ATI Maternal Newborn Dynamic Quizzing 5
A nurse is reinforcing teaching about preventing engorgement to a client who is planning to use formula to feed her newborn. Which of the following instructions should the nurse include? a. "Apply ice packs to your breasts." b. "Hand express milk from your breasts 3 times each day." c. "Try to avoid wearing a bra as much as possible throughout the day." d. "Request a prescription for medication to suppress lactation."
a. "Apply ice packs to your breasts."
A nurse is teaching a client who is pregnant and has pregestational diabetes about dietary changes. Which of the following statements should the nurse include in the teaching? a. "Carbohydrates should make up 55% of your diet." b. "Protein should make up 70% of your diet." c. "Fats should make up 45% of your diet." d. "Fiber should make up 10% of your diet."
a. "Carbohydrates should make up 55% of your diet." For clients who have pregestational diabetes, intake of simple carbohydrates should be limited. The ideal diet is composed of 55% carbohydrates, 20% protein, 25% fat, and less than 10% saturated fat
A nurse is providing teaching to a client who is 1 hour postpartum about using the perineal squeeze bottle. Which of the following instructions should the nurse include? a. "Fill the perineal bottle with warm water prior to use." b. "Squeeze the perineal bottle while standing up in the bathroom to cleanse the perineum." c. "Only use half of the perineal bottle for cleansing." d. "Wipe the perineum with toilet paper from back to front after using the perineal bottle."
a. "Fill the perineal bottle with warm water prior to use."
A nurse is teaching a prenatal class about pain management during labor. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I can apply a heating pad to my back to relieve back pain." b. "I can have a low spiral block to help with labor pain." c. "I can have butorphanol every 2 hours during labor." d. "My time limit for staying in the hydrotherapy tub is 30 minutes."
a. "I can apply a heating pad to my back to relieve back pain." Heat application to the lower back can help promote relaxation and relieve pain because they reduce ischemia in the muscles and bring more blood flow to the area. The client should have 1 to 2 layers of cloth between her skin and the heating pad.
The guardian of a 3-day-old female newborn tells the nurse that he noticed a small amount of blood-tinged mucus discharge on the newborn's labia. Which of the following responses should the nurse make? a. "The blood-tinged mucus is a result of pseudomenstruation." b. "The blood-tinged mucus indicates a urinary tract infection." c. "The blood-tinged mucus is due to uric acid crystals." d. "The blood-tinged mucus is a result of initial genital examination."
a. "The blood-tinged mucus is a result of pseudomenstruation."
A nurse is caring for a pregnant client who reports nausea and vomiting. Which of the following instructions should the nurse share with the client? a. "You should eat some crackers before rising from bed in the morning." b. "You should eat food served at warm temperatures." c. "You should sip whole milk with breakfast." d. "You should brush your teeth immediately after meals."
a. "You should eat some crackers before rising from bed in the morning."
A nurse is caring for a client at 12 weeks gestation who has a BMI of 45. Which of the following pieces of information should the nurse provide for the client regarding the recommended weight gain during her pregnancy? a. "You should plan to gain no more than 30 pounds during your pregnancy." b. "You should plan to gain between 25 to 35 pounds during your pregnancy." c. "You should not plan to gain any weight during your pregnancy because you are already well-nourished." d. "Since you have higher energy needs than an average-sized pregnant client, you should plan to gain 45 to 50 pounds.
a. "You should plan to gain no more than 30 pounds during your pregnancy."
A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide? a. "You should slightly increase your exposure to sunlight." b. "You will need extensive dermatological treatment for this condition after you deliver your baby." c. "Your provider will schedule weekly lab testing to monitor your liver function." d. "Your provider will prescribe isotretinoin cream."
a. "You should slightly increase your exposure to sunlight." It is a condition of pregnancy that causes generalized itching without the presence of a rash. This occurs due to the stretching of the skin. Exposure to sunlight can reduce itching, will resolve without extensive treatment, it will go away after delivery, it does not affect the liver. Therefore, the client will not need a weekly liver function study. Isotretinoin is used to treat acne and should not be prescribed to a pregnant client because of its teratogenic effect on the fetus.
