PN VATI Maternal Newborn

A nurse is reinforcing teaching with the guardians of a newborn about the care of the umbilical stump. Which of the following instructions should the nurse include in the teaching?

"Sponge bathe your baby until the umbilical stump has fallen off." The nurse should reinforce with guardians that submerging the umbilical stump in water can impede healing and promote infection. Therefore, the guardians should sponge bathe their newborn until the umbilical stump has fallen off.

A nurse is caring for a postpartum client who has an episiotomy. Which of the following actions should the nurse take?

Apply an anesthetic spray to the client's perineal area as needed for pain. The nurse should apply an anesthetic spray to the episiotomy site as needed to decrease pain.

A nurse is assisting with the care of a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following findings should the nurse identify as a potential complication of phototherapy?

Decreased urinary output The nurse should closely monitor urinary output while the newborn is receiving phototherapy. Phototherapy can increase the rate of insensible water loss, which can lead to dehydration. The nurse should ensure the newborn is eating every 2 to 3 hr to promote adequate hydration.

A nurse in an antepartum clinic is collecting data from a client who is at 28 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential complication?

Dysuria The nurse should identify that dysuria is an unexpected finding during pregnancy that can indicate a urinary tract infection. The nurse should report this finding to the provider.

A nurse is collecting data from a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse report to the provider as potentially indicating a complication of pregnancy?

Frequent headaches Manifestations such as frequent headaches, visual disturbances, swelling of the face or fingers, and epigastric pain are manifestations of preeclampsia or hypertensive conditions during pregnancy. The nurse should identify frequent headaches as a potential complication of pregnancy and report this manifestation to the provider.

A nurse is assisting with collecting data from a newborn who is 4 hr old. Which of the following findings is the priority for the nurse to report to the provider?

Generalized petechiae When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority finding is generalized petechiae. This finding is a potential indication of a severe infection or a clotting factor deficiency and should be immediately reported to the provider.

A nurse is planning to administer phytonadione IM to a newborn shortly after birth. The nurse should identify that this medication is administered to prevent which of the following complications?

Hemorrhagic disease The nurse should administer phytonadione because the newborn does not produce vitamin K on their own until 7 days of age, when intestinal flora is present in the newborn's gastrointestinal tract. Therefore, this medication is administered to prevent hemorrhagic disease in the newborn until spontaneous production of vitamin K takes place.

A nurse is collecting data from a newborn who has Down syndrome. Which of the following findings should the nurse expect in a term newborn who has Down syndrome?

Hypotonic muscle tone The nurse should expect a newborn who has Down syndrome to display hypotonicity. Other manifestations include epicanthal folds, small ears, and a single palmar crease.

A nurse is assisting with the admission assessment of a client whose labor is being induced. The client reports using heroin 6 hr ago. For which of the following manifestations of abstinence should the nurse monitor the client?

Insomnia Abstinence manifestations begin within 6 hr after the last drug use and might include insomnia, shivering, body aches, vomiting, nausea, body shivers, abdominal pain, muscle jerks, and diarrhea.

A nurse is reinforcing teaching with a client who is pregnant and has iron deficiency anemia. Which of the following food sources should the nurse instruct the client to include in their diet to increase absorption of an iron supplement?

Oranges The nurse should reinforce that consuming oranges, which are rich in vitamin C, enhances the absorption of iron supplements. The nurse should also instruct the client to take the supplement on an empty stomach.

A nurse is assisting with the data collection of a newborn who is 1 hr old. Which of the following manifestations should indicate to the nurse that the newborn is experiencing difficulty transitioning to extrauterine life?

Retractions Grunting, nasal flaring, retractions, and tachypnea are manifestations that indicate the newborn is having difficulty transitioning to extrauterine life. The nurse should report the findings to the provider.

A nurse is collecting data from a client who is 24 hr postpartum. Which of the following findings is the priority for the nurse to report to the provider?

Saturated perineal pad within 15 min A saturated perineal pad within 15 min can indicate a cervical or vaginal tear. Therefore, the nurse should report this finding to the provider immediately.

A nurse is reinforcing teaching about home safety with a client who is postpartum. Which of the following statements should the nurse include in the teaching?

"You should dress your baby in a one-piece sleeper at bedtime." The nurse should instruct the client to use a sleep sack or one-piece sleeper and refrain from covering the newborn with blankets to reduce the newborn's risk of entrapment or suffocation.

A nurse is reinforcing teaching with a client who is at 8 weeks of gestation and has chlamydia. Which of the following statements should the nurse include?

