoid given to clients in preterm labor to hasten surfactant production. (ATI Ch 10: Onset of Labor)

A nurse in labor and delivery is providing care for a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? a. Calcium gluconate b. Indomethacin c. Nifedipine d. Betamethasone

a. UTI b. Multifetal pregnancy d. Diabetes mellitus e. Uterine abnormalities Rationale: a. A urinary tract infection is a risk factor of preterm labor. b. Multifetal pregnancy is a risk factor of preterm labor. c. Hydramnios (excessive amniotic fluid) is a risk factor of preterm labor. d. Diabetes mellitus is a risk factor of preterm labor. e. Uterine abnormalities are risk factors of preterm labor. (ATI Ch 10: Onset of Labor)

A nurse is caring for a client who reports indications of preterm labor. Which of the following findings are risk factor of this condition. (Select all that apply.) a. UTI b. Multifetal pregnancy c. Oligohydramnios d. Diabetes mellitus e. Uterine abnormalities

c. Is performed primarily for the benefit of the fetus. Rationale: The most common indications for cesarean birth are danger to the fetus related to labor and birth complications. Cesarean births are increasing in the United States. Wealthier women who have health insurance and who give birth in a private hospital are more likely to experience cesarean birth. A woman's right to elect cesarean surgery is in dispute, as is her right to refuse it if in doing so she endangers the fetus. Legal issues are not absolutely clear. (Evolve Ch 32: Labor and Birth Complications)

A nurse providing care to a woman in labor should be aware that cesarean birth: a. Is declining in frequency in the United States. b. Is more likely to be performed in the poor in public hospitals who do not receive the nurse counseling that wealthier clients do. c. Is performed primarily for the benefit of the fetus. d. Can be either elected or refused by women as their absolute legal right.

b. "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures." Rationale: The statement in B is most appropriate. The statements in A, C, and D are not accurate. Maternal and fetal risks are associated with every cesarean section. Physiologic and psychologic recovery from a cesarean section is multifactorial and individual to each client each time. Preoperative teaching should always be performed regardless of whether the client has already had this procedure. (Evolve Ch 32: Labor and Birth Complications)

In planning for an expected cesarean birth for a woman who has given birth by cesarean section previously and who has a fetus in the transverse presentation, the nurse includes which information? a. "Because this is a repeat procedure, you are at the lowest risk for complications." b. "Even though this is your second cesarean birth, you may wish to review the preoperative and postoperative procedures." c. "Because this is your second cesarean birth, you will recover faster." d. "You will not need preoperative teaching because this is your second cesarean birth."

2. Obtain equipment for a manual pelvic examination. Rationale: Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia. Test-Taking Strategy: Focus on the subject, nursing care of the client with placenta previa. Use knowledge of the pathophysiology associated with placenta previa. Note the words question which prescription in the event query. Also, note that the correct option is the only procedure that is invasive to the pregnancy and endangers the physiological safety of the client and the fetus. (NCLEX Ch 28: Problems with Labor and Birth)

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription? 1. Prepare the client for an ultrasound. 2. Obtain equipment for a manual pelvic examination. 3. Prepare to draw a hemoglobin and hematocrit blood sample. 4. Obtain equipment for external electronic fetal heart rate monitoring.

2. Monitoring the fetal heart rate Rationale: Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority. Test-Taking Strategy: Note the strategic word, priority. Use Maslow's Hierarchy of Needs theory and the ABCs—airway-breathing-circulation—to assist in answering the question. (NCLEX Ch 28: Problems with Labor and Birth)

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1. Providing comfort measures 2. Monitoring the fetal heart rate 3. Changing the client's position frequently 4. Keeping the significant other informed of the progress of the labor

3. Perform a vaginal examination every shift. Rationale: Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic. Test-Taking Strategy: Note the word question. This word indicates the activity that the nurse should not implement without clarification. Options 1, 2, and 4 are comparable or alike and are expected activities for the nurse to perform for a client with premature rupture of the membranes. Performing a vaginal examination every shift should not be done on a client with premature rupture of the membranes because of the risk of infection, so the nurse would question this prescription. (NCLEX Ch 28: Problems with Labor and Birth)

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. Monitor fetal heart rate continuously. 2. Monitor maternal vital signs frequently. 3. Perform a vaginal examination every shift. 4. Administer an antibiotic per HCP prescription and per agency protocol.

b. Leans forward to bring breast toward the baby. Rationale: To maintain a comfortable, relaxed position, the mother should bring the baby to the breast, not the breast to the baby. The mother would need further demonstration and teaching to correct the ineffective action. The other actions described are correct. (Evolve Ch 25: Newborn Nutrition and Feeding)

Which action of a breastfeeding mother indicates the need for further instruction? a. Holds breast with four fingers along bottom and thumb at top. b. Leans forward to bring breast toward the baby. c. Stimulates the rooting reflex and then inserts nipple and areola into newborn's open mouth. d. Puts her finger into newborn's mouth before removing breast.

c. Its most important function is to afford the opportunity to administer antenatal glucocorticoids. Rationale: Buying time for antenatal glucocorticoids to accelerate fetal lung development might be the best reason to use tocolytics. Once the pregnancy has reached 34 weeks, the risks of tocolytic therapy outweigh the benefits. There are important maternal contraindications to tocolytic therapy. Tocolytic-induced edema can be caused by IV fluids. (Evolve Ch 32: Labor and Birth Complications)

With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that: a. The drugs can be given efficaciously up to the designated beginning of term at 37 weeks. b. There are no important maternal (as opposed to fetal) contraindications. c. Its most important function is to afford the opportunity to administer antenatal glucocorticoids. d. If pulmonary edema develops while the client is receiving tocolytics, IV fluids should be given.

a. "They are administered in an oral form." Rationale: a. Chemical agents that promote cervical ripening include medications administered in oral form. b. Hygroscopic sponges, which are a mechanical method to promote cervical ripening, act by absorbing fluid from surrounding tissues to enlarge the cervical opening. c. Mechanical and physical methods promote cervical ripening by dilation. d. An amniotomy is a mechanical method to promote cervical ripening. (ATI Ch 15: Therapeutic Procedures to Assist with Labor and Delivery)

A nurse educator in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly hired nurses. Which of the following statements by a nurse indicates understanding of the teaching? a. "They are administered in an oral form." b. "They act by absorbing fluid from tissues." c. "They promote dilation of the os." d. "They include an amniotomy."

a. Fetal distress c. Vaginal bleeding d. Cervical dilation greater than 6cm Rationale: a. Acute fetal distress is a complication that is a contraindication for use of magnesium sulfate therapy. b. Preterm labor is an indication for use of magnesium sulfate. c. Vaginal bleeding is a complication that is contraindication for magnesium sulfate therapy. d. Cervical dilation greater than 6 cm is a complication for magnesium sulfate therapy. e. Severe gestational hypertension is an indication for the use of magnesium sulfate. (ATI Ch 10: Onset of Labor)

A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? (Select all that apply) a. Fetal distress b. Preterm labor c. Vaginal bleeding d. Cervical dilation greater than 6cm e. Severe gestational hypertension

c. meconium aspiration Rationale: a. Intrauterine growth restriction occurs earlier in the pregnancy and not at this point. b. A postterm neonate is at risk for hypoglycemia, not hyperglycemia. c. postterm neonates are at risk for aspiration of meconium. d. Postterm pregnancies result in oligohydramnios, not polyhydramnios. (ATI Ch 16: Complications Related to the Birth Process)

A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus is at risk for developing? a. intrauterine growth restriction b. hyperglycemia c. meconium aspiration d. polyhydramnios

b. Duration of 90 to 120 seconds Rationale: a. The contraction pattern does not require discontinuing the infusion of oxytocin. b. Oxytocin is discontinued if uterine hyperstimulation occurs with contraception duration longer than 90 seconds. c. This contraction pattern does not require discontinuing the infusion of oxytocin. d. This contraction pattern does not require discontinuing the infusion of oxytocin. (ATI Ch 15: Therapeutic Procedures to Assist with Labor and Delivery)

