OB Week 6

A 35-year-old client is seen for her 2-week postoperative appointment after a suction curettage was performed to evacuate a hydatidiform mole. The nurse explains that the human chorionic gonadotropin (hCG) levels will be reviewed every 2 weeks and teaches about the need for reliable contraception for the next 6 months to a year. The client states, "I'm 35 already. Why do I have to wait that long to get pregnant again?" What is the nurse's best response?

"A contraceptive is used so that a positive pregnancy test resulting from a new pregnancy will not be confused with the increased level of hCG that occurs with a developing malignancy."

The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct?

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."

Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiological jaundice) in newborns?

"Breastfed babies need supplements of glucose water to help lower bilirubin levels."

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing?

Bathe the baby under a radiant warmer.

A nurse teaches new parents that the bestway to help prevent infections in the newborn is which method?

Breastfeed.

A newborn male is circumcised. Which instruction would the nurse include in the discharge teaching plan for his parents?

Cover the glans generously with petroleum jelly.

A woman with cardiac disease is 32 weeks' gestation and alerts the nurse she has been having spells of light-headedness and dizziness every few days. The nurse provides which intervention as an option to the client?

Decrease activity and rest more often.

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums?

Epstein's pearls

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate?

It is a normal skin finding in a newborn.

A woman with class II heart disease is in the third trimester of her pregnancy. She has been taking good care of herself and has had little difficulty, but to be on the safe side the obstetrician has prescribed bed rest for her for the final month. For her own and the baby's safety, in what position should the nurse advise the client to sleep?

Lie in a semirecumbent position.

What important instruction should the nurse give a pregnant client with tuberculosis?

Maintain adequate hydration.

An African American baby has discoloring which appears similar to bruising on his buttock after a normal vaginal birth. This assessment should be documented as:

Mongolian spots.

A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation?

Newborns have the ability to focus only on objects in close proximity.

A pregnant woman diagnosed with diabetes should be instructed to perform which action?

Notify the primary care provider if unable to eat because of nausea and vomiting.

A nurse caring for a pregnant client suspected substance use during pregnancy. What is the priority nursing intervention for this client?

Obtain a urine specimen for a drug screening.

When providing counseling on early pregnancy loss, the nurse should discuss which factor as the most common cause for spontaneous abortion?

chromosomal abnormality

A pregnant client with a history of heart disease has been admitted to a health care center reporting breathlessness. The client also reports shortness of breath and easy fatigue when doing ordinary activity. The client's condition is markedly compromised. The nurse would document the client's condition using the New York Heart Association (NYHA) classification system as which class?

class III

When providing nutritional counseling to a pregnant woman with diabetes, the nurse would urge the client to obtain most of her calories from which source?

complex carbohydrates

While examining a newborn, a nurse observes salmon patches on the nape of the neck and on the eyelids. Which is the most likely cause of these skin abnormalities?

concentration of immature blood vessels

A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism?

conduction

Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism?

convection

A nurse is interviewing a pregnant woman who has come to the clinic for her first prenatal visit. During the interview, the client tells the nurse that she works in a day care center with 2- and 3-year olds. Based on the client's history, the nurse would be alert for the development of which condition?

cytomegalovirus

A nurse is caring for a young woman who is in her 10th week of gestation. She comes into the clinic reporting vaginal bleeding. Which assessment finding best correlates with a diagnosis of hydatidiform mole?

dark red, "clumpy" vaginal discharge

A nurse is assessing a pregnant client for the possibility of preexisting conditions that could lead to complications during pregnancy. The nurse suspects that the woman is at risk for hydramnios based on which preexisting condition?

diabetes

A 29-year-old client has gestational diabetes. The nurse is teaching her about managing her glucose levels. Which therapy would be most appropriate for this client?

diet

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which occurrence?

lack of thoracic compressions during birth

The nurse is describing fetal circulation to new parents and how the circulation changes after birth. The nurse describes a structure that allows the pulmonary circulation to be bypassed, but that shortly after birth this structure should close. Which structure is the nurse describing?

ductus arteriosus

When caring for a pregnant woman with cardiac problems, the nurse must be alert for signs and symptoms of cardiac decompensation (congestive heart failure), which include:

dyspnea, crackles, and irregular weak pulse.

