OB HESI

In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the

Anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month

A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take?

Apply cold compresses to both breasts for comfort.

A woman who is bottle feeding her newborn infant calls the clinic 72 hours after delivery and tells the nurse that both of her breasts are swollen, warm, and tender. What instructions should the nurse give?

Apply ice to the breasts

Vasodilation below the nerve block results in pooling in the lower extremities and maternal hypotension. Which is the quantity of IV lactated ringers the client should be hydrated with 20 minutes prior to operation?

Approximately 20 minutes prior to nerve block anesthesia, the client should be hydrated with 500-1000 cc of lactated ringers IV

The nurse providing care for the laboring woman should understand that accelerations with fetal movement:

Are reassuring

The nurse is assessing a client who is having a non-stress test (NST) at 41- week gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take?

Ask the client if she has felt any fetal movement.

To assess uterine contractions the nurse would

Assess duration from beginning to end of each contraction., frequency by measuring the time between the beginnings of contractions, and palpate the fundus of the uterus for strength.

The nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics. The infant expels a bloody stool. Which action should the nurse implement?

Assess for abdominal distension

The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which intervention is most important for the nurse to implement?

Assess the child's mucous membranes and skin turgor.

A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse initial response would be to:

Assess the fetal heart rate pattern.

The nurse's assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first?

Assess the infant's blood glucose level.

A nurse assesses a male newborn and determines that he has the following vital signs: Axillary temp of 95.1 F, HR of 136, RR of 48. Based on these findings, which action should the nurse take first?

Assess the infant's glucose level

The fetal heart rate of a client in active labor shows variable decelerations. The cervix is 7cm dilated and the membranes are intact. What intervention should the nurse implement first?

Assist client with turning to the left side.

During cardiopulmonary resuscitation, which of the following actions should be performed?

Assisted ventilations should be administered at a rate of 40 to 60 per minute

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan?

Avoid alcohol because it is excreted in breast milk

A baby is born with erythroblastosis fetalis. Which of the following signs/symptoms would the nurse expect to see?

Babies born with erythroblastosis fetalis often ore in severe congestive heart failure and, therefore, exhibit anasarca

A baby has been admitted to the neonatal nursery whose mother is hepatitis B surface antigen positive. Which of the following actions by the nurse should be taken at this time?

Babies exposed to hepatitis B in utero should receive the first dose of hepatitis B vaccine as well as hepatitis B immune globulin (HBIG) within 12 hours of delivery to reduce transmission of the virus

A nurse has just received report on 4 neonates in the newborn nursery. Which of the babies should the nurse assess first?

Babies who are born to mothers who are GBS positive are at high risk for sepsis. The incidence of sepsis is reduced, however, when the mother receives IV antibiotics during labor.

A full term infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. The nurse should monitor this baby carefully for which of the following?

Babies who are hypoglycemic will often develop jitters

Which of the following would lead the nurse to suspect cold stress syndrome in a newborn with a temperature of 96.5 F?

Babies who have cold stress syndrome will develop respiratory distress. One symptom of the distress is tachypnea.

A 6 month old child developed kernicterus immediately after birth. Which of the following test should be done to determine whether or not this child has developed andy sequelae to the illness?

Because the central nervous system may have been damaged by the high bilirubin levels, testing of the senses as well as motor and cognitive assessment are appropriate

An adolescent with diabetes receives 30 units of Humulin N insulin at 7:00 am. In accordance with the peak insulin action time, the nurse would monitor for a hypoglycemic episode at what time?

Before supper

An infant in respiratory distress is placed on pulse ox. The O2 sat is 85%. What is the priority nursing intervention?

Begin humidified oxygen

A child with sickle cell anemia who is in vaso-occlusive crisis is admitted to the hospital. Which health care provider prescription would assist in reversing the vaso-occlusive crisis?

Begin intravenous fluids

A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?

Begin oxytocin 4hrs after misoprostol is given.

A newborn infant is jaundiced due to Rh incompatibility. Which finding is most important for the nurse to report to the healthcare provider?

Bilirubin

A pregnant client at risk for preterm labor has received betamethasone (Celestone) for 2 days. What is most important for the nurse to monitor?

Blood glucose level

A multigravida woman at 35 weeks is diagnosed with pregnancy induced hypertension. Which symptom should the nurse instruct the client to report immediately?

Blurred vision

A child is seen in the health care clinic for complaints of fever. On data collection, the nurse notes that the child is pale, tachycardic, and has petechiae. Aplastic anemia is suspected. The nurse understands that which diagnostic test will confirm the diagnosis of aplastic anemia?

Bone marrow Biopsy

A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic leukemia. During the initial nursing assessment, which symptoms will this child most likely exhibit?

Bone pain, pallor

Four babies in the well baby nursery were born with congenital defects. Which of the babies' complications developed as a result of the delivery method?

Brachial palsy can result from either a traumatic vertex or breech delivery

A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client?

Breastfeed the infant, ensuring that both breasts are completely emptied.

A mother calls the clinic because her 6-year-old son, who has been taking prescribed antibiotics for 7 of the previous 10 days, continues to have a cough that she reports is worsening. Further questioning by the nurse reveals that the cough is nonproductive. What advice should the nurse provide to this mother?

Bring the child to the clinic today for an examination related to the cough.

A mother is concerned because she has counted only 8 kicks from her baby in two, 2-hour intervals; what intervention is necessary?

CALL THE HCP

classification of magnesium sulfate

CNS depressant

You are evaluating the fetal monitor tracing of your client, who is in active labor. Suddenly you see the fetal heart rate (FHR) drop from its baseline of 125 down to 80. You reposition the mother, provide oxygen, increase intravenous (IV) fluid, and perform a vaginal examination. The cervix has not changed. Five minutes have passed, and the fetal heart rate remains in the 80s. What additional nursing measures should you take?

Call for help and notify the care provider immediately

One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM Å~ 1. What action should the nurse take immediately?

Call the healthcare provider to question the prescription.

A newborn's head circumference is 12inches and his chest measurement is 13 inches. The nurse notes that this infant has no molding and was a breech presentation delivered by Cesarean section. What action should the nurse take based on these data?

Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.

A primigravida at 12 weeks tells the nurse that she does not like dairy products. Which food should the nurse recommend increasing the client's calcium intake?

Canned sardines

While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross the suture lines. How should the nurse document this finding?

Caput succedaneum

The nurse is preparing a presentation on the organs of the developing fetus for a group of expecting families. When preparing this material, the nurse will include which organ system as being the most developed by 3 weeks of gestation?

Cardiovascular system

While inspecting the newborn's head the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding does the nurse document?

Cephalohematoma

The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first?

Change the client's position.

While evaluating an external monitor tracing of a woman in active labor, the nurse notes that the fetal heart rate (FHR) for five sequential contractions begins to decelerate late in the contraction, with the nadir of the decelerations occurring after the peak of the contraction. The nurse first priority is to:

Change the woman's position

A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective?

Changes in apical heart rate from the 180's to the 140's

Changes in fetal heart rate are the first and most important indicator of compromised blood flow to the fetus, and these changes require action! What is the normal FHR in a pregnant woman?

Changes in fetal heart rate are the first and most important indicator of compromised blood flow to the fetus, and these changes require action! *Remember, the normal FHR is 110 to 160 bpm.*

Fetal well being is determined by assessing fundal height, fetal heart tones/rate, fetal movement and uterine activity (contractions). What do changes in fetal heart rate indicate?

Changes in fetal heart rate are the first and most important indicator of compromised blood flow to the fetus, and these changes require action.

Fetal wellbeing is determined by assessing fundal height, fetal heart tones/rate, fetal movement and uterine activity (contractions). What do changes in fetal heart rate indicate?

Changes in fetal heart rate are the first and most important indicator of compromised blood flow to the fetus, and these changes require action.

A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first?

Check the infant's oxygen saturation rate

A client at 28 weeks gestation reports occasional blurry vision and demonstrates clonus on exam. What action is most important for the nurse take?

Check urine specimen for protein.

A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited?

Choking, coughing, and cyanosis

A client at 35 weeks gestation complains of a "pain whenever the baby moves". On assessment, the nurse notes the client's temperature to be 101.2F with severe abdominal or uterine tenderness on palpation. The nurse knows that these findings are indicative of which condition?

Chorioamnionitis

The parents of a child with a cleft lip are concerned and ask the nurse when the lip will be repaired. With which statement should the nurse respond?

Cleft-lip repair is usually performed during the first weeks of life.

A client with prior traumatic delivery and history of D&C may experience miscarriage or preterm. What is the most common cause of miscarriages?

Clients with prior traumatic delivery, history of D&C, multiple abortions, or daughters of DES mothers may experience miscarriage or preterm labor related to incompetent cervix. The cervix may be surgically repaired prior to pregnancy, or during gestation.

A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?

Come to the clinic today for an ultrasound

A client at 28-weeks gestation calls the antepartum clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. Which instruction should the nurse provide?

Come to the clinic today for an ultrasound

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client?

Complete bedrest decreases oxygen needs and demands on the heart muscle tissue

A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior?

Concerns for body integrity

The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method?

Conduction

A 2-year-old child with Downs Syndrome is brought to the clinic for his regular physical exam. The nurse knows which problem is frequently associated with DS

Congenital heart disease

A 2-year-old with gastroesophageal reflux disease has developed a fear of eating. What instruction should the RN include in the parent's teaching plan?

Consistently follow a set meal-time routine

A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and contractions are occurring irregularly every 10-15 minutes. Which assessment finding confirms to the nurse that the client is not in labor at this time?

Contractions decrease with walking.

The umbilical cord in a newborn should contain 3 vessels, 1 vein which carries oxygenated blood to the fetus and 2 arteries which carry unoxygenated blood back to the placenta. What do cord abnormalities usually indicate?

Cord abnormalities usually indicate cardiovascular or renal anomalies.

Perinatal nurse are legally responsible for:

Correctly interpreting fetal heart rate (FHR) patterns, initiating appropriate nursing interventions, and documenting the outcomes

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness?

Correctly place the infant on the breast

Corticosteroids are used short term in low doses during exacerbations. What side effect do corticosteroids have on long term?

Corticosteroids are used short term in low doses during exacerbations. Long term use is avoided due to side effects and their adverse effect on growth

When assessing a newborn infant's HR, what technique is most important for the nurse to use?

Count the HR for at least one full minute

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use:

Counter pressure against the sacrum

The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention?

Cover the bladder with a nonadhering plastic wrap.

A primigravida in labor has complete cervical dilatation. Contractions are occurring every 1 1/2 to 2 minutes lasting 60 to 90 seconds. Upon examination, the nurse determines that birth is imminent because what has occurred?

Crowning

A patient suspected of abruptio placentae or placenta previa should be monitorized for bleeding at IV sites and gums due to increased risk of DIC. What isn't DIC related to?

DIC is related to fetal demise, infection/sepis, pregnancy-induced hypertension ( Preeclampsia) and abruptio placentae. Cervical carcinoma is related to podophyllin

A patient suspected of abruptio placentae or placenta previa should be monitored for bleeding at IV sites and gums due to increased risk of DIC. What isn't DIC related to?

DIC is related to fetal demise, infection/sepsis, pregnancy-induced hypertension (Preeclampsia) and abruptio placentae. Cervical carcinoma is related to podophyllin

Diabetis mellitus (DM) in children was typically diagnosed as insulin dependent diabetes until recently. What diabetes type has been discovered to occur more often in Native Americans, African Americans, and Hispanic children and adolescents?

DM in children was typicall diagnosed as insulin dependent until recently.

Diabetes mellitus (DM) in children was typically diagnosed as insulin dependent diabetes until recently. What diabetes type has been discovered to occur more often in Native Americans, African Americans, and Hispanic children and adolescents?

DM in children was typically diagnosed as insulin dependent until recently. A marked increase in Type 2 DM has occurred recently in the US.

A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain?

Date of last normal menstrual period

Which cardiovascular findings should the nurse assess further in a client at 20 weeks?

Decrease in pulse

The nurse is planning for the care of the 30-year-old primigravida with pre-gestational diabetes. What is the most important factor affecting this client's pregnancy outcome?

Degree of glycemic control during pregnancy

The nurse observes a 4-year-old boy in a day care setting. Which behavior should the nurse consider normal for this child?

Demonstrates aggressiveness by boasting when telling a story

A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement?

Describe diet changes that can improve the management of her diabetes

A woman in the first trimester of her pregnancy has a Hemoglobin level of 11 mg/dl and MCV of 113 fL. What action should the nurse take?

Determine folate and Vitamin B12 levels.

A 3-year-old boy is brought to the emergency room after swallowing an entire bottle of multi-vitamins. Which intervention should RN implement first?

Determine the child's pulse and respirations

The nurse is giving discharge instructions for a client following a suction curettage for a hydatidiform mole. The client asks why oral contraceptives are being recommended for the next 12 months. What information should the nurse provide?

