OB HESI STUDY SET
A vaginal 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
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 breath into her cupped hands.
What action should the nurse implement when preparing to measure the fundal height of a pregnant client?
Have the client empty her bladder i. Bladder must be empty to avoid elevation of the uterus
The nurse is preparing to give an enema to a laboring client. Which client requires the most cautions when carrying out this procedure?
A 40 week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged
24 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 the 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 i. Trauma from delivery
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 of the breast If the infant on the breast only grasping too little of the areola or grasping only the nipple. There will be soreness
A HCP 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 A rigid abdomen i. These are the most common symptoms
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 woman with type 2 DM 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
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 greatest concern?
Edema, basilar rales, and an irregular pulse
The nurse is planning preconception care for a new female client. Which information should the nurse provide the client?
Encourage healthy lifestyles for families desiring pregnancy. i. Being healthy is an overall goal for a client preparing for pregnancy
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 i. Normal bilirubin is 6-12 after 1 day of life. The infant should be monitored to prevent further complications bc of their rise of levels
A client in active labor complains of cramps in her leg. What intervention should the nurse implement?
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 i. Dorsiflexing the foot by pushing the sole of the foot forward or by standing and putting the heel of the foot on the floor is the best means of relieving leg cramps.
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 i. Breastfeeding infants should be kept in the room with the mother
A primigravida at 40 weeks gestation is receiving Pitocin to augment labor. Which adverse effect should the nurse monitor for during the infusion?
Hyperstimulation
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 EDD?
May 9, 2007
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 succedaneum. Which additional information should the nurse provide to the new mother?
The scalp edema will subside in a few days after birth.
The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding?
Three vessels: two arteries and one vein
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
In evaluating the respiratory effort of a one hour old infant using the Silverman-Anderson Index, the nurse determines the infant has synchronized chest and abdominal movement, just visible lower chest retractions, just visible xiphoid retractions, minimal and transient nasal flaring, and an expiratory grunt heard only on auscultation. What score should the nurse assign to the infant?
4
A client at 32 weeks gestation is hospitalized with severe pregnancy induced hypertension. And Mag Suf 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 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
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 i. Respiratory tract infections are common in pediatric patients, an AIDS patient has a decreased ability to defend the body against these infections and often the present symptom.
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 HCP?
A platelet count of 67,000/mm^3
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 gestational age assessment on a full term newborn during the first hour of transition using the Ballard scale. Based on this assessment, the nurse determines that the neonate has a maturity of 40 weeks. What findings should the nurse identify to determine if the neonate is small for gestation age? (select all that apply)
Admission weight of 4 lbs, 15 oz (2244 grams) Head to heal length of 17 inches Frontal occipital circumference is 12.5 inches i. Know the normal criteria for a newborn measurements
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 the nursing intervention?
An over-distended bladder could be traumatized during labor as well as prolong the progress of labor.
In developing a teaching plan for expectant parents, the nurse plans to include info about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn:
Anterior fontanel closes at 12-18 months and the posterior by the end of the second month i. Normal ranges
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 primigravida client is being induced with Pitocin secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement?
Apply firm pressure to sacral area
The nurse is assessing a client who is having a non stress test at 41 weeks gestation. The nurse determines that the client is not having contractions, the FHR baseline is 144, and no FHR accelerations are occurring. What actions should the nurse take?
Ask the client if she has felt any fetal movement.
When assessing a client who is 12 weeks gestation, the nurse recommends that she and her husband consider attending childbirth classes. When is the best time for the couple to attend these classes?
At 30 weeks gestation
The nurse is teaching a woman how to use her basal body temp pattern as a tool to assist her in conceiving a child. Which temp pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?
Between the time the temp falls and rises i. In most women the BBT drops slightly 24-36 hours before ovulation and rises 24-72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone.
A multigravida client at 41 weeks gestation present 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 info about fetal status?