A 28-year-old woman presents in the emergency department with severe abdominal pain. She has not had a normal period for 2 months, but she reports that that is not abnormal for her. She has a history of endometriosis. What might the nurse suggest to the primary care provider as a possible cause of the client's abdominal pain?

ectopic pregnancy

A woman with an incomplete abortion is to receive misoprostol. The woman asks the nurse, "Why am I getting this drug?" The nurse responds to the client, integrating understanding that this drug achieves which effect?

ensures passage of all the products of conception

A newborn in the nursery has a temperature of 97.4° F (36.3° C). What may happen first, if the infant continues to be cold stressed?

respiratory distress

Which statement by a pregnant client indicates the need for more teaching about preeclampsia?

"If I have changes in my vision, I will lie down and rest."

The nurse is caring for a client with preeclampsia and understands the need to auscultate this client's lung sounds every two hours. Why would the nurse do this?

pulmonary edema

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn?

radiation, convection, and conduction

The nurse orienting a student to the nursery determines that teaching has been effective when the student states that the signs of neonate respiratory distress include which findings? Select all that apply.

-Nasal flaring -Respiratory rate of 64 breaths per minute -Chest retractions

A nurse is caring for a newborn with transient tachypnea. What nursing interventions should the nurse perform while providing supportive care to the newborn? Select all that apply.

-Provide oxygen supplementation. -Observe respiratory status frequently. -Ensure the newborn's warmth.

A woman of 16 weeks' gestation telephones the nurse because she has passed some "berry-like" blood clots and now has continued dark brown vaginal bleeding. Which action would the nurse instruct the woman to do?

"Come to the health facility with any vaginal material passed."

A nurse is talking to a newly pregnant woman who had a mitral valve replacement in the past. Which statement by the client reveals an understanding about the preexisting condition?

"I understand that my fetus and I both are at risk for complications."

The primapara tells the nurse, "My baby jumps every time I pick her up. Is she afraid that I will drop her?" Which response by the nurse would be best?

"No, it is the Moro reflex. This reflex simulates the action of warding off an attacker."

After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between abruptio placenta and placenta previa. Which statement should the nurse include in the teaching?

"Placenta previa causes painless, bright red bleeding during pregnancy due to an abnormally implanted placenta that is too close to or covers the cervix; abruptio placenta is associated with dark red painful bleeding caused by premature separation of the placenta from the wall of the uterus before the end of labor."

A client experiences a threatened abortion. She is concerned about losing the pregnancy and asks what activity level she should maintain. What is the most appropriate response from the nurse?

"Restrict your physical activity to moderate bedrest."

A 16-year-old client gave birth to a 12 weeks' gestation fetus last week. The client has come to the office for follow-up and while waiting in an examination room notices that on the schedule is written her name and "follow-up of spontaneous abortion." The client is upset about what is written on the schedule. How can the nurse best explain this terminology?

"Spontaneous abortion is a more specific term used to describe a spontaneous miscarriage, which is a loss of pregnancy before 20 weeks. This term does not imply that you did anything to affect the pregnancy."

When instructing a new mom on providing skin care to her newborn, which statement should not be included in the teaching?

"Use talc powders to prevent diaper rash."

A nurse teaches new parents about how to soothe their crying newborn. Which statement by the parents indicates that they understand how to soothe their newborn if he becomes upset?

"We'll turn the mobile on that's hanging above his head in his crib."

A 25-year-old pregnant client comes to the office for the first prenatal visit. During the history, the client tells the nurse she had tuberculosis 5 years ago. What is the nurse's best response?

"You will have to maintain an adequate level of calcium during your pregnancy."

A client visits a health care facility reporting amenorrhea for 10 weeks, fatigue, and breast tenderness. Which additional signs and symptoms suggest the presence of molar pregnancy? Select all that apply.

-elevated hCG levels -absence of fetal heart sound -hyperemesis gravidarum

A nursing instructor explains to students that, regardless of their gestational age, all newborns experience the same pattern that includes which periods? Select all that apply.

-first period of reactivity -period of decreased responsiveness -second period of reactivity

What are the functions of kangaroo care? Select all that apply.

