Test 1 352

"You'll want to wear a sports bra for 24 hours a day until your breasts are soft."

A primiparous patient tells the nurse she wants to bottle-feed her baby. What is the most therapeutic response by the nurse? "Have you tried breastfeeding? Let's see if we can get baby to latch." "You'll want to wear a sports bra for 24 hours a day until your breasts are soft." "We do not advocate bottle-feeding, so you'll need to bring your own formula." "Are you sure? Breastmilk is so much healthier for your baby."

Insert the needle at a 90-degree angle. Obtain a written consent. Administer in vastus lateralis.

The nurse is preparing to administer the Hepatitis B vaccine to a newborn. Which are the appropriate nursing actions? Select all that apply. Draw up the medication in a 1-mL syringe with a 25-gauge, ½ inch needle. Insert the needle at a 90-degree angle. Obtain a written consent. Put on sterile gloves. Administer in vastus lateralis.

The parent places the bulb syringe straight back in the mouth to elicit a gag reflex.

The nurse is providing discharge information to parents regarding use of the bulb syringe. The nurse identifies further teaching is needed when the parent demonstrates which behavior? The parent removes drainage from the syringe onto a tissue. The parent cleans the bulb syringe after each use with warm soapy water. The parent uses the bulb syringe in the mouth prior to inserting in the nose. The parent places the bulb syringe straight back in the mouth to elicit a gag reflex.

A client who does not wash their hands between perineal care and breast-feeding

5. A nurse is providing care to four clients on the postpartum unit. Which of the following clients is at greatest risk for developing a postpartum infection? A. A client who has an episiotomy that is erythematous and has extended into a third-degree laceration B. A client who does not wash their hands between perineal care and breastfeeding C. A client who is not breastfeeding and is using measures to suppress lactation D. A client who has a cesarean incision that is well-approximated with no drainage

Backseat rear facing

5. A nurse is reviewing car seat safety with the parents of a newborn. Which of the following instructions should the nurse include in the teaching regarding car seat position? A. Front seat, rear-facing B. Front seat, forward-facing C. Back seat, rear-facing D. Back seat, forward-facing

Match the parents identification band with a newborn band

5. A nurse is taking a newborn to a parent following a circumcision. Which of the following actions should the nurse take for security purposes? A. Ask the parent to state their full name. B. Look at the name on the newborn's bassinet. C. Match the parent's identification band with the newborn's band. D. Compare name on the bassinet and room number.

This is commonly seen in newborn with dark skin called Mongolian spots

5. A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish brown marking across the newborn's lower back. The nurse should include which of the following information in the teaching? A. "This is more commonly seen in newborns who have dark skin." B. "This is a finding indicating hyperbilirubinemia." C. "This is a forceps mark from an operative delivery." D. "This is related to prolonged birth or trauma during delivery."

"This is a benign tumor on the uterine wall."

A female client with a leiomyoma of the uterus asks the nurse to explain what this is. What is the best explanation by the nurse? "This is a fluid filled cyst on your uterus." "This is a cancerous growth on your uterus." "This is a pseudopregnancy." "This is a benign tumor on the uterine wall."

Secondary dysmenorrhea

A female client with endometriosis reports painful menstruation. The nurse knows this symptom is associated with which menstrual abnormality? Primary dysmenorrhea Secondary dysmenorrhea Premenstrual syndrome Oligomenorrhea

Herpes can be transmitted to sexual partners, even when there are no visible lesions or sores. Herpes outbreaks can be shortened by taking anti-viral medications, such as acyclovir.

A female client with genital herpes has requested education on her condition. Which items should the nurse include in the teaching? Select all that apply. The cure for herpes is anti-viral medication, such as acyclovir. Herpes can be transmitted to sexual partners, even when there are no visible lesions or sores. A pregnant woman with a history of herpes must deliver by cesarean section. Herpes outbreaks can be shortened by taking anti-viral medications, such as acyclovir. The use of condoms can prevent transmission of herpes between sexual partners.

-Your son is showing an adverse sibling response

A nurse is caring for a client who is 2 days postpartum. The client states " my four year old son was toilet trained, and now he is frequently wedding himself" which of the following statements should the nurse provide the client -Your son was probably not ready for toilet training and should wear training pants -Your son is showing an adverse sibling response -Your son may need counseling

Assess the fundus for location, position and tone

A nurse is caring for a patient in the first hour following a vaginal delivery. What is the priority nursing intervention? Facilitate bonding between the mother and infant Assess the fundus for location, position and tone Administer pain medications Inspect the perineum for tearing

1. Preform fundal massage 2. Notify the physician or midwide of excessive blood loss 3. Achieve free-flowing venous access 4. Increase frequency of vital signs

A nurse is caring for a patient in the immediate postpartum period. Upon assessment, the nurse notes heavy bleeding and a boggy uterus that does not respond to fundal massage. What are the priority nursing actions? Place in the correct order. Preform fundal massage Notify the physician or midwide of excessive blood loss Achieve free-flowing venous access Increase frequency of vital signs

I need a second vaccination at my postpartum visit

A nurse is completing postpartum, discharge teaching to a client who has no immunity to varicella, and was given the varicella vaccine. Which of the following statements by the client indicates understanding of the teaching? -I will need to use contraception for three months before considering pregnancy -I need a second vaccination at my postpartum visit -I was given the vaccine because my baby is O positive -I will be tested in three months to see if I have developed immunity

Absent startle reflex

A nurse is concerned that a newborn has hearing loss. Which assessment data correlates with possible hearing loss? Low-set ears Absent startle reflex Ear pits or tags Failed hearing screen

-Apply cold compresses between feedings

A nurse is conducting a home visit for a client who is one week postpartum and breast-feeding. The client reports breast engorgement. Which of the following recommendations to the nurse make -Apply cold compresses between feedings -Take a warm shower right after feeding -Apply breast milk to the nipples and allow them to air dry -Use various positions for feeding

-moderate lochia rubra

A nurse is performing a fundle assessment for a client who is two days postpartum and observes parenael pad for Lokia. The pad is saturated approximately 12 cm with lochia that is bright, red and contain small clot. Which of the following findings should the nurse document? -Moderate Lochia rubra -Excessive Lochia serousa -light Lochia rubra -scant Lochia serosa

Side-lying position Football hold

A nurse is preparing to assist a new mother with breastfeeding following a cesarean section delivery. Which positions will the nurse recommend to maximize patient comfort while breastfeeding? Select all that apply. Side-lying position Cradle hold C-cup positioning Using a breast pump Football hold

Do not breastfeed the infant.

A pregnant client presents to the labor and delivery unit in active labor with a history of no prenatal care. Initial lab work indicates a positive HIV status. What should the nurse advise the client to do? Complete a living will. Do not breastfeed the infant. Do not tell the family about the result. Consider placing the baby up for adoption.

"Infants are less likely to need NICU care when placed skin-to-skin with the mother."