A nurse is caring for a client who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin? a. Frequency of every 2 min b. Duration of 90 to 120 seconds c. Intensity of 60 to 90 mm hg d. Resting tone of 15 mm hg

b. Attempts to place his hand in his mouth Rationale: a. Spitting up, coughing, or gagging on mucus is an attempt by the newborn to clear his airway. b. Readiness-to-feed cues include the newborn making hand-to-mouth and hand-to-hand movements, sucking motions, rooting, and mouthing. c. The infant turns his head toward sounds in the environment as a sensory response indicating normal central nervous system functioning. d. Lying quietly with eyes open is an alerting behavior, indicating normal newborn reactivity. (ATI Ch 25: Newborn Nutrition)

A nurse is caring for a newborn. which of the following actions by the newborn indicates readiness to feed? a. Spits up clear mucus b. Attempts to place his hand in his mouth c. Turns his head toward sounds d. Lies quietly with his eyes open

a. Cervical cap Rationale: Women with a history of TSS should not use a cervical cap. Condoms, vaginal film, and vaginal sheaths are not contraindicated for a woman with a history of TSS. (Evolve Ch 8: Contraception and Abortion)

A woman was treated recently for toxic shock syndrome (TSS). She has intercourse occasionally and uses over-the-counter protection. On the basis of her history, what contraceptive method should she and her partner avoid? a. Cervical cap b. Condom c. Vaginal film d. Vaginal sheath

3. Drying the infant with a warm blanket Rationale: Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface (indirect contact). Test-Taking Strategy: Note the strategic words, most effective. Recalling that evaporation of moisture from a wet body dissipates heat along with the moisture will assist in directing you to the correct option. (NCLEX Ch 31: Care of the Newborn)

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

2. Place the client in Trendelenburg position. Rationale: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and reduce blood flow further. Also as a first action, the examiner should place a gloved hand into the vagina and hold the presenting part off the umbilical cord. Oxygen, 8 to 10 L/minute, by face mask is administered to the client to increase fetal oxygenation. Test-Taking Strategy: Note the strategic word, first, and that the umbilical cord is protruding from the vagina. Options 3 and 4 can be eliminated first because these actions delay necessary and immediate treatment. Recalling that the goal is to relieve cord compression and to increase fetal oxygenation will direct you to the correct option. Also remember that the cord should not be pushed back into the vagina. (NCLEX Ch 28: Problems with Labor and Birth)

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? 1. Gently push the cord into the vagina. 2. Place the client in Trendelenburg position. 3. Find the closest telephone and page the health care provider stat. 4. Call the delivery room to notify the staff that the client will be transported immediately.

3. Document the findings. Rationale: The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours, and this is part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. Only if the bleeding were excessive would the nurse apply gentle pressure with a sterile gauze. If bleeding cannot be controlled, the blood vessel may need to be ligated, and the nurse would notify the HCP. Because the findings identified in the question are normal, the nurse would document the assessment findings. Test-Taking Strategy: Note the strategic words, most appropriate, and focus on the assessment findings in the question. This should assist in directing you to the correct option, because this is a normal occurrence after circumcision. (NCLEX Ch 31: Care of the Newborn)

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1. Apply gentle pressure. 2. Reinforce the dressing. 3. Document the findings. 4. Contact the health care provider (HCP).

4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches. Rationale: Phototherapy (bili-light or bili-blanket), is the use of intense fluorescent light to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment (done with a special device known as a photometer), monitors skin temperature closely, and increases fluids to compensate for water loss. The newborn may have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued. Test-Taking Strategy: Focus on the subject, phototherapy. Recalling that adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can occur will assist in determining the correct interventions. (NCLEX Ch 31: Care of the Newborn)

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches.

4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding." Rationale: Phytonadione is necessary for the body to synthesize coagulation factors. It is administered to the newborn to prevent bleeding disorders. It also promotes liver formation of the clotting factors II, VII, IX, and X. Newborns are vitamin K-deficient because the bowel does not have the bacteria necessary to synthesize fat-soluble vitamin K. The normal flora in the intestinal tract produces vitamin K. The newborn's bowel does not support the normal production of vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced. Test-Taking Strategy: Note the strategic word, best. Because immunity and jaundice are not related to the action of vitamin K, eliminate options 1 and 2. From the remaining options, recall the action of vitamin K to direct you to the correct option. Remember that vitamin K does not promote the growth of bacteria, but is administered to prevent bleeding. (NCLEX Ch 31: Care of the Newborn)

The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? 1. "Your newborn needs the medicine to develop immunity." 2. "The medicine will protect your newborn from being jaundiced." 3. "Newborns have sterile bowels, and the medicine promotes the growth of bacteria in the bowel." 4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

a. Wash the top of can and can opener with soap and water before opening the can. Rationale: Washing the top of the can and can opener with soap and water before opening the can of formula is a good habit for parents to get into to prevent contamination. Directions on the can for dilution should be followed exactly and not adjusted according to weight gain to prevent nutritional and fluid imbalances. Honey is not necessary and could contain botulism spores. The formula should be warmed in a container of hot water because a microwave can easily overheat it. (Evolve Ch 25: Newborn Nutrition and Feeding)

The nurse taught new parents the guidelines to follow regarding the bottle feeding of their newborn. They will be using formula from a can of concentrate. The parents would demonstrate an understanding of the nurse's instructions if they: a. Wash the top of can and can opener with soap and water before opening the can. b. Adjust the amount of water added according to weight gain pattern of the newborn. c. Add some honey to sweeten the formula and make it more appealing to a fussy newborn. d. Warm formula in a microwave oven for a couple of minutes prior to feeding.

2. Continue to breast-feed every 2 to 4 hours. Rationale: Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary. Test-Taking Strategy: Eliminate options 3 and 4 are comparable or alike. These options discourage the continuation of breast-feeding and should be eliminated. From the remaining options, recalling the pathophysiology associated with hyperbilirubinemia will assist you in eliminating option 1. (NCLEX Ch 31: Care of the Newborn)

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? 1. Feed the newborn less frequently. 2. Continue to breast-feed every 2 to 4 hours. 3. Switch to bottle-feeding the infant for 2 weeks. 4. Stop breast-feeding and switch to bottle-feeding permanently.

c. Short interval between pregnancies d. Patient receiving a trial of labor (TOL) following a VBAC delivery e. Patient who had a primary caesarean section with a classic incision Rationale: The shorter the interval between pregnancies/deliveries, the higher the risk of uterine rupture. A patient who is having a TOL following a VBAC and a patient who has had a C section with a classic incision into the uterus are at increased risk for uterine rupture. A pregnant woman with a singleton pregnancy (one fetus), even if preterm, is not considered to be at increased risk for uterine rupture; nor is a multipara who has delivered all her infants vaginally. (Evolve Ch 32: Labor and Birth Complications)

Which factors would lead to an increased likelihood of uterine rupture? Select all that apply. a. Preterm singleton pregnancy b. G3P3 with all vaginal deliveries c. Short interval between pregnancies d. Patient receiving a trial of labor (TOL) following a VBAC delivery e. Patient who had a primary caesarean section with a classic incision

d. High rate of neuromuscular disorders Rationale: Fetuses with neuromuscular disorders have a higher rate of breech presentation, perhaps because they are less capable of movement within the uterus. Breech is the most common malpresentation, affecting 3% to 4% of all labors. Descent is often slow because the breech is not as good a dilating wedge as the fetal head. Diagnosis is made by abdominal palpation and vaginal examination, and is confirmed by ultrasound. (Evolve Ch 32: Labor and Birth Complications)

Which statement is most likely to be associated with a breech presentation? a. Least common malpresentation b. Descent rapid c. Diagnosis by ultrasound only d. High rate of neuromuscular disorders

b. "Nonoxynol-9 does not provide protection against sexually transmitted infections, as originally thought; also, it has been linked to an increase in the transmission of human immunodeficiency virus (HIV) and can cause genital lesions." Rationale: Answer B is a true statement. Nonoxynol-9 may cause vaginal irritation. It has no effect on the quality of sexual activity or on penile sensitivity. (Evolve Ch 8: Contraception and Abortion)