-is skin-to-skin contact -keeps the neonate warm -helps the parents bond with their neonate

A nurse is assessing a newborn who is about 8 hours old. The nurse suspects that the newborn may be experiencing cold stress based on which findings? Select all that apply.

-lethargy -tachypnea -hypotonia

A nurse is teaching new parents about keeping follow-up appointments and calling their health care provider if they notice signs of illness in their newborn. The nurse determines that the teaching was successful when the parents identify which signs as needing to be reported? Select all that apply.

-temperature of 38.3° C (101° F) or higher -refuse feeding -abdominal distention

New parents are upset their newborn has lost weight since birth. The nurse explains that newborns typically lose how much of their birth weight by 3 to 4 days of age?

10%

A pregnant woman determined to be at high risk for gestational diabetes is undergoing a 1-hour glucose challenge test. The nurse schedules the client for a 3-hour glucose tolerance test based on which result?

146 mg/dL

A woman at 26 weeks' gestation is undergoing screening for diabetes with a 1-hour oral glucose challenge test. On the client's return visit, the nurse anticipates the need to schedule a 3-hour glucose challenge test based on which result of the previous test?

146 mg/dL

Part of the assessment of the first prenatal visit includes screening for rubella antibodies. The nurse determines that a client with which titer shows evidence of immunity against rubella?

1:8

How long is the neonatal period for a newborn?

28

A nurse is assessing a newborn's temperature. Which reading would the nurse document as normal?

37.0° C (98.6° F)

A nurse is caring for a 3-hour-old newborn boy. The nurse makes the initial assessment and finds the following: respiratory rate 30 bpm, BP 60/40 mm/Hg, heart rate 155 bpm, axillary temperature 98.2° F (36.8° C). The nurse assesses that the newborn is in a state of quiet alert. What should the nurse do?

Document the data.

During pregnancy a woman's blood volume increases to accommodate the growing fetus to the point that vital signs may remain within normal range without showing signs of shock until the woman has lost what percentage of her blood volume?

40%

A newborn is 7 minutes old. Her heart rate is 92 bpm, her cry is weak, her muscles are limp and flaccid, she makes a face when she is stimulated, and her body and extremities are pink. What would the nurse assign as her Apgar score?

5

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life?

5% to 10% of their birth weight

A nurse is explaining to new parents how a newborn adapts to extrauterine life. When discussing the physiologic changes that occur, the nurse would explain that this transition usually takes the first:

6 to 10 hours of life.

When teaching a class of new parents about the needs of their newborn, the nurse explains that the newborn's voiding is a good indicator that he or she is getting enough fluids. The nurse determines that the teaching was successful when the parents state which number of voiding per day as a good indicator of adequate fluids?

6 to 8

A pregnant woman with type 2 diabetes is scheduled for a laboratory test of glycosylated hemoglobin (HbA1C). What does the nurse tell the client is a normal level for this test?

6%

A pregnant woman with diabetes is having her glycosylated hemoglobin level evaluated. The nurse determines that the woman's glucose is under control and continues the woman's plan of care based on which result?

6.5%

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is:

7 to 10.

A nurse is performing Apgar scoring on a newborn. The newborn demonstrates the following: a heart rate of 110 bpm; a good, strong cry; muscles of the extremities well flexed; a grimace in response to a slap to the sole of the foot; and normal pigment in most of the body, with blue at the extremities. Which score would be the total Apgar score for this newborn?

8

A woman with a long history of controlled asthma has just had her first antenatal visit for her fourth child. She is late for a meeting and says she knows what to do. What is the best action the nurse can take?

Acknowledge her need to leave but ask her to demonstrate the use of her inhaler and her peak flow meter before she goes; make any necessary corrections to her technique. Remind her to take her regular medications.

A nurse is caring for a client with hyperemesis gravidarum. Which nursing action is the priority for this client?

Administer IV NS with vitamins and electrolytes.

A postpartum mother has the following lab data recorded: Rh is negative, and rubella titer is positive. What is the appropriate nursing intervention?

Administer Rho(D) immune globulin within 72 hours.

A pregnant client is screened for tuberculosis during her first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. Which sign would indicate a positive test result?

An indurated wheal over 10 mm in diameter appears in 48 to 72 hours.

A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first?

Assess the client's vital signs.

