Exam 2 - NCLEX-Style Practice Questions

Four babies are in the newborn nursery. The nurse pages the neonatologist to see the baby who exhibits which of the following? 1. Intracostal retractions. 2. Erythema toxicum. 3. Pseudostrabismus. 4. Vernix caseosa.

1. Intracostal retractions.

A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the client's health care practitioner? 1. Foul-smelling lochia. 2. Engorged breasts. 3. Cracked nipples. 4. Cluster of hemorrhoids.

1. Foul-smelling lochia. Rationale: Sign of endometritis

Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma? 1. Pain. 2. Bleeding. 3. Warmth. 4. Redness.

1. Pain.

A woman states that all of a sudden her 4-day-old baby is having trouble feeding. On assessment, the nurse notes that the mother's breasts are firm, red, and warm to the touch. The nurse teaches the mother manually to express a small amount of breast milk from each breast. Which observation indicates that the nurse's intervention has been successful? 1. The mother's nipples are soft to the touch. 2. The baby swallows after every 5th suck. 3. The baby's pre- and postfeed weight change is 20 milliliters. 4. The mother squeezes her nipples during manual expression.

1. The mother's nipples are soft to the touch.

A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? 1. Urine output 200 mL for the past 8 hours. 2. Weight decrease of 2 pounds since delivery. 3. Drop in hematocrit of 2% since admission. 4. Pulse rate of 68 beats per minute.

1. Urine output 200 mL for the past 8 hours. Rationale: The nurse must divide the amount of urine output by the number of hours. The output in the scenario is equal to 25 mL/hr. This is well below the accepted output of 30 mL/hr. Plus, because this is a postpartum client, the nurse would expect high urinary outputs.

A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate? 1. Advise the woman to apply ice packs to her breasts. 2. Encourage the woman to breastfeed frequently. 3. Inform the woman that she should wean immediately. 4. Direct the woman to notify her pediatrician as soon as possible.

2. Encourage the woman to breastfeed frequently.

A client is 10 minutes postpartum from a forceps delivery of a 4,500-gram neonate with a cleft lip. The physician performed a right mediolateral episiotomy during the delivery. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time? 1. Ineffective breastfeeding. 2. Fluid volume deficit. 3. Infection. 4. Pain.

2. Fluid volume deficit. Rationale: This is the priority nursing diagnosis. Because the baby is macrosomic, the client is high risk for uterine atony that could lead to heavy vaginal bleeding possibly resulting in fluid volume deficit.

birth. For which of the following complications should the nurse monitor this client? 1. Seizures. 2. Hemorrhage. 3. Infection. 4. Thrombosis.

2. Hemorrhage. Ratiaionle: An average size baby weighs 2,500 to 4,000 grams. The baby in the scenario is macrosomic. As a result, the mother's uterus has been stretched beyond its expected capacity. The client is, therefore, at high risk for uterine atony, which could result in a postpartum hemorrhage.

A client's vital signs and reflexes were normal throughout pregnancy, labor, and delivery. Four hours after delivery the client's vitals are 98.6°F, P 72, R 20, BP 150/100, and her reflexes are 4+. She has an intravenous infusion running with 20 units of Pitocin (oxytocin) added. Which of the following actions by the nurse is appropriate? 1. Nothing, because the results are normal. 2. Notify the obstetrician of the findings. 3. Discontinue the intravenous immediately. 4. Reassess the client after fifteen minutes.

2. Notify the obstetrician of the findings. Rationale: Likely preeclampsia

A client is 1 day post-cesarean section with spinal anesthesia. Even though the nurse advised against it, the client has had the head of her bed in high Fowler's position since delivery. Which of the following complications would the nurse expect to see in relation to the client's action? 1. Postpartum hemorrhage. 2. Severe postural headache. 3. Pruritic skin rash. 4. Paralytic ileus.

2. Severe postural headache.

A postpartum client has been diagnosed with deep vein thrombosis. For which of the following additional complications is this client high risk? 1. Hemorrhage. 2. Stroke. 3. Endometritis. 4. Hematoma.

2. Stroke.

A breastfeeding woman calls the pediatric nurse with the following complaint: "I woke up this morning with a terrible cold. I don't want my baby to get sick. Which kind of formula should I have my husband feed the baby until I get better?" Which of the following replies by the nurse is appropriate at this time? 1. "Any formula brand is satisfactory, but it is essential that it be mixed with water that has been boiled for at least 5 minutes." 2. "Don't forget to pump your breasts every 3 hours while the baby is being fed the prescribed formula." 3. "The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula." 4. "In addition to giving the baby formula, you should wear a surgical face mask when you are around him."

3. "The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula."

The nurse should expect to observe which behavior in a 3-week-multigravid postpartum client with postpartum depression? 1. Feelings of infanticide. 2. Difficulty with breastfeeding latch. 3. Feelings of failure as a mother. 4. Concerns about sibling jealousy.

3. Feelings of failure as a mother.

Which of the following is a priority nursing diagnosis for a woman, G10 P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage? 1. Alteration is comfort related to afterbirth pains. 2. Risk for altered parenting related to grand multiparity. 3. Fluid volume deficit related to blood loss. 4. Risk for sleep deprivation related to mothering role.

3. Fluid volume deficit related to blood loss.

A nurse has administered Methergine (methylergonovine) 0.2 mg po to a grand multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes indicates that the medication is effective? 1. Blood pressure 120/80. 2. Pulse rate 80 bpm and regular. 3. Fundus firm at umbilicus. 4. Increase in prothrombin time.

3. Fundus firm at umbilicus. Rationale: Methergine is an oxytocic agent. It is administered after delivery if the uterus is atonic or if the client is high risk for uterine atony. When the uterus is noted to be well contracted and at the appropriate position in the abdomen, the nurse can conclude that the medication was successful.

A woman has just had a low forceps delivery. For which of the following should the nurse assess the woman during the immediate postpartum period? 1. Infection. 2. Bloody urine. 3. Heavy lochia. 4. Rectal abrasions.

3. Heavy lochia. Rationale: There are two main maternal complications associated with forceps use—hemorrhage and infection. Hemorrhage usually occurs early, secondary to cervical, vaginal, or perineal lacerations. Infection usually develops later in the postpartum period secondary to contamination of the uterine cavity during the application of the forceps.

The blood glucose of a client with type 1 diabetes 12 hours after delivery is 96 mg/dL. The client has received no insulin since delivery. The drop in serum levels of which of the following hormones of pregnancy is responsible for the glucose level? 1. Estrogen. 2. Progesterone. 3. Human placental lactogen (hPL). 4. Human chorionic gonadotropin (hCG).

3. Human placental lactogen (hPL).

In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)? 1. The woman complains of numbness in the toes and heel of one foot. 2. The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed. 3. One of the woman's calves is swollen, red, and warm to the touch. 4. The veins in the ankle of one of the woman's legs are spider-like and purpl

3. One of the woman's calves is swollen, red, and warm to the touch.

A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first? 1. PP1 from vaginal delivery with complaints of burning on urination. 2. PP2 from forceps delivery with blood loss of 500 mL at time of delivery. 3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL. 4. PO4 from cesarean delivery with complaints of firm and painful breasts

3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL.

Which of the following would lead the nurse to suspect cold stress syndrome in a newborn with a temperature of 96.5°F? 1. Blood glucose of 50 mg/dL. 2. Acrocyanosis. 3. Tachypnea. 4. Oxygen saturation of 96%.

3. Tachypnea.

A 1-day-old neonate, 32 weeks' gestation, is in an overhead warmer. The nurse assesses the morning axillary temperature as 96.9°F. Which of the following could explain this assessment finding? 1. This is a normal temperature for a preterm neonate. 2. Axillary temperatures are not valid for preterm babies. 3. The supply of brown adipose tissue is incomplete. 4. Conduction heat loss is pronounced in the baby.

3. The supply of brown adipose tissue is incomplete.

The nurse is caring for a postoperative cesarean client. The woman is obese and is an insulin-dependent diabetic. For which of the following complications should the nurse carefully monitor this client? 1. Failed lactogenesis. 2. Dysfunctional parenting. 3. Wound dehiscence. 4. Projectile vomiting.

3. Wound dehiscence.

On admission to the labor and delivery suite, the nurse assesses the discharge needs of a primipara who will be discharged home 4 days after a cesarean delivery. Which of the following questions should the nurse ask the client? 1. "Have you ever had anesthesia before?" 2. "Do you have any allergies?" 3. "Do you scar easily?" 4. "Are there many stairs in your home?"

4. "Are there many stairs in your home?" Rationale: Discharge care must begin on admission to the hospital. Cesarean section clients will need some assistance after discharge, especially if they must climb up and down stairs.

A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is "bleeding and saturating a pad about every 1/2 hour." Which of the following is an appropriate response by the nurse? 1. "That is normal. You are starting to menstruate again." 2. "You should stay on complete bed rest until the bleeding subsides." 3. "Pushing during a bowel movement may have loosened your stitches." 4. "The physician should see you. Please go to the emergency department."

4. "The physician should see you. Please go to the emergency department."

A client who received a spinal for her cesarean delivery is complaining of pruritusand has a macular rash on her face and arms. Which of the following medications ordered by the anesthesiologist should the nurse administer at this time? 1. Reglan (metoclopramide). 2. Zofran (ondansetron). 3. Compazine (prochlorperazine). 4. Benadryl (diphenhydramine).

4. Benadryl (diphenhydramine).

The nurse is creating a plan of care for a postpartum pt with a small vulvar hematoma. The nurse would include which specific action during the first 12 hours after delivery? A) Encourage ambulation hourly B) Assess vital signs every 4 hours C) Measure fundal height every 4 hours D) Prepare an ice pack for application to the area

D) Prepare an ice pack for application to the area

Which initial nursing intervention should the nurse anticipate implementing when monitoring a newborn for adequate breast milk intake? A) Assess the infant's weight. B) Instruct the mother to keep an infant feeding log. C) Assess the mother's breasts and nipples. D) Weigh the infant's wet diapers.

