RN Maternal Newborn Online Practice 2019 B with NGN

A nurse is teaching a client who is Rh negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching? "I will receive this medication if my baby is Rh-negative." "I will receive this medication when I am in labor." "I will need a second dose of this medication when my baby is 6 weeks old." "I will need this medication if I have an amniocentesis."

"I will need this medication if I have an amniocentesis." Rho(D) immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.

A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make? "You can miss your period for several other reasons. Describe your typical menstrual cycle." "If you have been sexually active and haven't used protection, it is likely that you are pregnant." "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" "Because you have missed your period, you should try taking a home pregnancy test before you start worrying."

"You can miss your period for several other reasons. Describe your typical menstrual cycle." Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions.

A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching? "You can share your room with your baby for the next few weeks." "Cover your baby with a light blanket while sleeping." "Check the temperature of your baby's bath water with your hand." "Your baby can nap in the car seat during the daytime."

"You can share your room with your baby for the next few weeks." The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome.

A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching? "You should replace the diaphragm every 5 years." "You should leave the diaphragm in place for at least 6 hours after intercourse." "You should use an oil-based product as a lubricant when inserting the diaphragm." "You should insert the diaphragm when your bladder is full."

"You should leave the diaphragm in place for at least 6 hours after intercourse." The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy.

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching? "You should take the medication within 72 hours following unprotected sexual intercourse." "You should avoid taking this medication if you are on an oral contraceptive." "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test." "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it."

"You should take the medication within 72 hours following unprotected sexual intercourse." Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse.

A nurse at a provider's office is caring for a client who is 28 years of age. History and Physical Day 1 at 1000:Gravida 3, Para 2, Abortion 1Asthma (managed with levalbuterol inhaler as needed)Pelvic inflammatory disease (PID)Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age)Voluntary termination of pregnancy (3rd pregnancy) Nurses' Notes Day 1 at 1000:Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to 10 pain scale. Client is alert and oriented, appears anxious. Speech clear. Skin warm and dry to touch. Heart rate regular at 90/min. Respirations even and non-labored. Lungs slight inspiratory wheezes. Bowel sounds hyperactive in all four quadrants. Abdomen tender to touch right lower quadrant. Perineal pad with scant amount of dark red vaginal spotting. Day 1 at 1100:Client was given information about ectopic pregnancy. Client to notify provider or go to the emergency room if excessive bleeding, severe sharp abdo

-Temperature 35.3° C (95.5° -HgOxygen saturation 94% (oxygen @2 L/min via nasal cannula) -Skin cool and moist to touch. -Pedal pulse +1 bilateral

A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1 g orally now." Available is 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

4 tablets orally.

A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor? Passive descent Active Early Descent

Active The nurse should identify that the client is in the active phase of labor. This phase is characterized by a cervical dilatation of 6 to 10 cm and contractions every 1.5 to 5 min, each lasting 40 to 90 seconds.

A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider? Bilirubin 9 mg/dL Hemoglobin 18 g/dL Platelets 175,0000/mm3 Hematocrit 45%

Bilirubin 9 mg/dL A bilirubin level of 9 mg/dL is above the expected reference range for a newborn who is 4 hr old. The expected reference range for a newborn who is less than 24 hr old is 2 to 6 mg/dL. The nurse should report this finding to the provider.

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client? Percutaneous umbilical blood sampling Amnioinfusion Biophysical profile (BPP) Chorionic villus sampling (CVS)

Biophysical profile (BPP) The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli.