Biophysical profile
A client with gestational hypertension is in active labor and receiving an infusion of magnesium sulfate. Which drug should the nurse have available for sign of potential 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 clients pulse is 84, BP 156/96. The HCP prescribes Methergine 0.2 mg IM. What action should the nurse take immediately?
Call the HCP to question the prescription. i. Contraindicated for clients with elevated BP
Which assessment finding should the nursery nurse report to the pediatric HCP?
Central cyanosis when crying
A 4 week old premature infant has been receiving epoetin alfa for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective?
Changes in apical heart rate from the 180s to the 140s
What action should the nurse implement ot decrease the client's risk for hemorrhage after a c-section?
Check the firmness of the uterus q15 minutes. i. Assessment of the fundus every 15 minutes provides frequent intervals to stimulate the fundus to contract and prevent bleeding.
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 infants oxygen saturation rate i. The pediatrician should be notified if the o2 rate is below 90%
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 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 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. What action should the nurse implement next?
Complete a sterile vaginal exam
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?
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 moist cough. Which question is most important for the nurse to ask?
Do you have a history of rheumatic fever? With this history they may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the increase blood volume that occurs in pregnancy
A 24 hour old newborn has a pink popular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement?
Document the finding in the infant's record i. Erythema toxicum is a newborn rash that is commonly referred to as flea bites but is a normal finding
A client who has an autosomal dominant inherited disorder is exploring planning options and the risk of transmission of the disorder to an infant. The nurse's response should be based on what info?
Each pregnancy carries a 50% chance of inheriting the disorder
The HCP 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 i. Brethine increases blood glucose levels
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
The nurse attempts to help an unmarried teenager deal with her feelings following a spon. 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 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 infants profile with her fingertips
At 14 weeks gestation, a client arrives at the ER complaining of dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. 30 minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, HR of 120, and blood pressure of 86/48. Which action should the nurse implement?
Increase the rate of IV fluids
RhoGAM Indications Nursing Considerations Patient Education
Indications: Administer to Rh-negative women who have been exposed to Rh-positive blood by doing the following: 1. Delivering an Rh- positive infant 2. Aborting an Rh-positive fetus 3. Undergoing chorionic villus sampling, amniocentesis, or intra-abdominal trauma while carrying an Rh-positive fetus 4. Receiving inadvertent transfusion of Rh-positive blood Nursing Considerations: Type and antibody screening of the mother's blood and cord blood type of the newborn must be performed to determine the need for the medication. The mother must be Rh-negative and negative for Rh antibodies. The newborn must be Rh-positive. If the fetal blood type after termination of pregnancy is uncertain, the medication should be administered. The newborn may have a weakly positive antibody test if the woman received Rho(D) immune globulin during pregnancy. The drug is administered to the mother, not the infant. The deltoid muscle is recommended for IM administration. Patient Education: 1. Report promptly early signs of allergic reactions, including anaphylaxios, chest tightness, generalized uticaria, hives, and wheezing. 2. Be aware that administration of Rho immune globulin (antibody) prevents hemolytic disease of the newborn in a subsequent pregnancy.
Oxytocin (Pitocin) Indications Nursing Considerations Patient Education
Indications: Induction or augmentation of labor at or near term. Maintenance of firm uterine contractions after birth to control postpartum bleeding. Management of inevitable or incomplete abortion. Nursing Considerations: Intrapartum: Assess the fetal HR for at least 20 minutes before induction to identify reassuring or nonreassuring patterns. Observe uterine activity for establishment of effective labor pattern: contraction frequency every 2-3 minutes, duration of 40-90 seconds, intensity of 50-80 mm Hg. Postpartum: Observe uterus for firmness, height, and deviation. Massage until firm if uterus is soft ("boggy"). Observe lochia for color, quantity, and presence of clots. Notify the birth attendant if the uterus fails to remain contracted or if lochia is bright red or contains large clots. Assess for cramping. Assess vital signs every 15 minutes or according to protocol for the recovery period. Monitor intake and output and breath sounds to identify fluid retention or bladder distention. Inevitable or Complete Abortion: Observe for cramping, vaginal bleeding, clots, and passage of products of conception. Observe maternal vital signs, intake, and output as noted under postpartum nursing implications. Patient Education: Be aware of purpose and anticipated effect of oxytocin. Report sudden, severe headache immediately to HCP.