Following cesarean delivery, a stable female infant weighing 3,126 grams is placed skin-to-skin with the mother. The client's partner asks why the infant is placed with the mother during the remainder of the surgery. What is the best response from the nurse? "Placing the infant with the mother reduces the need to have another nurse in the crowded operating room." "We can discuss this later, I need to help the surgeon right now." "Infants are less likely to need NICU care when placed skin-to-skin with the mother." "It is important to get a picture immediately after delivery of the infant."

is a normal postpartum finding is caused by hemodynamic changes in the immediate postpartum period should be fully assessed to rule out excessive blood loss

Orthostatic hypotension ______________. Select all that apply. is a medical emergency that indicates postpartum hemorrhage is a normal postpartum finding is caused by hemodynamic changes in the immediate postpartum period should be fully assessed to rule out excessive blood loss episodes will require strict bedrest for several hours afterward

perineal and hand hygiene, ambulation, hydration

Patient education to prevent infection should focus on _______________. hand hygiene, perineal compression, and douching perineal and hand hygiene, ambulation, hydration perineal and hand hygiene, rest, high-protein diet perineal soaks, hand hygiene, ambulation, analgesia

placing the infant in the nursery to promote rest

Postoperative care of the mother and infant includes all of the following except ___________. placing the infant in the nursery to promote rest encouraging early ambulation monitoring voids after the Foley catheter is removed assisting with breastfeeding

"Chlamydia can lead to infertility and ectopic pregnancy."

The community health nurse is teaching a group of female clients about chlamydia. Which statement should be included in the education? "Most women who are infected with chlamydia will have pelvic pain, fever, and abnormal discharge." "Chlamydia is treated with a single IM dose of ceftriaxone." "Chlamydia can lead to infertility and ectopic pregnancy." "Chlamydia is the most common viral sexually transmitted infection (STI)."

convection, radiation, conduction, evaporation

The four mechanisms of heat loss are ___________________. evaporation, condensation, conduction, radiation evaporation, conduction, convection, microwave convection, radiation, conduction, evaporation radiation, confluence, evaporation, convection

The mother relives and speaks of the birthing experience

The nurse assesses a mother's bonding with her new baby. Which action made by the mother does the nurse identify as the initial maternal phase? The mother relives and speaks of the birthing experience The mother responding and picking up the infant when she cries The mother goes back to work. The mother asking questions about infant care

Acquaintance and learning to care

The nurse is assessing a new mother who brought her 6-month-old infant for a well check. The mother is 16-years-old and her mother came with her to the visit. The infant's grandmother is holding the new baby and answering all of the questions. What part of the becoming a mother process does the nurse note to be lacking? Commitment, attachment and preparation Acquaintance and learning to care Learning a new normal Achieving maternal identity

Retractions of chest wall

The nurse is assessing a newborn and suspects respiratory distress. Which assessment data by the nurse will require further evaluation? Irregular breathing pattern 32 breaths per minute Retractions of chest wall Diaphragmatic and abdominal breathing

Use under-buttock calibrated drapes

The nurse is assessing a patient and suspects postpartum hemorrhage. Which method of measuring blood loss should the nurse use? Examining all pads and linens for saturation Weigh soaked pads and add the weight of dry pads Use under-buttock calibrated drapes Compare the patient's hemoglobin level to the last hemoglobin level obtained prenatally

Tone

The nurse is assessing a patient who is a G5T5P0A0L5 and delivered vaginally four hours ago. The patient's labor history included a 16 hour oxytocin induction for a macrosomic infant. Assessment findings include a boggy uterus and a completely saturated peri pad with the presence of blood clots. What does the nurse identify as the most likely cause for the increased bleeding? Tone Tissue Trauma Thrombin

Pulse 120 beats/min

The nurse is assessing a postpartum patient who had an uncomplicated vaginal delivery one hour ago. Which assessment finding requires immediate intervention? Blood pressure 152/88 mmHg Temperature 99.8 F (37.7 C) Pulse 120 beats/min Respiratory rate 16 breaths/min

The client reports no voiding since the catheter was removed.

The nurse is assessing client 12 hours post cesarean section delivery, of a healthy male infant weighing 9 pounds 3 ounces. The client's Foley catheter was removed three hours ago. Which subjective assessment data requires immediate intervention? The client reports pain at a level of four and can tolerate a five. The client reports the infant nursed for about 20 minutes one and a half hours ago. The client has a blood pressure of 92/48. The client reports no voiding since the catheter was removed.

"I will stay awake with the baby while his mother sleeps." "Will you help me wrap him up?"

The nurse is assessing the interaction between a newborn and his father. Which statement by the father shows progressed infant-father bonding? Select all that apply. "I will stay awake with the baby while his mother sleeps." "We're tired, can you take him to the nursery?" "I don't change diapers." "Will you help me wrap him up?" "He looks like his mom."

Assess the penis every 15 minutes for the first hour for signs of bleeding, then every 2 to 3 hours per hospital policy. Assess for urination and document findings. Administer pain medication if ordered.

The nurse is caring for a male infant who was circumcised 30 minutes ago. What are the responsibilities of the nurse after the procedure? Select all that apply. Clean the penis every diaper change and wrap with petroleum-impregnated gauze. Assess the penis every 15 minutes for the first hour for signs of bleeding, then every 2 to 3 hours per hospital policy. Assess for urination and document findings. Administer pain medication if ordered. Fasten the diaper firmly over the penis to prevent friction and promote hemostasis.

Magnesium sulfate infusion

The nurse is caring for a patient following the delivery of a 36-week infant due to maternal preeclampsia. The infant is stable and rooming-in with the mother. The nurse observes the mother demonstrating a slow response to the infant cues. What does nurse attribute this slow response to? Magnesium sulfate infusion Increased blood pressure Hyperactive reflexes Subtle cues due to prematurity

Retained placental tissue and infection. Presence of uterine fibroids.

The nurse is caring for a patient on the postpartum unit who has been diagnosed with subinvolution post-delivery. The nurse understands that subinvolution is associated with what labor and birth complications? Coagulation disorders such as DIC. Postpartum hemorrhage due to perineal laceration. Uterine tetany and overproduction of oxytocin. Retained placental tissue and infection. Presence of uterine fibroids.

\"Tell her it\"s okay and I will be here with her.\"

The nurse is caring for a patient that speaks Spanish. When using an interpreter, it's inappropriate to use which phrase when talking to the patient? \"Tell her it\"s okay and I will be here with her.\" \"You\"re 5cm dilated, which means you are halfway to having to push.\" \"You baby needs to eat, how can I help you feed her?\" \"Did you baby have a wet diaper or a dirty diaper?\"

Document on the report sheet as "normal" and proceed with plan of care.

The nurse is caring for a patient who delivered via cesarean section two hours ago and is now in the recovery room. Upon reviewing the delivery record, the nurse notices that her estimated blood loss was 800mL. What is the appropriate nursing intervention? Document on the report sheet as "normal" and proceed with plan of care. Call the provider to obtain an order for a complete blood count (CBC) and IV fluids. Explain to the patient that she will not be able to breastfeed until her hemoglobin and hematocrit increases by 10%. Prepare the patient for a dilation and curettage (D&C).

"My diabetes will resolve in the next few weeks, so there is no need for follow up."

The nurse is caring for a patient who was diagnosed with gestational diabetes mellitus (GDM) at 28 weeks of pregnancy. The patient had an uncomplicated vaginal birth 12 hours ago. Which statement made by the patient would require further education? "Breastfeeding my baby will help reduce my risk for developing Type II diabetes." "My diabetes will resolve in the next few weeks, so there is no need for follow up." "I have a much higher risk of developing Type II diabetes now that I have had gestational diabetes." "I need to see a provider for preconception glucose control prior to my next pregnancy."

Give the patient time to reflect.

The nurse is caring for a primiparous woman who just delivered her child. Which action should the nurse take to adhere to the taking-in stage? Help the mother change the diaper. Give the patient time to reflect. Start to teach about her new mother body. Start to promote maternal independence.