A nurse is caring for a postpartum client History and Physical Delivered at 38 weeks of gestation via cesarean delivery 48 hr ago42 years oldGravida 2, Para 1History of hypertensionHistory of asthmaNo antihypertensive medications during pregnancy. Treatment plan included diet and exercise. Nurses' Notes 1730:Client is awake and alert.Fundus is firm, midline, and 2 cm below the umbilicus.Incision is intact, light amount of lochia rubra observed.+2 pitting edema observed to bilateral lower extremities.Reports headache pain as 3 on a scale of 0 to 10.Reports headache and heartburn began about 1 hr ago. Vital Signs 1730:Blood pressure 152/105 mm HgTemperature 37.8° C (100° F)Pulse 70/minRespiratory rate 20/minOxygen saturation 98% Diagnostic Results Admission laboratory values (48 hr ago):Hgb 11 g/dL (greater than 11 g/dL)Platelets 150,000/mm³ (150,000 to 400,000/mm³)BUN 19 mg/dL (10 to 20 mg/dL)Creatinine 1 mg/dL (0.5 to 1 mg/dL)Aspartate aminotransferase (AST) 33 units/L (0 to 35 units/L)Alanine aminotransferase (ALT) 32 units/L (4 to 36 units/L)Urinalysis:Color: pink-tingedpH 6.2 mg/dL (4.6 to 8 mg/dL)Specific gravity 1.022 (1.010 to 1.025)Leukocyte esterase Negative (Negative)Nitrite ne

Blood pressure 152/110 mm Hg is correct. The client's blood pressure is above the expected reference range. An elevated blood pressure can be an indication of anxiety or preeclampsia; therefore, the nurse should report this finding to the provider. +2 pitting edema is correct. The client has +2 pitting edema, which may not be indicative of any disorder but should be investigated, especially if it is occurring with other manifestations; therefore, the nurse should report this finding to the provider. Headache is correct. The client reports a headache that began 1 hr ago. A headache that coincides with an elevated blood pressure might be an indication of preeclampsia; therefore, the nurse should report this finding to the provider. Heartburn is correct. The client reports heartburn that began 1 hr ago. Although heartburn can occur after eating, the client is also experiencing other manifestations along with the heartburn; therefore, the nurse should report this finding to the provider.

A nurse is caring for a postpartum client. History and Physical Delivered at 38 weeks of gestation via cesarean delivery 48 hr ago42 years oldGravida 2, Para 1History of hypertensionHistory of asthmaNo antihypertensive medications during pregnancy. Treatment plan included diet and exercise. Nurses' Notes 1730:Client is awake and alert.Fundus is firm, midline, and 2 cm below the umbilicus.Incision is intact, light amount of lochia rubra observed.+2 pitting edema observed to bilateral lower extremities.Reports headache pain as 3 on a scale of 0 to 10.Reports headache and heartburn began about 1 hr ago. Vital Signs 1730:Blood pressure 152/105 mm HgTemperature 37.8° C (100° F)Pulse 70/minRespiratory rate 20/minOxygen saturation 98% Diagnostic ResultsAdmission laboratory values (48 hr ago):Hgb 11 g/dL (greater than 11 g/dL)Platelets 150,000/mm³ (150,000 to 400,000/mm³)BUN 19 mg/dL (10 to 20 mg/dL)Creatinine 1 mg/dL (0.5 to 1 mg/dL)Aspartate aminotransferase (AST) 33 units/L (0 to 35 units/L)Alanine aminotransferase (ALT) 32 units/L (4 to 36 units/L)Urinalysis:Color: pink-tingedpH 6.2 mg/dL (4.6 to 8 mg/dL)Specific gravity 1.022 (1.010 to 1.025)Leukocyte esterase Negative (Negative)Nitrite ne

Box 1 Preeclampsia is correct. The client has an increased blood pressure of 152/105 mm Hg, which is above the expected reference range. Some clients do not develop manifestations of preeclampsia until they are in the postpartum period. The client is also experiencing a headache and epigastric pain, along with an elevated blood pressure. These findings are consistent with preeclampsia and place the client at greatest risk for developing this condition. Box 2 Increased blood pressure is correct. The client has an increased blood pressure of 152/105 mm Hg, which is above the expected reference range. This finding, along with other assessment findings, is consistent with preeclampsia and places the client at greatest risk of developing this condition.

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.) Cholecystitis Hypertension Human papillomavirus Migraine headaches Anxiety disorder

Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives.