"After treatment, you will need another test in 3 weeks and again between 35 and 37 weeks." The nurse should reinforce with the client that they will need to be retested for chlamydia 3 weeks after completing the prescribed regimen and again between 35 and 37 weeks of gestation. Most clients who have chlamydia are asymptomatic. Therefore, clients should be retested to identify potential reinfection, which would allow for additional treatment and decrease the risk for harm to the fetus during delivery.

A nurse is reinforcing teaching with a client who plans to use a modified-paced breathing technique to relieve labor pain. Which of the following instructions should the nurse include in the teaching?

"Begin and end modified-breathing with a deep cleansing breath. The nurse should instruct the client that all breathing patterns begin with a deep, relaxing, cleansing breath to "greet the contraction" and end with an exhaled deep breath to "blow the contraction away." Deep breaths ensure sufficient oxygenation for both the client and fetus.

A clinic nurse is reviewing dietary instructions with a client who is at 20 weeks of gestation and taking iron supplements. Which of the following statements by the client indicates an understanding of the instructions?

"I should increase my fluid intake while l am taking iron." The client should increase their fluid intake while taking iron to help lessen the occurrence of constipation, which is a common adverse effect of iron supplements.

A nurse is reinforcing teaching about daily fetal movement count with a client who is at 34 weeks of gestation. Which of the following statements by the client indicates an understanding of the teaching?

"I will notify my provider if I do not feel my baby move for 12 hours." The nurse should instruct the client to report absence of fetal movement for 12 hr to the provider. This is known as the fetal alarm signal, which can indicate fetal distress

A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian demonstrates an understanding of the teaching?

"I will place my baby at a 45-degree angle in the car The newborn should be placed in the car seat at a 45° angle to prevent slumping and airway obstruction. The newborn will be unable to hold their head erect. Therefore, the newborn's head should be supported at all times.

A nurse is reinforcing teaching about an amniocentesis with a client who is at 36 weeks of gestation. Which of the following statements by the client indicates an understanding of the teaching?

"The procedure will determine if my baby's lungs are mature." The provider performs an amniocentesis late in the pregnancy to determine fetal lung maturity. The amniotic fluid will be evaluated for the lecithin/sphingomyelin ratio. A ratio of at least 2:1 indicates fetal lung maturity.

A nurse in an antepartum clinic is reinforcing teaching with a client who is at 32 weeks of gestation and is scheduled for a nonstress test. Which of the following information should the nurse include in the teaching?

"You will be asked to press a button when you feel your baby move during the test. The nurse should instruct the client to press a hand-held button attached to the monitor when they feel the baby move. Pressing the hand-held button will help to accurately correlate fetal movement with the fetal heart rate.

A nurse is reinforcing teaching with a client who is at 11 weeks of gestation about a transvaginal ultrasound. Which of the following client statements indicates an understanding of the teaching?

"i might feel some pressure when the probe is moved during the ultrasound." The nurse should instruct the client that a transvaginal ultrasound is not painful. However, the client might feel pressure when the provider moves the

A nurse is reinforcing dietary teaching with a client who is at 10 weeks of gestation. Which of the following foods should the nurse identify as containing the highest amount of folate?

3% oz beef liver The nurse should identify that 3 % oz of beef liver contains 200 mcg of folate. The nurse should instruct the client to consume at least 600 mcg of folate per day during pregnancy to decrease the risk of neural tube defects in the fetus.

A nurse is contributing to the plan of care for a client who is in labor and tested positive for group B streptococcus B-hemolytic. Which of the following interventions should the nurse include in the plan of care?

Administer ampicillin via intermittent IV bolus. The nurse should administer ampicillin via intermittent IV bolus to the client who is positive for group B streptococcus B-hemolytic because transmission can occur during a vaginal birth, which can result in serious ilness in or death of the newborn.

A nurse is caring for a client who is 1 hr postpartum and has a third-degree perineal laceration. Which of the following actions should the nurse perform? (Select all that apply.)

Apply an ice pack to the client's perineum is correct. The nurse should apply an ice pack to the client's perineum to decrease edema and promote comfort. Place witch hazel pads on the client's perineum is correct. The nurse should place witch hazel pads on the client's perineum to promote comfort. Encourage the client to use a squeeze bottle to cleanse the perineum with each void is correct. The nurse should encourage the client to use a squeeze bottle to cleanse the perineum with each void to prevent infection.

A nurse in a clinic is caring for a client who tests positive for gonorrhea. Which of the following findings should the nurse expect during data collection?

Chronic pelvic pain Female clients who have gonorrhea are often without symptoms. However, they might report increased vaginal discharge, chronic or acute severe pelvic or lower abdominal pain, irregular or more painful menstrual cycles, dysuria, and low back pain.