Diagnostic testing for hCG levels are elevated by pregnancy

In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect?

Diminished femoral pulses

Which behavior would the nurse expect a 2-year-old to exhibit?

Display possessiveness of toys

A 7lb 8oz baby would need 50 calories x7lbs=350 calories plus 25 calories= 375 calories per day. Taking into consideration that most infant formulas contain 20 calories/ounce, how many ounces of formula are needed per day?

Dividing 375 by 20 =18.75 ounces of formula needed per day for a 7lb 8oz baby

The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he "has a tummy ache." After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question?

Do not give if the child has chickenpox, flu, or any other viral illnesses

A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client?

Do you have a history of rheumatic fever?

When assessing the integument of a 24-hour newborn, the nurse notes a pink papular rash with superimposed vesicles on the thorax, back, and abdomen. What action should the nurse implement next?

Document the finding as erythema toxicum

While evaluating an external monitor tracing of a woman in active labor whose labor is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate in a slow curve at the onset of several contractions and returns to baseline before each contraction ends. The nurse should:

Document the finding in the client's record

The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. On the basis of this information, the LPN should:

Document the findings because they reflect the expected contraction pattern for the active phase of labor

The early decelerations in fetal heart rate monitoring are the transient decrease in heart rate which coincides with the onset of the uterine contraction. Between what cm do the early decelerations caused by head compression and fetal descent usually occur in the 2nd stage?

Early decelerations, caused by head compression and fetal descent, usually occur between 4 and 7 cm in the 2nd stage. Check for labor progress if early decelerations are noted

An infant with hypothyroidism is often described as a "good, quite baby" by the parents. What early disease detection is essential in preventing mental retardation in infants?

Early detection of hypothyroidism and phenylketonuria is essential in preventing mental retardation in infants.

An infant with hypothyroidism is often described as a "good, quite baby" by the parents. What early disease detection is essential in preventing mental retardation in infants?

Early detection of hypothyroidism and phenylketonuria is essential in preventing mental retardation in infants. Knowledge of normal growth and development is important, a lack of attainment can be used to detect the existence of these metabolic/endocrine disorders and attainment can be used for evaluating the treatments effect.

At 6 weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client?

Early postpartum, within 72 hours of delivery.

The nurse tells a client in her first trimester that she should increase her daily intake of calcium. The client doesn't like milk. What dietary adjustment should the nurse recommend?

Eat more green leafy veggies

An ambulatory client at 39-weeks gestation presents to the emergency center with an obvious injury to her arm that occurred as the result of a fall. Which concurrent symptom is a priority for the nurse to assess.

Ecchymotic knees.

With regard to systemic analgesics administered during labor, nurse should be aware that:

Effects on the fetus and newborn can include decreased alertness and delayed sucking

Maternity nurse often have to answer questions about the many, sometimes unusual ways people have tried to make the birthing experience more comfortable. For instance, nurse should be aware that:

Electrodes attached to either side of the spine to provide mild-intensity electrical impulses facilitate the release of endorphins

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine, and it was positive for ketones. The nurse should instruct the mother to take which action?

Encourage the child to drink liquids.

The nurse is caring for a client whose fetus died in utero at 32 weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures. Which action is important for the nurse to take?

Encourage the mother to hold and spend time with her baby.

A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement?

Encourage the mother to stop feeding for a few minutes and comfort the infant.

When managing the care of a woman in the second stage of labor, the nurse uses various measures to enhance the progress of fetal descent. These measures include:

Encouraging the woman to try various upright positions, including squatting and standing. Giving positive feedback about her efforts.

Your patient is a nulliparous woman, requesting pain relief. You examine her and she is 8 cm. What is the best option for pain relief at this point?

Epidural

The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge ...

Evaluate infant feeding technique prior to discharge.

The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37 weeks gestation. What nursing action should be implemented first?

Evaluate the newborns color and respiration

The nurse is teaching the parents of a 2-year-old child with a congenital heart defect about signs and symptoms of congestive heart failure. Which information about the child is most important for the parents to report to the health care provider?

Exhibits a sudden and unexplained weight gain

A 6-year-old is admitted to the pediatric unit after falling off of a bicycle. Which intervention should the RN implement to help the child adjust to the unit.

Explain hospital schedules, including mealtime

A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein(AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

Explain that a sonogram should be scheduled for definitive results.

The nurse prepares to administer an injection of Vitamin K to a newborn infant. The mother tells the nurse, "Wait! I don't want my baby to have a shot" Which response would be best for the nurse to make?

Explore the mother's concerns about the infant receiving the shot.

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?

Extend the leg and dorsiflex the foot

A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse implement?

Extend the leg and dorsiflex the foot.

During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing?

Eye exams

Which client finding should the nurse document as a positive sign of pregnancy?

FHTs heard with a doppler

In the first 12 hours after delivery, the 22-year-old client shows signs of hemorrhage. What is one of the common reasons for uterine atony and/or hemorrhage in the first 24 hours after delivery?

FULL BLADDER is one of the most common reasons for uterine atony and/or hemorrhage in the first 24 hours after delivery.

The nurse, assessing a client who is 32 weeks pregnant during a routine visit, is concerned that the fetus is in the breech presentation. What did the nurse assess in the client?

Fetal heart rate above the umbilicus.

A number of methods to assist in the assessment of fetal well-being have been developed for use in conjunction with electronic fetal monitoring. These various technologies assist in supporting interventions for a nonreassuring fetal heart rate pattern when necessary. The labor and delivery nurse should be aware that one of these modalities, fetal oxygen saturation monitoring, includes the use of:

Fetal pulse oximetry

The most common cause of decreased variability in the fetal heart rate (FHR) that lasts 30 minutes or less is:

Fetal sleep cycles The fetus sleeps in 20-30 cycles

Through vaginal examination the nurse determines that a woman is 4 cm dilated, and the external fetal monitor shows uterine contractions every 3.5 to 4 minutes. The nurse would report this as:

First stage, active phase

When examining a client after delivery, the nurse finds the fundus soft, boggy, and displaced above and to the right of the umbilicus. What action should the nurse take first in this case?

First the nurse should perform fundal massage; then have the client empty her bladder.

The nurse is assessing a 12-hour old infant with maternal history of frequent alcohol consumption during pregnancy. Which finding should the nurse report that is most suggestive of fetal alcohol syndrome?

Flat nasal bridge

A newborn's assessment reveals spina bifida occulta. Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication?

Folic acid deficiency

A 22 year old primigravida at 12 weeks gestation has a high Hgb of 9.6 g/dl and a Hct of 31% and she has gained 3 pounds during the first trimester, even if the gain of 3.5 to 5 pounds during the first trimester is recommended. Taking into consideration that the client is anemic, what supplements should be recommended to her?

For the anemic pregnant client, supplemental iron and a diet high in iron is needed

A 22-year-old primigravida at 12 weeks gestation has a high Hgb of 9.6 g/dl and a Hct of 31% and she has gained 3 pounds during the first trimester, even if the gain of 3.5 to 5 pounds during the first trimester is recommended. Taking into consideration that the client is anemic, what supplements should be recommended to her?

For the anemic pregnant client, supplemental iron and a diet high in iron is needed.

Skin traction for fracture reduction should not be removed unless prescribed by healthcare provider. What fractures have serious consequences in terms of growth of the affected limb?

Fractures involving the epiphyseal plate ( growth plate) can have serious consequences in terms of growth of the affected limb

Skin traction for fracture reduction should not be removed unless prescribed by healthcare provider. What fractures have serious consequences interms of growth of the affected limb?

Fractures involving the epiphyseal plate (growth plate) can have serious consequences in terms of growth of the affected limb.

Sperm lives approximately 3 days and eggs live abut 24 hours. Which is the time interval a couple should avoid unprotected intercourse after the ovulation?

From ovulation to the begging of the next menstrual cycle is usually exactly 14 days. In other words, ovulation occurs 14 days before the next menstrual period

Sperm lives approximately 3 days and eggs live abut 24 hours. Which is the time interval a couple should avoid unprotected intercourse after the ovulation?

From ovulation to the begging of the next menstrual cycle is usually exactly 14 days. In other words, ovulation occurs 14 days before the next menstrual period.

The menstrual phase varies in length for most women. How many days usually are from ovulation to the beginning of the next menstrual cycle?

From ovulation to the beginning of the next menstrual cycle is usually exactly 14 days. In other words, ovulation occurs 14 days before the next menstrual period

The menstrual phase varies in length for most women. How many days usually are from ovulation to the beginning of the next menstrual cycle?

From ovulation to the beginning of the next menstrual cycle is usually exactly 14 days. In other words, ovulation occurs 14 days before the next menstrual period.

A baby, admitted to the nursery, was diagnosed with galactosemia from an anmiocentesis. Which of the following actions must the nurse take?

Galactosemia is one of the few diseases that is a contraindication for the intake of breast milk, or any milk based formula.

A 30-year-old primigravida delivers a 9-pound (4082 gram) infant vaginally after a 30-hour labor. What is the priority nursing action for this client?

Gently massage the fundus every 4 hours.

The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition?

Gestational Diabetes

The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant?

Gonorrhea. Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmica neonatorum, and infection caused by gonorrhea, and including conjunctivitis,, an infection caused by chlamydia. The infant may be exposed to these bacteria when passing through the birth canal.

A baby is grunting in the neonatal nursery. Which of the following actions by the nurse is appropriate?

Grunting is often accompanied by tachypnea, another sign of respiratory distress

What does a brace do for scoliosis?

Halts the progression of most curvatures. DOES NOT FIX CURVATURE.

What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta?

Hard board like abdomen

The nurse in the gynecology clinic is reviewing the record of a pregnant client after the first prenatal visit. The nurse notes that the health care provider has documented that the woman has a platypelloid pelvis. On the basis of this documentation, the nurse plans care, knowing that this type of pelvis has which characteristic?

Has a flat

A 12-month-old is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority?

Have a bulb syringe readily available to remove secretions

The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?

Have the client breathe into her cupped hands

The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?

Have the client breathe into her cupped hands.

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client?

Have the client empty the bladder

A pregnant client presents to the antepartum clinic complaining of brownish vaginal bleeding. The nurse notes that she has a greatly enlarges uterus and is complaining of severe nausea. The client reports that her period was "about 2 and a half months ago". Vital signs are: temperature 98.7F, pulse rate 70bpm, rr 18, and bp 190/110 mmHg. Based on these findings, what laboratory value should the nurse review?

HcG values.

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should:

Help her breathe into a paper bag

An infant is born to a mother with hepatitis B. Which prophylactic measure would be indicated for the infant?

Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?

Her arms and hands receive the infant and she then traces the infant's profile with her fingertips

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?

Her arms and hands receive the infant, and she traces the infant's profile with her fingertips.

At approximately 28 - 32 weeks gestation, the maximum plasma volume increase of 25 - 40% occurs, resulting in normal hemodilution of pregnancy and Hct values of 32 - 42%. What does Hct in reality represent, even if its values may look "good"?

High Hct values may look "good" but in reality, represent pregnancy induced hypertension and depleted vascular space

At approximately 28 - 32 weeks gestation, the maximum plasma volume increase of 25 - 40% occurs, resulting in normal hemodilution of pregnancy and Hct values of 32 - 42%. What does Hct in reality represent, even if its values may look "good"?

High Hct values may look "good" but in reality, represent pregnancy induced hypertension and depleted vascular space.

Supplemental iron is not given to clients with sickle cell anemia because the anemia is not caused by iron deficiency. What aspect is very important in treatment of sickle cell disease because it promotes hemodilution and circulation of red cells through the blood vessels?

Hydration is very important in treatment of sickle cell disease because it promotes hemodilution and circulation of red cells through blood vessels

Supplemental iron is not givento clients with sickle cell anemia because the anemia is not caused by iron deficiency. What aspect is very important in treatment of sickle cell disease because it promotes hemodilution and circulation of red cells through the blood vessels?

Hydration is very important in treatment of sickle cell disease because it promotes hemodilution and curculation of red cells through blood vessels

A client who is 18 weeks gestation has been diagnosed with hydatiform mole (gestational trophoblastic disease). In addition to vaginal loss, which of the following signs/symptoms would the nurse expect to see?

Hyperemesis and hypertension are often seen in clients with hydatiform mole

A client who is 18 weeks gestation has been diagnosed with hydatiform mole (gestational trophoblastic disease). In addition to vaginal loss, which of the following signs/symtoms would the nurse expect to see?

Hyperemesis and hypertension are often seen in clients with hydatiform mole

The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10 inches. Based on these physical findings, assessments for which condition has the highest priority?

Hypoglycemia

A nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing?

Hypotonic

As a perinatal nurse you realize that a fetal heart rate that is tachycardic, is bradycardic, or has late decelerations with loss of variability is nonreassuring and is associated with

Hypoxemia/acidemia Late decels are associated with poor placenta perfusion.