A male client asks the nurse why it is better to purchase condoms that are not lubricated with nonoxynol-9 (a common spermicide). The nurse's most appropriate response is: a. "The lubricant prevents vaginal irritation." b. "Nonoxynol-9 does not provide protection against sexually transmitted infections, as originally thought; also, it has been linked to an increase in the transmission of human immunodeficiency virus (HIV) and can cause genital lesions." c. "The additional lubrication improves sex." d. "Nonoxynol-9 improves penile sensitivity."

c. "You should increase your intake of calcium" e. "Irregular vaginal spotting can occur" Rationale: a. Weight gain can occur when taking medroxyprogesterone. b. Medroxyprogesterone does not provide protection against STIs/ c. Clients should take calcium and vitamin D to prevent loss of bone density, which can occur when taking medroxyprogesterone. d. Antibiotics are not contraindicated when taking medroxyprogesterone. e. Medroxyprogesterone can cause irregular vaginal bleeding. (ATI Ch 1: Contraception)

A nurse in a clinic is teaching a client about her new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? (Select all that apply) a. "Weight loss can occur" b. "You are protected against STIs" c. "You should increase your intake of calcium" d. "You should avoid taking antibiotics" e. "Irregular vaginal spotting can occur"

d. "I will check to be sure the strings of the IUD are still present after my periods." Rationale: a. An IUD will be replaced every 3 to 5 years, dependent upon the type of IUD used. b. Clients do not have to have given birth prior to the insertion of an IUD. It will be necessary for the client to have a negative pregnancy test prior to insertion of the IUD. c. Fertility will resume immediately following removal of the IUD. d. The client should check for presence of the IUD strings following each menstruation to ensure the device is still present. A change in the length of the strings should be reported to the provider. (ATI Ch 1: Contraception)

A nurse in an obstetrical clinic is teaching a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching? a. "An IUD should be replaced annually during a pelvic exam" b. "I cannot get an IUD until after I've had a child" c. "I should plan on regaining fertility 5 months after the IUD is removed" d. "I will check to be sure the strings of the IUD are still present after my periods."

d. Position the neonate skin‐to‐skin on the client's chest. Rationale: a. This is an appropriate action, but another intervention is the priority. b. This is an appropriate action, but another intervention is the priority. c. This is an appropriate action, but another intervention is the priority. d. placing the neonate in the en face position on the client's chest immediately after birth is the priority nursing intervention to promote maternal-infant bonding. (ATI Ch 18: Baby-Friendly Care)

A nurse in the delivery room is planning to promote maternal‐infant bonding for a client who just delivered. Which of the following is the priority action by the nurse? a. Encourage the parents to touch and explore the neonate's features. b. Limit noise and interruption in the delivery room. c. Place the neonate at the client's breast. d. Position the neonate skin‐to‐skin on the client's chest.

d. Call for assistance. Rationale: a. The nurse should place the client in the Trendelenburg position. However, evidence-based practice indicates that another action/assessment is the priority. b. the nurse should apply pressure to the presenting part with her fingers. However, evidence-based practice indicates that another action/assessment is the priority. c. the nurse should administer oxygen at 10 L/min via a face mask. However, evidence-based practice indicates that another action/assessment is the priority. d. According to evidence-based practice the nurse should first call for assistance. (ATI Ch 16: Complications Related to the Birth Process)

A nurse is caring for a client in active labor. When last examined 2 hr ago, the client's cervix was 3 cm dilated,100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states "my water broke." The monitor reveals a FHR of 80 to 85/min, and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? a. place the client in the trendelenburg position. b. apply pressure to the presenting part with her fingers. C. administer oxygen at 10 l/min via a face mask. d. Call for assistance.

a. Fetal engagement Rationale: a. Prior to the performance of an amniotomy, the amniotic membranes should have ruptured. It is also imperative that the fetus is engaged at 0 station at the level of the maternal ischial spines to prevent prolapse of the umbilical cord. b. Fetal lie pertains to the axis of the maternal spine in relation to the fetal spine and is determined by Leopold maneuvers. c. Fetal attitude is the relationship of the fetal extremities and chin to the fetal torso. It is determined by Leopold maneuvers. d. Fetal position refers to the direction of a reference point in the fetal presenting part to the maternal pelvis. It is not a criterion when performing a amniotomy. (ATI Ch 15: Therapeutic Procedures to Assist with Labor and Delivery)

A nurse is caring for a client who has been in labor for 12 hr, and her membranes are intact. The provider has decided to perform an amniotomy in an effort to facilitate the progress of labor. The nurse performs a vaginal examination to ensure which of the following prior to the performance of the amniotomy? a. Fetal engagement b. Fetal lie c. Fetal attitude d. Fetal position

a. Demonstrates apathy when the infant cries c. Views the infant's behavior as uncooperative during diaper changing Rationale: a. This behavior demonstrates a lack of interest in the infant and impaired maternal-infant bonding. b. touching the infant and maintaining close proximity are signs of effective maternal-infant bonding. c. A client's view of her infant as being uncooperative during diaper changing is a sign of impaired maternal-infant bonding. d. Endowing the infant with family characteristics indicates effective maternal-infant bonding. e. Recognizing the infant's behavior as meaning and a way to express needs is an indication of effective maternal-infant bonding. (ATI Ch 18: Baby-Friendly Care)

A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation and mother‐infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all that apply.) a. Demonstrates apathy when the infant cries b. Touches the infant and maintains close physical proximity c. Views the infant's behavior as uncooperative during diaper changing d. Identifies and relates infant's characteristics to those of family members e. Interprets the infant's behavior as meaningful and a way of expressing needs

b. "Your son is showing an adverse sibling response." Rationale: a. This is not an appropriate intervention by the nurse because it overlooks the child's emotional response to a new family member. b. Adverse responses by a sibling to a new infant can include regression in toileting habits. c. Recommending that the child receive counselling is not an appropriate nursing intervention for a child who is demonstrating an adverse sibling response. d. Recommending that the child be sent to preschool is not an appropriate nursing intervention for a child who is demonstrating an adverse sibling response. (ATI Ch 18: Baby-Friendly Care)

A nurse is caring for a client who is 2 days postpartum. The client states, "My 4‐year old son was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? a. "Your son was probably not ready for toilet training and should wear training pants." b. "Your son is showing an adverse sibling response." c. "Your son may need counseling." d. "You should try sending your son to preschool to resolve the behavior."

d. Prolapsed umbilical cord Rationale: a. Breech presentation would most likely cause dystocia (prolonged, difficult labor) rather than a precipitous labor. b. Breech presentation has no effect on rupture of membranes. c. Breech presentation is not associated with postmaturity syndrome. d. A prolapsed umbilical cord is a potential complication for a fetus in a breech presentation. (ATI Ch 16: Complications Related to the Birth Process)

A nurse is caring for a client who is admitted to the labor and delivery unit. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? a. Precipitous labor b. Premature rupture of membranes c. Postmaturity syndrome d. Prolapsed umbilical cord

a. oligohydramnios c. Fetal cord compression Rationale: a. Oligohydramnios is an indication for an amnioinfusion because inadequate amniotic fluid can contribute to intrauterine growth restriction of the fetus. b. Hydramnios is excessive amniotic fluid. c. Oligohydramnios results in fetal cord compression. d. Amnioinfusion does not increase hydration. IV fluids or oral intake would provide hydration. e. Fetal immatury is not a reason for performing an amnioinfusion. (ATI Ch 15: Therapeutic Procedures to Assist with Labor and Delivery)

A nurse is caring for a client who is at 42 weeks of gestation and is admitted to the labor and delivery unit. During an ultrasound, it is noted that the fetus is large for gestational age. The nurse reviews the prescription from the provider to begin an amnioinfusion. Which of the following conditions should the nurse plan to prepare an amnioinfusion? (Select all that apply.) a. oligohydramnios b. hydramnios c. Fetal cord compression d. hydration e. Fetal immaturity

a. Hands and knees Rationale: a. having the client assume a position on her hands and knees can help the fetus rotate from a posterior to an anterior position. b. The lithotomy position is when the client lies on her back with her knees elevated and does not facilitate labor progression. c. The Trendelenburg position requires the client to lie on her back and does not assist in the rotation of the fetus. d. The supine position with a rolled towel under one hip can assist in preventing vena cava syndrome but does not assist in the rotation of the fetus. (ATI Ch 16: Complications Related to the Birth Process)