A) Assess the infant's weight. Rationale: Nursing interventions to monitor an infant for adequate nutritional intake include assessing the condition of the breasts and nipples to identify problems that might interfere with feeding. It is also essential to assess the mother's knowledge about breastfeeding to determine her need for assistance or education. Also, examining the breasts and nipples during late pregnancy is important. The nurse should also plan to monitor the number of wet or dirty diapers and body weight.

A female client who has just delivered a newborn tells the nurse she is planning to feed her baby exclusively with formula to prevent jaundice. Which response by the nurse is most appropriate? A) "If breast milk jaundice runs in your family, you should use formula only." B) "Breastfeeding may actually help prevent jaundice in your baby." C) "Breastfeeding is known to cause jaundice in infants." D) "You should alternate between breastmilk and formula when feeding your baby."

B) "Breastfeeding may actually help prevent jaundice in your baby." Rationale: Breastfeeding has many positive effects on the neonate, including immunological benefits and a natural laxative effect that allows for excretion of excess bilirubin. *Breastfeeding is not contraindicated with any form of infant jaundice*, and the nurse should educate the client further on the benefits of breastfeeding. Infants who are not breastfed or who have difficulty breastfeeding are actually more likely to develop hyperbilirubinemia, because excess bilirubin is not excreted as efficiently.

The nurse is gathering data from the parent of an infant concerned that their baby is not getting enough breastmilk. Which parental statement should the nurse correlate with inadequate nutritional intake? A) "My baby falls asleep after feeding for 20 minutes. B) "My baby frequently thrusts his tongue out of his mouth." C) "My baby swallows slowly when he is breastfeeding." D) "My baby seems to latch on to the breast quickly."

B) "My baby frequently thrusts his tongue out of his mouth." Rationale: Frequent tongue thrusting, smacking, or clicking sounds and dimpling of the cheeks are associated with inadequate nutrition.

A client born via vacuum-assisted vaginal delivery develops a cephalohematoma and hyperbilirubinemia in the hours immediately following birth. Which sign indicates that the client is developing a complication of this condition? A) Effective latch during breastfeeding B) Production of dark-colored stools C) White sclera of the eyes D) Yellow skin despite improvement of hematoma

D) Yellow skin despite improvement of hematoma Rationale: This client's condition is likely a result of the hematoma, which leads to increased red cell breakdown, excess serum bilirubin, and jaundice, which is a yellow tint to the skin and sclera of the eyes. The hematoma may improve; however, excess bilirubin in the blood may deposit in the brain and start to cause complications like seizures, lethargy, and unresponsiveness.

The nurse is reviewing oxytocin with a newly graduated nurse who is orienting to the labor and delivery unit. Complete the following sentence. During delivery, the _______ (ovaries, placental cells, pituitary gland) release(s) oxytocin to increase _______ (uterine contraction, bowel motility, fetal oxygenation). During the postpartum period, it is expected that levels of oxytocin __________ (increase, decrease, remain the same).

During delivery, the *pituitary gland* release(s) oxytocin to increase *uterine contraction*. During the postpartum period, it is expected that levels of oxytocin *decrease*.

Based on their history, the nurse is discharging a postpartum client at an increased risk of developing perinatal depression. The nurse should include which instruction during the teaching session? Complete the following sentence by choosing from the list of options. Feeling emotionless, sad, or hopeless for more than ________ (seven days, two weeks, six weeks) is not normal, and if you feel like you are unable to care for yourself or your baby, you should ________ (isolate yourself from the baby, bottle-feeding instead of breastfeeding, reach out to your healthcare provider).

Feeling emotionless, sad, or hopeless for more than *two weeks* is not normal, and if you feel like you are unable to care for yourself or your baby, you should *reach out to your healthcare provider*.

Which of the following is the priority nursing action during the immediate postpartum period? 1. Palpate fundus. 2. Check pain level. 3. Perform pericare. 4. Assess breasts.

1. Palpate fundus.

A nurse is performing a postpartum assessment on a newly delivered client. Which of the following actions will the nurse perform? Select all that apply. 1. Palpate the breasts. 2. Auscultate the carotid. 3. Check vaginal discharge. 4. Assess the extremities. 5. Inspect the perineum

1. Palpate the breasts. 3. Check vaginal discharge. 4. Assess the extremities. 5. Inspect the perineum

The nurse is discharging five Rh-negative clients from the maternity unit. The nurse knows that the teaching was successful when the client who had which of the following deliveries asks why she must receive a RhoGAM injection? Select all that apply. 1. Abortion at 10 weeks' gestation. 2. Amniocentesis at 16 weeks' gestation. 3. Fetal demise at 24 weeks' gestation. 4. Birth of Rh-negative twins at 35 weeks' gestation. 5. Delivery of a 40-week-gestation, Rh-positive baby.

1. Abortion at 10 weeks' gestation. 2. Amniocentesis at 16 weeks' gestation. 3. Fetal demise at 24 weeks' gestation. 5. Delivery of a 40-week-gestation, Rh-positive baby.

A client has been transferred to the post-anesthesia care unit from a cesarean delivery. The client had spinal anesthesia for the surgery. Which of the following interventions should the nurse perform at this time? 1. Assess the level of the anesthesia. 2. Encourage the client to urinate in a bedpan. 3. Provide the client with the diet of her choice. 4. Check the incision for signs of infection.

1. Assess the level of the anesthesia. Rationale: The nurse should assess the level of anesthesia every 15 minutes while in the postanesthesia care unit. The nurse in the postanesthesia care unit (PACU) is concerned with monitoring for immediate postoperative and postpartum complications and the client's recovery from the anesthesia.

For which of the following reasons would a nurse in the well-baby nursery report to the neonatologist that a newborn appears to be preterm? 1. Baby has a square window angle of 90°. 2. Baby has leathery and cracked skin. 3. Baby has popliteal angle of 90°. 4. Baby has pronounced plantar creases.

1. Baby has a square window angle of 90°. Rationale: A baby whose square window sign is 90° is preterm. A baby whose skin is cracked and leathery is exhibiting a sign of postmaturity. A baby whose popliteal angle is 90˚ is full term. A baby whose plantar creases are pronounced is full term.

A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which of the following actions should the nurse take at this time? 1. Encourage the woman exclusively to breastfeed her baby. 2. Have the woman massage her breasts hourly. 3. Obtain an order to culture her expressed breast milk. 4. Take the temperature and pulse rate of the woman.

1. Encourage the woman exclusively to breastfeed her baby.

A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide safe newborn care, which of the following actions should the nurse perform? 1. Cover the baby's eyes with eye pads. 2. Turn the lights on for ten minutes every hour. 3. Clothe the baby in a shirt and diaper only. 4. Tightly swaddle the baby in a baby blanket.

1. Cover the baby's eyes with eye pads.

A full-term infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. Which of the following actions should the nurse perform at this time? 1. Feed the baby formula or breast milk. 2. Assess the baby's blood pressure. 3. Tightly swaddle the baby. 4. Monitor the baby's urinary output.

1. Feed the baby formula or breast milk.

During a postpartum assessment, the nurse assesses the calves of a client's legs. The nurse is checking for which of the following signs/symptoms? Select all that apply. 1. Pain. 2. Warmth. 3. Discharge. 4. Ecchymosis. 5. Redness.

1. Pain. 2. Warmth. 5. Redness. Rationale: Postpartum clients are high risk for deep vein thrombosis (DVT). At each postpartum assessment the nurse assesses the calves for signs of the complication, i.e., those seen in any inflammatoryresponse: pain, warmth, redness, andedema. If the signs/symptoms are noted, the nurse should request an order from the primary healthcare practitioner for diagnostic tests to be performed, like a Doppler series. Homan's sign is no longer recommended to assess for DVT.

Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate? 1. Provide the woman with warm blankets. 2. Put the woman in the Trendelenburg position. 3. Notify the primary health care provider. 4. Increase the intravenous infusion.

1. Provide the woman with warm blankets. Rationale: Postpartum shaking is thought to be caused by nervous responses and/or vasomotor changes. The shaking is very common and, unless accompanied by a fever, is of no physiological concern. The best action by the nurse is supportive—providing the client with a warm blanket and reassuring her that the response is within normal limits.

A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed? 1. Respiratory rate 8 rpm. 2. Complaint of thirst. 3. Urinary output of 250 mL/hr. 4. Numbness of feet and ankles.

1. Respiratory rate 8 rpm.

A baby exhibits weak rooting and sucking reflexes. Which of the following nursing diagnoses would be appropriate? 1. Risk for deficient fluid volume. 2. Activity intolerance. 3. Risk for aspiration. 4. Feeding self-care deficit.

1. Risk for deficient fluid volume. Rationale: When a baby roots and sucks poorly, the baby is unable to transfer milk effectively. Because milk intake is the baby's source of fluid, the baby is high risk for fluid volume deficit.

A baby was born 24 hours ago to a mother who received no prenatal care. The infant has tremors, sneezes excessively, constantly mouths for food, and has a shrill, high-pitched cry. The baby's serum glucose levels are normal. For which of the following should the nurse request an order from the pediatrician? 1. Urine drug toxicology test. 2. Biophysical profile test. 3. Chest and abdominal ultrasound evaluations. 4. Oxygen saturation and blood gas assessments.

1. Urine drug toxicology test. Rationale: The symptoms are characteristic of neonatal abstinence syndrome. A urine toxicology would provide evidence of drug exposure.

A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? 1. Type O negative. 2. Type A negative. 3. Type B positive. 4. Type AB positive.