A primigravida, when returning for the results of her multiple marker screening (triple screen), asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to describe best how the test is interpreted?

If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect.

A nurse consults a mother and detects cord prolapse. How should the examiner position the pregnant woman to relieve pressure on the cord?

If cord prolapse is detected, the examiner should position the mother to relieve pressure on the cord, Knee chest position, or push the presenting part off the cord until Immediate cesarean delivery can be accomplished

Approximately 20 prior to nerve block anesthesia, the client should be hydrated with 500-1000 cc of lactated ringers IV. What should the nurse do if hypotension occurs?

If hypotension occurs- turn client to her side, administer O2 at 10 L/min by face mask, and increase IV rate

The first day of a womans last normal menstrual period was October 17. By using Nagele's rule, what is the EDB?

If the first day of a womans last normal menstrual period was October 17, her EDB using Nagele's rule is July 24. Count back 3 months and add 7 days (Always give February 28 days)

Oxytocin should be administered after the placenta is delivered because the drug will cause the uterus to contract. What can happen if the drug is administered before the placenta is delivered?

If the oxytocic drug is administered before the placenta is delivered, it may result in a retained placenta, which predisposed the client to hemorrhage and infection.

The screening for neural tube defects is highly associated with both false positives and false negatives. Through what does the screening for neural tube defects in some states?

In some states, the screening for neural tube defects through either maternal seru AFP levels or amniotic fluid AFP levels is mandated by state law. This screening test is highly associated with both false positives and false negatives.

A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement?

Increase the rate of the oxytocin (Pitocin) infusion.

necrotizing enterocolitis (NEC): what will nurse expect to find as a complication

Increased amount of residual gastric volume from earlier feedings

A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn?

Infant's condition at birth and treatment received.

A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?

Inform her that a decreased need for insulin occurs while breastfeeding.

At 0600 while admitting a woman for a scheduled repeat cesarean section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. What action would the nurse take first?

Inform the anesthesia care provider.

Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations, and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/ minute. What action should the nurse perform next?

Initiate positive pressure ventilation.

When assessing a child with asthma, the nurse should expect intercostal retractions during

Inspiration

A nullipara client admitted to the labor and delivery unit says "I feel like I'm going to have a bowel movement."Upon assessment, the client's cervix is dilated to 10 cm, the baby is at 1+ station, and contractions are every 2-3 minutes lasting 60-90 seconds. What is the best action for the nurse to take?

Instruct the client on quality pushing.

A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3cm. The nurse's assessment findings and electronic fetal monitoring(EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribed and oxytocin drip. Which data is most important for the nurse to monitor?

Intensity, interval, and length of contractions.

Four babies are in the newborn nursery. The nurse pages the neonatologist to see the baby who exhibits which of the following?

Intracostal retractions are symptomatic of respiratory distress syndrome

When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman's risk for has increased.

Intrauterine infection

If a child is on oral iron medication, the family should be taught by the nurse how it should be administered. Out of the following options, what oral iron administration advise is inappropriate?

Iron can be fatal in severe overdose and as a result, it should be kept away from children. Also, do not give with dairy products.

The nurse is assessing a 2-year-old. Which behavior indicates that the child's language development is within normal limits.

Is capable of making a three word sentence

Regardless of who performs the physical assessment, the nurse must know normal versus abnormal variations of the newborn. What is the difference between caput succedaneum and cephalhematoma?

It is difficult to differentiate between caput succedaneum (edema under the scalp) and cephalhematoma (blood under the periosteum). The caput crosses suture lines and is usually present at birth, while cephalhematoma does not cross suture lines and manifests a few hours after birth.

Most providers prescribe prenatal vitamins to ensure that the client receives and adequate intake of vitamins. However, only the healthcare provider can prescribe prenatal vitamins. Whis is the quantity of milk a pregnant woman should drink per day for ensuring that the daily calcium needs are met?

It is recommended that pregnant woman drink one quart of milk a day. This will ensure that the daily calcium needs are met and help to alleviate the occurrence of leg cramps.

The umbilical cord should always be checked at birth. What should the umbilical card contain in a newborn?

It should contain 3 vessels, 1 vein which carries oxygenated blood to the fetus and 2 arteries which carry unoxygenated blood back to the placenta. This is opposite of normal circulation.

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period is

January 30-31

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse ly calculates that the woman's next fertile period is

January 30-31

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period will be

January 30-31. This woman can expect her next period to begin 36 days from the first day of her last menstrual period - the cycle begins at the first day of the cycle and continues to the first day of the next cycle. Her next period would, therefore, began on February 13. Ovulation occurs 14 days before the first day of the menstrual period. Therefore, ovulation for this woman would occur January 31.

A client in the last trimester of pregnancy is prescribed sulfonamide for a urinary tract infection. What risk will this medication be to the developing fetus?

Jaundice

A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?

Keep an airway at the bedside.

Which action should the nurse implement when caring for a newborn immediately after birth?

Keep the newborn's airway clear

A nurse consults a pregnant mother and detects late decelerations which indicate uteroplacental insufficiency. What conditions are late decelerations associated with?

Late decelerations indicate uteroplacental insufficiency and are associated with conditions such as post maturity, preeclampsia, diabetes mellitus, cardiac disease, and abruptio placentae.

positive Contraction stress test indicates

Late decelerations of the fetal heart rate are occurring with each contraction. also uteroplacental insufficiency

An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father?

Let him know that these are normal maternal/fetal bonding behaviors which occur once the mother feels fetal movement

An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father?

Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

For women who have a history of sexual abuse, a number of traumatic memories may be triggered during labor. The woman may fight the labor process and react with pain or anger. Alternately she may become a passive player and emotionally absent herself from the process. The nurse is in a unique position of being able to assist the client to associate the sensations of labor with the process of childbirth and not the past abuse. The nurse can implement a number of care measures to help her client view the childbirth experience in a positive manner. Which intervention would be key for the nurse to use while providing care?

Limiting the number of procedures that invade her body

What position would be least effective when gravity is desired to assist in fetal descent?

Lithotomy

Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?"

Lying prone with a pillow on the abdomen

When caring for a child with congenital heart disease and polycythemia, which nursing intervention has the highest priority?

Maintaining adequate hydration

During a prenatal counseling session for women trying to get pregnant in 3-6 months, what information should the nurse provide?

Make sure to include adequate folic acid in the diet

Nursing care measures are commonly offered to women in labor. Which nursing measure reflects application of the gate-control theory?

Massaging the woman's back

While assessing a 40-week gestation primigravida in active labor, the client's membranes rupture spontaneously and the nurse notices that the amniotic fluid is meconium stained. Which additional finding is most important for the nurse to report to the healthcare provider?

Maternal blood pressure of 130/85 mmHg.

A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nagele's rule, what is the estimated date of delivery?

May 9, 2007

A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nägele's rule, what is the estimated date of delivery?

May 9, 2007

A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?

Meet the mother's physical needs and demonstrate warmth toward the infant

A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?

Meet the mother's physical needs and demonstrate warmth toward the infant.

Which finding in a 19 yr old female client should trigger further assessment by the nurse?

Menstruation has not occurred

A woman in active labor receives an analgesic, an opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease?

Meperidine (Demerol)

Pitocin should be given with caution to clients with hypertension. What drug shouldn't be given to clients with hypertension due to its vasoconstrictive action?

Methergine is NOT given to clients with hypertension due to its vasoconstrictive action. Pitocin given with caution to those with hypertension.

A woman in the active phase of labor takes slow, deep breaths at the beginning of each contraction, while increasing the rate and decreasing the depth of her breaths as she reaches the peak of the contraction. Once the contraction is over, her breathing becomes slower and deeper again. What breathing pattern does the nurse recognize this client is using?

Modified-paced breathing

The nurse notes an irregular bluish hue on the sacral area of a 1-day old Hispanic infant. How should the nurse document this finding?

Mongolian spots

The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at 32 weeks who has severe preeclampsia with pulmonary edema. As the PAC enters the right ventricle, what is the priority nursing assessment?

Monitor for premature ventricular contractions

An infant with hyperbilirubinemia is receiving phototherapy. What intervention should the nurse implement?

Monitor temperature

When inserting a nasogastric tube into the stomach of a 3-month-old infant, which nursing intervention is most important to implement?

Monitor the infant's heart rate.

A woman in labor has just received an epidural block. The most important nursing intervention is to:

Monitor the maternal blood pressure for possible hypotension

A 38-week primagravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?

Move about every hour

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?

Move about every hour

A laboring woman received meperidine (Demerol) intravenously 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of Demerol on the neonate?

Naloxone (Narcan)

Which procedure evaluates the effect of fetal movement on the fetal heart activity?

Non-stress test

An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivers a 7-pound infant 12 hours ago is reporting a severe headache. The client blood pressure is 110/70 mmHg, respiratory rate is 18 breaths/minute, heart rate is 74 bpm, and temperature is 98.6F. The client's fundus is firm and one fingerbreadth above the umbilicus. Which action should the charge nurse implement first?

Notify the healthcare provider of the assessment findings.

On admission to the prenatal clinic, a 23-year old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) would be

November 22

On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) is

November 22

A 3-month-old develops oral thrush. Which pharmacological agent should the RN administer?

Nystatin

The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?

Observe for an asymmetrical Moro (startle) reflex)

What preoperative nursing intervention should be included in the plan of care for an infant w/ pyloric stenosis?

Observe for projectile vomiting

A client who is 32 weeks gestation arrives at the clinic reporting nausea and vomiting for the past 24 hours. The nurse reviews the records and observes there has been a rapid weight gain over 6 weeks. Which action should the nurse implement next?

Obtain a blood pressure.

One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first?

Obtain a serum glucose level.

An infant is receiving digoxin for congestive heart failure. The apical heart rate is assessed at 80 beats/min. What intervention should the nurse implement?

Obtain a therapeutic drug level.

The nurse is caring for a client whose is 10 weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

Obtain human chronic gonadotropin levels.

A macrosomic infant is in stable condition after a difficult forceps assisted delivery. After obtaining the infant's weight at 9lb 6oz, what is the priority nursing action?

Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia

A primiparous woman is in the triage room being evaluated for labor. She has been having contractions for 2 days, has slept little and is feeling exhausted. On cervical exam she is 1.5 cm dilated, 50% effaced, -1 station - which is not changed from a day ago. Contractions are irregular, 30-40 secs long. Which of the following is the best option for her?

Offer morphine IM, and a sedative to help her sleep

Which of the following is true about placenta previa?

Once placenta previa is diagnosed by a 20 week ultrasound, it is very likely the placenta will resolve in the third trimester

Which nonpharmacological interventions should the nurse implement to provide the most effective response in decreasing procedural pain to the neonate?

Oral sucrose and nonnutritive sucking

Which menu selection by a child w/ celiac disease indicates to the nurse that the child understands necessary dietary considerations?

Oven-baked potato chips and cola

Which GI finding should the nurse be concerned about in a client at 28 weeks?

PICA

What is an expected characteristic of amniotic fluid?

Pale, straw color with small white particles

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that the perineal pad is saturated, and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement first?

Palpate the firmness of the fundus

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the client is lying in a 6 inch diameter pool of blood. Which action should the nurse implement next?

Palpate the firmness of the fundus. A firm fundus is needed to control bleeding from the placental site of attachment on the uterine wall. The nurse should first assess for firmness and massage the fundus as indicated.

When discussing discipline with the mother of a 4-year-old, the nurse should include which guideline?

Parental control should be constant

A nurse must use knowledge base to differentiate between abruptio placentae from placenta previa. What assessments should be done in case of a patient suspected of abruptio placentae or placenta previa.

Patients with abruptio placentae or placenta previa should have No abdominal or vaginal manipulation. No Leopold's maneuvers. No vaginal exams. No rectal exams, enemas, or suppositories. No internal monitoring

A nurse must use knowledge base to differentiate between abruptio placentae from plaventa previa. What assessments should be done in case of a patient suspected of abruptio placentae or placenta previa.

Patients with abruptio placentae or placventa previa should have No abdominal or vaginal manipulation. No Leopold's maneuvers. No vaginal exams. No rectal exams, enemas, or suppositories. No internal monitoring

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?

Perform Leopold's maneuvers

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?

Perform a vaginal examination every shift.

Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother's vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse take first?

Perform fundal massage until firm.

A client at 35 week visits the clinic for a prenatal checkup. Which complaint by the client warrants further assessment?

Periodic abdominal pain

Physiologic jaundice (normal inability of the immature liver to keep up with normal RBC destruction) occurs 2-3 days of life. When does jaundice become pathologic?

Physiologic jaundice (normal inability of the immature live to keep up with normal RBC destruction) occurs at 2-3 days of life. It occurs before 24 hours or persists beyond 7 days, it becomes pathologic

Physiologic jaundice is the normal inability of the immature liver to keep up with normal RBC destruction. When does jaundice occur in newborns?