A patient who delivered vaginally after a two-hour labor A patient who delivered twins A patient with Von Willebrand disease

The nurse is caring for five postpartum patients. Which patients does the nurse recognize as being at an increased risk for postpartum hemorrhage (PPH)? Select all that apply. A patient who delivered vaginally after a two-hour labor A patient who delivered a 3300-gram infant via repeat cesarean A patient who delivered twins A patient with Von Willebrand disease A patient with a history of preeclampsia during her previous pregnancy

Uterine tenderness and foul-smelling lochia

The nurse is caring for patient newly diagnosed with endometritis. What assessment findings are consistent with endometritis? Abdominal cramping and cloudy urine Dizziness and hypotension Edema and hypertension Uterine tenderness and foul-smelling lochia

Incidental

The nurse is describing the transition to parenthood during a childbirth education course. During the class, the nurse mentions that most knowledge of parental expectations comes through observation of other parents. What term does the nurse use to describe this knowledge acquisition? Incidental Intentional Instructional Interrogation

Commitment and preparation for infant increasing attachment to infant moving toward a new normal achieving maternal identity

The nurse is discussing the stages of "becoming a mother" with a patient. In what order will the nurse review the stages?

"I will apply a lubricant over the circumcision site with each diaper change."

The nurse is instructing a new parent on appropriate circumcision care to his newborn son. Which statement by the parent demonstrates effective teaching regarding circumcision care? "I can expect the circumcision to be fully healed within 3 to 5 days." "I will apply a lubricant over the circumcision site with each diaper change." "I will need to remove the plastibell in 7 to 10 days." "It is not uncommon for circumcised babies to void 36 to 42 hours after the procedure."

Turning the head towards the mother's voice

The nurse is performing the Brazelton Neonatal Behavioral Assessment Scale on a neonate. Which assessment data does the nurse document as appropriate for orientation? Sleeping in a loud nursery Turning the head towards the mother's voice Moving arms out of blanket to mouth Able to soothe by holding

A G5P4 patient with obesity and undergoing labor induction.

The oncoming nurse is reviewing her assignment for the day, and would like to identify who see first based on acuity. Which woman is at greatest risk for primary postpartum hemorrhage? A G5P4 patient with obesity and undergoing labor induction. A G2P2 patient who delivered a baby vaginally after an 8-hour labor augmented by oxytocin. A G1P1 woman who just delivered via emergency cesarean section for fetal distress. A G2P2 woman delivering vaginally after a cesarean section with her first pregnancy.

"I need this because my blood type is negative and my baby is positive." "This medication will help protect my future babies."

The postpartum nurse is preparing to administer Rh (D) Immune Globulin (RhoGAM) to a post- cesarean section patient on the mother-baby unit. What statements made by the patient indicate an understanding of RhoGAM? Select all that apply. "I need this because my blood type is negative and my baby is positive." "I will avoid pregnancy for 4 weeks." "This medication will help protect my future babies." "I only need to get this once in my lifetime." "I need to receive RhoGAM within 48 hours of giving birth."

Massage the uterus until firm.

The recovery room nurse is completing a postpartum assessment on a newly delivered patient. Upon assessment, the nurse finds the peripad saturated with lochia, with large, visible clots. What is the priority nursing intervention based on these findings? Document the findings on the medical record. Massage the uterus until firm. Start an IV and give a bolus of oxytocin. Walk the patient to the bathroom

"You can take an analgesic for pain." "Wear a supportive bra or sports bra 24 hours a day."

When educating a non-breastfeeding primiparous patient, what information is important for the nurse to include? Select all that apply. "Wear a supportive bra or sports bra 24 hours a day." "If your breasts become engorged, you should pump to relieve the pressure." "Do not apply ice packs to the breasts because it will stimulation milk production." "You can take an analgesic for pain." "You may experience milk leakage for the first 1 to 2 weeks."

It will take up to two weeks for the site to heal completely.

When educating patients caring for an infant who was circumcised, which of the following is true? Infants circumcised with a plastibell should have their diaper thoroughly lubricated with every change. If any yellow crust forms, be sure to wipe it away to prevent infection. It will take up to two weeks for the site to heal completely. Parents should check for bleeding every 24 hours for the first four days.

Vaginal sponge

Which form of contraception should not be used if the patient or spouse has an allergy to spermicide? Combined oral contraceptive pill Copper intrauterine contraceptive device Vaginal sponge Vaginal ring

Obesity

Which of the following increases a woman's chance of developing breast and endometrial cancers? Vegan diet Human papillomavirus Obesity Multiparity

Desired parity

Which of the following is a consideration when discussing a hysterectomy? Desired parity Exercise habits Family history of breast cancer Number of sexual partners

Sedentary lifestyle

Which of the following is a risk factor for the development of a DVT? Primiparity in an adolescent Sedentary lifestyle Long-distance running Delivering a small for gestational age infant

"It will take between 6-8 weeks for my uterus to return to normal size." "Contractions will cause my uterus to shrink."

Which response by a postpartum patient indicates to the nurse that learning of uterine involution has taken place? Select all that apply. "My uterus will stay this big until I get my period again." "It will take between 6-8 weeks for my uterus to return to normal size." "Contractions will cause my uterus to shrink." "My uterus will not be as small as it was before I had a baby." "My uterus will return to the size of a volleyball."

Review the woman's prenatal and intrapartum records Prevent overdistention of the bladder Assess for signs of complications and intervene early

The nurse is planning care for several postpartum patients. Which nursing actions should be included in the care plan to reduce the risk of postpartum complications? Select all that apply. Review the woman's prenatal and intrapartum records Provide dietary counseling to prevent macrosomia Prevent overdistention of the bladder Encourage bed rest to prevent fatigue. Assess for signs of complications and intervene early

Fathering older children. Parenting support. Being there for the child.

The nurse is preparing a class for first time expectant fathers and are all anticipating delivery in the next couple of months. What known themes for expectant fathers will the nurse include during the class? Select all that apply. Paternal involvement. Fathering older children. Parenting support. College savings. Being there for the child.

On a stool next to the client's head.

The nurse is preparing a client for a cesarean section. Following the epidural anesthesia, the nurse is ready to show the partner where to stay during the surgery. Where does the nurse show the partner to go? On a stool next to the client's head. On a stool next to the infant warmer. In a waiting room next to the operating room. In the recovery room, to await completion of the surgery.

A woman who is pregnant is at higher risk of IPV.

The nurse is providing community education on intimate partner violence (IPV). Which should be included in the presentation? Select all that apply. Intimate partner violence mostly affects lower socioeconomic classes. Stalking or psychological aggression is not considered violence. A woman who is pregnant is at higher risk of IPV. 1 in 10 women in the U.S. will experience IPV during their lifetime.

"Mothers tend to be more fatigued than fathers following the birth of a new infant."

The nurse is providing teaching to new parents regarding the levels of fatigue that may occur following childbirth. Which statement should the nurse include in the teaching? "You are going to feel less fatigued after 3 months of having your infant at home." "Since you are younger parents, you will feel less fatigued than an older parent would." "Older mothers tend to report higher levels of stress than younger mothers." "Mothers tend to be more fatigued than fathers following the birth of a new infant."