History and Physical Delivered at 38 weeks of gestation via cesarean delivery 48 hr ago42 years oldGravida 2, Para 1History of hypertensionHistory of asthmaNo antihypertensive medications during pregnancy. Treatment plan included diet and exercise. Nurses' Notes 1730:Client is awake and alert.Fundus is firm, midline, and 2 cm below the umbilicus.Incision is intact, light amount of lochia rubra observed.+2 pitting edema observed to bilateral lower extremities.Reports headache pain as 3 on a scale of 0 to 10.Reports headache and heartburn began about 1 hr ago. 1745:Client reports headache pain as 3 on a scale of 0 to 10. Client reports that the pain is dull and behind the eyes.Client states heartburn "Is still happening in my upper right stomach" and "I still have a little nausea."DTRs 3+. Clonus negative. Denies visual disturbances 1810:Clonus positive. DTRs +4Resting, lights dim, environment quiet. Lochia small, fundus 1 cm below umbilicus, midline. 1840:Resting, reports headache as 4 on 0 to 10 pain scale. Edema +2 pitting to bilateral lower extremities Vital Signs 1730:Blood pressure 152/105 mm HgTemperature 37.8° C (100° F)Pulse 70/minRespiratory rate 20/minOxygen saturation 98% 1745:

Clonus positive. DTRs 4+ is correct. The nurse should identify that the client's reflex irritability has increased, and the client is now at greater risk for seizure activity; therefore, this finding indicates the client's condition is not improving. Reports headache as 4 on 0 to 10 pain scale is correct. The nurse should identify that the client's headache is worsening, which indicates increased cerebral irritability and places the client at a greater risk for seizure activity; therefore, this finding indicates the client's condition is not improving. Platelets 95,000/mm³ (150,000 to 400,000/mm³) is correct. The nurse should identify that the client's platelet level is below the expected reference range, which indicates that the client's preeclampsia is worsening; therefore, this finding indicates the client's condition is not improving. Aspartate aminotransferase (AST) 60 units/L (0 to 35 units/L) is correct. The nurse should identify that the client's AST level is above the expected reference range, which indicates that the client's preeclampsia is worsening; therefore, this finding indicates the client's condition is not improving. Alanine aminotransferase (ALT) 50 units/L (0 to 36 units/L) is correct. The nurse should identify that the client's ALT level is above the expected reference range, which indicates that the client's preeclampsia is worsening; therefore, this finding indicates the client's condition is not improving.

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first? Determine respiratory function. Increase the IV fluid rate. Access emergency medications from cart. Collect a maternal blood sample for coagulopathy studies.

Determine respiratory function. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation.

A nurse is caring for a postpartum client. History and Physical Delivered at 38 weeks of gestation via cesarean delivery 48 hr ago42 years oldGravida 2, Para 1History of hypertensionHistory of asthmaNo antihypertensive medications during pregnancy. Treatment plan included diet and exercise. Nurses' Notes 1730:Client is awake and alert.Fundus is firm, midline, and 2 cm below the umbilicus.Incision is intact, light amount of lochia rubra observed.+2 pitting edema observed to bilateral lower extremities.Reports headache pain as 3 on a scale of 0 to 10.Reports headache and heartburn began about 1 hr ago. Vital Signs 1730:Blood pressure 152/105 mm HgTemperature 37.8° C (100° F)Pulse 70/minRespiratory rate 20/minOxygen saturation 98% Diagnostic ResultsAdmission laboratory values (48 hr ago):Hgb 11 g/dL (greater than 11 g/dL)Platelets 150,000/mm³ (150,000 to 400,000/mm³)BUN 19 mg/dL (10 to 20 mg/dL)Creatinine 1 mg/dL (0.5 to 1 mg/dL)Aspartate aminotransferase (AST) 33 units/L (0 to 35 units/L)Alanine aminotransferase (ALT) 32 units/L (4 to 36 units/L)Urinalysis:Color: pink-tingedpH 6.2 mg/dL (4.6 to 8 mg/dL)Specific gravity 1.022 (1.010 to 1.025)Leukocyte esterase Negative (Negative)Nitrite n

Dropdown 1 Assess the client's deep tendon reflexes (DTRs) is correct. The priority intervention for the nurse is to assess the client's DTRs to check the reflex irritability. According to evidence-based practice, increased DTR reflex irritability places the client at a greater risk for seizure activity. y. Dropdown 2 Assess the client for visual disturbances is correct. According to evidence-based practice, the nurse's next priority intervention is to assess the client for visual changes, such as blurred vision and scotoma, which are caused by vasospasms and decreased amounts of blood flow to the retina. Although the client is in the postpartum period, some clients do not develop manifestations of preeclampsia until this time. The client is experiencing a headache, heartburn, and has elevated blood pressure, which can indicate preeclampsia.