Physiologic jaundice (normal inability of the immature liver to keep up with normal RBC destruction) occurs at 2-3 days of life.

Skin traction for fracture reduction should not be removed unless prescribed by healthcare provider. What do the pin sites usually cause in an infant client?

Pin sites can be sources of infection. The nurse should monitor signs of infection and cleanse and dress sites as prescribed.

What action should the nurse implement when caring for a newborn receiving phototherapy?

Place an eyeshield over the eyes

The nurse is caring for a postpartum client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?

Place procedure equipment at bedside.

Upon admission to the nursery, the nurse places a newborn supine under a radiant warmer, an external heat source. What intervention should the nurse implement to ensure safe thermoregulation?

Place temperature probe on the abdomen in line with the radiant heat source.

A nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action?

Place the client in Trendelenburg's position.

Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement?

Place the client in a slight Trendelenburg position.

A 3-month-old infant returns from surgery with elbow restraints and a Logan bow over a cleft lip suture line. Which intervention should the nurse implement to maintain suture line integrity during the initial postoperative period?

Place the infant upright in an infant seat position.

The health care provider prescribes patching for a child with strabismus of the right eye, and the nurse instructs the mother regarding this procedure. What should the nurse include in the instructions?

Place the patch on the left eye.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take?

Place the woman in a lateral position

The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of which condition?

Placental separation

Which basic type of pelvis includes the correct description and percentage of occurrence in women?

Platypelloid: flattened, wide, shallow; 3%

The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse S/S are commonly associated with this therapy?

Polyuria and polydipsia

What assessment is least likely to be associated with a breech presentation?

Post term gestation

Which of the following neonates is at highest risk for cold stress syndrome?

Postdate babies are at high risk for cold stress syndrome because while still in utero they often metabolize the brown adipose tissue for nourishment when the placental function deteriorates..

Cord abnormalities usually indicate cardiovascular or renal anomalies. What happens if fetal structures of foramen ovale, ductus arteriosus and ductus venous do no close postnatal?

Postnatally, the fetal structures of foramen ovale, ductus arteriosus and ductus venosus should close. If they do not, cardiac and pulmonary compromise will develop.

A multiparous client with active herpes lesion is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse do first?

Prepare for a cesarean section.

What action should the nurse implement with the family when an infant is born with anencephaly?

Prepare the family to explore ways to cope with the imminent death of the infant

A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation. Which assessment finding suggests the presence of a common complication often experienced by those with Down syndrome?

Presence of a systolic murmur

The factors that affect the process of labor and birth, known commonly as the five Ps, include all EXCEPT:

Pressure The 5 P's are: 1. Powers (contractions) 2. Passengers (fetus and placenta) 3. Passageway (birth canal) 4. Position (of the mother) 5. Psychological Response

A 1-day old neonate, 32 weeks gestation, is in an overhead warmer. The nurse assesses the morning axillary temperature as 96.9 F. Which of the following could explain this assessment finding?

Preterm babies are born with an insufficient supply of brown adipose tissue that is needed for thermogenesis, or heat generation

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?

Prevent hemorrhagic disorders.

In developing a teaching plan for a 5-year-old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first.

Process of glucose testing

Which statement by a client who is pregnant indicates to the nurse an understanding of the role of protein during pregnancy?

Protein helps the fetus grow while I am pregnant

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first?

Provide assistance to the mother to begin breastfeeding as soon as possible after delivery

Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first?

Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery.

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?

Put the newborn to breast

As pregnancy advances, the uterus presses on the abdominal vessels ( vena cava and aorta). What position is best for increasing perfusion according to the latest research?

Recent research indicated that the knee chest position is best for increasing perfusion and that the side lying position (either left or right side lying) is the second most desirable position to increase perfusion. Prior to this research, the left side lying position was usually encouraged.

As pregnancy advances, the uterus presses on the abdominal vessels (vena cava and aorta). What position is best for increasing perfusion according to the latest research?

Recent research indicated that the knee chest position is best for increasing perfusion and that the side lying position (either left or right side lying) is the second most desirable position to increase perfusion. Prior to this research, the left side lying position was usually encouraged.

When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastroesophageal reflux disease, which intervention is most important for the nurse to implement?

Record weight daily

A nurse should teach newbie parents to take both axillary and rectal temperature of the child. How long should the thermometer be held in place if it is done by rectum?

Rectal temperature: the thermometer should be used with blunt end. Insert thermometer 1/4 to 1/2 inch and hold in place for 5 minutes. Hold feet and legs firmly.

The nurse is developing a plan of care for a preterm newborn infant. The nurse develops measures to provide skin care, knowing that the preterm newborn infant's skin appears in what way?

Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat

The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do?

Reduce activity level and notify the healthcare provider.

Monitoring for fetal position is important because the mother cannot tell you she has back pain, which is the cardinal sign of persistent posterior fetal position. Why do the regional blocks, especially epidural and caudal, often result in assisted delivery?

Regional blocks, especially epidural and caudal, often result in assisted delivery due to inability to push effectively in the 2nd stage.

Internal rotation is harder to achieve when the pelvic floor is relaxed by anesthesia resulting in persistent occiput posterior of fetus. What regional blocks often result in assisted delivery due to the inability to push effectively in the 2nd stage?

Regional blocks, especially epidural and caudal, often result in assisted delivery due to the inability to push effectively in 2nd stage

Postpartum blues are usually normal, especially 5 - 7 days after delivery. In what case is RhoGAM given to a mother after delivery?

Remember RhoGRAM is given to a Rh negative mother who delivers a Rh positive fetus and has a negative direct Coombs. If the mother has a positive Coombs, there is no need to give RhoGRAM since the mother is already sensitized.

A six-month-old returns from surgery with elbow restraints. What nursing care should be included when caring for a child in restraints?

Remove restraints one at a time and provide ROM exercises

The nurse assesses a high-risk neonate under a radiant warmer who has an umbilical catheter and identifies that the neonate's feet are blanched. What nursing should be implemented?

Report findings to the Dr.

The nurse is providing discharge teaching for a gravid client who is being released from the hospital after placement of a cerclage. Which instruction is the most important for the client to understand?

Report uterine cramping or low backache

What three measures should the nurse implement to provide intrauterine resuscitation? Select the response that best indicates the priority of actions that should be taken.

Reposition the mother, increase intravenous (IV) fluid, and provide oxygen via face mask

The nurse is caring for a client following an emergency cesarean delivery under general anesthesia. Which assessment finding occurring in the first 8 hours after deliver is most critical and requires immediate intervention?

Respiratory rate of 12bpm

A primipara client at 42 weeks gestation is admitted for induction. Within one hour after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm dilated, contractions are occurring every 1 minute with a 75 second duration. The nurse stops the oxytocin and starts oxygen. After 30 minutes of uterine rest, the contractions are occurring every 5 minutes with 20 second duration. What intervention should the nurse implement?

Restart oxytocin infusion rate per protocol.

The nurse caring for a client with a diagnosis of subinvolution should understand that which is a primary cause of this diagnosis?

Retained placental fragments from delivery

What bowel habits are seen in children with Hirschsprung's disease?

Ribbon-like and brown

An 18-hour old baby is placed under the bili lights with an elevated bilirubin level. Which of the following is an expected nursing action in these circumstances?

Rotating the baby's position maximizes the therapeutic response because the more skin surface that is exposed to the light source, the better the results are

Which finding indicates to the nurse that a 4 day old infant is receiving adequate breast milk?

Saturates 6-8 diapers per day

The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is recommended for which purpose?

Screen for neural tube defects

The nurse should explain to a 30-year-old gravida client that alpha fetoprotein testing is recommended for which purpose?

Screen for neural tube defects

A woman whose pregnancy is confirmed asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide?

Secretes both estrogen and progesterone

A child comes to the school nurse complaining of itching. Further assessment reveals that the child has impetigo. What action should the nurse take?

Send the child home with the parents to see the health care provider before returning to school.

The nurse is calculating the estimated date of confinement (EDC) using Ngele's rule for a client whose last menstrual period started on December 1. Which date is most accurate?

September 8

A 3-year-old client with sickle cell anemia is admitted to the Emergency Department with abdominal pain. The nurse palpates an enlarged liver, an x-ray reveals an enlarged spleen, and a CBC reveals anemia. These findings indicate which type of crisis?

Sequestration.

With regard to a pregnant woman's anxiety and pain experience, nurse should be aware that:

Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on

A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's intravenous fluid for a pre-procedural bolus. She reviews her laboratory values and notes that the woman's hemoglobin is 12 g/dl, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for the woman?

She has thrombocytopenia

An 18-month-old child returns to the unit following a cardiac catheterization with a cannulated femoral artery site. Which intervention should the nurse implement?

Show the parents how to hold the child with the extremity extended.

A nurse should teach the pregnant clients to immediately report any of the following danger signs because early intervention can optimize maternal and fetal outcome. Which are the signs of infection in a pregnant woman?

Signs of infection in a pregnant woman are Chills, Dysuria, pain in abdomen, fluid discharge from vagina, and increased FHR

After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil® Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac® Soy Isomil® Formula, a soy protein isolate based infant formula. What information should the nurse provide to the mother about the newly prescribed formula?

Similac Soy Isomil Formula is a soy-based formula that contains sucrose

After each feeding, a 3-day old newborn is spitting up large amounts of Enfamil Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac Soy Isomil Formula, a soy protein isolate based on infant formula. What information should the nurse provide to the mother about the newly prescribed formula?

Similac Soy Isomil Formula is a soy-based formula that contains sucrose. The nurse should explain that the newborn's feeding intolerance may be related to the lactose found in cow's milk formula and is being replaced with the soy-based formula that contains sucrose which is well-tolerated in infants with milk allergies and lactose intolerances

A woman who is 38 weeks gestation is receiving magnesium sulfate for severe preeclampsia. Which assessment finding warrants immediate intervention by the nurse?

Sinus tachycardia

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is appropriate?

"A home pregnancy test can be used right after your first missed period."

A woman who thinks she could be pregnant calls her neighbor, who is a nurse, to ask when she should use a home pregnancy test. Which response is appropriate?

"A home pregnancy test can be used right after your first missed period."

A child is scheduled for a tonsillectomy in a day surgical unit. On the day after surgery, the mother calls the surgical unit and expresses concern because the child has a bad mouth odor. Which response is most appropriate?

"Bad mouth odor is normal and may be relieved by drinking more liquids."

Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn?

"Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period."

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide the client?

"Complete bedrest decreases oxygen needs and demands on the heart muscle tissue."

A client at 32 weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue and a moist cough. Which question is most important for the nurse to ask this client?

"Do you have a history of rheumatic fever?" Clients with a history of rheumatic fever may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the increased blood volume that occurs during pregnancy, so obtaining information about this client's health history is a priority.

A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding?

Skin color that is slightly jaundiced

Fractures in older children are common as they fall during play and are involved in motor vehicle accidents. What fractures in children are related to child abuse?

Spiral fractures (caused by twisting) and fractures in infants may be related to child abuse.

The vital signs of 4 yr old child w/ polyuria are: BP 80/40, pulse, 118, and Resp. 24. The child's pedal pulses are present w/ a volume of +1, and no edema is observed. What action should the nurse implement first?

Start an IV infusion of normal saline

A child with cystic fibrosis is having stools that float and are foul smelling. Which descriptive term should the nurse use to document the finding?

Steatorrhea

The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to:

Stimulate uterine contraction

A neonate who is receiving an exchange transfusion for hemolytic disease develops respiratory distress, tachycardia, and a cutaneous rash. What nursing intervention should be implement first?

Stop the transfusion

if the structures of the foramen ovale, ductus arteriosus and ductus venosus don't close postnatally, cardiac and pulmonary compromise will develop. What should be suctioned by the nurse firstly?

Suctioning the mouth first and then the nose. Stimulating the nares can initiate inspiration which could cause aspiration of mucus in oral pharynx.

A woman of childbearing age present at an emergency room with unilateral and bilateral abdominal pain. What should the nurse correctly suspect in this case?

Suspect ectopic pregnancy in any woman of childbearing age who presents at an emergency room, clinic, or office with unilateral or bilateral abdominal pain. Most are misdiagnosed with appendicitis.

What nursing action should be included in the plan of care for a newborn experiencing symptoms of drug withdrawal?

Swaddle the infant snugly and hold tightly.

During labor a fetus with an average heart rate of 175 beats/min over a 15-minute period would be considered to have:

Tachycardia Normal FHR: 110-160

A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28- weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate?

Tachycardia and a feeling of nervousness

A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide?

Take your blood pressure now, and if it is seriously elevated, go to the hospital.

A father of a 5-year-old boy calls the nurse to report that his son, who has had an upper respiratory infection, is complaining of a headache, and his temperature has increased to 103° F, taken rectally. Which intervention has the highest priority?

Tell the parent to take the child to the emergency department.