Magnesium Sulfate Indications Nursing Considerations Patient Education
Indications: Prevention and control of seizures in sever preeclampsia; prevention of uterine contractions in preterm labor. Nursing Considerations: Monitor BP closely during administration. Assess the woman for respiratory rate above 12 bpm, presence of DTRs, and urinary output greater than 30 mL/hr before administering magnesium. Place resuscitation equipment (suction, oxygen) in the room. Keep calcium gluconate, which as an antidote to magnesium, in the room, along with syringes and needles. Patient Education: Drink sufficient water during the day when drug is administered orally to prevent net loss of body water.
Rubella Vaccine Indications Nursing Considerations Patient Education
Indications: Prevention is the only effective for fetus. Prenatal rubella antibody screen is performed on each pregnant woman to determine if she is immune to rubella. If she is not immune, rubella vaccine is recommended after childbirth to prevent her from acquiring rubella during subsequent pregnancies, when it can cause serious fetal anomalies and spontaneous abortions. Nursing Considerations: Contact precautions. Infant may shed virus for 1 year after birth. Diagnosed by presence of antibody and virus. Treatment supportive. Tell women that they should not get pregnant 28 days after receiving the vaccine because it is a live virus. Patient Education: Teach pt. S&S of anaphylaxis and if they notice any of these symptoms notify their HCP.
Hepatitis B Vaccine (Engerix-B) Indications Nursing Considerations Patient Education
Indications: Prevention of hepatitis B in exposed and unexposed infants. Nursing Considerations: If a vial is used, shake the solution well before preparing. Give vaccine within 12 hours of birth to infants of infected mothers. Do not inject IV or intradermally. Obtain parental consent. Patient Education: Teach pt. S&S of anaphylaxis and if they notice any of these symptoms notify their HCP.
Vitamin K Phytonadione (Aqua MEPHYTON) Indications Nursing Considerations Patient Education
Indications: Prevention or treatment of Vitamin K—deficiency bleeding (hemorrhagic disease of the newborn). Nursing Considerations: Protect the drug from light until just before administration to prevent decomposition and loss of potency. Observe all infants for signs of Vitamin K deficiency (eccyhmoses or bleeding from any site). Check that the infant has had Vitamin K before a circumcision is performed. Patient Education: Maintain consistency in diet and avoid significant increases in daily intake of vitamin K-rich foods when drug regimen is stabilized. Know sources rich in Vitamin K: asparagaus, broccoli, cabbage, lettuce, turnip greens, pork or beef liver, green tea, spinach, watercress, and tomatoes.
Erythromycin Ophthalmic Ointment (Iloyticin) Indications Nursing Considerations Patient Education
Indications: Prophylaxis against the organism Neisseria gonorrhoeae; helps prevent opthalmia neonatorum in infants of mothers infected with gonorrhea; prophylaxis against gonorrhea, required by law for all infants, even if the mother is not known to be infected. Nursing Considerations: Do not rinse. Ointment may be wiped from the outer eye after 1 minute. Observe for irritation. Patient Education: Notify prescriber for S & S of superinfection. Notify prescriber immediately for S&S of pseudomembranous entercolitis, which may occur even after the drug is discontinued. Report any ototoxic effects including dizziness, vertigo, nausea, tinnitus, roaring noises, hearing impairment.