40-year-old with history of human papillomavirus (HPV), last Pap test 10 years ago

The nurse is reviewing medical records of female clients in the outpatient setting. Which client has the highest risk for cervical cancer? 40-year-old with history of human papillomavirus (HPV), last Pap test 10 years ago 16-year-old has never had sexual intercourse, and her mother had cervical cancer 25-year-old with normal Pap one year ago, history of chlamydia 70-year-old with no history of abnormal Pap tests, last pap test five years ago

Clean the perineal area with water every 1 to 3 hours to decrease risk of diaper dermatitis. Bathe with neutral pH soap. Drying and flaking of skin is a natural process during the first few weeks of life. A rash with red macules and papules are normal and will disappear with no treatment.

The nurse is teaching a class on newborn care to new parents. What should be taught to the parents regarding skin characteristics and care for neonates? Select all that apply. Clean the perineal area with water every 1 to 3 hours to decrease risk of diaper dermatitis. Apply petroleum and/or zinc oxide at each diaper change as a barrier. Bathe with neutral pH soap. Drying and flaking of skin is a natural process during the first few weeks of life. A rash with red macules and papules are normal and will disappear with no treatment.

Hypothalamus Ovaries

The nurse is teaching a female client who desires pregnancy about the female reproductive cycle. Which are the main sites of regulation of the menstrual cycle? Select all that apply. Hypothalamus Posterior pituitary Ovaries Adrenal glands Hippocampus

"The mother passes IgA through breastmilk and this provides additional protection to the newborn." "The newborn receives IgG antibodies which provide immunity from infections which the mother has previously developed antibodies."

The nurse is teaching a new mother about how the immune system protects the newborn. Which statement made by the nurse is correct? Select all that apply. "The maternal transfer of IgM through delivery protects the newborn." "The mother passes IgA through breastmilk and this provides additional protection to the newborn." "The newborn receives IgG antibodies which provide immunity from infections which the mother has previously developed antibodies." "The fragile newborn skin and mucous membranes cause exposure to bacteria." "Active immunity is only acquired through vaccination."

Late postpartum hemorrhage

The nurse is triaging a postpartum patient who reports heavy vaginal bleeding 7 days after delivering a term infant. The estimated blood loss is 750 mL. Which postpartum complication is she experiencing? Endometritis Uterine atony Early postpartum hemorrhage Late postpartum hemorrhage

"Tell me more about what you know about bathing newborns."

The nurse overhears a client and spouse discussing the needs for the newborn to have daily baths to maintain cleanliness. What is the appropriate response from the nurse? "Babies smell so good right after a bath." "Nobody bathes infants daily anymore." "Daily baths with soap are important for newborns." "Tell me more about what you know about bathing newborns."

Abundant lanugo

The nurse performs an assessment on a 34-week neonate born four hours ago. Which assessment finding would be indicative of a preterm neonate? Acrocyanosis Abundant lanugo Hypertonia Tachycardia

How they were parented Length of the relationship between partners Education Finances

The nurse understands that different factors influence role transitions for new parents. Which of these factors are included? Select all that apply. Living on their own How they were parented Length of the relationship between partners Education Finances

Administer IV fluid bolus

The obstetric nurse is preparing a client for an epidural. What is the priority nursing intervention prior to this procedure? Monitor fetal heart tones Obtain maternal blood pressure Administer IV fluid bolus Assess for prior epidural anesthesia

The glomerular filtration rate is low, but doubles by two weeks of life.

Which statement below is true when discussing the renal system of a newborn? The glomerular filtration rate is low, but doubles by two weeks of life. The glomerular filtration rate is low, which prevents dehydration but will put the infant at risk for over-hydration. The kidneys are too immature to filter and concentrate urine, which creates an increased risk of hyperbilirubinemia. The kidneys are unable to breakdown glycogen efficiently, putting the infant at risk for hypoglycemia if they get dehydrated.

Babies need to be placed in the supine position for sleeping.

Which statement should the nurse include in an education program for parents regarding Sudden Infant Death Syndrome (SIDS)? Babies need to be placed in the supine position for sleeping. Babies should be swaddled from birth until one year old. Babies should be placed in the prone position for naps to prevent abnormal head shape. Pacifiers should not be offered to babies who established effective breastfeeding.

Assess the c-section incision

While assessing a post-operative cesarean section client, the nurse notes a temperature of 102.1?. Prior to calling the provider, what other assessment should the nurse complete to include when reporting the concern? Identify the time of last pain medication Assess the c-section incision Assess lung sounds and incentive spirometry Assess uterine fundus and lochia

Advanced maternal age Breech position

While presenting an educational session on childbirth the nurse was asked to discuss risk factors requiring a cesarean section. What should the nurse include in her response? Select all that apply. Advanced maternal age Spontaneous labor onset Breech position Maternal request Multiparity

"Tell me about how you are feeling right now."

While the nurse is preparing a client for an emergency cesarean section, the family voices concern that the client is extremely nervous about the procedure. How does the nurse respond to the client? "Tell me about how you are feeling right now." "We do many c-sections every day, you will be fine." "I am going to insert the foley catheter now." "It is important that you try to calm down for the baby."

D. When latched on, the infant's nose, cheek, and chin are touching the breast.

1. A nurse is giving instructions to a parent about how to breastfeed their newborn. Which of the following actions by the parent indicates understanding of the teaching? A. The parent places a few drops of water on their nipple before feeding. B. The parent gently removes their nipple from the infant's mouth to break the suction. C. When they are ready to breastfeed, the parent gently strokes the newborn's neck with a finge D. When latched on, the infant's nose, cheek, and chin are touching the breast.

Erythromycin

1. A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent ophthalmia neonatorum. Which of the following medications should the nurse anticipate administering? A. Ofloxacin B. Nystatin C. Erythromycin D. Ceftriaxone

Keep diaper fold below coRd

1. A nurse is reviewing care of the umbilical cord with the parent of a newborn. Which of the following matructions should the nurse include in the teaching? A Caver the cord with a small gauze square. n. Trickle clean water over the cord with each diaper change. C. Apply hydrogen peroxide to the cord twice a day D. Keep the diaper folded below the cord.

Evaporation

2. A newborn was not dried completely after birth. This places the infant at risk for which of the following types of heat loss? A. Conduction B. Convection C. Evaporation D. Radiation

Hold the newborn in a semi sitting position, then allow the newborns head and trunk to fall back

3. A nurse is assessing the reflexes of a newborn. In checking for the Moro reflex, the nurse should perform which of the following? A. Hold the newborn vertically under arms and allow one foot to touch table. B. Stimulate the pads of the newborn's hands with stroking or massage. C. Stimulate the soles of the newborn's feet on the outer lateral surface of each foot. D. Hold the newborn in a semi-sitting position, then allow the newborn's head and trunk to fall backward.

It assist with blood clotting

4. A nurse is preparing to administer a vitamin K (phytonadione) injection to a newborn. Which of the following responses should the nurse make to the newborn's parent regarding why this medication is given? A. "It assists with blood clotting." B. "It promotes maturation of the bowel." C. "It is a preventative vaccine." D. "It provides immunity."