A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? a. Hands and knees b. Lithotomy c. Trendelenburg d. Supine with a rolled towel under one hip

b. Reduced fetal oxygen supply Rationale: a. Precipitous labor, not prolonged labor, is often the result of hypertonic contractions and inadequate uterine relaxation between contractions. b. Inadequate uterine relaxation results in reduced oxygen supply to the fetus. c. Hypertonic concentrations and inadequate relaxation of the uterus between contractions does not delay cervical dilation. d. A contraction pattern of hypertonic contractions and inadequate relaxation between contractions will increase maternal distress, but this is not an adverse effect. (ATI Ch 16: Complications Related to the Birth Process)

A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increases the risk for which of the following complications? a. Prolonged labor b. Reduced fetal oxygen supply c. Delayed cervical dilation d. Increased maternal stress

b. Dizziness Rationale: a. Blood-tinged sputum production is an adverse effect associated with indomethacin. b. Dizziness and lightheadedness are associated with orthostatic hypotension, which occurs when taking nifedipine. c. Facial flushing and heat sensation are adverse effects associated with nifedipine. d. Nervousness, jitteriness, and sleep disturbances are adverse effects associated with nifedipine. (ATI Ch 10: Onset of Labor)

A nurse is caring for a client who is receiving nifedipine for prevention of preterm labor. The nurse should monitor the client for which of the following manifestations? a. Blood-tinged sputum b. Dizziness c. Pallor d. Somnolence

b. A fetal heart rate (FHR) of 180 with absence of variability. Rationale: A fetal heart rate (FHR) of 180 with absence of variability is nonreassuring; the oxytocin should be immediately discontinued and the physician should be notified. The oxytocin should also be discontinued if uterine hyperstimulation occurs. Uterine contractions that occur every 8 to 10 minutes do not qualify as hyperstimulation. The client needing to void is not an indication to discontinue the oxytocin induction immediately or to call the physician. The oxytocin does not need to be discontinued when the membranes rupture, but the physician should be notified. (Evolve Ch 32: Labor and Birth Complications)

A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of: a. Uterine contractions occurring every 8 to 10 minutes. b. A fetal heart rate (FHR) of 180 with absence of variability. c. The client needing to void. d. Rupture of the client's amniotic membranes.

c. Rho(d) immune globulin Rationale: a. Prostaglandin gel is a cervical ripening agent and is not administered prior to an external version. b. Magnesium sulfate is a tocolytic, which may be administered prior to the version. But because the client has no prenatal care and is Rh-negative, there is another medication the nurse should anticipate administering. c. Rho(D) immune globulin is administered to an Rh-negative client at 28 weeks of gestation. Because this client has no prenatal care, it should be given prior to the version to prevent isoimmunization. d. Oxytocin is administered to increase contraction frequency, intensity, and duration. It is not administered prior to an external version. (ATI Ch 15: Therapeutic Procedures to Assist with Labor and Delivery)

A nurse is caring for client who had no prenatal care, is Rh- negative, and will undergo an external version at 37 weeks of gestation. Which of the following medication should the nurse plan to administer prior to the version? a. Prostaglandin gel b. Magnesium sulfate c. Rho(d) immune globulin d. Oxytocin

d. When latched on, the infant's nose, cheek, and chin are touching the breast. Rationale: a. The infant is enticed to suck when the mother spreads colostrum on the nipple. b. The mother should insert a finger in the side of the newborn's mouth to break the suction before removing her nipple. c. The mother should stroke the newborn's lips to promote sucking. d. Effective latching-on includes the infant's nose, cheek, and chin touching the mother's breast. (ATI Ch 25: Newborn Nutrition)

A nurse is giving instructions to a mother about how to breastfeed her newborn. Which of the following actions by the mother indicates understanding of the teaching? a. The mother places a few drops of water on her nipple before feeding. b. The mother gently removes her nipple from the infant's mouth to break the suction. c. When she is ready to breastfeed, the mother gently strokes the newborn's neck with her finger. d. When latched on, the infant's nose, cheek, and chin are touching the breast.

c. Shortness of breath Rationale: a. Reduced menstrual blood flow is a common adverse effect of oral contraceptives and usually subsides after a few months. b. Breast tenderness is a common adverse effect of oral contraceptives and usually subsides after a few months of use. c. Shortness of breath can indicate a pulmonary embolus or myocardial infarction and should be reported to the provider immediately. d. Headaches are a common adverse effect of oral contraceptives and usually subsides after a few months of use. (ATI Ch 1: Contraception)

A nurse is instructing a client who is taking an oral contraceptive about danger signs to report to her provider. The nurse determines the client understands the teaching when the client states the need to report which of the following? a. Reduced menstrual flow b. Breast tenderness c. Shortness of breath d. Headaches

d. Cradle Rationale: a. An over-the-shoulder position can be used when burping the newborn. b. The supine position is appropriate for the sleeping newborn. c. Holding the newborn upright with the chin supported is a position that can be used when burping the newborn. d. The cradle position for breast feeding includes the mother laying the newborn across her forearm with her hand supporting the lower back and buttocks. (ATI Ch 25: Newborn Nutrition)

A nurse is reviewing breastfeeding positions with the mother of a newborn. Which of the following positions should the nurse discuss? a. Over‐the‐shoulder b. Supine c. Chin‐supported d. Cradle

d. Keep a daily record of fetal kick counts Rationale: a. The client who has ruptured membranes should not insert anything into her vagina. b. The nurse should instruct the client to avoid tub bathes and take showers. c. The nurse should instruct the client to wipe from front to back when performing perineal hygiene. d. The client should record daily fetal kick counts. (ATI Ch 10: Onset of Labor)

A nurse is reviewing discharge teaching with a client who has premature rupture of membranes at 26 weeks gestation. Which of the following instructions should the nurse include in the teaching? a. Use a condom with sexual intercourse b. Avoid bubble bath solution when taking a tub bath c. Wipe from the back to front when performing perineal hygiene d. Keep a daily record of fetal kick counts

c. Place used bottles in the dishwasher. d. Check the nipple for appropriate flow of formula. e. use tap water to dilute concentrated formula. Rationale: a. Chemicals from the disinfectant wipe can remain on the lid during opening and mix with the formula. b. Once formula is prepared, it can be refrigerated for up to 48 hours. c. bottles can be placed in a dishwater or washed by hand in hot soapy water using a good bottle brush. d. The flow of formula from the nipple should be checked to determine that it is not too fast or too slow. e. Tap water is used to mix concentrated or powder formula. If the water is from a questionable source, it should be boiled first. (ATI Ch 25: Newborn Nutrition)

A nurse is reviewing formula preparation with parents who plan to bottle‐feed their newborn. Which of the following information should the nurse include in the teaching? (Select all that apply.) a. Use a disinfectant wipe to clean the lid of the formula can. b. Store prepared formula in the refrigerator for up to 72 hr. c. Place used bottles in the dishwasher. d. Check the nipple for appropriate flow of formula. e. use tap water to dilute concentrated formula.

b. Irregular vaginal bleeding c. Weight gain d. Breast changes Rationale: a. Tinnitus is not an adverse effect of implantable progestins. b. Irregular vaginal bleeding is a potential adverse effect of implantable progestins. c. Weight gain is a potential adverse effect of implantable progestins. d. Breast changes are a potential adverse effect of implantable progestins. e. Gingival hyperplasia is not an adverse effect of implantable progestins. (ATI Ch 1: Contraception)