A pregnant client has a temperature over 100.4 F, Dysuria and fluid discharge from vagina. What could these signs most probable indicate?

Temperature over 100.4 F, Dysuria, and fluid discharge from vagina are signs of infection.

Which class of anti-infective drugs is contraindicated for use in children under 8 yrs. of age?

Teteracyclines

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best?

That is normal; the head will return to a round shape within 7 to 10 days

A neonate is in the warming crib for poor thermoregulation. Which of the following sites is appropriate for the placement of the skin thermal sensor?

The abdominal wall is the appropriate placement for the skin thermal sensor.

In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan?

The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.

Which of the following laboratory findings would the nurse expect to see in a baby diagnosed with erythroblastosis fetalis?

The baby with erythroblastosis fetalis would exhibit signs of severe anemia, which a hematocrit of 24% reflects.

A pregnant client's medical record shows: Gravida 6 Term 2 Preterm 1 Abortion 2. Assuming that no children passed away after birth, how should the nurse interpreted this data?

The client has 3 living children.

A patient is placed on bed rest at home for mild preeclampsia at 38 weeks gestation. Which of the following must the nurse teach the patient regarding her condition?

The client should call her primary caregiver to report swollen hand and face.

The nurse is conducting a home health visit of a client who delivered 3 weeks ago and is formula feeding the infant. Which observations should the nurse find most concerning?

The client's eyes are red from crying and infant is fussing in the crib.

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy?

The client's last baby weighed 10 pounds at birth.

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client?

The client's readiness to learn

The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis?

"I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions?

"I need to lie flat on my back to perform the kick count"

The nurse provided discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicate that further teaching is necessary?

"I'll let him decide when to return to his play activities."

A client who is in the second trimester tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide?

"It is important that you want to take part in your care."

A female client with insulin-dependent diabetes arrives at the clinic seeking a plan to get pregnant in approximately 6 months. She tells the nurse that she wants to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client?

"Maintain blood sugar levels in a constant range within normal limits during pregnancy."

A 30-year old multiparous woman who has a 3 year old boy and a newborn girl tells the nurse, "My son is so jealous of my daughter. I don't know who I'll ever manage both children when I get home." How should the nurse respond?

"Regression in behaviors in the older child is a typical reaction so he needs attention at this time." Preschool-aged children frequently regress in habits or behaviors, such as toileting and sleep habits, as a method of seeking attention so the parents should distribute their attention between the children and include the preschooler during infant care.

A new mother asks the nurse about an area of swelling on her baby's head near the posterior fontanel that lies across the suture line. How should the nurse respond?

"That is called caput succedaneum. It will absorb and cause no problems."

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head" Which response by the nurse is best?

"That is normal, the head will return to a round shape within 7 to 10 days."

Several children have contracted rubeola (measles) in a local school, and the school nurse conducts a teaching session for the parents of the schoolchildren. Which statement made by a parent indicates a need for further teaching regarding this communicable disease?

"The disease can be spread to others 10 days before any sign of the disease appears to 15 days after the rash appears."

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot". Which explanation should the nurse give to this anxious client?

"There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair." The anterior fontanel or "large soft spot" normally closes at 12-18 months of age.

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client?

"There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb their hair"

A client at 36-week gestation is scheduled to receive Rho(D) immune globulin (RhoGAM) injection after delivery of her first child. The nurse is teaching the client about the purpose of the medication. Which statement by the client confirms that teaching has been effective?

"This injection will prevent the development of antibodies that may harm my next child."

The nurse suspects that a pregnant client is experiencing domestic violence. During the assessment, the client tells the nurse that this is the first time it ever happened and does not expect it to occur again. What should the nurse respond to the client?

"This type of behavior can continue after the child is born and may include the child as well."

The nurse is caring for a primigravid client who is 38 weeks pregnant. During her visit, the client tells the nurse, "my belly gets really tight sometimes and I get this lightning bolt sensation that goes down my legs and even in my vagina." What is the best response by the nurse?

"When your belly gets tight, does the tightness go away if you walk around or change positions?"

A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client?

"You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk."

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation will the nurse provide?

"your milk is sufficient if the baby is voiding pale straw-colored urine 6-10 times/day."

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.)

- A sterile glove - An amniotic hook - A Doppler

Which interventions should the nurse include in the teaching plan for the mother of a 6-year-old who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.)

- Administer mineral oil daily. - Eliminate dairy products. - Initiate consistent toileting routine.

A baby is suspected of having esophageal atresia. The nurse would expect to see which of the following signs/symptoms? (Select all that apply)

- Babies with esophageal atresia would be expected to expel large amounts of mucus from the mouth - Abdominal distention can be seen with esophageal atresia as air enters the stomach via the trachea

A baby is suspected of having esophageal atresia. The nurse would expect to see which of the following signs/symptoms? (Select all that apply)

- Babies with esophageal atresia would be expected to expel large amounts of mucus from the mouth - Abdominal distention can be seen with esophageal atresia as air enters the stomach via the trachea

During labor, the patient at 4 cm suddenly becomes dyspneic, cyanotic, and hypotensive. The nurse must prepare immediately for: (Select all that apply.)

- Cesarean Delivery - CPR

A child is admitted to the pediatric unit with a diagnosis of acute stage Kawasaki disease. In performing an assessment on the child, which findings are characteristic of this disorder? Select all that apply.

- Cracking lips - Conjunctival hyperemia - Desquamation of the skin

Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.)

- Cramping with bright red spotting - Lack of tenderness of the breast - Increased right-side flank pain

The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply)

- Diaphragmatic with chest retraction - Grunting heard with a stethoscope - Chest breathing with nasal flaring

The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (select all that apply)

- Diaphragmatic with chest retractions - Grunting heard with stethescope - Chest breathing with nasal flaring

A primigravida at 12 weeks gestation who just moved to the USA indicates she has not received any immunizations. Which immunizations should the nurse administer at this time? (Select all that apply)

- Hep B - Diphtheria - Tetanus

Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.)

- Increased heartburn that is not relieved with doses of antacids - Chronic headache that has been lingering for a week behind the client's eyes

A 3-week-old newborn is brought to a clinic for follow-up after a home birth. The child bottle feeds for 5 minutes only then falls asleep. A loud murmur characteristic of ventricular septal defect (VSD), and finds the newborn acyanotic with a RR of 64 bpm. What instruction should be provided to ensure the newborn gets adequate fluid intake? (Select all that apply).

- Monitor the infant's weight and number of wet diapers per day -Increase the infant's intake per feeding by 1-2 ounces per week - Allow the infant to rest and refeed on demand or every 2 hours - Use a softer nipple or increase the size of the nipple opening

The nurse is caring for an infant with congenital cardiac defect is monitoring the child for which of the following early signs of congestive heart failure? (Select all that apply)

- No matter whether a baby or an adult were developing CHF, the patient would be tachypneic - No matter whether a baby or an adult were developing CHF, the patient would be tachycardic - No matter whether a baby or an adult were developing CHF, the patient would be diaphoretic

A child diagnosed with scarlet fever is being cared for at home. The home health nurse performs an assessment on the child and checks for which clinical manifestations of this disease? Select all that apply.

- Pastia's sign - White strawberry tongue - Edematous and beefy-red pharynx - Petechial red, pinpoint spots on the soft palate

Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the client's blood pressure? (Select all that apply.)

- Place the woman in a lateral position - Increase intravenous (IV) fluids - Administer ephedrine per MD order

A woman is being interviewed by a triage nurse at a medical doctor's office. Which of the following signs/symptoms by the client would warrant the nurse to suggest that a pregnancy test be done? (Select all that apply)

- Pregnancy is the most common cause of amenorrhea - A common complaint of women in early pregnancy is fatigue - A common complaint of women is early pregnancy is nausea

The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply.

- Presence of Aschoff's bodies - Elevated antistreptolysin O titer - Elevated erythrocyte sedimentation rate

Which interventions should the nurse include when preparing a care plan for a child with hepatitis? Select all that apply

- Providing a low-fat, well-balanced diet. - Teaching the child effective hand-washing techniques. - Instructing the parents to avoid administering medications unless prescribed.

Which assessment findings should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.)

- Steatorrhea - Foul-smelling stools - Delayed growth - Pulmonary congestion

The macrosomic baby in the nursery is suspected of having a fractured clavicle from a traumatic delivery. Which of the following signs/symptoms would the nurse expect to see? (Select all the apply)

- The baby will complain of pain at the site. - If not in the immediate period after the injury, within a few days there will be a palpable lump on the bone at the site of the break - Because of the break, the baby is likely to position the arm in an atypical posture - Because of the injury to the bone, the baby is unable to respond with symmetrical arm movement

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (select all that apply)

- a sterile glove - an amnihook - lubricant

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (select all that apply)

- a sterile glove - an amniotic hook - a Doppler

The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40 weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? Select all that apply

- admission weight of 4 pounds, 15 ounces (2244 grams) - head to heel length of 17 inches (42.5 cm) - Frontal occipital circumference of 12.5 in (31.25 cm). The normal full-term appropriate for gestational age (AGA) newborn should fall between the measurement ranges of weight 6-9 pounds, length 19-21 inches, FOC 13-14 inches. This neonate's parameters plot below the 10% percentile, which indicate that the infant is SGA.

A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply)

- dark, red vaginal bleeding - increased uterine irritability

When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply)

- mood swings - tearfulness

Put the following actions in order to prevent hypotension in the pregnant client:

- reposition the client - increase the IV fluid - provide oxygen via face mask - call the healthcare provider.

The healthcare provider prescribes zidovudine 100mg po 5x daily for a pregnant woman who is HIV positive. How much do you administer? (?)

10

chorionic villi sampling when can it be done

10 weeks and no later than 12 weeks

What is the therapeutic level of theophylline?

10-20 mcg/dL

A multigravida client in labor is receiving oxytocin 4mu/minute to help promote an effective contraction pattern. The available solution is Lactacted Ringer's 1,000 mL with oxytocin 20 units. The nurse should program the infusion pump to deliver how many mL/hr?

12

The nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse should respond to the client knowing that the gender of the fetus is determined by which weeks?

13 to 16

A baby, born at 3,199 grams, now weighs 2,746 grams. The baby is being monitored for dehydration because of the following percent weight loss? (calculate to the nearest hundreth) ____________________________%

14.16% The formula for percentage of weight loss is : Original weight minus current weight divided by original weight. The value is then multiplies by 100 to convert the number to percentage: 3199-2746=453 453/3199=0.1416*100=14.16%

A nulliparous woman asks the nurse when she will begin to feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately how many weeks of gestation?

18 weeks

Match the degree of tear or episiotomy to its description.

1st degree = small nick in the perineum, not involving muscle 2nd degree = a tear through part or all of the perineal muscles 3rd degree = Laceration through part or all of anal sphincter muscle 4th degree = Laceration that goes through the anal sphincter and the rectal wall

normal l/s ratio

2.0-2.5; shows fetal lung maturity

A client at 32 weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?

3+ deep tendon reflexes and hyperclonus

A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?

3+ deep tendon reflexes and hyperclonus

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the nurse document in this client's record?

3-1-1-0-3

A newborn infant who is 24 hours old is on a 4 hour feeding schedule of formula. To meet daily caloric needs, how many oz are recommended each feeding?

3.5 oz

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and expects which finding?

30 cm

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the nurse document in the client's record?

31103. The client has been pregnant 3 times including the current pregnancy (G3); She had one full-term infant (T1); She also had a preterm (P1) twin pregnancy (a multifetal gestation is considered one birth when calculating parity); There were no abortions (A0), so this client has a total of 3 living children.

A client at 39 weeks is admitted into the labor unit. Her OB history includes 3 live births at 39 weeks, 34 weeks, 35 weeks. Using the GTPAL system which designation is the most accurate summary of this client's obstetrical history?

4-1-2-0-3

patient with eclampsia, when does risk for seizure decrease

48 hours postpartum

The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign?

5

signs of a ruptured tubal pregnancy occur when

6 weeks into pregnancy

A 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 98.9° F. What caloric amount does this child need?

600 calories/day

The nurse is preparing to give an enema to a laboring client. Which client would require the most caution when carrying out this procedure?

A 40-wk primigravida who is at 6 cm dilation and the presenting part is not engaged. When the presenting part is ballottable, it is floating out of the pelvis. In such a situation, the cord can descent before the fetus causing a prolapsed cord, which is an emergency situation.

As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider?

A 6-month old with failure to thrive that has a closed anterior fontanel

A nurse caring for a 7lb 8oz baby feeds him with 18.75 ounces of infant formual needed per day. If every infant formula contains 20 calories/ounce, which is the total amunt of calories a baby needs per day?