Kegal Excericse

4. A nurse is providing discharge instructions to a postpartum client following a cesarean birt The client reports leaking urine every time they sneeze or cough. Which of the following interventions should the nurse suggest? A. Sit-ups B. Pelvic tilt exercises C. Kegel exercises D. Abdominal crunches

distended bladder

A deviated uterus in the postpartum period indicates a _______________. distended bladder diastis recti cystitis pre-eclampsia

Tachypnea Hypoglycemia Lethargy

A newborn is experiencing cold stress. Which assessment data by the nurse will require further evaluation? Tachypnea Shivering Hypoglycemia Hypertonia Lethargy

prolapsed cord

An example of a complication that would require an emergent cesarean section is __________. breech presentation intrauterine growth retardation (IUGR) diagnosis prolapsed cord category I strip with a maternal febrile episode

providing continuous support by a labor nurse or doula

Cesarean sections can often be avoided by ___________________. providing continuous support by a labor nurse or doula ensuring the woman is moving through the labor phases as quickly as possible encouraging the patient to get an epidural attempting vaginal deliveries more frequently when breech and previa complications arise

Emergent, immediately

Sally is a 38-year-old G3P1011 at 33 weeks 4 days admitted to antepartum for a placenta previa. She's begun having painless, heavy bleeding, and her vital signs are 100/51 mm Hg, pulse 108, respirations 20, oxygen saturation 94%, temperature 99.8°F. What type of cesarean section will she receive? Scheduled at 35 weeks Urgent, within the next hour Nonurgent, sometime during this shift after the other scheduled surgeries Emergent, immediately

Perineal and rectal pains

Sitz baths are used for which postpartum complication? Mastitis Postpartum hemorrhage Perineal and rectal pains Chorioamnionitis

Painful nipples

The nurse understands that which is a primary reason that women stop breastfeeding before the eighth week? Engorgement Painful nipples Mastitis Thrush

"Sorry, it won't stop crying, and we are so tired."

The nurse walks into a postpartum room noting a screaming infant in a crib near the bedside. Both parents are asleep. Which statement by the mother shows the need for further assessment for ineffective bonding? "Sorry, it won't stop crying, and we are so tired." "We are so tired, she kept us up all night." "We are so tired, we must have been sound asleep." "We are so tired. What if this happens at home?"

Pulmonary vascular resistance decreases as lung function begins. The foramen ovale closes but may reopen from significant hypoxia. Amniotic fluid remaining in the lungs after birth may inhibit lung expansion.

The nursing instructor is explaining to a group of students how the neonate transitions to extrauterine life. Which changes regarding the respiratory and cardiovascular systems are correct? Select all that apply. Pulmonary vascular resistance decreases as lung function begins. The foramen ovale closes but may reopen from significant hypoxia. Hypoxemia and acidosis leads to vasodilation of the pulmonary arteries. Amniotic fluid remaining in the lungs after birth may inhibit lung expansion. Cardiac murmurs auscultated at birth will resolve by 72 hours of age.

mental health concerns

Women experiencing infertility concerns may experience _____________. empty nest syndrome mental health concerns HELP syndrome dysmenorrhea

An extra 500 calories a day.

Your giving baby Sarah's moms discharge teaching about breastfeeding. What would be your best reply when they ask how many extra calories they should be taking in? An extra 500 calories a day. An extra serving of dairy and vegetables is sufficient. An extra 1500 calories a day. They shouldn't be taking in any extra calories a day.

Attempts to place hands in mouth

• A nurse is caring for a newborn. Which of the following actions by the newborn indicates readiness to feed? A. Spits up clear mucus B. Attempts to place their hand in their mouth C. Turns the head toward sounds D. Lies quietly with their eyes open

-A normal postural discharge of lochia

During ambulation to the bathroom, postpartum client experiences of gush of dark red blood that soon stops. On assessment, a nurse finds the uterus, be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data is being? -Evidence of a possible vaginal hematoma -An indication of a cervical or peroneal laceration -A normal postural discharge of lochia

Increase in childcare tasks Financial concerns Increase in fatigue level

During an office visit at 2-weeks postpartum, the gravida 3, para 3 patient, she mentions an increase in stress level following delivery of this child. The nurse explains that the increase may be attributed to which considerations? Select all that apply. Increase in childcare tasks Financial concerns Lack of paternal participation Increase in fatigue level Decrease in partner intimacy

should be praised for interactions and encouraged to discuss beliefs on fathering

Fathers who are detached from the process of pregnancy, delivery, and infant care due to cultural reasons_____________. should be left in their detachment, and nursing interventions should focus on the mother won't be able to bond with their infants, and will not form attachment to them should be praised for interactions and encouraged to discuss beliefs on fathering need to be watched closely for signs of abusive interactions with the mother and infant

6%, 42%, 52%

Human breastmilk is composed of proteins, carbohydrates, and fats. What is the correct composition for proteins, carbohydrates, and fat in human breastmilk? 52%, 42%, 6% 42%, 6%, 52% 6%, 42%, 52% 6%, 52%, 42%

Covering the newborn head with a cap

3. A nurse is caring for a newborn immediately following birth. Which of the following nursing interventions is the highest priority? A. Initiating breastfeeding B. Performing the initial bath C. Giving a vitamin K injection D. Covering the newborn's head with a cap

Where is supportive bra continuously for 72 hours

3. A nurse is providing discharge teaching for a nonlactating client. Which of the following instructions should the nurse include in the teaching? A. "Wear a supportive bra continuously for the first 72 hours." B. "Pump your breast every 4 hours to relieve discomfort." C. "Use breast shells throughout the day to decrease milk supply." D. "Apply warm compresses until milk suppression occurs."

Suction the mouth and nose with a bulb syringe.

A nurse notes a 4-hour-old neonate gagging and cyanotic around the mouth. What is the priority nursing action for this neonate? Rub the back to stimulate crying. Administer oxygen per protocol. Suction the mouth and nose with a bulb syringe. Notify the provider and begin CPR.

"The baby is too large for your pelvis."

A provider has determined a client needs a cesarean section for cephalopelvic disproportion. The client asks the nurse to explain what cephalopelvic disproportion means. What is the best response by the nurse? "You are needing a c-section due to the baby experiencing stress from labor." "Let's focus on preparing for the surgery." "The baby is too large for your pelvis." "Have you had a recent ultrasound to estimate the baby's weight?"

"Itchiness, also known as pruritis, is a common reaction to morphine and is not considered an allergy."

Following a cesarean section a few hours ago, the partner of a client comes out to the nurses' station to report severe itchiness the client is experiencing. The partner voices concern that the client is experiencing an allergic reaction to the morphine given during surgery. How does the nurse respond to the client when entering to the room to assess the itching? "Itchiness, also known as pruritis, is a common reaction to morphine and is not considered an allergy." "Here is some medication to stop the itching." "I will note in your medical record that you have an allergy to morphine." "Let me call the provider and report the itching."

Postpartum hemorrhage

Following a cesarean section, the nurse caring for the client notes the following assessment data: Temperature 99.1?, Heart rate 136, Respirations 20, Blood pressure 82/48, and skin pale and clammy to the touch. The nurse reports concern of what postpartum complication to the provider? Respiratory depression Renal failure Wound infection Postpartum hemorrhage

Document the findings as within normal limits

Immediately after birth, the nurse notes the patient's fundus is palpated midway between the umbilicus and symphysis pubis. What is the priority nursing action? Document the findings as within normal limits Perform fundal massage Instruct the woman to empty her bladder Reassess every 5 minutes

tone, tissue, trauma, thrombin disorders

The four Ts that represent the most common causes of a PPH are ___________________. tone, tissue, trauma, thrombin disorders tone, time, trauma, thrombin disorders tone, T-cell, trauma, thrombin disease trauma, time, tone, thrombolytic disease

Keep the nipple full of formula

2. A nurse is teaching a group of new parents about proper techniques for bottle feeding. Which of the following instructions should the nurse provide? A. Burp the newborn at the end of the feeding. B. Hold the newborn close in a supine position. C. Keep the nipple full of formula throughout the feeding. D. Refrigerate any unused formula.

"Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum."

A perinatal nurse is educating a patient with preeclampsia about potential complications during delivery. What important information should the nurse include in the teaching? "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 2 weeks postpartum." "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 6 weeks postpartum." "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 6 months postpartum." "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum."

Assessing for flatulence

In addition to assessing bowel sounds, what other priority gastrointestinal assessment should be completed on a client following a cesarean section delivery? Assessing for nausea Last bowel movement before surgery Assessing for flatulence Tolerance of a full liquid diet

Intimate partner violence

Untreated serious injuries can indicate which of the following? Anemia Poverty and a lack of transportation Intimate partner violence AIDS

Massage the fundus with the palm of the hand

When performing a fundal assessment on a patient, 2 hours following an uncomplicated vaginal delivery, the postpartum nurse notes a boggy uterus. What is the priority nursing action for this patient? Massage the fundus with the palm of the hand Place an indwelling catheter Notify the physician or midwife Give Oxytocin as per the physician's orders

She may have feelings of guilt and anxiety. She will reconnect with her partner. She will accept the infant as a separate entity and regain her independence.

Which of the following statements describe a mother in the letting-go phase? Select all that apply. She may have feelings of guilt and anxiety. She will transition to the role of mother. She will need assistance in caring for herself and the infant. She will reconnect with her partner. She will accept the infant as a separate entity and regain her independence.

It is a very common finding in postpartum mothers. Rest and emotional support can help to resolve it.

Which of the following statements is true about postpartum blues? Select all that apply. It is a very common finding in postpartum mothers. It only happens to multiparas. It needs emergency intervention and hospital admittance. Rest and emotional support can help to resolve it. It usually arises in the taking-in phase.

Respiratory

Which system is established first at delivery and has the most profound impact on the other body systems in the immediate postpartum period? Cardiac Respiratory Hepatic Immune

Appropriate for gestational age

1. A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which of the following? A. Low birth weight B. Appropriate for gestational age C. Small for gestational age D. Large for gestational age

Epstein pearls

2. A nurse is completing a newborn assessment and observes small pearly white nodules on the roof of the newborn's mouth. This finding is a characteristic of which of the following conditions A. Mongolian spots B. Milia spots C. Erythema toxicum D. Epstein's pearls

Hypospadias Family history of hemophilia Epispadias

2. A nurse is reviewing contraindications for circumcision with a newly hired nurse. Which of the following conditions are contraindications? (Select all that apply.) A. Hypospadias B. Hydrocele C. Family history of hemophilia D. Hyperbilirubinemia E. Epispadias

I will clean the penis with every diaper change with WARM WATER NO SOAP

3. A nurse is providing discharge teaching to the parents of a newborn regarding circumcision care. Which of the following statements made by a parent indicates an understanding of the teaching? A. "The circumcision will heal within a couple of days." B. "I should remove the yellow mucus that will form." C. "I will clean the penis with each diaper change." D. "I will give him a tub bath within a couple of days."

Early onset of menarche Breast cancer gene (BRCA1 or BRCA2) mutation Smoking

A female client is concerned about breast cancer. Which factors should the nurse explain are risk factors for breast cancer? Select all that apply. Early onset of menarche Early onset of menopause Breast cancer gene (BRCA1 or BRCA2) mutation Oral contraceptive use Smoking

Apply petroleum guys to the site for 24 hours, prevent the skin edges from sticking

4. A nurse is caring for a newborn immediately following a circumcision using a Gomco procedure. Which of the following actions should the nurse implement? A. Apply Gelfoam powder to the site. B. Place the newborn in the prone position. C. Apply petroleum gauze to the site. D. Avoid changing the diaper until the first voiding.

Apnea for 10 second periods and obligatory nose breathing

4. A nurse is completing an assessment. Which of th following data indicate the newborn is adapting to extrauterine life? (Select all that apply.) A. Expiratory grunting B. Inspiratory nasal flaring C. Apnea for 10-second periods D. Obligatory nose breathing E. Crackles and wheezing

C. Place used bottles in the dishwasher. D. Check the nipple for appropriate flow of formula. E. Use tap water to dilute concentrated formula

4. A nurse is reviewing formula preparation with parents who plan to bottle-feed their newborn. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Use a disinfectant wipe to clean the lid of the formula can. B. Store prepared formula in the refrigerator for up to 72 hr. C. Place used bottles in the dishwasher. D. Check the nipple for appropriate flow of formula. E. Use tap water to dilute concentrated formula.

Genital herpes

A female client presents to acute care reporting genital blisters that are very painful. She also reports muscle aches and malaise. Which condition does the nurse anticipate the client will be treated for? Influenza Syphilis Genital herpes Condyloma

Candidiasis

A female client presents to the outpatient clinic for a possible vaginal infection. She reports vaginal itching and, upon examination, has vulvar erythema and thick curd-like discharge. Which condition should the nurse anticipate treatment for? Trichomoniasis Candidiasis Bacterial vaginosis Chlamydia

"The mammogram can detect early stages of breast cancer, even before a lump is felt."

A 50-year-old female client has a screening mammogram ordered, and asks the nurse, "Why do I need this if I don't feel any breast lumps?" Which is the best response by the nurse? "The mammogram can detect early stages of breast cancer, even before a lump is felt." "The mammogram can tell if the lump is a fluid-filled cyst or a solid mass." "The mammogram uses magnets and radio waves to find breast tumors." "There will be a small needle inserted in your breast to check for cancer."

lanugo and vernix caseosa

A baby born prematurely at 30 weeks will have an increased amount of ___________ and _________ compared to a term infant born at 40 weeks. hyperglycemia and erythema toxicum lanugo and millia lanugo and vernix caseosa vernix caseosa and erythema toxicum

"It is normal for the baby to lose 5 to 10% of her weight during the first week due to diuresis."

A breastfeeding client asks the nurse, "Why has my baby lost 5 ounces since she was born?" What is the best response by the nurse? "She may lose weight until your milk comes in." "It is normal for the baby to lose 5 to 10% of her weight during the first week due to diuresis." "The baby may be dehydrated, which is not uncommon in a breastfed baby." "The baby is having bowel movements, which results in a weight change."

"The stool is normal and called meconium. The baby may pass this for the first day or two."

A breastfeeding mother changes her newborn's diaper and asks the nurse why the stool is black and difficult to clean. What is the best response by the nurse? "This can be caused by blood in the stool and I will check it to make sure everything is okay." "Let me call the physician and see if we need to supplement the baby with formula." "The stool is normal and called meconium. The baby may pass this for the first day or two." "The iron you took during the pregnancy caused the stool to be tarry and thick."

B. Give the client time to express her feelings. The nurse should recognize that the client in is the taking‑in phase, which begins immediately following birth and lasts a few hours to a couple of days.

A client in the early postpartum period is very excited and talkative. She is repeatedly telling the nurse every detail of her labor and birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following action should the nurse take? a. Come back later when the client is more cooperative b. Give the client time to express her feelings c. Tell the client she needs to be quiet so the assessment can be completed d. Redirect the client's focus so that she will become quiet

Heavy menstrual bleeding

A client in the gynecology clinic asks the nurse about the word "menorrhagia," which the client saw written in their medical record. What is the correct definition of menorrhagia? Painful menstruation Bleeding between periods Heavy menstrual bleeding No menstruation in three months

"Get all of the nipple and as much areola as you can in the baby's mouth."