1. Type O negative.

A woman has just had a macrosomic baby after a 12-hour labor. For which of the following complications should the woman be carefully monitored? 1. Uterine atony. 2. Hypoprolactinemia. 3. Infection. 4. Mastitis.

1. Uterine atony. Rationale: The uterus of a woman who delivers a macrosomic baby has been stretched beyond the usual pregnancy size. The muscle fibers of the myometrium, therefore, are stretched. After delivery the muscles are unable to contract effectively to stop the bleeding at the placental separation site.

A client who delivered a 3,900-gram baby vaginally over a right mediolateral episiotomy states, "How am I supposed to have a bowel movement? The stitches are right there!" Which of the following is the best response by the nurse? 1. "I will call the doctor to order a stool softener for you." 2. "Your stitches are actually far away from your rectal area." 3. "If you eat high-fiber foods and drink fluids you should have no problems." 4. "If you use your topical anesthetic on your stitches you will feel much less pain."

2. "Your stitches are actually far away from your rectal area." Rationale: A right mediolateral episiotomy is angled away from the perineum and rectum.

A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lb 2 oz, 21 inches long, TPR: 96.6°F, 158, 62, jittery, pink body with bluish hands and feet, crying. Which of the following actions is of highest probability? 1. Swaddle the baby to provide warmth. 2. Assess the glucose level of the baby. 3. Take the baby to the mother for feeding. 4. Administer the neonatal medications.

2. Assess the glucose level of the baby. Rationale: this baby is macrosomic and hypothermic, both of which make the baby at high risk for hypoglycemia. Plus, jitters are a classic symptom in hypoglycemic babies. To make an accurate assessment of the problem, the baby's glucose level must be assessed.

The birth of a baby, weight 4,500 grams, was complicated by shoulder dystocia. Which of the following neonatal complications should the nursery nurse observe for? 1. Leg deformities. 2. Brachial palsy. 3. Fractured radius. 4. Buccal abrasions.

2. Brachial palsy. Ratioanle: During a difficult delivery with shoulder dystocia, the brachial nerve can become stretched and may even be severed. The nurse should, therefore, observe the baby for signs of palsy.

To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours. 4. Spray the perineum with povidone-iodine after toileting.

2. Change the peripad at each voiding.

A maternity nurse knows that obstetric clients are most at high risk for cardiovascular compromise during the one hour immediately following a delivery because of which of the following? 1. Weight of the uterine body is significantly reduced. 2. Excess blood volume from pregnancy is circulating in the woman's periphery. 3. Cervix is fully dilated and the lochia flows freely. 4. Maternal blood pressure drops precipitously once the baby's head emerges.

2. Excess blood volume from pregnancy is circulating in the woman's periphery. Rationale: It is essential that the nurse closely monitor the vital signs of a newly delivered gravida. Because of the surge in blood volume resulting from the delivery of the placenta, the woman is high risk for cardiovascular compromise. Women frequently develop bradycardia, a normal finding, as a result of the increased peripheral blood volume.

A newborn nursery nurse notes that a 36-hour-old baby's body is jaundiced. Which of the following nursing interventions will be most therapeutic? 1. Maintain a warm ambient environment. 2. Have the mother feed the baby frequently. 3. Have the mother hold the baby skin to skin. 4. Place the baby naked by a closed sunlit window.

2. Have the mother feed the baby frequently. rationale: Bilirubin is excreted through the bowel. The more the baby consumes, the more stools she or he will produce; in other words, the more feces the baby excretes, the more

The nurse informs a postpartum woman that which of the following is the reason ibuprofen (Advil) is especially effective for afterbirth pains? 1. Ibuprofen is taken every two hours. 2. Ibuprofen has an antiprostaglandin effect. 3. Ibuprofen is given via the parenteral route. 4. Ibuprofen can be administered in high doses.

2. Ibuprofen has an antiprostaglandin effect. Rationale: Prostaglandins are produced as part of the inflammatory response. When ibuprofen is administered, the client receives the pain-reducing action of the medication as well as its anti-inflammatory properties.

An infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. The nurse should monitor this baby carefully for which of the following? 1. Jaundice. 2. Jitters. 3. Erythema toxicum. 4. Subconjunctival hemorrhages.

2. Jitters.

During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see? 1. Diaphoresis. 2. Lochia alba. 3. Cracked nipples. 4. Hypertension

2. Lochia alba. rationale: The normal progression of lochial change is as follows: lochia rubra, days 1 to 3; lochia serosa, days 3 to 10; and lochia alba, days 10 until discharge stops. There is some variation in the exact timing of the lochial change, but it is important for the client to know that the lochia should not revert backward. In other words, if a client whose lochia is alba again begins to have bright red discharge, she should notify her health care practitioner.

A client, G1 P0101, postpartum 1 day, is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and deviated to the right. Which of the following actions should the nurse take first? 1. Notify the woman's primary health care provider. 2. Massage the woman's fundus. 3. Escort the woman to the bathroom to urinate. 4. Check the quantity of lochia on the peripad.

2. Massage the woman's fundus. rationale: When a postpartum client's bladder is distended, the uterus becomes displaced and boggy. The client should be escorted to the bathroom to void; the lochia flow should also be assessed. However, before escorting the client to urinate, the nurse should gently massage the uterus.

A woman who received an intravenous analgesic 4 hours ago has had prolonged late decelerations in labor. She will deliver her baby shortly. Which of the following is the priority action for the delivery room nurse to take? 1. Preheat the overhead warmer. 2. Page the neonatologist on call. 3. Draw up Narcan (naloxone) for injection. 4. Assemble the neonatal eye prophylaxis.

2. Page the neonatologist on call.

A baby has just been born to a type 1 diabetic mother with retinopathy and nephropathy. Which of the following neonatal findings would the nurse expect to see? 1. Hyperalbuminemia. 2. Polycythemia. 3. Hypercalcemia. 4. Hypoinsulinemia.

2. Polycythemia. Rationale: Because the placenta is likely to be functioning less than optimally, it is highly likely that the baby will be polycythemic. The increase in red blood cells would improve the baby's oxygenation in utero.

A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion? 1. The father may become sad and weepy. 2. Postpartum blues last about a week or two. 3. Medications are available to relieve the symptoms. 4. Very few women experience postpartum blues.

2. Postpartum blues last about a week or two.

A nurse in the newborn nursery suspects that a new admission, 42 weeks' gestation, was exposed to meconium in utero. What would lead the nurse to suspect this? 1. The baby is bradycardic. 2. The baby's umbilical cord is green. 3. The baby's anterior fontanel is sunken. 4. The baby is desquamating.

2. The baby's umbilical cord is green.

A breastfeeding woman, 11/2 months postdelivery, calls the nurse in the obstetrician's office and states, "I am very embarrassed but I need help. Last night I had an orgasm when my husband and I were making love. You should have seen the milk. We were both soaking wet. What is wrong with me?" The nurse should base the response to the client on which of the following? 1. The woman is exhibiting signs of pathological galactorrhea. 2. The same hormone stimulates orgasms and the milk ejection reflex. 3. The woman should have a serum galactosemia assessment done. 4. The baby is stimulating the woman to produce too much milk.

2. The same hormone stimulates orgasms and the milk ejection reflex. Rationale: It is important for the nurse in the obstetrician's office to warn breastfeeding clients of this situation. Because clients are strongly encouraged to refrain from having intercourse until they are 6 weeks postpartum, the postpartum nurse may not include this information in the client's discharge instructions. When the client is seen for her postpartum check, however, the information should be included.

The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.

2. Well-approximated edges. Rationale: The best tool to use when assessing any incision is the REEDA scale. The nurse assesses for: R—redness, E—edema, E—ecchymosis, D—drainage, and A—poor approximation. If there is evidence of any of the findings, they should be documented and monitored and reported.

A breastfeeding client, 7 weeks postpartum, complains to an obstetrician's triage nurse that when she and her husband had intercourse for the first time after the delivery, "I couldn't stand it. It was so painful. The doctor must have done something terrible to my vagina." Which of the following responses by the nurse is appropriate? 1. "After a delivery the vagina is always very tender. It should feel better the next time you have intercourse." 2. "Does your baby have thrush? If so, you should be assessed for a yeast infection in your vagina." 3. "Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort." 4. "Sometimes the stitches of episiotomies heal too tight. Why don't you come in to be checked?"

3. "Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort."

A medication order reads: Methergine (ergonovine) 0.2 mg po q 6 h × 4 doses. Which of the following assessments should be made before administering each dose of this medication? 1. Apical pulse. 2. Lochia flow. 3. Blood pressure. 4. Episiotomy.

3. Blood pressure.

The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects? 1. Headache. 2. Nausea. 3. Cramping. 4. Fatigue.

3. Cramping.

The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period? 1. Decreased urinary output. 2. Increased blood pressure. 3. Decreased blood volume. 4. Increased estrogen level.

3. Decreased blood volume. rationale: During pregnancy, the blood volume increased by almost 50%. Once the placenta is delivered, the client no longer needs the added blood volume. Immediately after delivery, therefore, the woman experiences marked diuresis and diaphoresis as the blood volume drops.

The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, "I don't know what is wrong with me. I feel terrible. I should be happy, but I'm not." Which of the following nursing diagnoses is appropriate for this client? 1. Suicidal thoughts related to psychotic ideations. 2. Post-trauma response related to traumatic delivery. 3. Ineffective individual coping related to hormonal shifts. 4. Spiritual distress related to immature belief systems.

3. Ineffective individual coping related to hormonal shifts. Rationale: It is essential that nurses discuss postpartum blues with clients. When clients are unfamiliar with the phenomenon, they often feel like they are going crazy or that there is something very wrong with them. Other members of the family, especially the woman's partner, should also be forewarned.