A nurse at a provider's office is caring for a client who is 28 years of age History and Physical Day 1 at 1000:Gravida 3, Para 2, Abortion 1Asthma (managed with levalbuterol inhaler as needed)Pelvic inflammatory disease (PID)Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age)Voluntary termination of pregnancy (3rd pregnancy) Nurses' Notes Day 1 at 1000:Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to 10 pain scale. Client is alert and oriented, appears anxious. Speech clear. Skin warm and dry to touch. Heart rate regular at 90/min. Respirations even and non-labored. Lungs slight inspiratory wheezes. Bowel sounds hyperactive in all four quadrants. Abdomen tender to touch right lower quadrant. Perineal pad with scant amount of dark red vaginal spotting. Vital Signs Day 1 at 1000:Temperature 37.2° C (98.9° F)Heart rate 90/minRespirations 16/minBlood pressure 120/74 mm HgOxygen saturation 97% room air Diagnostic Res

Dropdown 1 Ectopic pregnancy is correct. The client reports late menses, abdominal pain, and scant dark red vaginal spotting. The assessment findings reveal right lower quadrant abdominal tenderness and scant dark red vaginal spotting on perineal pad, which are associated with ectopic pregnancy. The client also has a history of PID, which is a risk factor for ectopic pregnancy. Dropdown 2 Right lower quadrant abdominal tenderness is correct. The assessment findings reveal right lower quadrant abdominal tenderness and scant dark red vaginal spotting, which are findings associated with ectopic pregnancy.

A nurse at a provider's office is caring for a client who is 28 years of age. History and Physical Day 1 at 1000:Gravida 3, Para 2, Abortion 1Asthma (managed with levalbuterol inhaler as needed)Pelvic inflammatory disease (PID)Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age)Voluntary termination of pregnancy (3rd pregnancy) Nurses' Notes Day 1 at 1000:Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to 10 pain scale. Client is alert and oriented, appears anxious. Speech clear. Skin warm and dry to touch. Heart rate regular at 90/min. Respirations even and non-labored. Lungs slight inspiratory wheezes. Bowel sounds hyperactive in all four quadrants. Abdomen tender to touch right lower quadrant. Perineal pad with scant amount of dark red vaginal spotting. Vital Signs Day 1 at 1000:Temperature 37.2° C (98.9° F)Heart rate 90/minRespirations 16/minBlood pressure 120/74 mm HgOxygen saturation 97% room air Day 1 at 1030:

Dropdown 1 Heart rate is correct. The nurse should first address the client's heart rate, which is above the expected reference range, to establish a baseline for continued monitoring. Dropdown 2 Vaginal spotting is correct. The nurse should next address the amount and characteristics of the client's vaginal spotting to establish a baseline for continued monitoring.

A nurse at a provider's office is caring for a client who is 28 years of age. History and Physical Day 1 at 1000:Gravida 3, Para 2, Abortion 1Asthma (managed with levalbuterol inhaler as needed)Pelvic inflammatory disease (PID)Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age)Voluntary termination of pregnancy (3rd pregnancy) Nurses' Notes Day 1 at 1000:Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to 10 pain scale. Client is alert and oriented, appears anxious. Speech clear. Skin warm and dry to touch. Heart rate regular at 90/min. Respirations even and non-labored. Lungs slight inspiratory wheezes. Bowel sounds hyperactive in all four quadrants. Abdomen tender to touch right lower quadrant. Perineal pad with scant amount of dark red vaginal spotting. Day 1 at 1100:Client was given information about ectopic pregnancy. Client to notify provider or go to the emergency room if excessive bleeding, severe sharp abdomi

Ensure the client is NPO prior to surgery. Insert an 18-gauge peripheral IV prior to surgery. Obtain a complete blood count. Verify a consent form is signed by the client.