A nurse is caring for a client who is at 16 weeks of gestation and is at risk for developing hyperemesis gravidarum. Which of the following conditions places the client at an increased risk for developing this condition?

Diabetes mellitus The nurse should identify diabetes mellitus as a risk factor for the development of hyperemesis gravidarum. Other risk factors for developing this condition include gastrointestinal disorders, hyperthyroid disorders, molar pregnancy, asthma, and migraines.

A nurse is collecting data from an antepartum client who reports taking ferrous sulfate twice per day for the past month. The nurse should notify the provider of which of the following findings?

Diarrhea The nurse should report diarrhea to the provider because it is a potential adverse effect of the medication. Diarrhea can lead to dehydration, which can cause preterm labor. This finding should be reported to the provider.

A nurse is contributing to the plan of care for a client who plans to formula feed their newborn. Which of the following interventions should the nurse recommend to include?

Dilute concentrated formula with equal parts water. The nurse should instruct the client to dilute concentrated formula with an equal volume of water to provide the correct amount of nutrients to the newborn. Formula prepared with too little water is over concentrated and can provide protein and minerals in quantities that exceed the ability of the newborn's kidneys to excrete them, whereas formula prepared with too much water does not provide an adequate amount of calories for growth,

A nurse is assisting with the admission of a client who has pertussis and is at 28 weeks of gestation. Which of the following tyvpes of transmission- based isolation precautions should the nurse initiate for the client?

Droplet The nurse should initiate droplet precautions for a client who has pertussis. Droplet precautions include a private room or cohorting of clients and the use of a mask when providing client care. Other infections that require droplet precautions include rubella, pneumonia, and influenza,

A nurse is collecting data from a newborn whose mother tested positive for cocaine use. Which of the following newborn withdrawal manifestations should the nurse expect?

Excessive sucking The neurotoxic effects of cocaine can lead to excessive sucking and poor feeding patterns in the newborn. Additional manifestations include irritability, hypertonicity, tremors, and abnormal sleep patterns.

A nurse is reinforcing teaching with a client who is at 30 weeks of gestation and has a prescription for nifedipine to treat preterm labor. Which of the following adverse effects should the nurse include in the teaching?

Flushing When reinforcing teaching with the client regarding nifedipine the nurse should include information about adverse effects such as flushing, hypotension, headache, dizziness, and nausea. Nifedipine is a calcium channel blocker that relaxed that uterine smooth muscle to treat preterm labor. Nifedipine can also be used as an antihypertensive medication that can be administered to clients who have gestational hypertension

A nurse is reviewing the laboratory results of a client who is at 12 weeks of gestation. Which of the following results should the nurse report to the provider?

Hct 31% This hematocrit level is below the expected reference range of greater than 33% during pregnancy. The nurse should report this finding to the provider.

A nurse is reviewing the laboratory reports of four newborns. Which of the following laboratory results should the nurse report to the provider?

Hgb 10 g/dL A hemoglobin level of 10 g/dL is below the expected reference range of 14 to 24 g/dL for a newborn. The nurse should report this finding to the provider.

A nurse is reinforcing discharge teaching with a parent of a newborn following a circumcision using the Plastibell technique. Which of the following statements by the parent indicates an understanding of the teaching?

I will be sure that my babys diaper does not put pressure on his penis." The nurse should identify that this statement indicates an understanding of the teaching. The diaper should be applied loosely to prevent the application of pressure to the circumcision site.

A nurse is reinforcing teaching with a guardian about how to care for the umbilical cord of their newborn infant. Which of the following statements by the guardian indicates a need for further teaching?

I will give my newborn a bath once daily." The nurse should reinforce with the guardian to avoid giving the newborn a daily bath because it can damage the integrity of the newborn's skin.

A nurse is collecting data from a client who has hyperemesis gravidarum. Which of the following findings indicates that the client is at risk for dehydration?

Ketonuria Ketonuria indicates an excessive amount of ketones in the urine. When ketones are found in the client's urine, the initial indication is dehydration. Therefore, this is the most important initial laboratory test for clients who have hyperemesis gravidarum. The fluid volume deficiency and dehydration are directly related to excessive vomiting

A nurse is collecting data from a client who is pregnant and reports that the first day of their last menstrual period was January 27. According to Nägele's rule, the nurse should calculate the client's estimated date of delivery as which of the following?

November 3 The nurse should use Nägele's rule to calculate the client's estimated date of delivery. This involves subtracting 3 months and adding 7 days to the first day of the client's last menstrual period. Therefore, the nurse calculates the estimated date of delivery as November 3.