A nurse is caring for a client in the third trimester of pregnancy who is scheduled to undergo a non-stress test. Which of the following actions should the nurse take prior to the test? a. Ask the client to drink a glass of orange juice b. Prepare the client for a vaginal examination c. Request a serum hemoglobin level d. Obtain a clean-catch urine specimen
a. Ask the client to drink a glass of orange juice
A nurse is caring for a client who is experiencing preterm labor. Which of the following medications should the nurse anticipate administering to enhance fetal lung maturation? a. Betamethasone b. Nifedipine c. Indomethacin d. Verapamil
a. Betamethasone Nifedipine is administered as tocolytic therapy for preterm labor. Indomethacin is administered as tocolytic therapy for preterm labor. Verapamil is used to treat maternal and fetal arrhythmias during pregnancy.
A nurse is teaching a client who is at 12 weeks gestation about manifestations of potential complications that she should report to her provider. Which of the following pieces of information should the nurse include in the teaching? a. Facial swelling b. Urinary frequency c. White vaginal discharge d. Intermittent nausea
a. Facial swelling The nurse should instruct the client to report facial swelling because this can indicate hypertensive disorder or preeclampsia.
A nurse is providing nutritional counseling for a client who is pregnant. Which of the following nutrients should the nurse instruct the client to increase in her daily diet? a. Iron b. Calcium c. Vitamin E d. Vitamin K
a. Iron
A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? a. Respiratory depression b. hypothermia c. Hypoglycemia d. Jaundice
a. Respiratory depression
A nurse is planning educational sessions for clients in a childbirth class. Which of the following findings should the nurse plan to instruct the clients to report immediately? a. Vaginal leukorrhea b. Shortness of Breath a. Small, pinpoint, reddish-purple spots on the chest d. Lower back pain
a. Small, pinpoint, reddish-purple spots on the chest Swelling of face and feet is an indication of hypertensive disorders such as eclampsia. SOB is a common finding during the third trimester of pregnancy due to enlarging uterus pushing the diaphragm upward.
A nurse is performing an initial physical assessment of a newborn following a vaginal birth. Which of the following findings should the nurse report to the provider? a. Small, pinpoint, reddish-purple spots on the chest b. Bluish coloring of the feet c, Overlapping suture lines d. White, cheese-like substance covering the skin
a. Small, pinpoint, reddish-purple spots on the chest These marks are petechiae, which are commonly found above the neck if the umbilical cord was around the newborn's neck at birth. Petechiae in any other circumstance should be reported because this finding can indicate infection or a low platelet count.
A nurse is caring for a client who is in labor and is receiving IV oxytocin. The nurse notes contractions lasting 3 min each. What action should the nurse take? a. Stop the oxytocin infusion b. Apply oxygen at 2 L/min via nasal cannula c. Administer methylergonovine intramuscularly d. Prepare for an emergent cesarean birth
a. Stop the oxytocin infusion A pattern of contractions lasting longer than 2 minutes or of more than 5 contractions in a 10-minute period is considered tachysystole. This pattern can decrease the placental perfusion of oxygen. The appropriate action is to discontinue the oxytocin infusion.
A nurse is caring for a client in active labor whose membranes have ruptured. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first? a. Turn the client onto her left side b. Palpate the client's uterus c. Administer oxygen to the client d. Increase the client's IV fluids
a. Turn the client onto her left side Turning the client onto her side her side will relieve the pressure on the inferior vena cava, which decreases the oxygen to the placenta and the fetus.
A nurse is caring for a client who is at 16 weeks gestation and has severe iron-deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication? a. Use a 20-gauge needle to administer the medication using the z-track method. b. Use a 22-gauge needle and administer the medication deep into the thigh c. Use a 25-gauge needle and administer to the medication into the deltoid muscle. d. Use an 18-gauge needle and administer the medication into the rectus femoris muscle
a. Use a 20-gauge needle to administer the medication using the z-track method into the ventrogluteal muscle.