A 7lb 8oz baby would need 50 calories x 7lbs = 350 calories plus 25 calories = 375 calories per day. Most infant formulas contain 20 calories /ounce. Dividing 375 by 20 = 18.75 ounces of formula needed per day

A nurse working with a 24 hour old neonate is the well baby nursery has made the following nursing diagnosis: Risk for altered growth. Which of the following assessments would warrant this diagnosis?

A baby who has lost 8% of his or her weight after only 24 hours of life is very high risk for altered growth

A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?

A decrease in RR from 24 to 16

A client at 32-weeks gestation is hospitalized with severe pregnancy induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?

A decrease in respiratory rate from 24 to 16

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best?

A home pregnancy test can be used right after your first missed period.

The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide?

A large body surface area favors heat loss to the enviroment

A fetus is in the LOA position in utero. Which of the following findings would the nurse observe when doing Leopold's maneuvers?

A nurse could conclude that a fetus is in the LOA when feeling small objects- the fetal arms and legs- on the right side of the uterus.

Early detection of rheumatoid arthritis can decrease the amount of bone and joint destruction and often the disease will go into remission. What activity recommendations should the nurse provide a client with rheumatoid arthritis?

A nurse should advise the client to perform exercises slowly and smoothly so that no extra pain occurs

A client with type 1 diabetes mellitus is 6 weeks pregnant. Her fasting glucose and hemoglobin A1c are noted to be 168 mg/dL and 12%, respectively. Which of the following nursing diagnoses is appropriate for the nurse to make at this time?

A nursing diagnosis of risk for fetal injury is an appropriate nursing diagnosis.

Which client should the nurse report to the health care provider as needing a prescription for RhoGAM?

A primigravida mother who is rH negative.

The nurse is planning discharge teaching for 4 mothers. Which postpartum client is at highest risk for psychological difficulties during the postpartum period?

A primiparous woman who has recently immigrated to the U.S. with her spouse.

A client with severe preeclampsia is admitted to the maternity department. Which room assignment would be most appropriate for this client?

A private room two doors away from the nurses' station

Which growth and development characteristic should the nurse consider when monitoring the effects of a topical medication for an infant?

A thin stratum corneum that increases topical absorption.

Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate.

A trial of chorionic gonadotrophic hormone

A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types?

ABO incompatibility can arise when the mother is type O and the baby is either type A or B

A client at 28 weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client?

Abdominal ultrasound

Which of the following is NOT a reassuring component of the fetal heart rate

Absent FHR Variability

The role of the nurse with regard to informed consent is to:

Act as a client advocate and help clarify the procedure and the options

A client is admitted to the labor and delivery unit with contractions that are 3-5 minutes apart, lasting 60-70 seconds. She reports that she is leaking fluid. A vaginal exam reveals that her cervix is 80 percent effaced and 4 cm dilated and a -1 station. The nurse knows that the client is in which phase and stage of labor?

Active phase of First Stage

LPN can help their clients by keeping them informed about the distinctive stages of labor. What description of the phases of the first stage of labor is accurate?

Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours

The nurse is teaching a primigravida at 10 weeks about the need to increase her folic acid intake. Which explanation should the nurse provide that supports preventative perinatal care?

Adequate folic acid during embryogenesis reduces the incidence of neural tube defects

What intervention is required for a teenager experiencing acute glomerulonephritis with a BP of 170/88 (previously 210/110)?

Administer PRN nifedipine (Procardia) sublingually

A 16-year-old boy is brought to the E.D. with a crushed leg after falling off a horse. His last tetanus toxoid booster was received at 8-years old. Which action should the nurse take?

Administer tetanus toxoid booster

A nurse is caring for a client in the active stage of labor. The nurse notes that the fetal pattern shows a late deceleration on the monitor strip. Based on this finding the nurse should prepare for which appropriate nursing action?

Administering oxygen via face mask

A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the following actions should the nurse make during the procedure?

Alcohol can irritate the punctured skin and cause hemolysis

A 6-month-old boy and his mother are at the health clinic for a well-baby checkup and routine immunization. The HP recommends an influenza vaccine. What medications should the RN plan to administer?

All the immunizations with the influenza being administered in a different site

What nursing action should the nurse be implemented when intermittently gavage feeding a preterm a preterm infant?

Allow formula to flow by gravity

The nurse should teach the parents of a child with a cyanotic heart defect to perform which action when a hypercyanotic spell occurs?

Allow the child to assume a knee-chest position, with the head and chest slightly elevated.

Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home?

Allow the cord to air-dry as much as possible.

Concerning the third stage of labor, nurse should be aware that:

An active approach to managing this stage of labor reduces the risk of excessive bleeding

The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention?

An over-distended bladder could be traumatized during labor as well as prolong the process of labor

The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention?

An over-distended bladder could be traumatized during labor, as well as prolong the progress of labor

The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention?

An over-distending bladder could be traumatized during labor, as well as prolong the progress of labor

The nurse is teaching a group of students on fetal growth and development. Which statement regarding fetal circulation is incorrect?

The ductus venosus shunts blood from the pulmonary artery directly to the descending aorta, bypassing the lungs.

When using intermittent auscultation (IA) to assess uterine activity, nurse should be aware that:

The examiner's hand should be placed over the fundus before, during, and after contractions

The amniotic membranes of a client in active labor spontaneously rupture. The fluid is greenish brown with a foul odor. What action is a priority for the nurse?

The fetal heart rate should be monitored continuously using an internal fetal heart rate monitor, and the time of membrane rupture should be noted since birth should occur within 24 hours of the rupture of membranes.

A client at 25 weeks tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide?

The fetus can respond to sound by 24 weeks

A nurse makes the following observations when admitting a full term, breastfeeding baby, into the neonatal nursery: 9lb 2 oz, 21 inches long, TPR: 96.6 F, 158,62, jittery, pink body with bluish hands and feet, crying. Which of the following actions is of highest probability?

The glucose level should be assessed to determine whether or not this baby is hypoglycemic.

A client at 8 weeks gestation asks the nurse about the risk for congenital heart defects in her baby. Which response best explains why these defects occur?

The heart develops in the third - fifth weeks after conception

With regard to spinal and epidural (block) anesthesia, nurse should know that:

The incidence of after-birth headache is higher with spinal blocks than epidurals

A patient who is 32 weeks gestation has the following symptoms: dark, red vaginal bleeding, 100 bpm FHR, rigid abdomen and severe pain. What is the difference between abruptio placentae and placenta previa?

The nurse must use knowledge base to differentiate between abruptia placentae from placenta previa.

A patient who is 32 weeks gestation has the following symptoms: dark, red vaginal bleeding, 100 bpm FHR, rigid abdomen and severe pain. What is the difference between abruptio placentae and placenta previa?

The nurse must use knowledge base to diffferentiate betewwn abruptia placentae from placenta previa.

The triage nurse in an obstetric clinic received the following four messages during the lunch hour. Which of the woman should the nurse telephone first?

The nurse should call the postoperative cesarean client back first. It sounds, from her description, that she has a wound infection

A woman who states she smokes 2 pack of cigarettes each day is admitted to the labor and delivery suite in labor. The nurse should monitor this labor for which of the following?

The nurse should carefully monitor the labor for late decelerations

A patient who is 32 weeks gestation is experiencing dark red vaginal bleeding and the nurse determines the FHR to be 100 bpm and her abdomen is rigid and board like. What action should the nurse take first?

The nurse should immediately notify the healthcare provider and no abdominal or vaginal manipulation or exams should be done. Administer O2 per face mask and monitor for bleeding at IV sites and gums due to the increased risk of DIC

When examining a client after delivery, the nurse finds the fundus soft, boggy, and displaced above and to the right of the umbilicus. After preforming fundal massage and having the client empty her bladder when should the nurse recheck fundus?

The nurse should recheck fundus q 15 minutes *4 (1 hour); q 30 minutes *2 hours

A nurse who has just performed a vaginal examination notes that the fetus is in the LOP position. Which of the following clinical assessments would the nurse expect to note at this time?

The nurse would expect the client to complain of severe back pain.

Which of the following is NOT a reason to come to labor and birth.

The patient is 40 weeks and has contractions that are 8-10 minutes apart, 30 seconds long and been that way for 8 hours

An infant who weighs 3.8 kg is delivered vaginally at 39 weeks with a nuchal cord after a 30-minute second stage of labor. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide the parents about this finding?

The pinpoint spots are benign and disappear within 48 hours

When assessing a multiparous woman who has just given birth to an 8-pound boy, the nurse notes that the woman's fundus is firm and has become globular in shape. A gush of dark red blood comes from her vagina. The nurse concludes that:

The placenta has separated

A baby has been admitted to the neonatal intensive care unit with a diagnosis of post maturity. The nurse expects to find which of the following during the initial newborn assessment?

The post term baby does have dry, wrinkled, and often desquamating skin. The baby's dehydration is secondary to a placenta that progressively deteriorates after 40 weeks gestation.

With regard to a woman's intake and output during labor, nurse should be aware that:

The tradition of restricting the laboring woman to clear liquids and ice chips is being challenged because regional anesthesia is used more often than general anesthesia and studies are not showing harm from drinking fluids in labor.

A client at 28 weeks is concerned about her weight gain of 17 lbs. What information should the nurse provide to the client?

The weight gain is acceptable for the number of weeks pregnant

There has been an increase in the number of children diagnosed with Type 2 diabetes with the increasing rate of obesity in children thought to be a contributing factor. What other factors are thought to be contributing in the increase of Type 2 cases?

There has been an increase in the number of children diagnosed with Type 2 diabetes. The increasing rate of obesity is children is thought to be a contributing factor. Other contributing factors include lack of physical activity, and a family history of Type 2 diabetes.

An Rh negative mother and an Rh positive father are expecting a child. Screening revealed a positive indirect coombs test. Which statement regarding this result is correct?

There is no need to administer RhoGAM to this woman.

A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child?

They use lubricants with each sexual encounter to decrease friction

A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child?

They use lubricants with each sexual encounter to decrease friction

A couple has been trying to conceive for 9 months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child?

They use lubricants with each sexual encounter to decrease friction. The use of lubricants has the potential to affect fertility because some lubricants interfere with sperm motility.

The nurse is caring for a client in labor and delivery with the following history: G2 P1000, 39 weeks gestation in transition phase, FH 135 with the early decelerations. The client states, I'm so scared. Please make sure the baby is OK!" Which of the following responses by the nurse is appropriate?

This is the best response for the nurse to make. The nurse is providing the client with accurate, reassuring information without guaranteeing that there will definitely be a positive outcome.

The umbilical cord is being clamped by the obstetrician.. Which of the following physiological changes is taking place at this time?

This is the correct answer. When the cord is clamped, the blood is no longer being oxygenated through the placenta. The baby's oxygen levels, therefore, begin to drop.

A nurse has just recieved report on 4 neonates in the newborn nursery. Which of the babies should the nurse assess first?

This is the correct response. Babies who are born to mothers who are GBS positive are at high risk for sepsis. The incidence of sepsis is reduced, however, when the mother receives IV antibiotics during labor

A woman is admitted to the labor and delivery unit with active TB. She has not been under a physician's care and is not on medication. Which of the following actions should the nursery nurse perform when the neonate is delivered?

This response is accurate. The baby can be cared for in the well baby nursery but must be kept separated from its mother.

A woman is seeking counseling regarding tubal ligation. Which of the following should the nurse include in her discussion?

This response is correct. BTL surgery, usually performed laparoscopically, is done under general anesthesia.

The nurse is caring for a client, 37 weeks gestaton, who was just told that she is group B strep positive. The client states, "How could that happen? I only have sex with my husband. Will my baby be OK?" Based on this information, which of the following should the nurse communicate to the client?

This statement is accurate. Antibiotics will be administered to the mother during labor and delivery to prevent viral transmission.

Following a minor motor vehicle collision, a client at 36-weeks gestation is brought to the emergency center. She is lying supine on a backboard, is awake, and denies any complaints. Her blood pressure is 80/50 mmHg and heart rate is 130 bpm. Which action should the nurse implement first?

Tilt the backboard sideways to displace the uterus laterally.

The nurse is caring for a 35-week gestation infant delivered by cesarean section 2 hours ago. The nurse observes the infant's respiratory rate is 72 breaths/minute with nasal flaring, grunting, and retractions. The nurse should recognize these findings indicate which complication?

Transient tachypnea of the newborn.

A client has just received syntheric prostaglandins for the induction of labor. The nurse plans to monitor the client for which of the following side effects?

Two side effects of prostaglandin administration are nausea and uterine tetany.

A client has just recieved syntheric prostaglandins for the induction of labor. The nurse plans to monitor the client for which of the following side effects?

Two side effects of prostaglandin administration are nausea and uterine tetany.

A client at 29 weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client?

Ultrasonography

The nurse providing care for the laboring woman should understand that variable fetal heart rate (FHR) decelerations are caused by:

Umbilical cord compression

Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence?

Urinary catheterization

The nurse is giving a liquid iron preparation to a 3-year-old, which technique should the RN implement to encourage active engagement?