The nurse recognizes that documenting accurate blood pressures is vital in the diagnosing of preeclampsia and eclampsia. The nurse suspects preeclampsia based on which finding?

BP of 140/90 mm Hg on two occasions 6 hours apart

The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery?

Bathe the newborn thoroughly

The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as:

Epstein's pearls.

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash?

Expose the newborn's bottom to air several times a day.

A pregnant client with sickle cell anemia is at an increased risk for having a sickle cell crisis during pregnancy. Aggressive management for a client experiencing a sickle cell crisis with severe pain includes which measure?

I.V. fluids

What is the best rationale for trying to decrease the incidence of cold stress in the neonate?

If the neonate becomes cold stressed, it will eventually develop respiratory distress.

While teaching a newborn nutrition class to a group of pregnant women, the nurse encourages breastfeeding because it is a major source of which immunoglobulin?

IgA

A nurse is conducting a presentation for a group of pregnant women about conditions that can occur during pregnancy and that place the woman at high-risk. When discussing blood incompatibilities, which measure would the nurse explain as most effective in preventing isoimmunization during pregnancy?

Rho(D) immune globulin administration to Rh-negative women

A very healthy mother gave birth to a newborn with an immediate Apgar score of 10. The newborn was cradled in a kangaroo hold by both her mother and her father for 45 minutes. The parents feel ready to get cleaned up and let the newborn be taken care of by the health care personnel for a little while. What eye care action will the nurse now take?

Instill antibiotic 0.5 percent erythromycin.

A pregnant woman has been admitted to the hospital due to severe preeclampsia. Which measure will be important for the nurse to include in the care plan?

Institute and maintain seizure precautions.

A nurse is working as part of a community group focusing efforts on preventing isoimmunization during pregnancy at the local women's health clinic. Which measure would the group encourage?

Rho(D) immune globulin administration to Rh-negative women

A newborn has been taken to the nursery after birth. He has been cleaned in the labor and birth suite and is swaddled in a blanket. The nurse is going to check his pulse. What must the nurse do?

Wear gloves.

A 32-year-old gravida 3 para 2 at 36 weeks' gestation comes to the obstetric department reporting abdominal pain. Her blood pressure is 164/90 mm/Hg, her pulse is 100 beats per minute, and her respirations are 24 per minute. She is restless and slightly diaphoretic with a small amount of dark red vaginal bleeding. What assessment should the nurse make next?

Palpate the fundus, and check fetal heart rate.

The infant's temperature is 97.2° F (36.2° C) axillary an hour after birth. Which intervention is appropriate for the nurse?

Place the infant under a radiant warmer or in a heated isolette.

A newborn has secretions in his mouth and nose. What are the first steps the nurse should take to clear his airways?

Position the newborn on his side with his head slightly below his body; use a bulb syringe to clear his mouth.

A woman is pregnant and has asthma. Her primary care provider has told her to continue taking prednisone during pregnancy, but she is concerned the drug may be teratogenic. What advice would be best to give her regarding this?

Prednisone is considered safe in the doses prescribed by her care provider.

Which measure is recommended to prevent transmission of HIV to a newborn if the mother has AIDS?

Prepare for cesarean birth.

At birth there are multiple changes in the cardiac and respiratory systems. What is one of the changes to occur at birth in the cardiovascular system?

Pressure changes occur and result in closure of the ductus arteriosus

A woman with cardiac disease gave birth to a 7 lb (3.2 kg) baby by cesarean birth. Which intervention should be implemented during the immediate postpartum period?

Rest, use stool softeners, and monitor tolerance of activity.

A nurse is describing the use of Rho(D) immune globulin as the therapy of choice for isoimmunization in Rh-negative women and for other conditions to a group of nurses working at the women's health clinic. The nurse determines that additional teaching is needed when the group identifies which situation as an indication for Rho(D) immune globulin?

STI

A woman who has sickle cell anemia asks the nurse if her infant will develop sickle cell disease. The nurse would base the answer on which information?

Sickle cell anemia is recessively inherited.

A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?

Stools should be yellow-gold, loose, and stringy to pasty.

Why should a nurse monitor a newborn after cesarean birth more closely than after a vaginal birth?

The baby will have more fluid in its lungs, making respiratory adaptation more challenging.