A nurse is providing education for a pregnant client about symptoms that should be reported immediately to the provider. Which of the following client responses indicates an understanding of the teaching? a. "I should call my provider if I develop melasma." b. "If I notice that my eyes are puffy, I should call my provider." c. "I should call my provider if I notice that my feet and ankles are swollen." d. "If I notice periodic numbness and tingling in my fingers, I should call my provider."
b. "If I notice that my eyes are puffy, I should call my provider." Puffy eyes are associated with facial edema, which is a sign of pregnancy-induced hypertension. This should be reported immediately. Melasma, a blotchy pigmentation of the skin on the face, is an expected finding during pregnancy. Dependent or physiological edema during pregnancy requires no treatment. If the client also has swelling of the face or hands, reporting is warranted. These symptoms are caused by drooping of the shoulders during pregnancy, which causes traction on the brachial plexus nerve. This is a common occurrence during pregnancy. Maintaining good posture will help diminish the sensation.
A nurse is providing care to a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding? "Which of the following responses should the nurse make? a. "This could indicate a possible uterine infection." b. "The bleeding is minimal until I discontinue your IV medication." c. "You might have retained some fragments of your placenta." d. "You will require additional medication to increase your bleeding."
b. "The bleeding is minimal until I discontinue your IV medication."
A nurse is providing education to a client who is at 34 weeks of gestation about a non-stress test (NST). Which of the following pieces of information should the nurse include? a. "It will take about 10 minutes to complete the test." b. "You might have to drink orange juice during the test:' c. "During the test, you will be asked to massage your nipples." d. "During the test, you will receive a medication to relax your uterus."
b. "You might have to drink orange juice during the test:'
A nurse is teaching a client who is at 10 weeks gestation about an abdominal ultrasound in the first trimester. Which of the following pieces of information should the nurse include in the teaching? a. "You will have a nonstress test prior to the ultrasound." b. "You will need to have a full bladder during the ultrasound." c. "The ultrasound will determine the length of your cervix." d. "You will experience uterine cramping during the ultrasound."
b. "You will need to have a full bladder during the ultrasound."
A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? a. Anterior fontanel of 5 cm b. Central cyanosis c. Edematous scrotum d. capillary refill of under 2 seconds
b. Central cyanosis Central cyanosis is an indication of compromised cardiorespiratory status. Other manifestations include tachypnea, nasal flaring, retractions, and grunting.
A nurse is caring for a client who is in labor. The client speaks a different language than the nurse and is grimacing. Which of the following actions should the nurse take while waiting for an interpreter? a. Administer pain medication b. Change the client's position c. Insert an indwelling urinary catheter d. Prepare for an epidural insertion
b. Change the client's position
A nurse receives a report for a client who is in labor and is experiencing contractions that are 4 min apart. Which of the following patterns should the nurse expect on the fetal monitor tracing? a. Contractions that last for 60 sec each with a 4 min rest between contractions b. Contractions that last for 60 sec with a 3 min rest between contractions c. A contraction that lasts for 4 min followed by a period of relaxation d. Contractions that lasts for 45 sec each with a 3 min rest between contractions
b. Contractions that last for 60 sec with a 3 min rest between contractions A contraction interval indicates how often a uterine contraction occurs. The nurse measures the interval from the beginning of one contraction to the beginning of the next contraction. A contraction lasting 60 seconds with a relaxation of 3 minutes is equivalent to contractions every 4 minutes. a. This contraction interval is 5 minutes c. This pattern is longer than 4 minutes d. This contraction pattern is under 4 minutes
A nurse is providing teaching for new parents about formula feeding. Which of the following instructions should the nurse include? a. The bedtime bottle can be placed in the crib after the infant is 6 months of age. b. Discard opened cans of formula after 48 hr refrigeration. c. Powdered and concentrated formula can be reconstituted with tap water straight from the faucet. d. Bottles and nipples can be hand-washed in hot, soapy water.
b. Discard opened cans of formula after 48 hr refrigeration.