Use a colorful straw

Which action by the nurse is most helpful in communicating with a preschool-aged child?

Use a doll to play and communicate

A mother discovers a bug has flown into her child's ear and can hear the buzzing; what intervention is priority?

Use a flashlight to coax the insect out of the ear.

To assess the effectiveness of an analgesic administered to a 4-yr old, what intervention is best for the nurse to implement?

Use a happy-face/sad-face pain scale

A client who had her first baby 3 months ago & is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. Which information should the nurse provide this client?

Use an alternate form of contraceptive until a new diaphragm is obtained.

A client, pregnant with her first child, tells the nurse that she is vegan. When discussing the client's nutritional needs, what should the nurse include?

Use fortified soy or rice milk to meet dairy needs.

A 31-year-old woman uses an over-the-counter pregnancy test that is positive one week after a missed period. At the clinic the client tells the nurse she takes epilepsy medication, has a hx of irregular periods, is under stress at work, and has not been sleeping well. The client's physical exam and ultrasound do not indicate that she is pregnant. How should the nurse explain the most likely cause for obtaining a false-positive?

Using an anticonvulsant for epilepsy

At ten weeks gestation, a high-risk multiparous client with a Fhx of downs syndrome is admitted for observation following a CVS. What assessment findings requires immediate action?

Uterine Cramping

The nurse caring for the woman in labor should understand that maternal hypotension can result in:

Uteroplacental insufficiency

The nurse providing care for the laboring woman should understand that late fetal heart rate (FHR) decelerations are caused by:

Uteroplacental insufficiency

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

Variable decelerations

The nurse providing care for the laboring woman should understand that amnioinfusion is used to treat:

Variable decelerations

Nerve lock anesthesia (spinal or epidural) during labor blocks motor as well as nerve fibers. What does result from vasodilation below the level of the block?

Vasodilation below the level of the block results in blood pooling in the lower extremities and maternal hypotension.

When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation?

Vernix is a white, cheesy substance, predominantly located in the skin fold

When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation?

Vernix is a white, cheesy substance, predominantly located in the skin folds.

A 28-year-old pregnant woman has the following symptoms: visual disturbance, persistent vomiting, swelling of face, fingers or sacrum and severe continuous headache. What do these symptoms most probably indicate?

Visual disturbance, persistent vomiting, swelling of face, fingers or sacrum and severe continuous headache in pregnant woman possible indications of preeclampsia/ eclampsia.

A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of testing provides the greatest degree of accuracy?

Visualization of implantation by vaginal ultrasound.

Which prescription should the nurse administer to the newborn to reduce complications related to birth trauma?

Vitamin K

A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide?

Wash the hair and skin frequently with soap and hot water

A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first?

Wash the wound gently with mild soap and water

A baby exhibits weak rooting and sucking reflexes. Which of the following nursing diagnoses would be appropriate?

When a baby roots and sucks poorly, the baby is unable to transfer milk effectively. Because milk intake is the baby's source of fluid, the baby is high risk for fluid volume deficit.

A baby exhibits weak rooting and sudking reflexes. Which of the following nursing diagnoses would be appropriate?

When a boby roots and sucks poorly, the baby is unable to trasnsfer milk effectively. Because milk intake is the baby's source of fluid, the baby is high risk for fluid volume deficit

In a 24-year-old pregnant woman, the amniocentesis is done in early pregnancy. How should the bladder be to help support the uterus and to help push the uterus up in the abdomen for easy access?

When an amniocentesis is done in early pregnancy, the bladder must be full to help support the uterus and to help push the uterus up in the abdomen for easy access.

In a 24-year-old pregnant woman, the amniocenteses is done in late pregnancy. How should the bladder be to avoid puncturing the bladder?

When an amniocentesis is done in late pregnancy, the bladder must be empty to avoid puncturing the bladder.

At the examination of a expecting woman, the deceleration patterns are associated with decreased or absent variability and tachycardia. What should be done immediately in this case?

When deceleration patterns (late or variable) are associated with decreased or absent variability and tachycardia, the situation is OMINOUS (potentially disastrous) and requires immediate intervention and fetal assessment.

A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide safe newborn care, which of the following actions should the nurse perform?

When phototherapy is administered, the baby's eyes must be protected from the light source

The umbilical cord is being clamped by the obstetrician. Which of the following physiological changes is taking place at this time?

When the cord is clamped, the blood is no longer being oxygenated through the placenta. The baby's oxygen levels, therefore, begin to drop.

A newborn admitted to the nursery has a positive direct Coombs' test. Which of the following is an appropriate action by the nurse?

When the neonatal blood stream contains antibodies, hemolysis of the red blood cells occurs and jaundice develops

When it comes to X-linked recessive linked recessive trait, the trait is carried on the x chromosome, therefore, usually affects male offspring. What is the chance for a pregnant woman carrier her offspring to get the disease?

With each pregnancy of a woman who is a carrier there is a 25% chance of having a child with hemophilia. If the child is male, he has a 50% chance of having hemophilia. If the child is female, she has a 50% chance of being a carrier.

In autosomal recessive disease, both parents must be hererozygous, or carriers of the recessive trait, for the disease to be expressed in their offspring. If both parents are heterozygous, what is the chance the baby to have the disease as well?

With each pregnancy, there is a 1:4 chance of the infant having the disease.

In autosomal recessive disease, both parents must be heterozygous, or carriers of the recessive trait, for the disease to be expressed in their offspring. If both parents are heterozygous, what is the chance the baby to have the disease as well?

With each pregnancy, there is a 1:4 chance of the infant having the disease.

A woman who is 6 weeks pregnant has the following maternal history: a 2 yr old healthey daughter, a miscarriage at 10 weeks, 3 years ago and an elective abortion at 6 weeks, 5 years ago. Describe gravidity and parity in this case.

With this pregnancy, the woman is a gravida 4, para 1 ( only 1 delivery after 20 weeks gestation)

A woman who is 6 weeks pregnant has the following maternal history: a 2 yr old healthy daughter, a miscarriage at 10 weeks, 3 years ago and an elective abortion at 6 weeks, 5 years ago. Describe gravidity and parity in this case.

With this pregnancy, the woman is a gravida 4, para 1 (only 1 delivery after 20 weeks gestation)

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation should the nurse provide?

Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day.

The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?

a 40-week primigravida who is at 6 cm cervical dilation and the presenting part is not engaged.

medication to strop pre-term labor

a beta-adrenergic (has tocolytic agents)

circumoral pallor can indicate

a cardiac problem

Twenty four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line in a newborn variation known as

a cephalhematoma, caused by forceps trauma and may last up to 8 weeks

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as

a cephalhematoma, caused by forceps trauma and may last up to 8 weeks

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as

a cephalhematoma, caused by forceps trauma and may last up to 8 weeks.

A client at 32 weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved?

a decrease in respiratory rate from 24 to 16

A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is

a persistent cold

A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider?

a platelet count of 67,000/mm3. This low amount places the client at risk for bleeding from an epidural

hypertension in pregnancy puts mom at risk for

abruptio placentae

priority nursing intervention for pt admitted with abdominal pain and vaginal bleeding

administer oxygen

pt. arrives at high risk unit for delivery with abdominal pain and vaginal bleeding what does nurse do

adminster oxygen

what to avoid for a pt who is breastfeeding with PKU

amino acids

In developing a teaching plan for expectant parents, the nurse plans to including information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the

anterior fontanel closes at 12-18 months and the posterior by the end of the second month.

A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take?

apply cold compresses to both breasts for comfort.

A 40 week gestation primigravada client is being induced with an oxytocin (pitocin) secondary infusion and complains pain in her lower back. Which intervention should the nurse implement?

apply firm pressure on the sacral area

The nurse is assessing a client who is having a non-stress test (NST) at 41 weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take?

ask the client if she has felt any fetal movement.

When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?

at 30 weeks gestation

A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first?

bathe the infant with an antimicrobial soap. To reduce direct contact with the Human immuno-virus in blood and body fluids on the newborn's skin, a bath with an antimicrobial soap should be administered first.

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?

between the time the temperature falls and rises

A multigravida client at 41 weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status?

biophysical profile (BPP). This test provides data regarding fetal risk surveillance by examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate. The client's gestation has progressed past the estimated date of confinement, so the major concern is fetal well-being related to the aging placenta.

A client with gestational hypertension is in active labor and receiving an infusion of magnesium sulfate. Which drug should the nurse have available for signs of potential toxicity?

calcium gluconate

A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity?

calcium gluconate

One hour after giving birth to an 8 pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 bpm and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM x 1. What action should the nurse take immediately?

call the healthcare provider to question the prescription. Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription.

megaloblastic anemia in pregnancy

can cause neural tube defects mother needs to be started on folic acid supplements asap

hydatidiform mole

causes extra large utereus

Which assessment finding should the nursery nurse report to the pediatric healthcare provider?

central cyanosis when crying. An infant who demonstrates central cyanosis when crying is manifesting poor adaption to extrauterine life which should be reported to the healthcare provider for determination of a possible underlying cardiovascular problem.

A 35-year-old client comes to the clinic reporting pelvic pain and vaginal bleeding after sexual intercourse for the past few months. The client has a history of human papillomavirus (HPV). Laboratory values: hemoglobin 9 g/dl (90 g/l) and hematocrit 30% (0.30). Vital signs: temperature, 97.2°F (36.2°C); heart rate, 105 beats/min; blood pressure, 92/55 mm Hg. Complete the following sentence(s) by choosing from the lists of options. The nurse suspects the client is at highest risk for developing ____________ as evidenced by ____________ and ____________.

cervical cancer history of HPV Age of the client

A nurse is performing an assessment on a 30-year-old client who is trying to conceive. Past medical history includes: human papillomavirus (HPV) infection and herpes simplex virus. Vital signs: heart rate, 95 beats/min; blood pressure, 100/60 mm Hg. Laboratory values: hemoglobin 14 g/dl (140 g/l); white blood cell count, 6,000/mm3 (6.0 × 109/l). Complete the following sentence(s) by choosing from the lists of options. The nurse suspects the client is at highest risk for ____________ as evidenced by ____________.

cervical cancer history of human papilloma virus (HPV)

What action should the nurse implement to decrease the client's risk for hemorrhage after a cesarean section?

check the firmness of the uterus every 15 minutes. A client's risk for postpartal hemorrhage is decreased when the uterus is firm after delivery of the infant. Assessment of fundus consistency q15 min provides frequent intervals to stimulate the fundus to contract and prevent bleeding.

A newborn infant is brought to the nursery from the bathing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first?

check the infant's oxygen saturation rate

pt. with pre-eclampsia is admitted, after vitals are taken what is next priority

checking pt. reflexes

During the postpartum period a client tells a nurse that she has been having leg cramps. Which foods should the nurse encourage the client to eat?

cheese and broccoli *need calcium*

A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit?

choking, coughing and cyanosis

A client at 28 weeks gestation calls the antepartal clinical and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?

come to the clinic today for an ultrasound. Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound.

folic acid in patient with sickle cell is important for

compensating for a rapid turnover of red blood cells

A multigravida client arrives at the labor and delivery unit and tells the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140-150 bpm. What action should the nurse implement next?

complete a sterile vaginal exam. This is done to determine the presence of a prolapsed umbilical cord.

reason for increased pain in abruptio placentae

concealed hemorrhage

premature rupture of membranes can lead to

cord prolapse

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness?

correctly place the infant on the breast

when newborn has a meningocele priority nursing intervention is

covering sac with sterile moist gauze

A client with no prenatal care arrives at the labor unit screaming, "the baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 cm dilated and 75% effaced. What additional information is most important for the nurse to obtain?

date of last normal menstrual period

A client arrives at the clinic in preterm labor, and terbutaline (Brethine) is prescribed. For what therapeutic effect should the nurse monitor the client?

decreased frequency and duration of contractions

magnesium sulfate: how to know when you have reached therapeutic level

deep tendon reflexes +2

A 35-year old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data would indicate to the nurse that the client is experiencing magnesium sulfate toxicity?

deep tendon reflexes 2+

A woman with type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement?

describe diet changes that can improve the management of her diabetes

for patient with abuse what is priority action of the nurse

develop a safety plan

nursinging intervention for pt. with placental previa

document amount of bleeding

A 24-hour old newborn has a pink papular rash with vesicles superimposed on the thorax, back and abdomen. What action should the nurse implement?

document the finding in the infant's record. Erythema Toxicum (or erythema neonatorium) is a newborn rash that is commonly referred to as "flea bites." but is a normal finding that is documented in the infant's record and requires no further action.

heart burn while pregnant

don't take antacids with sodium

pt. receiving lovenox for DVT, what sign is most concerning

dyspnea

A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to the infant. The nurse's response should be based on what information?

each pregnancy carries a 50% chance of inheriting the disorder.