A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take? Tell the client to follow up with a dermatologist. Explain to the client this is an expected occurrence. Instruct the client to increase her intake of vitamin D. Inform the client she might have an allergy to her skin care products.

Explain to the client this is an expected occurrence. Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery.

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.) Flaccid uterus Cervical laceration Excess vaginal bleeding Increased afterbirth cramping Increased maternal temperature

Flaccid uterus is correct. Oxytocin increases the contractility of the uterus. Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding.

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care? Maintain the client NPO throughout the procedure. Place the client in a supine position. Instruct the client to massage the abdomen to stimulate fetal movement. Instruct the client to press the provided button each time fetal movement is detected.

Instruct the client to press the provided button each time fetal movement is detected. Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.

A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients? Calcium Vitamin E Iron Vitamin D

Iron The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old.

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication? Increased fetal movement Leakage of fluid from the vagina Upper abdominal discomfort Urinary frequency

Leakage of fluid from the vagina Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider.

A nurse is calculating a client's expected date of birth using Nägele's rule. The client tells the nurse that her last menstrual cycle started on November 27th. Which of the following dates is the client's expected date of birth? September 3rd September 20th August 3rd August 20th

September 3rd When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.

A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication. For which of the following findings should the nurse instruct the client to notify the provider? Shortness of breath Breakthrough bleeding Vomiting Breast tenderness

Shortness of breath The nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain.

A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include? Insert the syringe tip before compressing the bulb. Suction each of the nares before suctioning the mouth. Insert the tip of the syringe into the center of the newborn's mouth. Stop suctioning when the newborn's cry sounds clear.

Stop suctioning when the newborn's cry sounds clear. The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus.

A nurse is assessing a newborn who is 12 hr old. Which of the following manifestations requires intervention by the nurse? Acrocyanosis of the extremities Murmur at the left sternal border Substernal chest retractions while sleeping Positive Babinski reflex

Substernal chest retractions while sleeping Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This manifestation requires further assessment and intervention by the nurse.

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority? O2 saturation Temperature Blood pressure Urinary output

Temperature The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.

A nurse at a provider's office is caring for a client who is 28 years of age History and Physical Day 1 at 1000:Gravida 3, Para 2, Abortion 1Asthma (managed with levalbuterol inhaler as needed)Pelvic inflammatory disease (PID)Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age)Voluntary termination of pregnancy (3rd pregnancy) Nurses' Notes Day 1 at 1000:Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to 10 pain scale. Client is alert and oriented, appears anxious. Speech clear. Skin warm and dry to touch. Heart rate regular at 90/min. Respirations even and non-labored. Lungs slight inspiratory wheezes. Bowel sounds hyperactive in all four quadrants. Abdomen tender to touch right lower quadrant. Perineal pad with scant amount of dark red vaginal spotting. Vital Signs Day 1 at 1000:Temperature 37.2° C (98.9° F)Heart rate 90/minRespirations 16/minBlood pressure 120/74 mm HgOxygen saturation 97% room air Day 1 at 1030:Te

Transvaginal ultrasound is indicated. The nurse should anticipate a prescription for a transvaginal ultrasound. A transvaginal ultrasound is useful in determining the location of the ectopic pregnancy. Meperidine IM is contraindicated. Clients who receive methotrexate for an ectopic pregnancy should not take analgesics stronger than acetaminophen, because these medications can mask the manifestations of tubal rupture. Repeat quantitative β-hCG level is anticipated. The quantitative β-hCG level should be repeated within 48 hr to see if the level has changed from last recording. If increased levels are identified with no intrauterine pregnancy on ultrasound, this is indicative of ectopic pregnancy. Methotrexate IM is anticipated. The nurse should anticipate a prescription for methotrexate IM administration to prevent further embryonic cell reproduction. Blood typing is anticipated. The nurse should also anticipate potential surgical intervention for the client; therefore, blood typing is indicated.

A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first? Confirm the newborn's Apgar score. Verify the newborn's identification. Administer vitamin K to the newborn. Determine obstetrical risk factors.

Verify the newborn's identification. When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery.

A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? Large for gestational age Hyperglycemia Bradypnea Vomiting

Vomiting Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.