A nurse is teaching a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? (Select all that apply.) a. Tinnitus b. Irregular vaginal bleeding c. Weight gain d. Breast changes e. Gingival hyperplasia

c. Keep the nipple full of formula throughout the feeding. Rationale: a. The newborn should be burped after each ½ oz of formula. b. The newborn should be cradled in a semi-upright position. c. The nipple should always be kept full of formula to prevent the newborn from sucking in air during the feeding. d. Any unused formula should be discarded due to the possibility of bacterial contamination. (ATI Ch 25: Newborn Nutrition)

A nurse is teaching a group of new parents about proper techniques for bottle feeding. Which of the following instructions should the nurse provide? a. Burp the newborn at the end of the feeding. b. Hold the newborn close in a supine position. c. Keep the nipple full of formula throughout the feeding. d. Refrigerate any unused formula.

d. The cervix is effacing and dilated to 2 cm. Rationale: Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Irregular, mild contractions that do not cause cervical change are not considered a threat. Estriol is a form of estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been shown to increase before preterm birth. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic clues of preterm labor, such as cervical changes. (Evolve Ch 32: Labor and Birth Complications)

A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What finding indicates that preterm labor is occurring? a. Estriol is not found in maternal saliva. b. Irregular, mild uterine contractions are occurring every 12 to 15 minutes. c. Fetal fibronectin is present in vaginal secretions. d. The cervix is effacing and dilated to 2 cm.

d. One fetal movement noted in 1 hour of assessment by the mother Rationale: Self-care in a postterm pregnancy should include performing daily fetal kick counts three times per day. The mother should feel four fetal movements per hour. If she feels fewer than four movements, she should count for 1 more hour. Fewer than four movements in that hour warrants evaluation. The findings described in the other choices are normal at 42 weeks of gestation. (Evolve Ch 32: Labor and Birth Complications)

For a woman at 42 weeks of gestation, which finding requires more assessment by the nurse? a. Fetal heart rate of 116 beats/min b. Cervix dilated 2 cm and 50% effaced c. Score of 8 on the biophysical profile d. One fetal movement noted in 1 hour of assessment by the mother

a. A common practice among Mexican women is known as las dos cosas. Rationale: Las dos cosas refers to combining breastfeeding and commercial infant formula. It is based on the belief that combining the two feeding methods gives the mother and infant the benefits of breastfeeding along with the additional vitamins from formula. In the Muslim culture, breastfeeding for 24 months is customary; Muslim women may, however, choose to bottle-feed formula or expressed breast milk while in the hospital. Latino women born in the United States are less likely to breastfeed. East Indian and Arab women believe that hot foods, such as chicken and broccoli, are best for the new mother. The cultural descriptor hot has nothing to do with the temperature or spiciness of the food. (Evolve Ch 25: Newborn Nutrition and Feeding)

The maternity nurse must be cognizant that cultural practices have significant influence on infant feeding methods. Many regional and ethnic cultures can be found within the United States. One cannot assume that generalized observations about any cultural group will hold for all members of the group. Which statement related to cultural practices influencing infant feeding practice is correct? a. A common practice among Mexican women is known as las dos cosas. b. Muslim cultures do not encourage breastfeeding because of modesty concerns. c. Latino women born in the United States are more likely to breastfeed. d. East Indian and Arab women believe that cold foods are best for a new mother.

1. Bring the infant to the clinic. Rationale: Signs of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If signs of infection occur, the client should be instructed to notify a health care provider (HCP). If these symptoms occur, antibiotics may be necessary. Options 2, 3, and 4 are not the most appropriate nursing interventions for an umbilical cord infection as given in the question. Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the clinical manifestations provided in the question to assist in answering. Noting the word discharge in the question will assist in directing you to the option that indicates that the newborn needs to be seen by the HCP. (NCLEX Ch 31: Care of the Newborn)

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1. Bring the infant to the clinic. 2. This is a normal occurrence and no further action is needed. 3. Increase the number of times that the cord is cleaned per day. 4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

2. Maintaining standard precautions at all times while caring for the newborn Rationale: An infant born to a mother infected with HIV must be cared for with strict attention to standard precautions. This prevents the transmission of HIV from the newborn, if infected, to others and prevents transmission of other infectious agents to the possibly immunocompromised newborn. Options 1 and 3 are not associated specifically with the care of a potentially HIV-infected newborn. Mothers infected with HIV should not breast-feed. Test-Taking Strategy: Eliminate options 1 and 3 first because they are comparable or alike and are not associated specifically with the care of a potentially HIV-infected newborn. Recalling that HIV-infected mothers should not breast-feed will direct you to the correct option. (NCLEX Ch 31: Care of the Newborn)

The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely 2. Maintaining standard precautions at all times while caring for the newborn 3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment

4. Persistent nonreassuring fetal heart rate Rationale: Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged, but do not indicate fetal or maternal compromise. Coordinated uterine contractions and progressive changes in the cervix are a reassuring pattern in labor. Test-Taking Strategy: Focus on the subject, signs of fetal or maternal compromise. Eliminate options 1, 2, and 3 because they are comparable or alike and are normal expectations during labor. (NCLEX Ch 28: Problems with Labor and Birth)

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? 1. Maternal fatigue 2. Coordinated uterine contractions 3. Progressive changes in the cervix 4. Persistent nonreassuring fetal heart rate

1. Provide pain relief measures. Rationale: Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes, but would be encouraged to rest. Test-Taking Strategy: Focus on the strategic word, priority. Also note that options 2, 3, and 4 are comparable or alike and are therapeutic measures for hypotonic dysfunction. (NCLEX Ch 28: Problems with Labor and Birth)

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1. Provide pain relief measures. 2. Prepare the client for an amniotomy. 3. Promote ambulation every 30 minutes. 4. Monitor the oxytocin infusion closely.

2. Connect the resuscitation bag to the oxygen outlet. Rationale: The highest priority on admission to the nursery for a newborn with a low Apgar score is the airway, which would involve preparing respiratory resuscitation equipment and oxygen. The remaining options are also important, although they are of lower priority. The newborn would be placed on an apnea and cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support. The radiant warmer would provide an external heat source, which is necessary to prevent further respiratory distress. Test-Taking Strategy: Note the strategic words, highest priority. This question asks you to prioritize care on the basis of information about a newborn's condition. Use the ABCs—airway-breathing-circulation. A method of planning for airway support is to have the resuscitation bag connected to an oxygen source. (NCLEX Ch 31: Care of the Newborn)

The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? 1. Turn on the apnea and cardiorespiratory monitors. 2. Connect the resuscitation bag to the oxygen outlet. 3. Set up the intravenous line with 5% dextrose in water. 4. Set the radiant warmer control temperature at 36.5 °C (97.6 °F).

2. Hemorrhage Rationale: In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding. Options 1, 3, and 4 are not risks that are related specifically to placenta previa. Test-Taking Strategy: Focus on the subject, the risks associated with placenta previa. Thinking about the pathophysiology associated with this disorder and recalling that bleeding is a primary concern in this client will direct you easily to the correct option. (NCLEX Ch 28: Problems with Labor and Birth)

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

3. Irritability 4. Constant crying 5. Difficult to comfort Rationale: A newborn of a woman who uses drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held. This infant is not lethargic or sleepy. Test-Taking Strategy: Lethargy and sleepiness are comparable or alike in that they indicate hypoactivity of the newborn, and therefore can be eliminated. From the remaining options, recalling the pathophysiology associated with an infant born to a drug-addicted mother and that the newborn is irritable will assist you in eliminating that this infant will be easily comforted and cuddle when held. (NCLEX Ch 31: Care of the Newborn)

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply. 1. Lethargy 2. Sleepiness 3. Irritability 4. Constant crying 5. Difficult to comfort 6. Cuddles when being held

2. Uterine tenderness Rationale: Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy are signs of placenta previa. Test-Taking Strategy: Focus on the subject, abruptio placentae. Remember that the difference between placenta previa and abruptio placentae involves the presence of uterine pain and tenderness with abruptio placentae, as opposed to painless bleeding with placenta previa. (NCLEX Ch 28: Problems with Labor and Birth)

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding

4. Monitor the newborn's response to feedings and weight gain pattern. Rationale: Fetal alcohol syndrome, a diagnostic category delineated under fetal alcohol spectrum disorders (FASDs), is caused by maternal alcohol use during pregnancy. A primary nursing goal for the newborn diagnosed with fetal alcohol syndrome is to establish nutritional balance after birth. These newborns may exhibit hyperirritability, vomiting, diarrhea, or an uncoordinated sucking and swallowing ability. A quiet environment with minimal stimuli and handling would help to establish appropriate sleep-rest cycles in the newborn as well. Options 1, 2, and 3 are inappropriate interventions. Test-Taking Strategy: Note the strategic word, priority. Think about the pathophysiology that occurs in a newborn with this condition. Also, use Maslow's Hierarchy of Needs theory to direct you to the correct option. Remember that nutrition is a priority. (NCLEX Ch 31: Care of the Newborn)

The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? 1. Allow the newborn to establish own sleep-rest pattern. 2. Maintain the newborn in a brightly lighted area of the nursery. 3. Encourage frequent handling of the newborn by staff and parents. 4. Monitor the newborn's response to feedings and weight gain pattern.