The day after delivery, a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong: "All I do is go to the bathroom." Which of the following is an appropriate nursing response? 1. Catheterize the client per doctor's orders. 2. Measure the client's next voiding. 3. Inform the client that polyuria is normal. 4. Check the specific gravity of the next voiding.

3. Inform the client that polyuria is normal.

The nurse is examining a 2-day-postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? 1. Abnormal involution, lochia rubra heavy. 2. Abnormal involution, lochia serosa scant. 3. Normal involution, lochia rubra moderate. 4. Normal involution, lochia serosa heavy.

3. Normal involution, lochia rubra moderate. Rationale: Lochia rubra is bright red, lochia serosa is pinkish to brownish, and lochia alba is whitish. The nurse would expect the fundus to descend below the umbilicus approximately 1 cm per postpartum day. In other words, 1 day postpartum, the fundus is usually felt 1 cm below the umbilicus; 2 days postpartum, it is usually felt 2 cm below the umbilicus, and so on.

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority? 1. The client will breastfeed her baby every 2 hours. 2. The client will consume a normal diet. 3. The client will have a moderate lochial flow. 4. The client will ambulate to the bathroom every 2 hours.

3. The client will have a moderate lochial flow. Rationale: When establishing priorities, the test taker should consider the client's most important physiological functions—that is, the C-A-B —circulation, airway, and breathing. If the client were to bleed heavily, her circulation would be compromised. None of the other goals is directly related to the C-A-Bs.

A woman had a cesarean section yesterday. She states that she needs to cough but that she is afraid to. Which of the following is the nurse's best response? 1. "I know that it hurts but it is very important for you to cough." 2. "Let me check your lung fields to see if coughing is really necessary." 3. "If you take a few deep breaths in, that should be as good as coughing." 4. "If you support your incision with a pillow, coughing should hurt less."

4. "If you support your incision with a pillow, coughing should hurt less."

A baby is grunting in the neonatal nursery. Which of the following actions by the nurse is appropriate? 1. Place a pacifier in the baby's mouth. 2. Check the baby's diaper. 3. Have the mother feed the baby. 4. Assess the respiratory rate.

4. Assess the respiratory rate. Rationale: Grunting is often accompanied by tachypnea, another sign of respiratory distress.

A client, G1 P1001, 1 hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time? 1. Provide the woman with a bedpan. 2. Advise the woman that the feeling is likely related to the trauma of delivery. 3. Remind the woman that she still has a catheter in place from the delivery. 4. Assist the woman to the bathroom.

4. Assist the woman to the bathroom. rationale: Because they have elevated clotting factors, postpartum clients are at high risk for thrombus formation. When they need to urinate, they should be encouraged to ambulate to the bathroom to prevent pooling of blood. Clients should be accompanied to the bathroom, however, because they may be light-headed from the stress and work of labor and delivery.

A newborn admitted to the nursery has a positive direct Coombs' test. Which of the following is an appropriate action by the nurse? 1. Monitor the baby for jitters. 2. Assess the blood glucose level. 3. Assess the rectal temperature. 4. Monitor the baby for jaundice.

4. Monitor the baby for jaundice. Rationale: When the neonatal bloodstream contains antibodies, hemolysis of the red blood cells occurs and jaundice develops. The indirect Coombs' test is performed on the pregnant woman to detect whether or not she carries antibodies against her fetus's red blood cells. The direct Coombs' test is performed on the newborn to detect whether or not he or she carries maternal antibodies against his or her blood.

A nurse is assessing a 1-day-postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon? 1. Fundus at the umbilicus. 2. Nodular breasts. 3. Pulse rate 60 bpm. 4. Pad saturation every 30 minutes.

4. Pad saturation every 30 minutes.

A 42-week-gestation baby has been admitted to the neonatal intensive care unit. At delivery, thick green amniotic fluid was noted. Which of the following actions by the nurse is critical at this time? 1. Bath to remove meconium-contaminated fluid from the skin. 2. Ophthalmic assessment to check for conjunctival irritation. 3. Rectal temperature to assess for septic hyperthermia. 4. Respiratory evaluation to monitor for respiratory distress.

4. Respiratory evaluation to monitor for respiratory distress. Rationale: Meconium aspiration syndrome (MAS) is a serious complication seen in postterm neonates who are exposed to meconium-stained fluid. Respiratory distress would indicate that the baby has likely developed MAS.

The nurse is preparing to place a peripad on the perineum of a client who delivered her baby 10 minutes earlier. The client states, "I don't use those. I always use tampons." Which of the following actions by the nurse is appropriate at this time? 1. Remove the peripad and insert a tampon into the woman's vagina. 2. Advise the client that for the first two days she will be bleeding too heavily for a tampon. 3. Remind the client that a tampon would hurt until the soreness from the delivery resolves. 4. State that it is unsafe to place anything into the vagina until involution is complete.

4. State that it is unsafe to place anything into the vagina until involution is complete. Rationale: Because the cervix is still dilated and the uterine body is high risk for infection, it is unsafe to insert anything into the vagina until involution is complete.

A client informs the nurse that she intends to bottle feed her baby. Which of the following actions should the nurse encourage the client to perform? Select all that apply. 1. Increase her fluid intake for a few days. 2. Massage her breasts every 4 hours. 3. Apply heat packs to her axillae. 4. Wear a supportive bra 24 hours a day. 5. Stand with her back toward the shower water.

4. Wear a supportive bra 24 hours a day. 5. Stand with her back toward the shower water.

A baby has been admitted to the neonatal intensive care unit with a diagnosis of postmaturity. The nurse expects to find which of the following during the initial newborn assessment? 1. Abundant lanugo. 2. Flat breast tissue. 3. Prominent clitoris. 4. Wrinkled skin.

4. Wrinkled skin. rationale: The post-term baby does have dry, wrinkled, and often desquamating skin. The baby's dehydration is secondary to a placenta that progressively deteriorates after 40 weeks' gestation.

The postpartum nurse is assessing a pt who delivered a healthy infant via cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present? A) Paleness of the calf B) Coolness of the calf area C) Enlarged, hardened veins D) Palpable dorsalis pedis pulse

C) Enlarged, hardened veins

The nurse is completing patient education with expectant parents regarding the management of a preterm infant's respiratory function. Which information should the nurse include in the teaching? *Select all that apply.* A) Lung surfactant is administered at delivery to prevent damage to lungs due to improper ventilation. B) Lung surfactant will be administered after delivery to prevent the alveoli from collapsing. C) Antenatal steroids have to be administered during pregnancy to promote surfactant production. D) Antenatal steroids primarily work to prevent fetal lung damage due to infection. E) Antenatal steroids are administered before delivery to promote fetal lung maturation.

B) Lung surfactant will be administered after delivery to prevent the alveoli from collapsing. E) Antenatal steroids are administered before delivery to promote fetal lung maturation. Rationale: Lung surfactant is administered after delivery to prevent the alveoli from collapsing. Preterm infants are at risk of alveolar collapse due to the limited amount of surfactant produced before week 35 of gestation. During the antenatal period, corticosteroids like betamethasone and dexamethasone can be administered to promote fetal lung maturation. This is also known as antenatal corticosteroid therapy, and it is usually administered intramuscularly to pregnant clients at 24 to 33 weeks gestation who are expected to go into preterm labor.

A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time? 1. "That is very concerning. I will request that your physician order an enema for you." 2. "Two days is not that bad. Some patients go four days or longer without a movement." 3. "You have been taking antibiotics through your intravenous. That is probably why you are constipated." 4. "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."

That is probably why you are constipated." 4. "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."

The physician declares after delivering the placenta of a client during a cesarean section that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis? 1. Blood loss of 2,000 mL. 2. Blood pressure of 160/110. 3. Jaundiced skin color. 4. Shortened prothrombin time.

1. Blood loss of 2,000 mL. Rationale: A placenta accreta's chorionic villi burrow through the endometrial lining into the myometrial lining. Separation of the placenta from the uterine wall is severely hampered. Clients often lose large quantities of blood, and it is not uncommon for the physician to have to perform a hysterectomy to control the bleeding. Clients who have had multiple uterine scars are especially at high risk for this problem. If the test taker were unfamiliar with placenta accreta, he or she could deduce the answer, because the placenta is highly vascular and only one answer referred to a vascular issue. The average blood loss during a cesarean delivery is 1,000 mL.

The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts? 1. Gently massage the areas toward the nipple, especially during feedings. 2. Apply ice to the areas between feedings. 3. Bottle feed for the next twenty-four hours. 4. Apply lanolin ointment to the areas after each and every breastfeeding.

1. Gently massage the areas toward the nipple, especially during feedings. Rationale: A client who palpates a tender, hard nodule in her lactating breast is experiencing milk stasis. The stasis may be related to a blocked milk duct. It is very important that the woman gently massage the nodule while applying warm soaks and/or feeding her baby to prevent mastitis from developing.

A client has just received Hemabate (carboprost) because of uterine atony not controlled by IV oxytocin. For which of the following side effects of the medication will the nurse monitor this patient? Select all that apply. 1. Hyperthermia. 2. Diarrhea. 3. Hypotension. 4. Palpitations. 5. Anasarca.

1. Hyperthermia. 2. Diarrhea. Rationale: Hemabate can cause nausea, vomiting, diarrhea, and hyperthermia.

A nurse massages the atonic uterus of a woman who delivered 1 hour earlier. The nurse identifies the nursing diagnosis: Risk for injury related to uterine atony. Which of the following outcomes indicates that the client's condition has improved? 1. Moderate lochia flow. 2. Decreased pain level. 3. Stable blood pressure. 4. Fundus above the umbilicus.

1. Moderate lochia flow. Rationale: Expected outcomes relate to specific nursing diagnoses that are developed after making an assessment. This client's uterine muscle was boggy. The nursing action taken—massage—related directly to the nursing assessment—atonic uterus—and the outcome—normal lochia— indicated that the action was successful.