Hepatitis B Immune Globulin (HBIG) Indications Nursing Considerations
Indications: Prophylaxis for infants of hepatitis B surface antigen-positive mothers. Nursing Considerations: Do not shake or give intravenously. Hepatitis vaccine series should begin within 12 hours of birth. Give injections of vaccine and immune globulin at separate sites.
Methylergonovine Maleate (Methergine) Indications Nursing Considerations Patient Education
Indications: Used for the prevention and treatment of postpartum or postabortion hemorrhage caused by uterine atony or subinvolution. Nursing considerations: Before administering the medication, assess the blood pressure. Follow facility protocol to determine at what BP level medication must be withheld. Caution the mother to avoid smoking because nicotine constricts blood vessels. Remind her to report any adverse reactions. Patient Education: Report severe cramping or increased bleeding. Report any of the following: cold or numb fingers or toes, nausea or vomiting, chest or muscle pain.
Carboprost (Hemabate) Indications Nursing Considerations
Indications: Used for the treatment of postpartum hemorrhage caused by uterine atony. Also used for abortion. (uterus contracting compresses blood vessels). Nursing Considerations: Should be refrigerated. Give via deep IM injection and aspirate carefully to avoid IV injection. Rotate sites if repeated. Monitor Vital Signs. Administer anti-emetics and anti-diarrheals as ordered.
Dinosprostone (Cervidil) Vaginal Insert Indications Nursing considerations Patient teaching
Indications: Vaginal insert approved to start and/or continue the ripening of the cervix in pregnant women who are at or near the time of delivery and in whom there is a medical reason for inducing labor. Nursing Considerations: Monitor for postpartum DIC, fibrinolysis, anaphylactoid syndrome of pregnancy, uterine hyper-stimulation, commencement of labor, sustained uterine contractions, fetal distress, and for other fetal or maternal adverse reactions. Monitor for progression of cervical dilation and effacement. Monitor maternal vital signs. BLACK BOX warning: recommended doses of dinoprostone should NOT be exceeded. Patient Education: Continue taking your temperature (late afternoon) for a few days after discharge. Contact prescriber with onset of fever, bleeding, abd. cramps, abnormal or foul-smelling vaginal discharge. Avoid douches, tampons, intercourse, and tub baths for at least 2 wk. clarify with prescriber.
A full term infant is transferred to the nursery from labor and delivery. Which intervention 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 HR of 80 bpm and RR of 20. What action should the nurse perform next?
Initiate positive pressure ventilation i. The infant's vital signs are not within the normal range, and oxygen deprivation leads to cardiac depression in infants. (100-160 bpm, RR 40-60)
A client who is attending antepartum classes asks the nurse why her HCP 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
A client who is in the second trimester of pregnancy 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
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 Jan 8. The nurse correctly calculates that the woman's next fertile period is
Jan 30-31 i. Ovulation occurs 14 days before the first day of the menstrual period
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
During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with non smokers, mothers who smoke during pregnancy tend to produce infants who have
Low birth weights
Which nursing intervention is most helpful in relieving postpartum uterine contractions or afterpains?
Lying prone with a pillow on the abdomen i. Keeps the fundus contracted and is especially useful with multiparas
A female client with insulin dependent diabetes arrives at the clinic seeking a plan to get pregnant in approx. 6 months. She tells the nurse that she want to have an uncomplicated pregnancy and a healthy baby. What info should the nurse share with the client?
Maintain blood sugar levels in a constant range within normal limits during pregnancy
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 subQ. Which assessment is the highest priority for the nurse to monitor during the administration of the drug?
Maternal and fetal HR Terbutaline acts as a sympathomometic agent that stimulates both beta 1 receptors and stimulation of beta 2 receptors.
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?
Meet the mother's physical needs and demonstrate warmth toward the infant i. It is most important to meet the mothers requirement for attention to her needs so that she can begin infant care-taking
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. Cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
Monitor bleeding from IV sites
When explaining postpartum blues to a client who is day one postpartum, which symptoms should the nurse include in the teaching? (Select all that apply)
Mood swings Tearfulness i. PP blues is a common emotional response related to the rapid decrease in placental hormones after delivery and include: mood swings, tearfulness, feeling low, emotional, and fatigued.