A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in the teaching? "You will need to drink the glucose solution 2 hours prior to the test." "Limit your carbohydrate intake for 3 days prior to the test." "A blood glucose of 130 to 140 is considered a positive screening result." "You will need to fast for 12 hours prior to the test."

"A blood glucose of 130 to 140 is considered a positive screening result." The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus.

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? "I should have a goal of maintaining my fasting blood glucose between 100 and 120." "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." "I will continue taking my insulin if I experience nausea and vomiting." "I will ensure that my bedtime snack is high in refined sugar."

"I will continue taking my insulin if I experience nausea and vomiting." The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching? "I will get injections of the medication once daily until my labor stops." "My blood sugar may be low while I'm on this medication." "I will have blood tests because my potassium might decrease." "My blood pressure may increase while I'm on this medication."

"I will have blood tests because my potassium might decrease." An adverse effect of terbutaline is hypokalemia

A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make? "The nurse will carry your newborn to the nursery for procedures." "We will document the relationship of visitors in your medical record." "Your baby will stay in the nursery while you are asleep." "Staff members who take care of your baby will be wearing a photo identification badge."

"Staff members who take care of your baby will be wearing a photo identification badge." The nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs.

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration? "This medication will stop your labor." "This medication stimulates fetal lung maturity." "This medication will decrease your risk for uterine infections." "This medication will increase your baby's weight."

"This medication stimulates fetal lung maturity." The nurse should inform the client that betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of enzymes that release lung surfactant.

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps

- palpate the client's fundus to identify the fetal part. -determine the location of the fetal back. - palpate for the fetal part presenting at the inlet. -identify the attitude of the head.

A nurse at a provider's office is caring for a client who is 28 years of age History and Physical Day 1 at 1000:Gravida 3, Para 2, Abortion 1Asthma (managed with levalbuterol inhaler as needed)Pelvic inflammatory disease (PID)Spontaneous vaginal delivery X 2 (hypertension with first pregnancy at 20 years of age)Voluntary termination of pregnancy (3rd pregnancy) Nurses' Notes Day 1 at 1000:Client presents to the office with concerns of late menses, abdominal pain, and scant dark red vaginal spotting. Client reports menstrual period is usually regular and is 2 weeks late. Last menstrual period: 2/20/XX. Client reports occasional dull abdominal pain and rates it as 2 on a 0 to 10 pain scale. Client is alert and oriented, appears anxious. Speech clear. Skin warm and dry to touch. Heart rate regular at 90/min. Respirations even and non-labored. Lungs slight inspiratory wheezes. Bowel sounds hyperactive in all four quadrants. Abdomen tender to touch right lower quadrant. Perineal pad with scant amount of dark red vaginal spotting. Vital Signs Day 1 at 1000:Temperature 37.2° C (98.9° F)Heart rate 90/minRespirations 16/minBlood pressure 120/74 mm HgOxygen saturation 97% room air Select the 3 fi

Abdomen assessment is correct. The client reports dull abdominal pain and rates it as 2 on 0 to 10 pain scale. The nurse noted right lower quadrant abdominal tenderness during their assessment, which is an unexpected finding that requires immediate follow up. Vaginal spotting is correct. Spotting is defined as a scant amount of vaginal bleeding. The client reports spotting along with a late menstrual period, which are unexpected findings that require immediate follow up. Menstrual period is correct. The client reports a usual regular menstrual period; however, it is currently late by 2 weeks. This is an unexpected finding that requires immediate follow up.

A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse include in the plan of care for lactation suppression? Place warm, moist packs on the breasts. Apply cabbage leaves to the breasts. Wear a loose-fitting bra. Put green tea bags on the breasts.

Apply cabbage leaves to the breasts. Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement.

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next? Place a rolled towel beneath one of the client's hips. Apply internal upward pressure to the presenting part using two gloved fingers. Administer oxygen to the client via a nonrebreather mask at 10 L/min. Increase the IV infusion rate.

Apply internal upward pressure to the presenting part using two gloved fingers. Using evidence-based practice, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand.

A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take? Apply sacral counterpressure. Perform transcutaneous electrical nerve stimulation (TENS). Initiate slow-paced breathing. Assist with biofeedback.