Intermittent positive pressure boots have been ordered for a client who had an emergency cesarean section. Which of the following is the rationale for that order? 1. Postpartum clients are at high risk for thrombus formation. 2. Post-cesarean clients are at high risk for fluid volume deficit. 3. Postpartum clients are at high risk for varicose vein development. 4. Post-cesarean clients are at high risk for poor milk ejection reflex.

1. Postpartum clients are at high risk for thrombus formation. Rationale: Because of an elevation in clotting factors, all postpartum clients are at high risk for thrombus formation.

A nurse is assessing a 1-day postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10-point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client? 1. She should be assessed by her doctor. 2. She should have a sitz bath. 3. She may have a hidden laceration. 4. She needs a narcotic analgesic.

1. She should be assessed by her doctor. Rationale: This client is complaining of an excessive amount of pain after having received a relatively large dose of ibuprofen. Because the perineum is edematous, the lochial flow is normal, and the pain level is well above that expected, the nurse should suspect that the client has developed a hematoma. The client should be assessed by her health care provider. The client may benefit from a narcotic, but should be assessed first.

A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client's blood type is O− (negative), the baby's type is A+ (positive), and the direct Coombs' test is negative. Which of the following actions by the nurse is appropriate? 1. Advise the client to keep her physician appointment at the end of the week to receive her RhoGAM injection. 2. Make sure that the client receives a RhoGAM injection before she is discharged from the hospital. 3. Notify the client that because her baby's Coombs' test was negative she will not receive an injection of RhoGAM. 4. Inform the client's physician that because the woman is being discharged on the second day, the RhoGAM could not be given.

2. Make sure that the client receives a RhoGAM injection before she is discharged from the hospital. Rationale: The administration of RhoGAM is the only way to prevent an Rh- (negative) client's body from mounting a full antibody response to the delivery of an Rh+ (positive) baby. It is malpractice for a nurse to discharge the client before she receives her injection or to delay the injection beyond the 72-hour deadline.

The nurse is reviewing the prescriptions for a newborn client whose mother was diagnosed with Neisseria gonorrhoeae. Which of the following ophthalmic medications should the nurse anticipate administering? A) Silver nitrate B) Diclofenac sodium C) Erythromycin D) Timolol

C) Erythromycin

On assessment of a postpartum pt, the nurse notes that the uterus feels soft and boggy. The nurse would take which *initial* action? A) Document the findings B) Elevate the pt's legs C) Massage the fundus until it is firm D) Push on the uterus to assist in expressing clots.

C) Massage the fundus until it is firm

The nurse is preparing to care for four assigned pts. Which pt is at *most* risk for hemorrhage? A) Primaparous pt who delivered 4 hours age B) Multiparous pt who delivered 6 hours ago C) Multiparous pt who delivered a large baby after oxytocin induction D) Primaparous pt who delivered 6 hours ago and had epidural anesthesia

C) Multiparous pt who delivered a large baby after oxytocin induction

The nurse is monitoring a client after a complete placental abruption that required the administration of blood and blood products. Which long-term complication(s) related to abruptio placentae should the nurse anticipate monitoring the client for during the postpartum period? Select all that apply. A) Disseminated intravascular coagulation (DIC) B) Renal failure C) Tetanic uterine contractions D) Sheehan syndrome E) Hypovolemic shock

A) Disseminated intravascular coagulation (DIC) B) Renal failure D) Sheehan syndrome E) Hypovolemic shock Rationale: If not promptly treated, extensive bleeding from placental abruption may lead to serious complications for both the mother and fetus. Maternal complications include hypovolemic shock, which can cause renal failure, and Sheehan syndrome, a type of perinatal hypopituitarism. Another possible complication is disseminated intravascular coagulation (DIC) which causes a cascade of clotting and bleeding. The fetus is at risk for intrauterine hypoxia and asphyxia because the fetus is no longer receiving adequate oxygenation. Other fetal risks include premature birth or fetal death.

The nurse in the labor and delivery unit is caring for this client with a history of perinatal depression. The nurse should understand that this term describes depression during which period? A) During pregnancy and four weeks following delivery B) The entire duration of childbearing age C) Three years following delivery D) Onset of pregnancy until delivery

A) During pregnancy and four weeks following delivery

The nurse is assessing the pt in the fourth stage of labor and notes that the fundus is firm but that bleeding is excessive. Which would be the *initial* nursing action? A) Record the findings B) Massage the fundus C) Notify the obstetrician (OB) D) Place the pt in Trendelenberg position

C) Notify the obstetrician (OB)

The nurse is reviewing the medical records of a client who recently gave birth after being treated for a placenta previa. Which finding indicates the treatment was effective? A) Occasional episodes of heavy bleeding B) Minimal intrauterine growth restriction C) Several maternal blood transfusions during the pregnancy D) Fetus delivered at 38 weeks gestation

D) Fetus delivered at 38 weeks gestation Rationale: Delivery of a term fetus indicates the treatment for a placenta previa has been successful. The goal of the treatment is to deliver a healthy newborn as close to term as possible. A term fetus is between 39 and 40 weeks gestation.

The nurse is reviewing the obstetrical history of a client scheduled for labor induction with oxytocin. Which finding should the nurse report to the healthcare provider? A) A history of fetal demise B) A history of one cesarean section C) Gestational diabetes D) History of five vaginal deliveries

D) History of five vaginal deliveries Rationale: Oxytocin should be avoided in clients with grand multiparity, meaning they have given birth five or more times. Grand multiparity increases the risk for uterine hemorrhage.

The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn, and the birthing parent asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? A) Protects the newborns' eyes from possible infections acquired while hospitalized. B) Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. C) Prevents an infection called ophthalmia neonatorum from occurring after birth to in a newbo

D) Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn after birth in a newborn born to a parent with an untreated gonococcal infection.

A client who is 3 days postpartum asks the nurse, "When may my husband and I begin having sexual relations again?" The nurse should encourage the couple to wait until after which of the following has occurred? 1. The client has had her six-week postpartum checkup. 2. The episiotomy has healed and the lochia has stopped. 3. The lochia has turned to pink and the vagina is no longer tender. 4. The client has had her first postpartum menstrual period.

1. The client has had her six-week postpartum checkup.

A baby is in the NICU whose mother was addicted to heroin during the pregnancy. Which of the following nursing actions would be appropriate? 1. Tightly swaddle the baby. 2. Place the baby prone in the crib. 3. Provide needed stimulation to the baby. 4. Feed the baby half-strength formula.

1. Tightly swaddle the baby. Rationale: Drug-exposed babies exhibit signs of neonatal abstinence syndrome: hyperactivity, hyperreflexia, and the like. The test taker should look for a nursing intervention that would minimize those behaviors. Tightly swaddling the baby would help to reduce the baby's behavioral responses.

A neonatologist requests Narcan (naloxone) during a neonatal resuscitation effort for a baby weighing 3 kg. Which of the following dosages would be within the range of safety for the nurse to prepare? 1. 4 micrograms. 2. 40 micrograms. 3. 4 milligrams. 4. 40 milligrams.

2. 40 micrograms. Rationale: The recommended dosage for the administration of Narcan (naloxone) to a neonate has been cited as *0.01 mg/kg to 0.1 mg/kg.* Because there are 1000 micrograms per mg, if the dosage were written in micrograms, the dosage for a 3-kg neonate would be: 30 micrograms to 300 micrograms. If the dosage were written in mg, the dosage for a 3-kg neonate would be: 0.03 mg to 0.3 mg. The only choice that lies within the range of safety is 40 micrograms

A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.

2. Fundus.

A nurse is caring for the following four laboring patients. Which client should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select all that apply. 1. G1 P0000, delivered a fetal demise at 29 weeks' gestation. 2. G2 P1001, prolonged first stage of labor. 3. G2 P0010, delivered by cesarean section for failure to progress. 4. G3 P0200, delivered vaginally a 42-week, 2,200-gram neonate. 5. G4 P3003, with a succenturiate placenta.

2. G2 P1001, prolonged first stage of labor. 5. G4 P3003, with a succenturiate placenta. Rationale: The muscles of the uterus of a client who has experienced a prolonged first stage of labor are fatigued. In the postpartum period, therefore, they may fail to contract fully enough to control bleeding at the site of placental separation. A succenturiate placenta is characterized by one primary placenta that is attached via blood vessels to satellite lobe(s). These clients must be monitored carefully for postpartum hemorrhage.

Thirty seconds after birth a baby, who appears preterm, has exhibited no effort to breathe even after being stimulated. The heart rate is assessed at 50 bpm. Which of the following actions should the nurse perform first? 1. Perform a gestational age assessment. 2. Inflate the lungs with positive pressure. 3. Provide external chest compressions. 4. Assess the oxygen saturation level.

2. Inflate the lungs with positive pressure. Rationale: The baby's airway should be established by inflating the lungs with an ambu bag.

The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? Select all that apply. 1. The woman performs the procedure twice a day. 2. The woman washes her hands before and after the procedure. 3. The woman sits in warm tap water for ten minutes three times a day. 4. The woman sprays her perineum from front to back. 5. The woman mixes warm tap water with hydrogen peroxide.

2. The woman washes her hands before and after the procedure. 4. The woman sprays her perineum from front to back.

The nurse assesses a newborn as follows: Heart rate: 70 Respirations: weak and irregular Tone: flaccid Color: pale Baby grimaces when a pediatrician attempts to insert an endotracheal tube What should the nurse calculate the baby's Apgar score to be?

3

A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with "latch on" and recommends that the mother do which of the following? 1. Use a nipple shield at each breastfeeding. 2. Cleanse the nipples with soap 3 times a day. 3. Rotate the baby's positions at each feed. 4. Bottle feed for 2 days then resume breastfeeding.