1. Age 54 2. Body mass index of 28 3. Previous difficulty with fertility Rationale: Risk factors that increase a woman's risk for dysfunctional labor include the following: advanced maternal age, being overweight, electrolyte imbalances, previous difficulty with fertility, uterine overstimulation with oxytocin, short stature, prior version, masculine characteristics, uterine abnormalities, malpresentations and position of the fetus, cephalopelvic disproportion, maternal fatigue, dehydration, fear, administration of an analgesic early in labor, and use of epidural analgesia. Age 54 is considered advanced maternal age, and a body mass index of 28 is considered overweight. Previous difficulty with infertility is another risk factor for labor dystocia. A potassium level of 3.6 mEq/L (3.6 mmol/L) is normal and administration of oxytocin alone is not a risk factor; risk exists only if uterine hyperstimulation occurs. Test-Taking Strategy: Focus on the subject, risk factors for labor dystocia. Additionally, focus on the data in the question, look at each option, and determine if these are normal assessment findings. (NCLEX Ch 28: Problems with Labor and Birth)

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. 1. Age 54 2. Body mass index of 28 3. Previous difficulty with fertility 4. Administration of oxytocin for induction 5. Potassium level of 3.6 mEq/L (3.6 mmol/L)

4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age Rationale: Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. Test-Taking Strategy: First, eliminate options 1 and 2 because they are comparable or alike. Next, remember that the difference between placenta previa and abruptio placentae involves the presence of uterine pain and tenderness with abruptio placentae, as opposed to painless bright red bleeding with placenta previa. (NCLEX Ch 28: Problems with Labor and Birth)

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age

2. The client has a history of cardiac disease. Rationale: Preterm labor occurs after the twentieth week but before the thirty-seventh week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetric problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years. Test-Taking Strategy: Options 1, 3, and 4 are comparable or alike and are average and normal findings. Also note that the correct option is the only option that identifies an abnormal condition. (NCLEX Ch 28: Problems with Labor and Birth)

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? Excerpt From: Linda Anne Silvestri PhD, RN. "Saunders Comprehensive Review for 1. The client is a 35-year-old primigravida. 2. The client has a history of cardiac disease. 3. The client's hemoglobin level is 13.5 g/dL (135 mmol/L). 4. The client is a 20-year-old primigravida of average weight and height.

2. Maintaining safety because of low blood glucose levels Rationale: The newborn of a diabetic mother is at risk for hypoglycemia, so maintaining safety because of low blood glucose levels would be a priority. The newborn would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. Developmental delays, choking, and an elevated body temperature are not expected problems. Test-Taking Strategy: Note the strategic word, priority. Read each option thoroughly and eliminate options 1, 3, and 4 because they are comparable or alike in that newborns of diabetic mothers are not at risk for these problems. Also, note the relationship of the words diabetes mellitus in the question and the word glucose in the correct option. (NCLEX Ch 31: Care of the Newborn)

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1. Developmental delays because of excessive size 2. Maintaining safety because of low blood glucose levels 3. Choking because of impaired suck and swallow reflexes 4. Elevated body temperature because of excess fat and glycogen

c. Breastfeeding costs employers in terms of time lost from work. Rationale: Less time is lost from work by breastfeeding mothers, in part because infants are healthier than bottle-fed infants. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment, and it saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Also, breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal. (Evolve Ch 25: Newborn Nutrition and Feeding)

Which statement is not accurate regarding the effect of breastfeeding on the family or society at large? a. Breastfeeding requires fewer supplies and less cumbersome equipment. b. Breastfeeding saves families money. c. Breastfeeding costs employers in terms of time lost from work. d. Breastfeeding benefits the environment.

d. It varies from couple to couple, depending on the method and the users. Rationale: The contraceptive failure rate is strictly a statistical measure of likely accidental pregnancy over a couple's first year of use. Failure rates decline over time because users gain experience. Contraceptive effectiveness varies from couple to couple, depending on how well a contraceptive method is used and how well it suits the couple. (Evolve Ch 8: Contraception and Abortion)

Which statement is true about the term contraceptive failure rate? a. It refers to the percentage of users expected to have an accidental pregnancy over a 5-year span. b. It refers to the minimum level that must be achieved to receive a government license. c. It increases over time as couples become more careless. d. It varies from couple to couple, depending on the method and the users.

3. "I will ask the nurse to attend to my infant if I am napping and my husband is not here." Rationale: Precautions to prevent infant abduction include placing a newborn's crib away from the door, transporting a newborn only in the crib and never carrying the newborn, expecting health care personnel to wear identification that is easily visible at all times, and asking the nurse to attend to the newborn if the mother is napping and no family member is available to watch the newborn (the newborn is never left unattended). If the mother states that she will ask the nurse to watch the newborn while she is sleeping, she has understood the teaching. Options 1, 2, and 4 are incorrect and indicate that the mother needs further teaching. Test-Taking Strategy: Focus on the subject, that the client understands precautions to prevent infant abduction. Read each option carefully and select the option that provides protection to the infant. This will direct you to the correct option. (NCLEX Ch 31: Care of the Newborn)

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1. "I will place my baby's crib close to the door." 2. "Some health care personnel won't have name badges." 3. "I will ask the nurse to attend to my infant if I am napping and my husband is not here." 4. "It's okay to allow the nurse assistant to carry my newborn to the nursery."

a. The pills should be readily available during the initial learning phase when a woman is using a new method of contraception. Rationale: A backup method of birth control is also a good idea for beginners. The woman has up to 120 hours after unprotected intercourse to take emergency contraception pills; they do not, however, protect against pregnancy from subsequent unprotected intercourse. These pills are contraindicated during pregnancy and if the woman has undiagnosed abnormal vaginal bleeding. (Evolve Ch 8: Contraception and Abortion)

With regard to emergency contraception pills, nurses should be aware that: a. The pills should be readily available during the initial learning phase when a woman is using a new method of contraception. b. The pills must be taken no later than 48 hours after unprotected intercourse or birth control mishap. c. The pills protect the woman against pregnancy even if she engages in unprotected intercourse in the days after treatment. d. Emergency contraception has no medical contraindications.

b. Breastfeeding. Rationale: Breastfeeding is the best prevention strategy for decreasing childhood and adolescent obesity. Breastfeeding also helps the woman return to her prepregnant weight sooner. All breastfed infants should be fed on demand. Use of lower-calorie formula is an inappropriate strategy that does not meet the infant's nutritional needs. Breastfeeding is the most appropriate choice for infant feeding. Smaller feedings are not necessary. Infants should continue to be fed every 2 to 3 hours in the newborn period. (Evolve Ch 25: Newborn Nutrition and Feeding)

With regard to the long-term consequences of infant feeding practices, the nurse should instruct the obese client that the best strategy to decrease the risk for childhood obesity for her infant is: a. An on-demand feeding schedule. b. Breastfeeding. c. Lower-calorie infant formula. d. Smaller, more frequent feedings.