A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1-2 hours of delivery? a. Naloxone b. Erythromycin ophthalmic ointment c. Poractant alfa d. Rotavirus immunization
b. Erythromycin ophthalmic ointment Erythromycin ophthalmic ointment is administered to prevent gonorrheal or chlamydial infections transmitted from the mother. Naloxone is administered if the newborn has respiratory depression, it can occur if the mother received opioid pain medications shortly before giving birth. Newborns who are premature receive poractant alfa, a surfactant replacement, to prevent and treat respiratory distress syndrome.
A nurse is assessing the respiratory status of a newborn who was born 3 hours agon. Which of the following findings should the nurse identify as a manifestation of respiratory distress? a. Acrocyanosis b. Expiratory grunting c. Respiratory rate 56/min d. Irregular respirations
b. Expiratory grunting Grunting is an indication of respiratory distress that is caused by narrowing of the bronchi. The nurse should report this finding to the provider.
A nurse is teaching a client with pre-eclampsia who is scheduled to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching? a. Elevated blood pressure b. Feeling of warmth c. Hyperactivity d. Generalized pruritus
b. Feeling of warmth The nurse should tell the client to expect a feeling of warmth all over her body while the magnesium sulfate is infusing. The client should expect a decrease in blood pressure while the magnesium sulfate is infusing. The client will feel sedated while magnesium sulfate is infusing. Generalized pruritus can be a manifestation of an allergic reaction to magnesium sulfate.
A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? a. Overlapping suture lines b. Generalized petechiae c. Acrocyanosis d. Transient strabismus
b. Generalized petechiae The nurse should report generalized petechiae to the provider. This manifestation can be associated with an infection or a clothing-factor deficiency. Overlapping suture lines are an expected variation for a newborn, as the newborn's head molds during the second phase of labor to ease delivery from the vagina. Acrocyanosis is an expected manifestation for newborns during the first 24 hours following birth. Transient strabismus is an expected manifestation until the newborn is 3 to 4 months old.
A nurse is assessing a client who is 3 days postpartum. When examining the client's uterus, which of the following techniques should the nurse use? a. Press down and forward with the hand that is placed on the base of the uterus b. Measure the height of the fundus in fingerbreadths in relation to the umbilicus c. Place the client in a semi-Fowler's position prior to checking the uterus d. Massage the fundus with gentle palpation until it becomes soft to touch.
b. Measure the height of the fundus in fingerbreadths in relation to the umbilicus
A nurse is assessing a newborn. Which of the following findings suggests the newborn is post-mature? a. Pale, translucent skin b. Nails extending over fingers c. Weak gag reflex d. Thin covering of fine hair on shoulders and back
b. Nails extending over fingers
A nurse is obtaining the blood pressure of a client who is pregnant. The client's blood pressure is 142/90 mmHg. Which of the following actions should the nurse take? a. Repeat the measurement immediately using the opposite arm b. Repeat the measurement after allowing the client to sit for 5 to 10 minutes c. Repeat the measurement after repositioning the client so that her feet are off the floor d. Repeat the measurement while ensuring the client's arm is dangling at her side
b. Repeat the measurement after allowing the client to sit for 5 to 10 minutes
A nurse is providing education about newborn skin care for a group of new parents. which of the following instructions should the nurse include? a. Gently retract the foreskin to wash the glans with soap and water b. Sponge bathe the newborn every other day c. Use an antimicrobial soap for bathing d. Bathe the newborn with water between 46 and 48 C (115 and 120 F)
b. Sponge bathe the newborn every other day Daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The parents should sponge bathe the infant until the cord stump has detached and the area has healed. In uncircumcised males, the foreskin adheres to the glans penis. Parents should not attempt to retract the foreskin before the age of 3 years. Parents should wash the penis with soap and water. Parents should avoid using antimicrobial soaps; instead, soap should have a neutral pH and no preservatives to protect the acid mantle of the newborn's skin. The parents should maintain the bath water temperature between 38 to 40 C (100 and 104 F)
A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord? a. They can cause increased pain from the cord b. They can cause delayed cord separation c. They can cause swelling of the surrounding tissue d. They can cause skin discoloration
b. They can cause delayed cord separation
A nurse is monitoring a newborn who is receiving phototherapy. The nurse should identify which of the following findings as requiring intervention? a. Bilirubin level 5 mg/dL b. Weight loss 12% of birth weight c. Loose, green stools d. Axillary temperature of 36.6 C (97.9 F)
b. Weight loss 12% of birth weight
A nurse is teaching a client about breastfeeding. Which of the following client statements indicates an understanding of the teaching? a. "I should consume about 700 extra calories a day while breastfeeding." b. "I will introduce bottle feeding of pumped breast milk when my baby is 2 weeks old." c. "I may notice increased cramping when i am feeding my baby." d. "I will place my baby on a strict feeding schedule to help establish a good feeding pattern."