Apply sacral counterpressure. The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform? Reassess the client in 2 hr. Administer simethicone. Assist the client to empty her bladder. Instruct the client to lie on her right side.

Assist the client to empty her bladder. The nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage

A nurse is reviewing the laboratory report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider? Hgb 20 g/dL Total bilirubin 5 mg/dL Blood glucose 30 mg/dL WBC count 20,000/mm3

Blood glucose 30 mg/dL Newborns less than 24 hr old should have a blood glucose of 40 to 45 mg/dL. A blood glucose level of 30 mg/dL is below the expected reference range for a newborn who is 24 hr old and should be reported to the provider.

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? Decreased heart rate Chin quivering Pinpoint pupils Slowed respirations

Chin quivering Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow.

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? Cover the newborn's eyes while under the phototherapy light. Keep the newborn in a shirt while under the phototherapy light. Apply a light moisturizing lotion to the newborn's skin. Turn and reposition the newborn every 4 hr while undergoing phototherapy.

Cover the newborn's eyes while under the phototherapy light. Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light.

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect? Decreased platelet count Increased erythrocyte sedimentation rate (ESR) Decreased megakaryocytes Increased WBC

Decreased platelet count A client who has ITP has an autoimmune response that results in a decreased platelet count.

A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? Discuss contraceptive options with the client and her partner. Repeat information to ensure client understanding. Listen to the client and her partner as they reflect upon the birth experience. Demonstrate to the client how to perform a newborn bath.

Demonstrate to the client how to perform a newborn bath. Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new parent moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new parent confidence and promote maternal adjustment.

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is, "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following? Emotional lability Focusing phase Cognitive restructuring Couvade syndrome

Emotional lability The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect? Jitteriness Hypertonia Abdominal distention Mottling

Jitteriness Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia.

A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)? Just above the umbilicus Just above the symphysis pubis The right lower quadrant The left lower quadrant

Just above the symphysis pubis At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis.

A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart? Left upper quadrant Right upper quadrant Left lower quadrant Right lower quadrant

Left lower quadrant The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant.

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the nurse take next? Massage the client's fundus. Insert an indwelling urinary catheter. Administer oxygen at 10 L/min. Elevate the client's right hip.

Massage the client's fundus. The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions.

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care? Place the client in a supine position for 30 min following the first dose of anesthetic solution. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution.

Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution.

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring? Oligohydramnios Hyperemesis gravidarum Leukorrhea Periodic tingling of the fingers

Oligohydramnios The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.

The nurse is reviewing the postpartum client's medical record. History and Physical Delivered at 38 weeks of gestation via cesarean delivery 48 hr ago42 years oldGravida 2, Para 1History of hypertensionHistory of asthmaNo antihypertensive medications during pregnancy. Treatment plan included diet and exercise. Nurses' Notes 1730:Client is awake and alert.Fundus is firm, midline, and 2 cm below the umbilicus.Incision is intact, light amount of lochia rubra observed.+2 pitting edema observed to bilateral lower extremities.Reports headache pain as 3 on a scale of 0 to 10.Reports headache and heartburn began about 1 hr ago. 1745:Client reports headache pain as 3 on a scale of 0 to 10. Client reports that the pain is dull and behind the eyes.Client states heartburn "Is still happening in my upper right stomach" and "I still have a little nausea."DTRs 3+. Clonus negative. Denies visual disturbances Vital Signs 1730:Blood pressure 152/105 mm HgTemperature 37.8° C (100° F)Pulse 70/minRespiratory rate 20/minOxygen saturation 98% 1745:Blood pressure 156/108 mm HgPulse 70/minRespiratory rate 20/minOxygen saturation 98% Diagnostic Results Admission laboratory values (48 hr ago):Hgb 11 g/dL (greater

Place on seizure precautions is correct. The nurse should place the client on seizure precautions because the client has preeclampsia and is receiving magnesium sulfate. Administer magnesium sulfate IV bolus as prescribed is correct. The nurse should administer magnesium sulfate IV bolus as prescribed because this medication helps to prevent the client from progressing to eclampsia. Obtain creatinine, platelet, BUN, and liver enzymes as prescribed.correct. The nurse should obtain baseline laboratory values to monitor progression of the client's condition. Assess for worsening headache and epigastric pain hourly and PRN is correct. The nurse should assess for worsening headache and epigastric pain to determine if the client's condition is deteriorating. Monitor level of consciousness, DTRs, and visual disturbances hourly is correct. The nurse should monitor the client's level of consciousness, DTRs, and visual disturbances hourly and PRN to determine if the client's condition is deteriorating.