A client is 20 weeks pregnant. At a prenatal visit, the nurse begins the prenatal assessment. Which finding would necessitate calling the primary care provider to assess the client?

The client has pink vaginal discharge and pelvic pressure.

In returning to the hospital floor after a weekend off, the nurse takes over care of a pregnant client who is resting in a darkened room. The client is receiving betamethasone and magnesium sulfate. What could the nurse deduce from those findings?

The client is suffering from severe preeclampsia, and the care team is attempting to prevent advancement of the disorder to eclampsia; they are attempting to help the baby's lungs mature quickly so that they can have the baby be born as soon as possible.

A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding?

The infant is experiencing moderate difficulty in adjusting to extrauterine life.

Which statement is true regarding fetal and newborn senses?

The rooting reflex is an example that the newborn has a sense of touch.

What should the nurse expect for a full-term newborn's weight during the first few days of life?

There is a loss of 5% to 10% of birth weight in formula-fed and breastfed newborns.

Which statement is false regarding bathing the newborn?

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.

The newborn should have the neurologic status evaluated to determine its maturity and to identify any potential problems. The nurse tests the newborn's Babinski reflex. Which response would the nurse interpret as normal for the newborn?

Toes fan out when sole of foot is stroked.

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk?

Use the sealed and chilled milk within 24 hours.

A client in her first trimester has just experienced a miscarriage. The nurse knows that which occurrence is the most likely cause of the miscarriage?

abnormal fetal development

The clinic nurse teaches a pregestational type 1 diabetic client that constant insulin levels are very important in during pregnancy. The nurse tells the client that the best way to maintain a constant insulin level is to use:

an insulin pump.

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem?

apnea

A woman who is Rh negative asks the nurse how many children she will be able to have before Rh incompatibility causes them to die in utero. The nurse's best response would be that:

as long as she receives RhoGAM, there is no limit.

A nurse is caring for a pregnant client with heart disease in a labor unit. Which intervention is most important in the first 48 hours postpartum?

assessing for cardiac decompensation

A nurse is caring for a pregnant client with asthma. Which intervention would the nurse perform first?

assessing oxygen saturation

The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is the priority?

assessing the amount and color of the bleeding

A client is admitted at 22 weeks' gestation with advanced cervical dilatation to 5 centimeters, cervical insufficiency, and a visible amniotic sac at the cervical opening. What is the primary goal for this client at this point

bed rest to maintain pregnancy as long as possible

Which vital sign is not routinely assessed in a term, healthy newborn with an Apgar score of 9?

blood pressure

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?

blood sugar

A young mother has tested positive for HIV. When discussing the situation with the client, the nurse should advise the mother that she should avoid which activity?

breastfeeding

As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation?

bright red, raised bumpy area noted above the right eye

What is the primary mechanism for temperature regulation in a newborn infant?

brown fat store usage

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience?

evaporative

A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate?

fetal distress related to hypoxia

When examining a newborn's eyes, the nurse would expect which assessment?

follows a light to the midline

The nurse is assessing a neonate as he transitions to extrauterine life. The nurse integrates understanding that which structure closes as a result of tne neonate's first breath?

foramen ovale

A client has come to the office for a prenatal visit during her 22nd week of gestation. On examination, it is noted that her blood pressure has increased to 138/90 mm Hg. Her urine is negative for proteinuria. The nurse recognizes which factor as the potential cause?

gestational hypertension

A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements?

gestational hypertension

A pregnant client has been admitted with reports of brownish vaginal bleeding. On examination there is an elevated hCG level, absent fetal heart sounds, and a discrepancy between the uterine size and the gestational age. The nurse interprets these findings to suggest which condition?

gestational trophoblastic disease

A client has been admitted with abruptio placentae. She has lost 1,200 mL of blood, is normotensive, and ultrasound indicates approximately 30% separation. The nurse documents this as which classification of abruptio placentae?

grade 2

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as:

harlequin sign.