c. "I may notice increased cramping when i am feeding my baby."
A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching? a. "I should clean my diaphragm with alcohol each time I use it." b. "I should leave the diaphragm in place for 4 hours after intercourse." c. "I should replace my diaphragm every 2 years." d. "I should use a vaginal lubricant to insert my diaphragm."
c. "I should replace my diaphragm every 2 years." A diaphragm is a flexible rubber cup that is filled with spermicide and inserted over the cervix prior to intercourse. The diaphragm is a prescribed device fitted by a provider and should be replaced every 2 years. It should be cleaned with mild soap and water and dried gently. Alcohol dries it out and weakens the rubber, and it will reduce its effectiveness. It should remain in place for at least 6 hours after intercourse. It should be rinsed with water, and contraceptive jelly should be applied prior to placing the device into the vagina, do not use vaginal lubes, mineral oil, or baby oil because it weakens the rubber.
A nurse is caring for a client who had pelvic measurements recorded by the provider. The client asks, "Since my pelvis is gynecoid, will i be able to deliver vaginally?" Which of the following responses should the nurse make? a. "The shape of your pelvis will make vaginal childbirth difficult, but it is still possible." b. "The shape of your pelvis will require a cesarean childbirth." c. "The shape of your pelvis is ideal for vaginal childbirth." d. "The shape of your pelvis will change as you near delivery, and the provider will determine if vaginal delivery is possible."
c. "The shape of your pelvis is ideal for vaginal childbirth."
A nurse is providing teaching to a client who has come to the family planning clinic requesting an intrauterine device (IUD). Which of the following pieces of information should the nurse provide the client? a. "If you lose weight, you will need to have your IUD refitted." b. "An IUD provides protection from certain sexually transmitted infections." c. "Your risk for ectopic pregnancy increases with an IUD." d. "You shouldn't use an IUD if you want to have children later."
c. "Your risk for ectopic pregnancy increases with an IUD." It works by changing the lining of the uterus and fallopian tubes. Making fertilization in the uterus more difficult, an IUD increases risk of ectopic pregnancy.
A nurse is assessing a client who is 2 days postpartum. In which of the following locations should the nurse expect to locate the client's fundus? a. 3 cm above the umbilicus b. 1 cm above the umbilicus c. 3 cm below the umbilicus d. 1 cm below the umbilicus
c. 3 cm below the umbilicus The client's fundus should descend about 1 to 2 cm every 24 hours; therefore, at 2 days postpartum, the client's fundus should be located 3 cm below the umbilicus.
A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving this vaccine? a. Shellfish b. Gelatin c. Baker's yeast d. Eggs
c. Baker's yeast
A nurse is caring for a client who is in the first stage of labor. Which of the following findings should the nurse identify as a cause for concern? a. Pink, mucoid vaginal discharge b. Brownish vaginal discharge c. Contractions lasting 100 seconds d. Contractions occurring every 4 to 5 minutes
c. Contractions lasting 100 seconds Contractions during the first stage of labor range from 45 to 80 seconds. They should not exceed 90 seconds.
A nurse is providing teaching about the selection of commercial formula to the guardian of a newborn. Which of the following pieces of information should the nurse include? a. Soy-based formula is recommended to decrease colic. b. Amino acid formula is recommended to increase the newborn's protein intake. c. Cow's milk-based formula is recommended for healthy newborns. d. Low-iron formula is recommended to prevent excess iron intake.
c. Cow's milk-based formula is recommended for healthy newborns.