3. Rotate the baby's positions at each feed. Rationale: If a mother rotates positions at each breastfeeding, the baby is likely to put pressure on varying points on the nipple. A good, deep latch, however, is the most important way to prevent nipple soreness and cracking. The mother could also apply lanolin to her breasts after each feeding.

There is a baby in the neonatal intensive care unit (NICU) who is exhibiting signs of neonatal abstinence syndrome. Which of the following medications is contraindicated for this neonate? 1. Morphine. 2. Opium. 3. Narcan. 4. Phenobarbital.

3. Narcan.

A neonate has intrauterine growth restriction secondary to placental insufficiency. Which of the following signs/symptoms should the nurse expect to observe at delivery? Select all that apply. 1. Thrombocytopenia. 2. Neutropenia. 3. Polycythemia. 4. Hypoglycemia. 5. Hyperlipidemia.

3. Polycythemia. 4. Hypoglycemia. Rationale: Aging placentas function poorly, and therefore the fetuses receive less nutrition and oxygenation. The baby's body, therefore, must compensate for the losses by metabolizing glycogen and lipid stores and by producing increased numbers of red blood cells. The neonate, therefore, is often polycythemic, hypoglycemic, and hypolipidemic.

A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go on a diet?" Which of the following responses is appropriate? 1. "It is fine for you to start dieting right now as long as you drink plenty of milk." 2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding." 3. "You must eat at least 3,000 calories per day in order to produce enough milk for your baby." 4. "Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day."

4. "Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day."

the nurse is monitoring a postpartum pt, who delivered 1 hour ago and received epidural anesthesia for delivery, for the presence of a vulvar hematoma. Which assessment finding would *best* indicate the presence of a hematoma? A) Changes in vital signs B) Signs of heavy bruising C) Complaints of intense pain D) Complaints of tearing sensation

A) Changes in vital signs Rationale: Heavy bruising may be seen, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

The third stage of labor has just ended for a client who has decided to bottle feed her baby. Which of the following maternal hormones will increase sharply at this time? 1. Estrogen. 2. Prolactin. 3. Human placental lactogen. 4. Human chorionic gonadotropin.

2. Prolactin. Rationale: Because the hormones of pregnancy produced by the placenta—progesterone and estrogen— drop precipitously at this time, prolactin is no longer inhibited and, therefore, rises. The way the woman intends to feed her baby is irrelevant.

A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? 1. She pumps her breasts after each feeding. 2. She feeds her baby every 2 to 3 hours. 3. She feeds her baby 10 minutes on each side. 4. She supplements each feeding with formula.

2. She feeds her baby every 2 to 3 hours.

Which of the following neonates is at highest risk for cold stress syndrome? 1. Infant of diabetic mother. 2. Infant with Rh incompatibility. 3. Postdates neonate. 4. Down syndrome neonate.

3. Postdates neonate. Rationale: Postdate babies are at high risk for cold stress syndrome because while still in utero they often metabolize the brown adipose tissue for nourishment when the placental function deteriorates.

A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate? 1. Take the woman's temperature. 2. Advise the woman to decrease her fluid intake. 3. Reassure the woman that this is normal. 4. Notify the neonate's pediatrician.

3. Reassure the woman that this is normal.

A baby has just been admitted into the neonatal intensive care unit with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal factors would predispose the baby to this diagnosis? Select all that apply. 1. Hyperopia. 2. Gestational diabetes. 3. Substance abuse. 4. Chronic hypertension. 5. Advanced maternal age.

3. Substance abuse. 4. Chronic hypertension. 5. Advanced maternal age.

The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? 1. Fundus 1 cm above the umbilicus, lochia rosa. 2. Fundus 2 cm above the umbilicus, lochia alba. 3. Fundus 2 cm below the umbilicus, lochia rubra. 4. Fundus 3 cm below the umbilicus, lochia serosa.

4. Fundus 3 cm below the umbilicus, lochia serosa. Rationale: Although each client's postpartum course is slightly different, on day 3 postpartum, the nurse would expect the fundus of most clients to be 3 cm below the umbilicus and the lochia to have become serosa.

A macrosomic infant of a non-insulin dependent diabetic mother has been admitted to the neonatal nursery. The baby's glucose level on admission to the nursery is 25 mg/dL and after a feeding of mother's expressed breast milk is 35 mg/dL. Which of the following actions should the nurse take at this time? 1. Nothing, because the glucose level is normal for an infant of a diabetic mother. 2. Administer intravenous glucagon slowly over five minutes. 3. Feed the baby a bottle of dextrose and water and reassess the glucose level. 4. Notify the neonatologist of the abnormal glucose levels.

4. Notify the neonatologist of the abnormal glucose levels Rationale: If the glucose level has not risen to normal as a result of the feeding, the nurse should notify the physician and anticipate that the doctor will order an intravenous of dextrose and water.

A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery and the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for? 1. Pruritus. 2. Nausea. 3. Postural headache. 4. Respiratory depression.

3. Postural headache.

The parent of a newborn calls the clinic and reports that when cleaning the umbilical cord, it was noted that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this parent? A) Bring the infant to the clinic. B) This is a normal occurrence and no further action is needed. C) Increase the number of times that the cord is cleaned per day. D) Monitor the cord for another 24 to 48 hours, and call the clinic if the discharge continues.

A) Bring the infant to the clinic. Rationale: Signs of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If signs of infection occur, the client needs to be instructed to notify the primary health care provider.

A nurse on the maternity unit is caring for a client following a cesarean section of a postmature infant. Which maternal risk factor(s) may have predisposed the client to this condition? Select all that apply. A) First pregnancy B) Obesity C) Older maternal age D) Multiple pregnancies E) Girl sex of the fetus F) Prior preterm pregnancies

A) First pregnancy B) Obesity C) Older maternal age Rationale: Most commonly, the cause of post-term birth is unknown. The most important risk factors for post-term birth include *obesity; first pregnancy or previous post-term pregnancies; and advanced maternal age*. Genetic factors also influence post-term birth. Multiple pregnancies, girl fetal sex, and prior preterm pregnancies are not risk factors for post-term gestation or postmaturity.

The nurse is caring for a client in the recovery room who delivered an infant by emergency cesarean section due to a prolapsed umbilical cord. Which assessment finding indicates the treatment has been effective? A) Heart rate 78/min B) Respiratory rate 26/min C) Blood pressure 90/46 mmHg D) Sp02 92%

A) Heart rate 78/min Rationale: A pulse of 78/min is an expected finding. The normal heart rate for an adult is 60 to 100/min. The normal range for Sp02 is 95% to 100%. Sp02 of 92% indicates the client's oxygen saturation is inadequate.

The nurse is monitoring a pt in the immediate postpartum period for signs of a hemorrhage. Which sign, if noted, would be an *early* sign of excessive blood loss? A) Temperature of 100.4 F B) An increase in the pulse rate from 88 to 102 BPM C) A BP change from 130/88 to 124/80 mmHg D) An increase in the respiratory rate from 18 to 22 breaths per minute

B) An increase in the pulse rate from 88 to 102 BPM

A breastfeeding client is being seen in the emergency department with a hard, red, warm nodule in the upper outer quadrant of her left breast. Her vital signs are: T 104.6°F, P 100, R 20, and BP 110/60. She has a recent history of mastitis and is crying in pain. Which of the following nursing diagnoses is highest priority? 1. Ineffective breastfeeding. 2. Infection. 3. Ineffective individual coping. 4. Pain.

2. Infection. rationale: This client has a breast abscess. Although all of the nursing diagnoses are important, the most important diagnosis is infection. It is the only one of the four diagnoses that is related to the acute problem. Ineffective breastfeeding contributed to the development of the infection. Because of the infection, the client is in pain and is coping poorly. Once the abscess is drained and the antibiotics have been administered, the other three diagnoses will be on the road to being resolved.

A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her baby. Which of the following responses by the nurse is appropriate? 1. Suggest that the woman bottle feed for a few days. 2. Instruct the patient on how to massage her fundus. 3. Instruct the patient to feed using an alternate position. 4. Discuss the action of breastfeeding hormones.

4. Discuss the action of breastfeeding hormones. Rationale: *Oxytocin, the hormone of labor, also stimulates the uterus to contract* in the postpartum period to reduce blood loss at the placental site. Oxytocin is the same hormone that regulates the milk ejection reflex. Whenever a mother breastfeeds, therefore, oxytocin stimulates her uterus to contract. In essence, therefore, breastfeeding naturally benefits the mother by contracting the uterus and preventing excessive bleeding.

A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2°F. Which of the following is the appropriate nursing intervention at this time? 1. Notify the doctor to get an order for acetaminophen. 2. Request an infectious disease consult from the doctor. 3. Provide the woman with cool compresses. 4. Encourage intake of water and other fluids.

4. Encourage intake of water and other fluids.

A G2 P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal finding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary health care provider.

4. Notify the woman's primary health care provider. Rationale: The nurse must do some detective work when observing unexpected signs/symptoms. This client is bleeding more heavily than the nurse would expect. When the nurse assesses the two most likely sources of the bleeding—the fundus and the perineal sutures—normal findings are noted. The next most likely source of the bleeding —a laceration in the birth canal—is unobservable to the nurse because performing a postpartum internal examination is not a nursing function. The nurse, therefore, must notify the health care practitioner of the problem.

The nurse is caring for a client who had an emergency cesarean section for a prolapsed umbilical cord. Which information should the nurse include regarding the early recovery period for the post-cesarean teaching plan? A) Dietary restrictions B) Pain management C) Strict bed rest D) Delayed breastfeeding

B) Pain management Rationale: During the early recovery period, a post-cesarean teaching plan includes incision care, pain management, activity restrictions, and the importance of deep breathing, coughing, and early ambulation.