A nurse in a clinic is assisting with the plan of care for a client who is at 36 weeks of gestation. Which of the following actions should the nurse include in the plan of care?

Obtain a culture for group B streptococcus B-hemolytic. The nurse should plan to obtain a rectovaginal culture to screen for group B streptococcus B-hemolytic infection in clients who are at 35 to 37 weeks of gestation. Group B streptococcus is present as normal vaginal flora in 25% of healthy clients who are pregnant. A positive culture requires treatment of the client during labor to prevent infection in the newborn.

A nurse is contributing to the plan of care for a full-term newborn whose mother has type 1 diabetes mellitus. Which of the following is the priority action for the nurse to include in the plan of care?

Obtain the glucose level of the newborn. The newborn is at risk for developing hypoglycemia, If brain cells become completely depleted of glucose, brain damage can occur. Therefore, this is the priority action the nurse should include in the plan of care.

A nurse is assisting with the care of a client who is in active labor and notes late decelerations in the fetal heart rate, Which of the following actions should the nurse take first?

Place the client in a side-lying position. When using the urgent vs. nonurgent approach to client care, the nurse should identify that late decelerations indicate a disruption of oxygen to the fetus. Therefore, the first action the nurse should take is to place the client in a side-lying position to maximize blood flow to the placenta and increase oxygen transfer to the fetus.

A nurse is reviewing the laboratory results for a client who has a BP of 156/102 mm Hg and is at 36 weeks of gestation. Which of the following laboratory values should the nurse report to the provider?

Platelet count 100,000/mm The nurse should identify that a platelet count of 100,000/mm is below the expected reference range of 150,000 to 400,000/mm during pregnancy. A low platelet count can indicate HELLP syndrome; therefore, the nurse should report this laboratory value to the provider.

A nurse is assisting with the care of a client who is in the active stage of labor. For which of the following findings should the nurse notify the provider?

Prolapsed umbilical cord The nurse should notify the provider immediately for a prolapsed umbilical cord because fetal hypoxia due to cord compression can occur. The occlusion of blood flow to and from the fetus can result in damage to the fetus's CNS and possible death to the fetus.

A nurse is assisting with discharge teaching about pain management to a client who had a cesarean birth and is experiencing gas pains. Which of the following instructions should the nurse include in the teaching?

Rock in a rocking chair. The nurse should instruct the client that rocking in a rocking chair can help to relieve gas pains by aiding the client in expelling the gas.

Anurse is collecting data from a newborn who is 6 hr old. Which of the following manifestations should the nurse expect? (Select all that apply.)

Rust-stained urine is correct. A newborn's first void can contain uric acid crystals, which will give the urine a rust-stained appearance. Overlapping cranial sutures is correct. A newborn's cranial sutures should be palpable without evidence of fusion. Overlapping sutures can occur during a vaginal birth to allow passage of the fetus through the birth canal. Periodic breathing is correct. A newborn's respiratory effort is shallow and irregular and can have periods of 5 to 10 seconds with respiratory effort.

A nurse on a postpartum unit is reinforcing information should the nurse include? teaching with an assistive personnel (AP) about preventing newborn abduction. Which of the following

The AP should have their photo identification badge displayed. The AP should always wear their photo identification badge so that clients, staff, and families can easily identify them as hospital personnel who work on the

A nurse is reinforcing teaching with the parents of a newborn who is having a newborn screening test. Which of the following statements should the nurse include in the teaching?

The test will check your baby for phenylketonuria." The nurse should reinforce with the parents that the newborn screening test checks for multiple congenital disorders including sickle cell disease. phenylketonuria, galactosemia, and hypothyroidism. Most of these disorders are not symptomatic at birth.

A nurse in an antepartum clinic is collecting data from a client who is at 12 weeks of gestation. Which of the following findings should the nurse report to the provider?

Weight increase of 3 kg (6.6 Ib) in one month The nurse should report a weight increase of 3 kg (6.6 normal prepregnancy weight should gain 1 to 2 kg (2.2 to 4.4 Ib) during the first trimester and 0.4 kg (0.9 Ib) per week during the second and third trimesters. Ib) in one month because this is excessive weight gain for the first trimester of pregnancy. A client with a

A nurse in a prenatal clinic is reinforcing nutritional teaching with a client who is at 10 weeks of gestation. Which of the following statements by the client indicates an understanding of the instructions?

make sure that I get 1,000 milligrams of calcium per day." The client should consume a minimum of 1,000 mg of calcium daily during pregnancy to support fetal bone and tooth development.