A nurse is planning care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care? a. Swaddle the newborn in a receiving blanket during the treatment b. Maintain NPO status until the newborn's bilirubin is within the expected reference range. c. Ensure the newborn's eyes are closed before applying the eye shield. d. Apply lotion to the newborn's skin twice per day
c. Ensure the newborn's eyes are closed before applying the eye shield.
A nurse is planning care for a client who is at 35 weeks gestation. Which of the following laboratory tests should the nurse obtain? a. Rubella tither b. blood type c. Group B Streptococcus B-hemolytic d. 1-hour glucose tolerance test
c. Group B Streptococcus B-hemolytic The nurse should obtain a vaginal/anal group B streptococcus B-hemolytic (GBS) culture at 35 to 37 weeks gestation to screen for infection. Prophylactic antibiotics should be given during labor to clients who are positive for GBS. A rubella tither should be obtained during first prenatal visit to determine immunity to rubella. Maternal blood type should be obtained at first prenatal visit to determine if the client will need Rho(D) immune globulin at 28 weeks. A 1-hour glucose tolerance test at 24 to 28 weeks to screen for gestational diabetes.
A nurse is assessing a newborn, Which of the following findings should the nurse identify as an indication of recent maternal heroin use? a. Large for gestational age b. Hypotonicity c. Incessant crying d. Craniofacial anomalies
c. Incessant crying Heroine use can result in intrauterine growth retardation; therefore, the newborn would not be large for gestational age. Manifestations of neonatal abstinence syndrome due to maternal heroin use include hyperreflexia and hyperactivity, not hypotonicity. Craniofacial anomalies are a manifestation of fetal alcohol syndrome, not neonatal abstinence syndrome due to maternal heroin use.
A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn? a. Placenta previa b. Multiple gestation c. Infection d. Anemia
c. Infection Blood group incompatibilities, maternal infection, maternal diabetes, and the administration of oxytocin during labor are potential risk factors for the development of hyperbilirubinemia in newborns.
A nurse is caring for a client who had a precipitous delivery. Which of the following assessments is the priority during the fourth stage of labor? a. Obtaining the client's temperature b. Inspecting the client's perineum c. Palpating the client's fundus d. Checking the client for hemorrhoids
c. Palpating the client's fundus
A nurse is caring for a client in active labor who is experiencing hypotension following epidural placement. Which of the following actions should the nurse take? a. Decrease IV fluids b. Give oxygen 2L/min via nasal cannula c. Place the client in a lateral position d. Administer indomethacin
c. Place the client in a lateral position
A nurse is teaching new parents about newborn reflexes. Which of the following reflexes facilitates infant feeding? a. Stepping b. Moro c. Rooting d. Babinski
c. Rooting
A nurse is caring for a client who is in labor. A vaginal examination reveals the following findings: 2 cm, 50%, +1, right occiput anterior (ROA). Based on this information, which of the following fetal positions should the nurse document in the medical record? a. Transverse b. Breech c. Vertex d. Mentum
c. Vertex ROA describes the relationship of the presenting part of the fetus to the client's pelvis. In this case, the occipital bone is the presenting part and is located anteriorly on the client's right side. Base on the presentation of the fetus, the position is vertex. A transverse position indicates that the fetus is lying horizontally in the pelvis and is presenting with a shoulder. The breech position indicates that the fetus is upright in the uterus and is presenting with the buttocks or feet. Mentum indicates that the fetus has fully extended the head and is presenting with the chin.
A nurse is administering a rubella immunization to a client who is 2 days postpartum. Which of the following client statements indicates a need for further instruction? a. "I can continue to breastfeed." b. "I still need to have my provider perform a rubella titer check during my next pregnancy." c. "I cannot receive the rubella immunization during pregnancy." d. "I can conceive anytime I want after 10 days.
d. "I can conceive anytime I want after 10 days. A client who receives a rubella immunization should not conceive for at least 1 month after receiving the rubella immunization to prevent injury to the fetus.