A nurse on the postpartum unit is assigned a 35-year-old para 3 gravida 1 (P3G1) client who has just delivered their first child via cesarean section. The newborn is diagnosed with physiological jaundice and is being treated on a different unit with phototherapy. The client expresses their sadness that they cannot hold their baby often and repeatedly asks, "Is my baby going to be ok?" Which nursing diagnosis(es) should be added to the care plan for this client? Select all that apply. A) Ineffective breastfeeding related to continuous phototherapy treatment B) Powerlessness related to loss of control over infant's medical care C) Excess fluid volume related to impaired excretion of breast milk D) Disorganized infant behavior related to hyperbilirubinemia treatment E) Risk for impaired attachment related to impaired physical bonding

A) Ineffective breastfeeding related to continuous phototherapy treatment B) Powerlessness related to loss of control over infant's medical care E) Risk for impaired attachment related to impaired physical bonding

A nurse in the emergency department unit is caring for a client ten days postpartum. The client had a singleton pregnancy with a spontaneous vaginal delivery. Which infection is most likely to develop in this client? A) Mastitis B) Group beta streptococcal (GBS) infection C) Herpes simplex virus D) Chorioamnionitis

A) Mastitis Rationale: Mastitis is a common postpartum infection involving breast tissue inflammation. It may occur anytime during lactation, which makes it specific to the intrapartum and postpartum periods. Chorioamnionitis is an infection that can occur during pregnancy but is unlikely to occur ten days postpartum.

The student nurse is preparing to administer vitamin K via intramuscular (IM) injection to a full-term newborn. Which instruction(s) should the nursing instructor provide for the student? Select all that apply. A) Use a ⅝ inch needle with a 23-25 gauge. B) Provide the newborn with oral sucrose. C) After injection, cover the newborn's leg with an occlusive dressing. D) Discourage the parents from holding and distracting the newborn. E) Allow the newborn's leg to hang limp to promote relaxa

A) Use a ⅝ inch needle with a 23-25 gauge. B) Provide the newborn with oral sucrose. Rationale: When administering phytonadione (vitamin K) to a newborn, there are a number of nursing considerations to keep in mind. During administration,the nurse should stabilize the infant's leg to prevent injury. It may be helpful to have the mother hold or breastfeed the infant during the injection, because this can provide comfort and ease the infant's pain. Alternatively, provide comfort measures such as non-nutritive sucking or pain management using oral sucrose.Then, administer the medication in the vastus lateralis muscle located between the greater trochanter and the lateral femoral condyle using a ⅝ inch, 23-25 gauge needle. After administration, provide additional comfort measures as needed and monitor the infant for any bleeding, edema, inflammation or rash at the injection site.

The nurse is preparing a list of self-care instructions for a postpartum pt who was diagnosed with mastitis. Which instructions would be included on the list? Select all that apply. A) Wear a supportive bra B) Rest during the acute phase C) Maintain a fluid intake of at least 3000mL/day D) Take prescribed antibiotics until soreness subsides E) Continue to breastfeed if the breasts are not too sore F) Avoid decompression of breasts by breastfeeding of breast pump

A) Wear a supportive bra B) Rest during the acute phase C) Maintain a fluid intake of at least 3000mL/day E) Continue to breastfeed if the breasts are not too sore

The nurse in the mother-baby unit has administered intravenous (IV) methylergonovine (Methergine) to a client for treatment of severe postpartum hemorrhage. Which nursing assessment is the priority? A) Cranial nerves B) Blood pressure C) Breath sounds D) Lymphatic structures

B) Blood pressure Rationale: Clients receiving intravenous methylergonovine are at risk for cardiovascular effects which include hypo- or hypertension. The nurse should assess blood pressure to ensure the client does not develop these side effects.

A client in the neonatal intensive care unit (NICU) is being treated for cephalohematoma secondary to suspected hemophilia. Which laboratory test(s) should the nurse prepare the client for? Select all that apply. A) Vitamin K level B) Clotting factor assays C) Activated partial thromboplastin time (aPTT) D) Complete blood count (CBC) E) Prothrombin time (PT) test

B) Clotting factor assays C) Activated partial thromboplastin time (aPTT) D) Complete blood count (CBC) E) Prothrombin time (PT) test Rationale: Diagnosis of hemophilia is usually based on clinical presentation, family history, and lab tests. Tests include a complete blood count (CBC) which is usually normal except for cases of bleeding, as well as a normal prothrombin time (PT), since the extrinsic pathway is not involved, and a prolonged activated partial thromboplastin time (aPTT), since the intrinsic pathway is affected through deficiencies of factor VIII and IX. Also, the hemophilia type can be confirmed via factor assays to look at specific factor activities. Genetic testing may also be performed to identify the mutated gene.

The nurse in a NICU receives a telephone call to prepare for the admission of a newborn with Apgar scores of 1 and 4, born at 41 weeks gestation. In planning for admission of this newborn, what is the nurse's highest priority? A) Turn on the apnea and cardiorespiratory monitors B) Connect the resuscitation bag to the oxygen outlet. C) Set up the IV line with 5% dextrose in water. D) Set the radiant warmer control temperature at 36.5 C (97.6 F)

B) Connect the resuscitation bag to the oxygen outlet.

The postpartum nurse is providing instructions to the parents of a newborn with hyperbilirubinemia who is being breast/chest fed. The nurse would provide which instructions to the parent? A) Feed the newborn less frequently. B) Continue to breast/chest-feed every 2to 4 hours. C) Switch to bottle-feeding the infant for 2 weeks. D) Stop breast/chest-feeding and switch to bottle-feeding permanently.

B) Continue to breast/chest-feed every 2to 4 hours. Rationale: Early and frequent feeding hastens the excretion of bilirubin. Breast/chest-feeding needs to be initiated 2 hours after birth and every 2 to 4 hours thereafter.

A nurse cares for a client 48 hours after surgical delivery. Which question is most appropriate to determine whether the client is at risk for infection? A) Did you experience preeclampsia during pregnancy? B) Did you have a urinary catheter while in surgery? C) Does your infant have signs of deafness? D) Was this your first surgical delivery?

B) Did you have a urinary catheter while in surgery? Rationale: Insertion of a urinary catheter is commonplace during surgical deliveries. Urinary catheters increase the risk of developing urinary tract infections in the postpartum period. This question directly assesses a risk factor for postpartum infection.

A neonate in the outpatient clinic has a total serum bilirubin (TSB) level of 15 mg/dL on day 4 after birth. Two weeks later, the TSB level is 6 mg/dL. Based on this result, which nursing intervention should be implemented? A) Increase breast feedings to 30 minutes per session B) Educate the parents about concerning signs and symptoms C) Obtain a heel-stick capillary glucose level D) Initiate treatment with phototherapy

B) Educate the parents about concerning signs and symptoms Rationale: Most forms of neonatal jaundice resolve with time and effective feeding and do not result in severe brain damage. Normal bilirubin levels are 5mg/dL or below. Because this client's levels are almost within the normal range, it is unlikely this client has severe brain damage or other complications. Based on TSB levels, this client's treatment has been effective; however, it is important to continue to educate parents about signs and symptoms that may be concerning and require a follow-up visit to the client's provider.

A postpartum pt is diagnosed with cystitis. The nurse would plan for which *priority* action int he care of the pt? A) Providing sitz baths B) Encouraging fluid intake C) Placing ice on the perineum D) Monitoring hemoglobin and hematocrit levels

B) Encouraging fluid intake

Which nursing intervention(s) should be incorporated into the plan of care for a 48-hour-old neonate receiving phototherapy for jaundice? Select all that apply. A) Assessing oral temperature every 4 hours B) Ensuring eye protection is in place during treatment C) Performing frequent skin assessments and diaper changes D) Obtaining daily total serum bilirubin (TSB) levels E) Restrict breastfeeding to 20 minutes per day

B) Ensuring eye protection is in place during treatment C) Performing frequent skin assessments and diaper changes D) Obtaining daily total serum bilirubin (TSB) levels Rationale: Phototherapy is a treatment that involves exposing the neonate's skin to a special light that breaks down bilirubin into smaller molecules so it can be excreted. During treatment, the neonate's neurological status, temperature, feeding and hydration status, skin integrity, and total serum bilirubin levels should be routinely monitored. Eye protection must be in place at all times during light exposure.

The nurse on the mother-baby unit is preparing to administer a dose of oxytocin. Which admitting diagnosis could this medication be used to treat? Select all that apply. A) Lactation insufficiency B) Failure to progress C) Braxton Hicks contractions D) Postpartum uterine atony E) Incomplete abortion

B) Failure to progress D) Postpartum uterine atony E) Incomplete abortion Rationale: Oxytocin is a peptide hormone released by the posterior pituitary that causes uterine muscle contraction during labor. It is also responsible for the milk let-down reflex, where milk that is already stored in the breast is ejected during breastfeeding. Oxytocin is commonly used to induce labor or help strengthen uterine contractions to facilitate delivery. After delivery of the placenta, it is used to treat uterine atony, prevent postpartum hemorrhage, and manage incomplete or inevitable spontaneous abortion.