a. "A water-soluble lubricant should be used with condoms." Rationale: a. Condoms are used with water-soluble lubricants. b. A diaphragm should be removed no sooner that 6 hr and no later than 24 after intercourse. c. Acne is reduced when taking oral contraceptives. d. Contraceptive patches are replaced once a week. (ATI Ch 1: Contraception)

A Nurse in a health clinic is reviewing contraceptive use with a group of adolescent clients. Which of the following statements by an adolescent reflects an understanding of the teaching? a. "A water-soluble lubricant should be used with condoms." b. "A diaphragm should be removed 2 hours after intercourse" c. "Oral contraceptives can worsen a case of acne." d. "A contraceptive patch is replaced once a month."

a. Place the woman in the knee-chest position. Rationale: The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or knee-chest position) in which gravity keeps the pressure of the presenting part off the cord. Relieving pressure on the cord is the nursing priority. The nurse may also use her gloved hand or two fingers to lift the presenting part off the cord. If the cord is protruding from the vagina it may be covered with a sterile towel soaked in saline. The nurse should administer O2 by facial mask at 8 to 10 L/min until delivery is complete. If the cervix is fully dilated, the nurse should prepare for immediate vaginal delivery. Cesarean birth is indicated only if cervical dilation is not complete. (Evolve Ch 32: Labor and Birth Complications)

A pregnant woman's amniotic membranes rupture. Prolapsed cord is suspected. Which intervention is the nurse's top priority? a. Place the woman in the knee-chest position. b. Cover the cord in a sterile towel saturated with warm normal saline. c. Prepare the woman for a cesarean birth. d. Start oxygen by face mask.

1. Delivery of the fetus Rationale: Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the client or fetus is in jeopardy. Because delivery of the fetus is necessary, options 2, 3, and 4 are incorrect regarding management of a client with abruptio placentae. Test-Taking Strategy: Focus on the subject, management of abruptio placentae. Use knowledge regarding the management of abruptio placentae to answer the question. Note the words term gestation and moderate vaginal bleeding. Knowing that the goal is to deliver the fetus will direct you easily to the correct option. (NCLEX Ch 28: Problems with Labor and Birth)

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? 1. Delivery of the fetus 2. Strict monitoring of intake and output 3. Complete bed rest for the remainder of the pregnancy 4. The need for weekly monitoring of coagulation studies until the time of delivery

4. Administer oxygen, 8 to 10 L/minute, via face mask. Rationale: Oxygen is administered, 8 to 10 L/minute, via face mask to optimize oxygenation of the circulating blood. Option 1 is incorrect because the intravenous infusion should be increased (per health care provider prescription) to increase the maternal blood volume. Option 2 is incorrect because oxytocin stimulation of the uterus is discontinued if fetal heart rate patterns change for any reason. Option 3 is incorrect because the client is placed in the lateral position with her legs raised to increase maternal blood volume and improve fetal perfusion. Test-Taking Strategy: Note the strategic words, most important. Use the ABCs—airway-breathing-circulation. Oxygen is the only option that would improve cardiac output and improve perfusion to the fetus. The other options would not improve perfusion to the fetus. (NCLEX Ch 28: Problems with Labor and Birth)

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? 1. Slow the intravenous flow rate. 2. Continue the oxytocin drip if infusing. 3. Place the client in a high Fowler's position. 4. Administer oxygen, 8 to 10 L/minute, via face mask.

b. Even though more calories are needed for lactation, typically women who breastfeed lose weight more rapidly than women who bottle feed in the postpartum period. c. Weight loss diets are not recommended for women who breastfeed. d. If breastfeeding, she should regulate her fluid consumption in response to her thirst level. Rationale: Weight loss diet plans are not recommended for women who are breastfeeding because they can lead to depletion of reserves and nutrient stores and decreased milk production. Breastfeeding mothers need to increase their caloric intake by 400-500 calories/day to ensure adequate nutritional stores and milk production. Breastfeeding women lose weight faster postpartum than women who bottle feed their infants. Regulating fluid consumption in response to her thirst level will ensure that a breastfeeding woman has adequate hydration without overhydration. (Evolve Ch 25: Newborn Nutrition and Feeding)

Following a vaginal delivery, the patient tells the nurse that she intends to breastfeed her infant but she is very concerned about returning to her prepregnancy weight. On the basis of this interaction, the nurse would advise the patient that: Select all that apply. a. She should join Weight Watchers as soon as possible to ensure adequate weight loss. b. Even though more calories are needed for lactation, typically women who breastfeed lose weight more rapidly than women who bottle feed in the postpartum period. c. Weight loss diets are not recommended for women who breastfeed. d. If breastfeeding, she should regulate her fluid consumption in response to her thirst level. e. If she decreases her calorie intake by 100-200 calories a day she will lose weight more quickly.

c. Male condoms Rationale: For typical users, the failure rate for male condoms may approach 15%; however, if condoms are used correctly, the failure rate is only 2%. Failure rates are about 29% for spermicides, about 21% for female condoms, and 16% for diaphragms with spermicides. (Evolve Ch 8: Contraception and Abortion)

If used consistently and correctly, which of the barrier methods of contraception has the lowest failure rate? a. Spermicides b. Female condoms c. Male condoms d. Diaphragms

c. Whatever the position used, the infant is "belly to belly" with the mother. Rationale: The infant inevitably faces the mother, belly to belly. The football position usually is preferred after cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The mother should never push on the back of the head, because doing so might cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast. (Evolve Ch 25: Newborn Nutrition and Feeding)

In helping the breastfeeding mother position the baby, the nurse should keep in mind that: a. The cradle position is usually preferred by mothers who had a cesarean birth. b. Women with perineal pain and swelling prefer the modified cradle position. c. Whatever the position used, the infant is "belly to belly" with the mother. d. While supporting the head, the mother should push gently on the occiput.

b. Determine the woman's level of knowledge about contraception and commitment to any particular method. Rationale: All of these actions are part of the assessment, but determination of the woman's level of knowledge regarding contraception and her commitment to a method is the primary step and is necessary before completing the process and moving on to a nursing diagnosis. Once the client's level of knowledge is determined, the nurse can interact with her to compare options, reliability, cost, comfort level, protection from sexually transmitted infections (STIs), and a partner's willingness to participate. Data about frequency of coitus should include the number of sexual partners, level of partner contraceptive involvement, and any partner objections. A woman's willingness to touch her genitals and cervical mucus is a key factor for the nurse to discuss only if the client expresses interest in using one of the fertility awareness methods of contraception. (Evolve Ch 8: Contraception and Abortion)

Nurses, certified nurse-midwives, and other advanced practice nurses have the knowledge and expertise to assist women in making informed choices regarding contraception. A multidisciplinary approach should ensure that the woman's social, cultural, and interpersonal needs are met. Which action should the nurse take first when meeting with a new client to discuss contraception? a. Obtain data about the frequency of coitus. b. Determine the woman's level of knowledge about contraception and commitment to any particular method. c. Assess the woman's willingness to touch her genitals and cervical mucus. d. Evaluate the woman's contraceptive life plan.

a. Encourage the mother to continue breastfeeding because it is effective in meeting the newborn's nutrient and fluid needs. Rationale: Weight loss of 8 oz falls within the 5% to 10% expected weight loss from birth weight during the first few days of life, which for this newborn would be 6.6 to 13.2 oz. The infant is not undernourished, and the physician does not need to be notified. Breastfeeding is effective, and bottle feeding does not need to be initiated at this time. (Evolve Ch 25: Newborn Nutrition and Feeding)

The birth weight of a breastfed newborn was 8 lb, 4 oz. On the third day the newborn's weight is 7 lb, 12 oz. On the basis of this finding, the nurse should: a. Encourage the mother to continue breastfeeding because it is effective in meeting the newborn's nutrient and fluid needs. b. Suggest that the mother switch to bottle feeding because breastfeeding is ineffective in meeting newborn needs for fluid and nutrients. c. Notify the physician because the newborn is being poorly nourished. d. Refer the mother to a lactation consultant to improve her breastfeeding technique.

4. Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection. Rationale: Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law. Options 1, 2, and 3 are not the purposes for administering this medication to a newborn infant. Test-Taking Strategy: Note the strategic word, best. Use knowledge of the purpose of administering erythromycin ophthalmic ointment to a newborn infant. Remember that this is done to prevent ophthalmia neonatorum. (NCLEX Ch 31: Care of the Newborn)

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1. Protects the newborn's eyes from possible infections acquired while hospitalized. 2. Prevents cataracts in the newborn born to a woman who is susceptible to rubella. 3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. 4. Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.

1. Cyanosis 2. Tachypnea 4. Retractions 5. Audible grunts Rationale: A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Hypotension and a barrel chest are not clinical manifestations associated with respiratory distress syndrome. Test-Taking Strategy: Focus on the subject, signs of respiratory distress syndrome. Eliminate hypotension, as this is not a finding associated with respiratory distress syndrome. Also, respiratory distress syndrome is an acute occurrence and a barrel chest develops with a chronic condition. In addition, note the relationship between the diagnosis and the signs noted in the correct options. (NCLEX Ch 31: Care of the Newborn)

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. 1. Cyanosis 2. Tachypnea 3. Hypotension 4. Retractions 5. Audible grunts 6. Presence of a barrel chest

2. Abnormal palmar creases Rationale: Fetal alcohol syndrome, a diagnostic category of fetal alcohol spectrum disorders (FASDs), is caused by maternal alcohol use during pregnancy. Features of newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal assessment findings in the full-term newborn infant. Test-Taking Strategy: Use knowledge regarding normal assessment findings in the full-term newborn infant to answer this question. Length, birth weight, and head circumference are comparable or alike in that all are physical measurements assessed on a newborn and represent normal findings in a full-term newborn. (NCLEX Ch 31: Care of the Newborn)

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Birth weight of 6 lb, 14 oz (3120 g) 4. Head circumference appropriate for gestational age

d. They all require the cooperation of the woman's partner. Rationale: Fertile phases can be determined in a number of ways, but the sexual partner must cooperate in the method. Not all FAB methods calculate fertility phases by examining mucus; some use body temperatures and other signs. Some methods use chemical or physical barriers to conception during fertile periods. (Evolve Ch 8: Contraception and Abortion)

What important aspects do all the fertility awareness-based (FAB) methods have in common? a. They all require a woman to be able to touch her genitals to assess cervical mucus. b. They all involve abstinence at some point. c. They all rely on measurement of body temperature. d. They all require the cooperation of the woman's partner.

b. Women experiencing precipitous labor are about the only women experiencing dysfunctional labor who are not exhausted. Rationale: Precipitous labor lasts less than 3 hours. Short women more than 30 pounds overweight are more at risk for dysfunctional labor. Hypotonic uterine dysfunction, in which the contractions become weaker, is more common. Abnormal labor patterns are more common in women younger than 20 years. (Evolve Ch 32: Labor and Birth Complications)

With regard to dysfunctional labor, nurses should be aware that: a. Women who are underweight are more at risk. b. Women experiencing precipitous labor are about the only women experiencing dysfunctional labor who are not exhausted. c. Hypertonic uterine dysfunction is more common than hypotonic dysfunction. d. Abnormal labor patterns are most common in older women.

d. "Major complications after sterilization are rare." Rationale: Sterilization procedures can be safely done on an outpatient basis. Complications are uncommon and usually not serious. The average failure rate for female sterilization is 0.5% and for male sterilization is 0.15%. A vasectomy has no effect on potency or volume of ejaculate. Sterilization reversal is costly, difficult, and uncertain. (Evolve Ch 8: Contraception and Abortion)

A married couple is discussing male and female sterilization with the nurse. Which statement is most appropriate for the nurse to make? a. "Male and female sterilization methods are 100% effective." b. "A vasectomy may have a slight effect on sexual performance." c. "Tubal ligation can be easily reversed if you change your mind in the future." d. "Major complications after sterilization are rare."

d. Provide education about infant care when the father is present. Rationale: a. It is not helpful to push the father into infant care activities without first providing education. b. This is a nontherapeutic statement and presumes the nurse knows what the father is feeling. c. This is a nontherapeutic statement and offers the nurse's opinion. d. Nursing interventions to promote paternal bonding include providing education about infant care and encouraging the father to take a hands-on approach. (ATI Ch 18: Baby-Friendly Care)

A nurse concludes that the father of an infant is not showing positive signs of parent-infant bonding. He appears very anxious and nervous when the infant's mother asks him to bring her the infant. Which of the following actions should the nurse use to promote father-infant bonding? a. Hand the father the infant, and suggest that he change the diaper. b. Ask the father why he is so anxious and nervous. c. Tell the father that he will grow accustomed to the infant. d. Provide education about infant care when the father is present.

d. "You probably didn't ovulate during this cycle." Rationale: Pregnancy cannot occur without ovulation (which is being measured using the BBT method). The absence of a temperature decrease most likely is the result of lack of ovulation. Illness would most likely cause an increase in BBT. A comment such as the one in B discredits the client's concerns. (Evolve Ch 8: Contraception and Abortion)

A woman is using the basal body temperature (BBT) method of contraception. She calls the clinic and tells the nurse, "My period is due in a few days, and my temperature has not gone up." The nurse's most appropriate response is: a. "This probably means you're pregnant." b. "Don't worry; it's probably nothing." c. "Have you been sick this month?" d. "You probably didn't ovulate during this cycle."

c. Swelling and pain in one of her legs Rationale: Leg pain and swelling (edema) may indicate thrombophlebitis and should be reported immediately. Breast tenderness and weight gain are expected side effects of OCPs, and mood swings are a common side effect. (Evolve Ch 8: Contraception and Abortion)

A woman taking an oral contraceptive pill (OCP) as her birth control method of choice should notify her health care provider immediately if she notes: a. Breast tenderness and swelling b. Weight gain c. Swelling and pain in one of her legs d. Mood swings

b. Give the client time to express her feelings. Rationale: a. The nurse should continue her activities while encouraging the client to talk. b. The nurse should recognize that the client is in the taking-in phase, which begins immediately following birth and lasts a few hours to a couple of days. c. It is not necessary for the client to stop talking while the nurse completes the needed assessments. d. The client is in the taking-in phase, which includes talking about the birth experience. The client should be encouraged. (ATI Ch 18: Baby-Friendly Care)

A client in the early postpartum period is very excited and talkative. She is repeatedly telling the nurse every detail of her labor and birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following action should the nurse take? a. Come back later when the client is more cooperative. b. Give the client time to express her feelings. c. Tell the client she needs to be quiet so the assessment can be completed. d. Redirect the client's focus so that she will become quiet.

c. Breastfeeding an infant and an older sibling during the same period. Rationale: In tandem feeding, a mother nurses both an infant and an older child during the same period. (Evolve Ch 25: Newborn Nutrition and Feeding)

The concept of tandem feeding is based on: a. Adequate nutritional stores for the mother and infant. b. Using both breasts to nurse the baby. c. Breastfeeding an infant and an older sibling during the same period. d. Supplementing breastfeeding with bottle feeding to maintain adequate weight gain.

d. Weaning can be mother or infant initiated. Rationale: Weaning is initiated by the mother or the infant. With infant-led weaning, the infant moves at his or her own pace in omitting feedings, which leads to a gradual decrease in the mother's milk supply. In mother-led weaning, the mother decides which feedings to drop. Infants can be weaned directly from the breast to a cup. Bottles are usually offered to infants younger than 6 months. If the infant is weaned prior to 1 year of age, iron-fortified formula rather than cow's milk should be offered. The feeding of least interest to the baby or the one through which the infant is likely to sleep should be eliminated first. Every few days thereafter the mother drops another feeding. Gradual weaning over a period of weeks or months is easier for both the mother and the infant than an abrupt weaning. (Evolve Ch 25: Newborn Nutrition and Feeding)

Which statement regarding infant weaning is correct? a. Weaning should proceed from breast to bottle to cup. b. The feeding of most interest should be eliminated first. c. Abrupt weaning is easier than gradual weaning. d. Weaning can be mother or infant initiated.