A nurse is caring for a client who is at 34 weeks gestation and has prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority? a. "My ankles are swollen at the end of the day." b. "I can feel the baby kicking my ribs, and it is very uncomfortable." c. "I'm growing more and more worried every day." d. "My heart feels like its racing."
d. "My heart feels like its racing."
A nurse is caring for an adolescent who is in the second trimester of pregnancy. The client states. "I've gotten used to the idea of this pregnancy. It will be fun to have a little baby around the house." Which of the following is the appropriate response by the nurse? a. "Babies are not fun. They're a lot of work." b. "I'm so glad to see you're happy about the baby." c. "How are your parents reacting to the pregnancy?" d. "Tell me how you think your life will be after the baby is born."
d. "Tell me how you think your life will be after the baby is born."
A nurse is preparing to administer meperidine hydrochloride to a client who is in labor. Which of the following statements should the nurse make to the client? a. "This medication can cause your blood pressure to rise." b. "This medication can cause dry mouth." c. "This medication can cause you to urinate excessively." d. "This medication can make you sleepy."
d. "This medication can make you sleepy." Meperidine hydrochloride is an opioid analgesic used for moderate pain during labor. It binds to the brain's opioid receptors and alters the client's response to pain. The client should be informed of the possible adverse effects of this medication such as hypotension, confusion, sedation, headaches, respiratory depression, constipation, and urinary retention.
A nurse is preparing a client who is in labor for the insertion of an intrauterine pressure catheter. The client asks why this type of monitoring is needed. Which of the following responses should the nurse make? a. "This type of monitoring is necessary for timing the frequency of your contractions." b. " This type of monitoring is noninvasive, so it is the best way to monitor your labor contractions." c. "This type of monitoring allows us to evaluate your baby's heart rate while you are in labor." d. "This type of monitoring will allow us to measure the intensity of your contractions."
d. "This type of monitoring will allow us to measure the intensity of your contractions."
A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse include in the teaching? a. "You should eat foods served at warm temperatures." b. "You should brush your teeth right after you eat." c. "You should try to eat sweet foods when you feel nauseated." d. "You should eat dry foods that are high in carbohydrates when you wake up."
d. "You should eat dry foods that are high in carbohydrates when you wake up."
A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication to the use of this medication? a. Prolonged rupture of membranes at 38 weeks gestation b. Intrauterine growth restriction c. Post-term pregnancy d. Active genital herpes
d. Active genital herpes The use of oxytocin is contraindicated for clients who have an active genital herpes infection. The newborn can acquire the infection while passing through the birth canal. Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection. a. When the client is at or near term with prolonged rupture of membranes, oxytocin induction is indicated. b. Intrauterine growth restriction is an indication for the use of oxytocin to induce labor. c. Induction of labor with oxytocin is suggested in post-term pregnancies.
A nurse is assessing a female client 24 hr after delivery and notes the fundus is 2 cm above the umbilicus. Which of the following actions should the nurse take? a. Administer a tocolytic medication b. Apply a heating pad to the mid-abdominal area c. Reassess the fundus in 2 hr d. Ambulate the client to the bathroom
d. Ambulate the client to the bathroom An increase fundal height in postpartum period is a sign of a non-contracted uterus, which increases the risk of hemorrhage. The most common postpartum cause of an elevated fundal height is an over-distended bladder.
While caring for a client who is in active labor, a nurse notes late decelerations on the fetal monitor. Which of the following actions should the nurse take? a. administer methyl-prostaglandins IM b. Encourage the client to use the shower c. Place the client in a supine position d. Apply oxygen at 10L/min via a nonrebreather face mask
d. Apply oxygen at 10L/min via a nonrebreather face mask Late decelerations are caused by uteroplacental insufficiency and require intervention to increase oxygen flow to the fetus. Administering oxygen to the client will increase the amount of oxygen available to the fetus. Methyl-prostaglandin is a uterotonic medication that will increase the contractibility of the uterus. It should never be administered to a pregnant client. Placing the client in the shower might decrease maternal discomfort, but it does not increase oxygen flow to the fetus. Placing the client in a supine position can decrease uteroplacental blood flow further due to compression of the vena cava. The client should be placed in a lateral position to optimize cardiac output.