A nurse is providing discharge teaching to the parents of a newborn about car seat safety. Which of the following instructions should the nurse include? Place the shoulder harness in the slots above the newborn's shoulders. Place the retainer clip at the level of the newborn's armpits. Place the newborn at a 60° angle in the car seat. Place the newborn in a blanket before securing them in the car seat.

Place the retainer clip at the level of the newborn's armpits. The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits.

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider? Hct 39% Serum albumin 4.5 g/dL WBC 9,000/mm3 Platelets 50,000/mm3

Platelets 50,000/mm3 A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider.

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? Swelling of the face Varicose veins in the calves Nonpitting 1+ ankle edema Hyperpigmentation of the cheeks

Swelling of the face Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.

The nurse is reviewing the postpartum client's medical record. History and Physical Delivered at 38 weeks of gestation via cesarean delivery 48 hr ago42 years oldGravida 2, Para 1History of hypertensionHistory of asthmaNo antihypertensive medications during pregnancy. Treatment plan included diet and exercise. Nurses' Notes 1730:Client is awake and alert.Fundus is firm, midline, and 2 cm below the umbilicus.Incision is intact, light amount of lochia rubra observed.+2 pitting edema observed to bilateral lower extremities.Reports headache pain as 3 on a scale of 0 to 10.Reports headache and heartburn began about 1 hr ago. 1745:Client reports headache pain as 3 on a scale of 0 to 10. Client reports that the pain is dull and behind the eyes.Client states heartburn " Is still happening in my upper right stomach" and "I still have a little nausea."DTRs 3+. Clonus negative. Denies visual disturbances Vital Signs 1730:Blood pressure 152/105 mm HgTemperature 37.8° C (100° F)Pulse 70/minRespiratory rate 20/minOxygen saturation 98% 1745:Blood pressure 156/108 mm HgPulse 70/minRespiratory rate 20/minOxygen saturation 98% Diagnostic Results Admission laboratory values (48 hr ago):Hgb 11 g/dL (greate

Urinalysis is anticipated. The nurse should anticipate a prescription for a urinalysis. A urinalysis will reveal the presence of increased levels of protein in the urine, which might be indicative of preeclampsia. Monitor intake and output is anticipated. The nurse should anticipate a prescription for monitoring the client's intake and output. Although the client is in the postpartum period, some clients do not develop manifestations of preeclampsia until the postpartum period. Clients who experience preeclampsia are at risk for decreased urine output due to decreased renal perfusion. Adminster Magnesium sulfate is anticipated. The nurse should anticipate a prescription for magnesium sulfate. Although the client is in the postpartum period, some clients do not develop manifestations of preeclampsia until the postpartum period. Clients who have headaches, visual disturbances, and increased DTR irritability should be administered magnesium sulfate to help prevent seizure activity in the postpartum period. Place the client on seizure precautions is anticipated. The nurse should anticipate a prescription for seizure precautions. Although the client is in the postpartum period, some clients do not develop manifestations of preeclampsia until the postpartum period. The client is exhibiting manifestations of preeclampsia and could progress to eclampsia (seizures). Labetalol is contraindicated. The nurse should not anticipate a prescription for labetalol. This medication is contraindicated for clients who have asthma. This client's medical history includes asthma; therefore, the client should not be prescribed this medication. Draw creatinine and BUN is anticipated. The nurse should anticipate a prescription for creatinine and BUN labs to be drawn. Although the client is in the postpartum period, some clients do not develop manifestations of preeclampsia until the postpartum period. Increased creatinine levels are used to determine if kidney function is impaired. BUN levels can indicate impaired kidney function as well.