A client is breastfeeding her full-term newborn for the first time. She reports to the nurse that her nipples are sore. What suggestion can the nurse provide to the client after observing the feeding? "Bring your breast to the baby, as this will help the baby latch." "Get all of the nipple and as much areola as you can in the baby's mouth." "Let the baby suck only on the tip of the nipple." "Use a pacifier as a tool to get the baby to suck appropriately."

Vaginal birth

A client is pregnant with her second child following a cesarean section delivery with the first pregnancy for a breech fetal position. The couple plans to have three children total. What option does the nurse discuss as the best one for this couple? Vaginal birth Repeat c-section External cephalic version Only having two children

"This is inflammation of abnormal endometrial tissue found outside the uterus."

A client was diagnosed with endometriosis and asks the nurse what this is. How should the nurse respond? "This is inflammation of abnormal endometrial tissue found outside the uterus." "This is an infection of the lining of the uterus." "This is excessive growth of cells in the uterus." "This is a collection of benign growths on the uterus."

strong

A couple that enters into parenthood with a __________ relationship will have a smoother and less stressful transition. contractual authoritative/passive detached strong

"Avoid alcohol while taking this medication."

A female client has been prescribed oral metronidazole (Flagyl) for the treatment of bacterial vaginosis. What is essential for the nurse to teach the woman? "Male sexual partners should also be treated." "Avoid alcohol while taking this medication." "Take the medication until the symptoms resolve." "The medication can also treat candidiasis."

Polycystic Ovary Syndrome

A female client has been trying to get pregnant for over one year. Which condition does the nurse explain as the most common cause of female infertility? Endometriosis Polycystic Ovary Syndrome Chronic pelvic pain Vaginitis

"Your milk is not infected, so you can continue to breastfeed and we will prescribe an antibiotic today."

A mother who has been breastfeeding for three months calls the clinic to speak to the nurse. She reports a fever, unilateral breast swelling, pain and redness. She is worried about continuing to breastfeed. What is the appropriate nursing response? "Pump and discard your breastmilk until you finish your course of prescribed antibiotics." "Massaging the area while you breastfeed will treat the infection." "Your milk is not infected, so you can continue to breastfeed and we will prescribe an antibiotic today." "You need to be more diligent about cleaning your pump supplies."

Couplet #2: the infant has been breastfeeding successfully and the mother has required the uterine fundus to be massaged to firm.

A mother-baby nurse just received report on four mother baby couplets and is preparing to start the first assessments of the shift. All are recovering from cesarean section deliveries. Which couplet will need to be seen first? Couplet #1: the infant and mother have been doing well since delivery 3 days ago and would like to be discharged in the next couple hours. Couplet #2: the infant has been breastfeeding successfully and the mother has required the uterine fundus to be massaged to firm. Couplet #3: the mother has chosen to bottle feed the infant, and the infant has lost 89 grams of the 3200-gram birth weight at 2 days of age Couplet #4: the infant has been experiencing difficulties latching on to breastfeed and last nursed successfully an hour and a half ago.

"I caught my toddler hitting the baby when I was not in the room."

A new mother calls the provider's office, concerned about her toddler's behavior toward the family's newborn. Which statement by the mother would require further assessment by the nurse? "Even though my toddler is fully potty-trained, they have begun wetting their pants again." "My toddler has insisted on using a bottle at mealtimes." "I caught my toddler hitting the baby when I was not in the room." "My toddler said they 'hated' the baby and has started to throw tantrums."

"That is a normal finding as a result of the withdrawal of hormones from pregnancy."

A new mother in the postpartum unit calls the nurse to the bedside. The mother states, "I just changed my baby girl's diaper and noticed a small amount of pink discharge in her diaper. Do you think something is wrong with my baby?" Which statement is the nurse's best response to the mother? "I will call the pediatrician with your concern." "Let's go ahead and give the baby some formula in addition to your colostrum." "That is a normal finding as a result of the withdrawal of hormones from pregnancy." "That is nothing to worry about. All babies have pink discharge in the newborn period."

-Provide education about infant care when the parent is present

A nurse concludes that the parent of a newborn is not showing positive indications of parent input bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following action should the nurse use to promote parent infant bonding? -hand the parent the newborn, and suggest to change the diaper -Ask the parent why they are so anxious and nervous -Tell the parent they will grow accustomed to the newborn -Provide education about infant care when the parent is present

The newborn was crying loudly. The newborn was placing a hand near the mouth.

A nurse enters the room of a new mother and newborn. The mother is sleeping in the bed and the infant is lying in the bassinet. The nurse notices the baby showing early signs of hunger and wakes the mother to breastfeed. What did the nurse notice? Select all that apply. The newborn was placing a hand near the mouth. The newborn was in a deep sleep state. The newborn was sucking on their hand. The newborn was crying loudly. The newborn was in need of a diaper change.

D. Position the neonate skin-to-skin on the client's chest.

A nurse in the delivery room is planning to promote maternal-infant bonding for a client who just delivered. Which of the following is the priority action by the nurse? a. Encourage the parents to touch and explore the neonate's features b. Limit noise and interruption in the delivery room c. Place the neonate at the client's breast d. Position the neonate skin-to-skin on the client's chest

Neonates have decreased subcutaneous fat.

A nurse initiates measures to maintain thermoregulation in a newborn. Which statement best describes why neonates are at a higher risk for thermoregulatory problems? Neonates have a smaller body surface area. Neonates have decreased subcutaneous fat. Neonates are able to shiver and increase heat production. Neonates have a lower metabolic rate.

Urinary retention

A nurse is assessing a postpartum client with fundal height, location, and consistency. The fundus as noted to be displaced laterally to the right and there is uterus stony. The nurse should identify which of the following conditions as the cause of this? -Poor involution -Urinary retention -Hemorrhage -Infection

Assess the uterus for location, position and tone of fundus every 15 minutes Titrate IV Oxytocin infusion rate to uterine tone Provide information regarding afterpains Assess lochia for color, amount, and odor

A nurse is caring for a G2P2 patient in the initial hour after giving birth. What are the appropriate nursing interventions to be taken with this patient? Select all that apply. Assess the uterus for location, position and tone of fundus every 15 minutes Titrate IV Oxytocin infusion rate to uterine tone Provide information regarding afterpains Assess lochia for color, amount, and odor Inspect the inside of the vagina for tearing

Ampicillin

A nurse is caring for a client following a cesarean section four hours ago that occurred due to arrest of labor. Initially, the client was admitted to the hospital two days ago after experiencing spontaneous rupture of membranes. Which medication order does the nurse anticipate for this client? Bisacodyl Ampicillin Methergine Dexamethasone

-demonstrates apathy when the newborn cries -Use the newborns behavior as uncooperative during diaper changes

A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation and parent infant bonding. Which of the following behaviors by the client indicates the need for the nurse to intervene -demonstrates apathy when the newborn cries -Touches the newborn and maintains close physical proximity -Use the newborns behavior as uncooperative during diaper changes -Identifies and relates newborns characteristics of those a family -Interprets the newborns behavior is meaningful in the way of expressing needs

The mother cleans the umbilical cord with warm water and places on the outside of the diaper.

A nurse is providing discharge education to a new mother regarding umbilical cord care. Which action by the mother demonstrates effective teaching regarding umbilical cord care? The mother cleans the umbilical cord with an alcohol swab to prevent infection. The mother applies petroleum jelly to the cord to prevent it from sticking to the diaper. The mother places the umbilical cord in the diaper to prevent the cord from rubbing on clothing. The mother cleans the umbilical cord with warm water and places on the outside of the diaper.