The AGPAR score is based on which 5 parameters?

heart rate, muscle tone, reflex irritability, respiratory effort, and color

At birth, changes from fetal to newborn circulation must occur. What change causes the ductus arteriosus to close?

higher oxygen content of the circulating blood

Which changes in pregnancy would the nurse identify as a contributing factor for arterial thrombosis, especially for the woman with atrial fibrillation?

hypercoagulable state

The nurse is providing care to a neonate. Review of the maternal history reveals that the mother is suspected of abusing heroin. The nurse would be alert for which finding when assessing the neonate?

hypertonicity

A woman is admitted with a diagnosis of ectopic pregnancy. For which action would the nurse anticipate beginning preparation?

immediate surgery

A nurse is preparing to administer vitamin K to a newborn. The nurse would administer the drug by which route?

intramuscularly in the thigh

A nurse is caring for a pregnant adolescent client, who is in her first trimester, during a visit to the maternal child clinic. Which important area should the nurse address during assessment of the client?

knowledge of child development

When conducting an assessment, the nurse observes fine, downy hair covering the newborn's shoulders and back. The nurse interprets this finding as:

lanugo.

The nurse is aware that the infant's circulatory dynamics during transition can be greatly affected by which action?

late clamping of the umbilical cord after 3 minutes

Which change in insulin is most likely to occur in a woman during pregnancy?

less effective than normal

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client?

lethargy and hypotonia

The nurse is preparing a teaching plan for new parents about why newborns experience heat loss. Which information about newborns would the nurse include?

limited voluntary muscle activity

A client in her 20th week of gestation develops HELLP syndrome. What are features of HELLP syndrome? Select all that apply.

low platelet count elevated liver enzymes hemolysis

When providing education to a teenage prenatal class, the nurse states that infants born to teenage mothers are more likely to have which outcome?

low-birth weight

A nurse is reviewing the medical record of a pregnant client diagnosed with placenta previa. The physical exam reveals that the placenta is implanted near the internal os but does not reach it. The nurse interprets this as which type of placenta previa?

low-lying

After an examination, a client has been determined to have an unruptured ectopic pregnancy. Which medication would the nurse anticipate being prescribed?

methotrexate

Which medication would the nurse prepare to administer if prescribed as treatment for an unruptured ectopic pregnancy?

methotrexate

A pregnant client has tested positive for cytomegalovirus. What can this cause in the newborn?

microcephaly

Over the past 20 weeks, the following blood pressure readings are documented for a pregnant client with chronic hypertension: week 16 - 124/86 mm Hg; week 20 - 138/90 mm Hg; week 24 - 140/92 mm Hg; and week 28 - 142/94 mm Hg. The nurse interprets these findings as indicating which classification of her blood pressure?

mild hypertensive

The majority of skin variations are transient and fade or disappear with time. The nurse assesses a permanent skin variation in a newborn and counsels the parents to monitor it because of its link to potential childhood cancer. The nurse implements this counseling based on which finding?

nevus flammeus

The nurse explains to a pregnant client that she will need to take iron during her pregnancy after being diagnosed with iron-deficiency anemia. The nurse suggests that absorption of the supplemental iron can be increased by taking it with:

orange juice.

A nurse is observing the interaction between a new mother and her neonate. The nurse notes that the neonate moves his head and eyes to focus on the mother's voice and smile. The nurse interprets this as which behavioral response?

orientation

When the nurse is applying a skin temperature probe to a newborn who is lying on his side, which location would be most appropriate?

over the liver

A father is asking questions about the circumcision of his son. He is asking the nurse if there are any disadvantages to the procedure. How should the nurse respond?

pain administration may not be effective during the procedure

A pregnant woman with preeclampsia is to receive magnesium sulfate IV. Which assessment would be most important prior to administering a new dose?

patellar reflex

The nurse is assessing a woman with class III heart disease who is in for a prenatal visit. What would be the first recognizable sign that this client is in heart failure?

persistent rales in the bases of the lungs

A nurse is caring for a client undergoing treatment for ectopic pregnancy. Which symptom is observed in a client if rupture or hemorrhaging occurs before the ectopic pregnancy is successfully treated?

phrenic nerve irritation

The Ballard scoring system evaluates newborns on which two factors?

physical maturity and neuromuscular maturity

A client in her fifth month of pregnancy is having a routine clinic visit. The nurse should assess the client for which common second trimester condition?

physiological anemia

A nursing student is aware that fetal gas exchange takes place in which area?

placenta

A nurse is providing care to a multiparous client. The client has a history of cesarean births. The nurse anticipates the need to closely monitor the client for which condition?