A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take? a. Instruct the client to pant during contractions b. Position the client supine with legs elevated c. Encourage the client to soak in a warm bath d. Apply pressure to the client's sacral area during contractions
d. Apply pressure to the client's sacral area during contractions The nurse should provide counter-pressure to the sacral area with a palm or a firm object, such as a tennis ball, during contractions. Counter-pressure lefts the fetal head away from the sacral nerves, which decreases pain.
A nurse is caring for a client who is postpartum and is having difficulty voiding. Which of the following actions should the nurse take first? a. Place the client's hands in warm water b. Administer an analgesic to the client c. Pour water from a squeeze bottle over the client's perineum d. Assist the client to the bathroom
d. Assist the client to the bathroom
A nurse is counseling a female client who expresses a desire to conceive in the near future. Which of the following dietary recommendations should the nurse make to prevent neural tube defects? a. Take a multivitamin every day b. Decrease consumption of mercury-containing fish c. Increase consumption of dairy products d. Begin taking a folic acid supplement
d. Begin taking a folic acid supplement
A nurse is preparing to provide umbilical cord care for a newborn 12 hours after deliver. Upon inspection, the nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take? a. Check the newborn's heart rate b. Place a pressure dressing on the cord stump c. Administer vitamin K d. Check the integrity of the cord clamp.
d. Check the integrity of the cord clamp.
A nurse is caring for a client who is in labor. Which of the following methods will determine the frequency of the client's contractions? a. Palpating the firmness of the uterus during a contraction b. Calculating the time from the end of each contraction to the beginning of the next c. Measuring the time form the beginning of a contraction to the end of that same contraction d. Evaluating the time from the beginning of a contraction to the beginning of the next contraction.
d. Evaluating the time from the beginning of a contraction to the beginning of the next contraction.
A nurse is caring for a client who has a BMI of 22.6 and expresses concern about weight gain during pregnancy. Which of the following responses should the nurse make? a. "You're eating for 2, so you should double your caloric intake." b. "You'll lose weight easily after the birth of your baby." c. "Plan to gain a total of 15 to 20 pounds during pregnancy." d. Gaining weight will promote a healthy pregnancy."
d. Gaining weight will promote a healthy pregnancy." Recommended weight gain for BMI of 22.6 is 11.3 to 15.9 kg (25 to 35 lb)
A nurse is assessing a client who has hyperemesis gravidarum. Which of the following findings should the nurse expect? a. Elevated serum potassium level b. Rapid weight gain c. Peripheral edema d. Presence of ketones in the urine
d. Presence of ketones in the urine The nurse should expect a client who has hyperemesis gravidarum to have ketonuria due to inadequate dietary intake, resulting in the breakdown of protein and store fat.
A nurse provides education on interventions to promote optimal development for the parent of a premature infant. Which of the following actions should the nurse instruct the parent to perform? a. Maintain bright lighting to enable close observation of the infant at all times. b. Place the infant in a prone position with arms and legs extended c. Rouse the infant every 1-2 hr to provide auditory and visual stimulation d. Provide kangaroo care for the infant.
d. Provide kangaroo care for the infant. Studies show that premature infants who are held skin-to-skin "kangaroo care" demonstrate improved thermostability, oxygen saturation, interest in feeding, and maintenance of an organized, relaxed state.
A nurse is caring for a client who is using patterned-pace breathing during the first stage of labor. The client reports a lightheaded feeling and tingling of the fingers. Which of the following actions should the nurse take? a. Instruct the client to hold her breath and bear down. b. Ensure that the client's breathing rate is more than twice her normal rate. c. Apply counter-pressure to the client's lower back d. have the client breathe into a paper bag
d. have the client breathe into a paper bag The client is experiencing respiratory alkalosis from hyperventilation, which is a possible adverse effect of patterned-paced breathing. To correct hypocarbia, the client should breathe into a paper bag or her cupped hands, rebreathing CO2 and correcting the respiratory alkalosis.