A 38 week primigravida who works as a secretary and sits at a computer 8 hours a 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
On admission to the prenatal clinic, a 23 year old woman tells the nurse that her last menstrual period began on Feb 15, and that previously her periods were regular. Her pregnancy test is positive. The client's EDD?
November 22
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 reflex
The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take?
Observe the mother for other attachment behaviors. i. Parent and infant bonding is based on a mutual relationship which is commonly established by the enface position
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 these data, which intervention should the nurse implement first?
Obtain a specimen for urine analysis
A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the HCP immediately?
Onset of uterine contractions
A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her butt. 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 i. A firm uterus is needed to control bleeding from the placental site of attachment of the uterine wall. The nurse should assess the firmness and massage the fundus
A client is active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?
Patellar reflex 4+
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's BP drops from 120/80 to 90/60. What action should the nurse take?
Place the woman is a lateral position i. Place a pillow or wedge under the right hip to deflect the uterus, increase the rate of the main IV line infusion, and administer oxygen
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.
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 i. Will help contract the uterus and prevent a postpartum hemorrhage
A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement?
Raise the foot of the bed
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 HCP
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 how 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.
During labor the nurse determines that a full term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions?
Reposition the client Provide oxygen via face mask Increase IV fluids Call the HCP
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 is calculating the estimated date of confinement using Nagele's rule for a client whose last menstrual period started on Dec 1. Which date is most accurate?
September 8
A couple concerned bc the woman has not been able to conceive, is referred to a HCP for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complain indicates that the fallopian tubes are patent?
Shoulder pain i. If tubes are patent pain is referred to the shoulder from a subdiaphragmatic collection of peritoneal dye/gas.
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 HCP 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 is a soy-based formula that contains sucrose i. May be lactose intolerant
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 0.25 mg subQ to stop her labor contractions. The nurse plans to monitor for which primary side effect of Ter Sulf?
Tachycardia and a feeling of nervousness
A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client?
Take prescribed multivitamin and mineral supplements i. Need to take a multivitamin if you have had a stillbirth or spon. Abortion within 1.5 years
A 23 year old client who is receiving Medicaid benefits 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
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 7-10 days i. Reassures the mother that this is normal in the newborn and provides correct info regarding the return of normal shape
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 i. Readiness to learn is the most important
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
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. i. The use of lube has the potential to affect fertility bc some lube interfere with sperm motility
A 42 week gestational client is receiving an IV infusion of Pitocin to augment early labor. The nurse should discontinue the infusion for which pattern of contractions?
Transition labor with contractions every 2 minutes lasting 90 seconds each
The nurse is counseling a couple who has sought info about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs
Two weeks before menstruation
A 35 year old primigravida client with severe preeclampsia is receiving magnesium sulfate via IV infusion. Which assessment data indicated to the nurse that the client is experiencing magnesium sulfate toxicity?
Urine output 90 ml/ 4 hours i. Cardinal signs of Mag Sulf tox: urine output less than 100 ml/4 hours, absent DTRs, and a RR of less than 12
Which nursing intervention is helpful in relieving afterpains?
Using relaxation breathing techniques
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 white, cheesy substance, predominantly located in the skin folds. i. While pinpoint spots usually found over the nose and chin which represent blockage of the sebaceous glands
The nurse is assessing a 3 day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the HCP?
Yellowish tinge to the skin i. Cephalohematomas are characterized by bleeding between the bone and its covering, the periosteum. Due to the breakdown of the RBC within a hematoma, the infant is at a greater risk for jaundice
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 6-10 times a day i. The urine will be diluted if the infant is adequately hydrated
The nurse should encourage the laboring client to begin pushing
when the cervix is completely dilated