placenta accreta

The nurse is providing education to women who had diabetes prior to pregnancy. The nurse is discussing pregnancy-related complications from diabetes. Which factor is a potential complication?

polyhydramnios

A woman in labor has sharp fundal pain accompanied by slight vaginal bleeding. What would be the most likely cause of these symptoms?

premature separation of the placenta

Which should the nurse identify as a risk associated with anemia during pregnancy?

preterm birth

A woman in week 35 of her pregnancy with severe hydramnios is admitted to the hospital. The nurse recognizes that which concern is greatest regarding this client?

preterm rupture of membranes followed by preterm birth

A newborn has been circumcised, his temperature is stable, his breathing and heart rate are healthy, and he is ready to be discharged from the hospital. What can the nurse tell his parents to be on the lookout for that might indicate that the newborn needs medical attention?

redness at the base of the umbilical cord

The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3° F (36.2° C), pulse 88 beats/min, respirations 10 breaths/min, blood pressure 148/110 mm Hg. What other priority physical assessment by the nurse should be implemented to assess for potential toxicity?

reflexes

During the assessment of a laboring client, the nurse learns that the client has cardiovascular disease (CVD). Which assessment would be priority for the newborn?

respiratory function

All the options are signs of respiratory distress in the newborn except:

respiratory rate >50 breaths/minute.

A client is diagnosed with peripartum cardiomyopathy (PPCM). Which therapy would the nurse expect to administer to the client?

restricted sodium intake

The nurse is preparing to apply a thermistor probe to a newborn to monitor the newborn's temperature. At which location would the nurse apply the probe?

right upper abdominal quadrant

When dealing with a pregnant adolescent, the nurse assists the client to integrate the tasks of pregnancy while at the same time fostering development of which trait?

self-identity

The nurse is providing care to a neonate whose mother abuses heroin. Which finding would the nurse expect to assess?

sneezing

What is the role of the nurse during the preconception counseling of a pregnant client with chronic hypertension?

stressing the positive benefits of a healthy lifestyle

A nurse working in the neonatal nursery anticipates the primary care provider to prescribe which medication for a premature newborn having difficulty breathing?

surfactant

Which is the best place to perform a heel stick on a newborn?

the fat pads on the lateral aspects of the foot

With a hepatitis B (HbsAG) positive mother, what should the newborn receive?

the hepatitis B vaccination and 1 dose of hepatitis B immunoglobulin within 12 hours of birth

A mother points out to the nurse that following three meconium stools, her newborn has had a bright green stool. The nurse would explain to her that:

this is a normal finding.

A young woman presents at the emergency department reporting lower abdominal cramping and spotting at 12 weeks' gestation. The primary care provider performs a pelvic examination and finds that the cervix is closed. What does the care provider suspect is the cause of the cramps and spotting?

threatened abortion

What is the primary goal of nursing care immediately after birth?

to maintain the safety of the neonate from intrauterine to extrauterine life

When assessing the newborn's umbilical cord, what should the nurse expect to find?

two smaller arteries and one larger vein

Which measurements were most likely obtained from a normal newborn born at 38 weeks to a healthy mother with no maternal complications?

weight = 3500 g, length = 20 inches (51 cm), head circumference = 34 cm, and chest circumference = 32 cm

A pregnant client has tested positive for hepatitis B virus. When discussing the situation with the client, the nurse explains that her infant should be vaccinated with an initial HBV vaccine dose at which time?

within 12 hours of birth

The nurse caring for a newborn has to perform assessment at various intervals. When should the nurse complete the second assessment for the newborn?

within the first 2 to 4 hours, when the newborn reaches the nursery

The nurse describes the changes in stool that a new mother would see when feeding her newborn formula. Which description best indicates what the mother would observe after several days?

yellow-green, pasty, unpleasant-smelling stool

The nurse is providing teaching to a new mother who is breastfeeding. The mother demonstrates understanding of teaching when she identifies which characteristics as being true of the stool of breastfed newborns? Select all that apply.

yellowish gold color stringy to pasty consistency

The nurse is assessing the stools of a 36-hour-old neonate who is being breastfed. The nurse determines that the stools are within normal parameters based on which finding?

yellowy mustard color with seedy appearance