-Use a perineal squeeze bottle to cleanse the perineum -apply a topical anesthetic cream or spray to the perineum -apply cold ice packs to the perineum

A nurse is providing education to a client who has two hours postpartum and has peroneal lacerations. Which of the following information should the nurse include select all that apply -Use a perineal squeeze bottle to cleanse the perineum -sit in the perinium while resting in bed -apply a topical anesthetic cream or spray to the perineum -wipe from back to front -apply cold ice packs to the perineum

Cradle

A nurse is reviewing breastfeeding positions with the parent of a newborn. Which of the following positions should the nurse discuss? A. Over-the-shoulder B. Supine C. Chin-supported D. Cradle

Prolactin increases

A nurse is teaching a new mother about milk production. The client has questions about the hormones that stimulate milk production. What will the nurse include in the answer? Estrogen increases Oxytocin decreases Progesterone increases Prolactin increases

Tell the patient how well she does when she does the care for the infant.

A nurse observes a 14-year-old and her new baby. The nurse notes the grandmother doing most of the holding and care of the infant. What is the appropriate nursing intervention? Show the patient more baby care videos and ask if she is depressed Tell the mother, "It\"s time to grow up." Point out how well the grandmother is doing with the infant. Tell the patient how well she does when she does the care for the infant.

Thrombin

A patient delivered four hours ago after via cesarean section for preeclampsia calls the nurse to the bedside. The patient reports dizziness, diaphoresis and oozing of blood from her current IV site. The nurse determines these findings are consistent with which of the 4 Ts? Tone Tissue Trauma Thrombin

Pulmonary embolism

A patient who just delivered is experiencing dyspnea, tachycardia, fever, and tachypnea. What postpartum complication is this patient most likely experiencing? Hematoma Mastitis Anaphylactoid syndrome of pregnancy Pulmonary embolism

"The hard work of labor can cause your temperature to increase." "It is common for women to experience mild temperature elevation after giving birth." "Your body is going through a lot of hormonal changes right now, which can increase your temperature."

A postpartum client asks the nurse why her temperature is slightly elevated. What is the correct response from the nurse? Select all that apply. "You had a fever during labor and the antibiotics have not started working yet." "The hard work of labor can cause your temperature to increase." "It is common for women to experience mild temperature elevation after giving birth." "Your body is going through a lot of hormonal changes right now, which can increase your temperature." "Do you feel hot? I will get you some Tylenol."

"I will need you to keep track of your oral intake with the goal of drinking at least 1500 mL each day."

A postpartum mother delivered two hours ago and has a history of recurrent urinary tract infections (UTIs). She is very anxious about the risk of UTI after delivery and asks the nurse what she can do to decrease her risk. Which response by the nurse would require further education regarding recommendations to prevent UTI? "If you are unable to get up and walk to the bathroom to void in the next hour, I will need to insert a catheter to empty your bladder." "I will need you to keep track of your urine output with the goal of voiding at least 150 mL." "It is important to be changing your peri pad every 3-4 hours." "I will need you to keep track of your oral intake with the goal of drinking at least 1500 mL each day."

Assess the position, tone and location of the fundus Massage boggy uterus Quantify blood loss Instruct the client to void and reevaluate

A postpartum nurse caring for a patient who had a vaginal delivery 3 hours ago notices heavy lochia. What are the priority nursing interventions for this patient? Assess the position, tone and location of the fundus Massage a b doggy uterus Document the findings and reassess in 1 hour Quantify blood loss Instruct the client to void and reevaluate

Boggy uterus

A postpartum nurse is caring for a patient who gave birth 1 hour ago following a 24-hour long induction. The patient had an epidural for pain control during labor. What assessment finding should immediately be reported to the healthcare provider? Boggy uterus Bilateral lower extremity numbness Uncontrollable shaking Moderate vaginal bleeding

A G3P2 who was induced with Pitocin for preeclampsia

A postpartum nurse is caring for multiple patients on the mother-baby unit. Which patient does the nurse assess as being at the highest risk for fluid volume overload? A G1P0 who had an epidural for 6 hours during labor A G3P2 who was induced with Pitocin for preeclampsia A G8P2 with insulin-controlled gestational diabetes A G2P2 who had a repeat cesarean section 24 hours ago

"I understand your concern. Let's take a look at the back of your legs together."

A postpartum patient expresses concern that she will get a blood clot in her leg because her mother had one after her delivery. What is the most therapeutic response by the nurse? "Blood clots do not run in families, so you have nothing to worry about." "I understand your concern. Let's take a look at the back of your legs together." "Women are only at risk for developing blood clots during pregnancy." "I will assist you to ambulate around the hallway so that doesn't happen."

Dry the neonate thoroughly

After the birth of a newborn, what is the priority nursing action to prevent cold stress? Swaddle in warm blankets Place under a radiant warmer Place a stocking cap on the neonate's head Dry the neonate thoroughly

Avoid milk stasis, or milk staying in the breasts for long periods of time.

In order to prevent mastitis, patients should be encouraged to do which of the following? Supplement with bottles during the night. Schedule breastfeeding sessions every 3 hours. Breastfeed through nipple pain to ensure the breasts are emptied. Avoid milk stasis, or milk staying in the breasts for long periods of time.

Education on complimentary modalities Nutritional information

Nursing care for cancer patients should include which of the following? Select all that apply. Education on complimentary modalities Nutritional information Lectures on avoiding obesity and smoking Reducing caffeine intake Avoiding excessive exercise

enrollment in a home visiting program

Nursing interventions for adolescents should include _____________________. the same interventions as for any other mom enrollment in a home visiting program creating mutual role agreements between spouses enrollment into the foster system to insure proper care of the infant

Calling timeouts Placing identification bands on the infant and parents Placing the infant skin-to-skin

Nursing responsibilities during a cesarean section include which of the following? Select all that apply. Calling timeouts Placing identification bands on the infant and parents Obtaining consent for the procedure Placing the infant skin-to-skin Placing the grounding pad

Caput is primarily seen in cesarean section, and cephalhematoma occurs during normal vaginal deliveries. Caput crosses suture lines and disappears quickly, cephalhematoma does not cross suture lines and takes weeks to resolve.

One way to differentiate caput succedaneum and cephalhematoma is which of the below? Caput is primarily seen in cesarean section, and cephalhematoma occurs during normal vaginal deliveries. Cephalhematoma crosses suture lines and takes weeks to resolve, and caput will encompass the entire occipital area and resolve quickly. Caput is seen frequently in precipitous deliveries, cephalhematoma is seen when there is a prolonged second stage of labor. Caput crosses suture lines and disappears quickly, cephalhematoma does not cross suture lines and takes weeks to resolve.

Cultural beliefs can influence the woman's behaviors and the amount of time she spends in each phase. Cultural beliefs influence the degree of the father\"s care for the infant. Cultural beliefs can affect the role of extended family members. Cultural beliefs can influence the infant\"s name.

Why is it important for nurses to understand cultural competence for parental phases? Cultural beliefs can influence the woman's behaviors and the amount of time she spends in each phase. Cultural beliefs influence the degree of the father\"s care for the infant. Cultural beliefs can affect the role of extended family members. Cultural beliefs can influence the infant\"s name. Cultural beliefs can influence parental decisions when disciplining a young child.