The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of the greatest concern?

edema, basilar rates, and an irregular pulse

exstrophy

effects the bladder and can cause separation of pubic bones

most spontaneous abortions occur due to

embryonic defects

The nurse is planning preconception care for a new female client. Which information should the nurse provide to the client?

encourage healthy lifestyles for families desiring pregancy

The total bilirubin level of a 36 hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement?

encourage the mother to breastfeed frequently

what kind of epidural is used for a pt with class 1 heart disease

epidural regional

A client at 32 weeks gestation is diagnosed with preeclampsia. Which assessment is most indicative of an impending convulsion?

epigastric pain. Epigastric pain is indicative of an edematous liver or pancreas which is an early warning sign of an impending convulsion (eclampsia) and requires immediate attention.

A client in active labor complains of cramps in her leg. What intervention should the nurse implement?

extend the leg and dorsiflex the foot. "Toes to the nose"

The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class?

feed your baby every 2-3 hours or on demand, whichever comes first

when fetus makes a rapid decent the nurse worries about

fetal head trauma

what assessments are priority for pt with diagnosed abruptio placentae

fundal height, vital sighs, skin color, urine output, FHR

the key factors to a baby survival rate in the neonatal period

gestational age and birth weight

The healthcare provider prescribes terbutalne (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition?

gestational diabetes

A nurse is caring for a 33-year-old primigravida client who is obese and near the end of their second trimester. The client has a history of prepregnancy obesity, hypertension, and smoking. Complete the following sentence(s) by choosing from the lists of options. The client is at highest risk for developing ____________. The nurse provides discharge teaching to reduce the risks of developing this condition. Teaching should include ____________.

gestational diabetes change in lifestyle.

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8 weeks gestation. What type of emotional response should the nurse anticipate?

grief related to her perceptions about the loss of this child

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client?

have the client empty her bladder

what contraindicates pitocin

herpes infection

lepolds maneuver on patient with placental previa expects

high floating, presenting part

signs of hypoglycemia in newborn

high-pitched cry, jitteriness, and irregular respirations

A primigravida at 40 weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin?

hyperstimulation. Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the client is at risk for hyperstimulation which can lead to tetanic contractions, uterine rupture, and fetal distress or demise.

risk factor for abruptio placentae

hypertension

type 1 diabetes in pregnancy puts mom at risk for

hypertensive states

blood in urine in catheter back during c-section indicates

incisional nick in the bladder

At 14 weeks gestation, a client arrives at the EC complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?

increase the rate of IV fluids.

At 14 weeks gestation, a client arrives at the emergency center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 bpm, and a blood pressure of 86/48. Which action should the nurse implement next?

increase the rate of IV fluids. The client is demonstrating symptoms of blood loss, probably the result of an ectopic pregnancy, which occurs at approximately 14 weeks gestation when embryonic growth expands the fallopian tube causing its rupture and can result in hemorrhage and hypovolemic shock. Increasing the IV infusion rate provides intravascular fluid to maintain blood pressure.

magnesium sulfate and the importance of deep tendon reflexes

indicates respiratory depression

silverson anderson score means

indications if respiratory distress 0=no respiratory distress less than or equal to 7 means impending respiratory failure

A 36-year-old woman comes to the emergency department complaining of severe abdominal cramping and heavy bleeding. She informs the nurse that she is 10 weeks pregnant. Cervical examination reveals heavy bleeding; the cervical os is open and tissue is present. Which type of miscarriage is the client experiencing?

inevitable

A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn?

infant's condition at birth and treatment received

Immediately after birth, a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 bpm and respirations of 20 breaths/min. What action should the nurse perform next?

initiate positive pressure ventilation because the infant's vital signs are not within the normal range and oxygen deprivation leads to cardiac depression in infants. The normal newborn pulse is 100-160 bpm and respirations are 40-60 breaths/minute.

A nurse is caring for a 28-year-old female client in the emergency department (ED) who is accompanied by their partner. The client reports accidentally falling down stairs. Assessment reveals bruising at multiple stages of healing on upper extremities, back, and abdomen. X-ray reveals a right wrist fracture. The client does not make eye contact with the nurse and allows their partner to answer most of the questions. Complete the following sentence(s) by choosing from the lists of options. The nurse suspects the client is experiencing ____________ as evidenced by ____________.

intimate partner violence stages of bruising

red tinged mucus in the diaper of a female new born

is normal reaction to mothers hormones

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge?

it is difficult to consume 18 mg of additional iron by diet alone.

when a newborn is receiving oxygen via hood the nurse is responsible to

keep a hat on the infants head

when a patient is on magnesium sulfate

keep room dark and quiet

During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have

lower birth weights

corticosteriods are given to moms 24-34 weeks for

lung development

Which nurse intervention would be most helpful in relieving postpartum uterine contractions or "afterpains?"

lying prone with a pillow on the abdomen

A 30 year old gravida 2, para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg SQ. Which assessment is the highest priority for the nurse to monitor during the adminstration of this drug?

maternal and fetal heart rates

A 30 year old gravida, 2 para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug?

maternal and fetal heart rates

when newborn has necrotizing enterocolitis (NEC) it is important to

measure the abdominal girth frequently

greenish amniotic fluid indicates

meconium in amniotic fluid and dr should be notified immediately

primigravida in labor, priority nursing assessment is to

monitor FHR

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 bpm, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?

monitor for bleeding from IV sites. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruptio, characterized by abnormal bleeding.

new born baby eyes cross eyed

normal for first 6 months as they are trying to foucs

The nurse identifies crepitus when examining the chest of the newborn who was delivered vaginally. Which further assessment should the nurse perform?

observe for an asymmetrical Moro (startle) reflex. The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fractured clavicle should be suspected if the infant has limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex, crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick and high. Based on this data, which intervention should the nurse implement first?

obtain a specimen for urine analysis. This should be done first because preterm clients with uterine irritability and contractions are often suffering from a UTI, and this should be ruled out first.

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately?

onset of uterine contractions. Total (complete) placenta previa involves the placenta covering the entire cervical os (opening). The onset of uterine contractions places the client at risk for dilation and placental separation, which causes painless hemorrhaging.

vaginal hematoma

pain is severe and vagina feels full and heavy

low lying placenta in third trimester puts mom at risk for

painless vaginal bleeding

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?

patellar reflex 4+. A 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia, which is an indication of impending seizure.

what to assess before administration of magnesium sulfate

patellar reflexes and urinary output

what is a danger sign for a mom with history of preterm mulit gestational neonatal deaths

pelvic pressure

The nurse must prevent a 2-year-old with severe eczema on the face, neck and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis?

place elbow restraints on the child's arms

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action will the nurse take?

place the woman in a lateral position. The nurse should immediately turn the woman to a lateral position, place a pillow or wedge under the right hip to deflect the uterus, increase the rate of the main line IV infusion, and administer oxygen by face mask at 10-12 L/min. If the blood pressure remains low, especially if it further decreases ,the anesthesiologist/healthcare provider should be notified immediately. Turning off the continuous epidural may also be warranted, but such action is based on hospital protocol.

The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching?

places the infant prone in the bassinet. This is associated with an increased incidence of sudden infant death syndrome (SIDS)

multiple UTI's can cause what

preterm birth

A client's membranes rupture during labor. The nurse immediately assesses the electronic fetal heart rate. Variable decelerations lasting more than 90 seconds, followed by bradycardia, are observed on the monitoring strip. What does the nurse suspect as the cause of this change?

prolapsed cord

sitz baths

promote vasodilation

vertex postion

proper for delivery

What action should the nurse implement to prevent conductive heat loss in a newborn?

put a blanket on the scale while weighing the infant

An off-duty nurse finds a woman in a supermarket parking lot delivery an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?

put the newborn to breast. Putting the newborn to breast will help contract the uterus and prevent a postpartum hemorrhage - this intervention has the highest priority.

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?

raise the foot of the bed. These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed (Trendelenburg position) will increase venous return and provide blood to the vital areas.

The nurse is providing discharge for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do?

reduce activity level and notify the healthcare provider

pt on magnesium sulfide, what base line assessment is needed

respiration rate

The nurse is performing a focused assessment on a client who is 2 days postpartum. The client reports pelvic pain, chills, profuse dark, foul-smelling lochia with blood clots. The client states, "my bleeding before was light and now it is heavy." Vital signs: temperature, 99.5°F (37.5°C); heart rate, 102 beats/min; blood pressure, 100/66 mm Hg. Complete the following sentence(s) by choosing from the lists of options. The nurse suspects the client has _________ of placenta as evidenced by _______ and ________ with blood clots.

retained fragments pelvic pain profuse dark lochia

giving o2 to a infant can cause what

retinopathy of prematurity

The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is recommended for which purpose?

screen for neural tube defects

creatinine

should be between 0.4-0.9. if higher indicates kidney problems

A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which complaint would indicate to the nurse that that woman's fallopian tubes are patient?

shoulder pain

A 4 week old premature infant has been receiving epoetin alfa (Epogen) for the last 3 weeks. Which assessment finding indicates to the nurse that the drug is effective?

slowly increasing urinary output over the last week

A nurse is performing an assessment on a 25-year-old white female client who is obese and is trying to conceive. The client presents to the clinic concerned about a newly found lump in their breast. The nurse explains to the client the difference between benign nodules and breast cancer. Complete the following sentence(s) by choosing from the lists of options. The nurse determines client understanding of the difference between a lump that is a benign nodule and a lump that is breast cancer when the client states ____________ is a sign of a benign nodule and ____________ is a sign of breast cancer.

soft and movable hard and fixed

increase alpha fetoprotein indicates

spin bifid a or other neural turn defects

A nurse administers two serial intramuscular injections of betamethasone (Celestone) to a woman at 32 weeks' gestation who has been admitted in preterm labor. The nurse knows that this medication is given to:

stimulate surfactant production.

mom with mitral valve stenosis, ,what symptom indicates cardiac difficulties

syncope for exertion

A 26-year old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25mg SQ to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate?

tachycardia and a feeling of nervousness

A woman who had a miscarriage 6 months ago became pregnant. Which instruction is most important for the nurse to provide this client?

take prescribed multivitamin and mineral supplements

A 23 year old client who is receiving Medicaid is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client?

teach the client why keeping prenatal care appointments is important.

PKU test will not be done until

the baby has enough milk for the test to be accurate

The nurse should encourage the laboring client to begin pushing when

the cervix is completely dilated

The nurse should encourage the laboring patient to begin pushing when:

the cervix is completely dilated

What is an advantage of external electronic fetal monitoring?

the external EFM does not require rupture of the membranes or introduction of scalp electrode or IUPC which may introduce risk of infection or fetal scarring

positive CST result means

the function of the placenta has diminished

A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn?

the infant's condition at birth and treatment received

when newborns head circumference is 4cm smaller than chest circumference

the infants head size is smaller than average

While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succadeaneum. Which additional information should the nurse provide this new mother?

the scalp edema will subside in a few days after birth. Caput succadeaneum is edema of the fetal scalp that crosses over the suture lines and is caused by pressure on the fetal head against the cervix during labor. It will subside in a few days after birth without treatment.

a preterm infant and maintaing body heat

they do not have enough brown fat available to provide heat

The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding?

three vessels: two arteries and one vein

when newborn is small for gestational age priority nursing intervention is

to perform glucose test reading

safest position for mom with prolapsed cord

trandlenburg

A 42 week gestational client is receiving an intraenous infusion of oxytocin (pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions?

transition labor with contractions every 2 minutes, lasting 90 seconds each. When oxytocin causes uterine hyperstimulation as evidence by inadequate resting time between contractions, the oxytocin infusion should be discontinued because placental perfusion is impeded.

risk when undergoing IVF

tubal pregnancy

risk for hypotonic uterine dystocia

twin gestation

The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs

two weeks before menstruation

The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs

two weeks before menstruation

Physiologic jaundice which occurs 2-3 days after birth due to the liver's inability to keep up with RBC destruction. What is the culprit in this case?

unconjugated bilirubin is the culprit.

erbs palsy in newborn

upper and lower nerves are stretched caused by injury to brachial plexus

when pregnant with twins mom is at higher risk for hemorrhage due to

uterine atony

after internal fetal heart monitor placement dr listens to fetal heart rate for 1 full minute to monitor

uterine cord prolapse

threatened abortion

vaginal spotting, abdominal cramping, closed cervix

sign of preclampsia other than high blood pressure

weight gain of 6 pounds in 1 month

Vaginal examinations should be performed by the nurse under all of these circumstances EXCEPT:

when accelerations of the fetal heart rate (FHR) are noted

placental previa

when the placenta covers the opening of the cervix

The nurse is assessing a 3 day old infant with a cephaloheatoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider?

yellowish tinge to the skin. Cephalohematomas are characterized by bleeding between the bone and its covering, the periosteum. Due to the breakdown of the red blood cells within a hematoma, the infant is at a greater risk for jaundice so it should be reported.