A client and her partner present to the pediatrician's office with their newborn child for a follow-up visit. The client's partner confides in the nurse that they suspect the client may be suffering from perinatal depression. Which clinical manifestation(s) would support this diagnosis? Select all that apply. A) Occasional crying spells that resolve quickly B) Losing interest in previously enjoyable activities C) Extreme sadness D) Mild mood swings E) Changes in appetite and weight F) Lack of eye contact with the infant

B) Losing interest in previously enjoyable activities C) Extreme sadness E) Changes in appetite and weight F) Lack of eye contact with the infant

The postpartum nurse reviews the blood types of several mothers and their newborns. For which client should the nurse anticipate administering RhO (D) immune globulin? A) Maternal blood type: A+, Fetal blood type: AB- B) Maternal blood type: O-, Fetal blood type: B+ C) Maternal blood type: AB-, Fetal blood type: O- D) Maternal blood type: B+, Fetal blood type: AB+

B) Maternal blood type: O-, Fetal blood type: B+

When caring for a four-day-old infant, which finding(s) should the nurse recognize to indicate that the client is receiving adequate nutritional intake? Select all that apply. A) At least two bowel movements per day are recorded. B) Milk is dripping from the breast. C) Nutritive sucking is present. D) The infant appears satisfied after eating. E) There are at least three to four wet diapers per day. F) The infant has been fed 8 to 12 times within 24 hours.

B) Milk is dripping from the breast. C) Nutritive sucking is present. F) The infant has been fed 8 to 12 times within 24 hours. Rationale: Signs and symptoms of adequate nutritional intake in a newborn client include frequent swallowing during feeding; nutritive suckling; breast becoming softer during a feeding; milk in baby's mouth or dipping from the breast; the baby is fed 8 to 12 times each 24 hours; at least one or two wet diapers per day for the first two days after birth, at least three or four wet diapers day by day three, and at least six wet diapers per day by day four; at least three or four bowel movements per day by day three and four bowel movements per day after that time; satisfaction after feeding; and weight gain.

A pt in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the pt is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which would be the *initial* nursing action? A) Initiate an IV B) Assess the pt's BP C) Prepare to administer morphine sulfate D) Administer oxygen, 8-10 L/minute, by face mask

D) Administer oxygen, 8-10 L/minute, by face mask

The nurse in the well-baby nursery is caring for a client born via cesarean section 48 hours ago and notes the newborn's skin has developed a worsening yellow hue and the client is subsequently diagnosed with hyperbilirubinemia. According to the client's mother, the baby has been breastfeeding effectively. Which hyperbilirubinemia cause should the nurse suspect? A) Pathological jaundice of the newborn B) Physiologic jaundice of the newborn C) Breast milk jaundice D) Breastfeeding jaundice

B) Physiologic jaundice of the newborn Rationale: The most common cause of unconjugated hyperbilirubinemia is physiologic jaundice of the newborn, also called benign neonatal hyperbilirubinemia. This may occur because newborns have a great turnover and breakdown of red blood cells, but the liver is still relatively immature and inefficient at conjugating and excreting bilirubin. This typically manifests after the first 24 hours from birth, and resolves within one to two weeks. This is the most likely cause of hyperbilirubinemia for this client.

A newborn's indirect bilirubin level rises from 5 mg/dL 12 hours following spontaneous vaginal delivery to 27 mg/dL 24 hours after delivery. Which long-term complication(s) of elevated bilirubin levels is this client at risk for? Select all that apply. A) Retroperitoneal bleeding B) Seizure disorder C) Excess body hair D) Hearing loss E) Intellectual disability

B) Seizure disorder D) Hearing loss E) Intellectual disability Rationale: Pathologic jaundice is the most serious type of jaundice. It occurs within 24 hours after birth and is characterized by a rapid rise in a baby's bilirubin level. The normal bilirubin level in the newborn is less than 5 mg/dL within the first 24 hours of birth. The most likely cause is blood incompatibility or liver disease. Prompt medical attention is necessary, and blood transfusions may be required. Breastfeeding can continue during treatment. Acute complications of pathologic jaundice include kernicterus, or bilirubin toxicity of the brain, which results in seizures, fever, lethargy, poor feeding, and high-pitched cry. If the client's condition is severe or not treated promptly, prolonged brain damage from elevated bilirubin levels can cause encephalopathy, which can lead to seizure disorders, intellectual disability, and hearing loss.

A female has just delivered her second child via cesarean section. The client has Rh-negative blood and has not had Rh antibody prophylaxis. The newborn is exhibiting lethargy, poor feeding, and yellow discoloration of the skin and sclera and is diagnosed with hyperbilirubinemia. What additional symptom(s) is/are indicative of a worsening in the newborn's condition? Select all that apply. A) Hyperactivity B) Stupor C) Increased rooting reflex D) High-pitched cry E) Seizures F) Lanugo

B) Stupor D) High-pitched cry E) Seizures Rationale: Blood type incompatibility is one of the risk factors for pathological jaundice which can cause severe hyperbilirubinemia. Excess bilirubin can deposit in the brain and cause brain damage. As the condition worsens, clients may exhibit signs and symptoms such seizures, fever, lethargy, poor feeding, and high-pitched cry. If the client's condition is severe or not treated promptly, prolonged brain damage from elevated bilirubin levels can cause encephalopathy, which can lead to seizure disorders, intellectual disability, and hearing loss.

A nurse caring for a client is delivered via emergent cesarean section at 42 weeks gestation. Immediately after birth, the client is lethargic, with a thin, green umbilical cord and skin. Which action should the nurse take first? A) Swaddle the infant to restrict movement B) Suction the client's airway C) Obtain a blood glucose D) Apply warm blankets

B) Suction the client's airway Rationale: Post-term infants are at risk for meconium aspiration. There is evidence that this client was exposed to meconium in utero due to the green color of the umbilical cord and skin. Meconium is a fetal waste product that can become ingested or enter the airways of the fetus. A client delivered via cesarean section does not experience the compression of the birth canal, which can help expel fluids in the airways, if present. The nurse should prioritize maintaining a patent airway in this client before performing any other action.

The nurse is monitoring a client receiving oxytocin to augment their labor. The nurse should assess for which side effect related to this medication? A) Preterm labor B) Uterine hyperstimulation C) Rapid fetal descent D) Hypotension

B) Uterine hyperstimulation Rationale: An adverse effect of oxytocin is uterine hyperstimulation, which occurs when there are too many uterine contractions. Uterine hyperstimulation causes painful contractions and can result in uterine rupture and hemorrhag

The nurse is educating the parents of a newborn male about phytonadione (vitamin K). Which statement by the mother indicates that additional teaching is necessary? A) "I plan to hold my baby in my arms while the nurse gives the shot." B) "If my baby develops a rash on their leg, I will contact the doctor." C) "I want to schedule my son's vitamin K shot after his circumcision." D) "I am going to give my baby a pacifier during the injection."

C) "I want to schedule my son's vitamin K shot after his circumcision." Rationale: Vitamin K helps regulate the process of blood coagulation. Since newborns can bleed after a circumcision, they should receive the vitamin K injection prior to any invasive procedures. This statement indicates the mother requires additional education.

A nurse on the maternity unit is caring for four clients between 2 and 4 days postpartum. For which client should the nurse suspect postpartum infection? A) A client with a heart rate of 89 beats/min who states she feels disconnected from her baby B) A client with a blood pressure of 125/75 mmHg with red vaginal discharge C) A client with a temperature of 100.9F (38.3C) and mild back aching D) A client with a respiratory rate of 22 breaths per minute during ambulation for the first time after cesarean section

C) A client with a temperature of 100.9F (38.3C) and mild back aching Rationale: Fever or a temperature above 100.9F (38.3C) in the postpartum client is not normal and indicative of infection. A mild backache may be expected or indicate an infection within the abdominal cavity or urinary tract. In the first 24 hours after delivery, a slight elevation in temperature may be expected, and 101.6F or 38.7C is considered the threshold for infection concern in this timeframe.

The nurse is preparing to administer 0.5% erythromycin ophthalmic ointment to a newborn for neonatal eye prophylaxis. Which is the correct technique for administration? A) Administering the ophthalmic ointment to the bilateral corneas B) Gently touching the tip of the applicator directly to the newborn's lower lid C) Applying a one centimeter ribbon of ointment along the lower conjunctival sac D) After applying the ointment, close the newborn's eyes for two minutes

C) Applying a one centimeter ribbon of ointment along the lower conjunctival sac

The nurse is monitoring a client who had an emergency cesarean section due to placental abruption. Which assessment finding should the nurse immediately communicate to the healthcare provider? A) Nausea and vomiting B) Uterine cramping C) Bleeding at the IV site D) Incisional pain 6/10

C) Bleeding at the IV site Rationale: A client with placental abruption is at risk for disseminated intravascular coagulation (DIC). DIC occurs when abnormal clotting occurs throughout the body. A clinical finding associated with DIC is unexplained bleeding, such as from an IV site. DIC is a medical emergency because the client is at risk for hypovolemic shock and death from bleeding.

The nurse educator provides information to a group of pregnant clients. Which information should the nurse educator include about the indication(s) for analgesics used during labor and delivery? Select all that apply. A) Joint pain B) Headache C) Cervical stretching D) Generalized myalgia E) Uterine contractions F) Vaginal distention

C) Cervical stretching E) Uterine contractions F) Vaginal distention Rationale: Analgesics are medications used to relieve pain and for various reasons in obstetrics. During pregnancy, clients can use them to manage headaches, back, or pelvic pain. Analgesics may help reduce pain from uterine contractions, cervical stretching, and vaginal distension during delivery. Lastly, Clients can use these medications following a vaginal delivery for perineal lacerations or following cesarean delivery for pain at the incisional site.

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? A) Apply gentle pressure. B) Reinforce the dressing. C) Document the findings. D) Notify the primary health care provider.

C) Document the findings. Rationale: The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours, and this is part normal healing. The nurse would expect the area would be red with a small amount of bloody drainage.

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? A) Warming the crib pad B) Closing the doors to the room C) Drying the infant with a warm blanket D) Turning on the overhead radiant warmer

C) Drying the infant with a warm blanket

The nurse in the family medical practice is assessing a five-week-old infant brought in by their mother due to uncontrollable crying. The infant appears stable but unsettled in their car seat and cries loudly. The mother is known to the practice and was recently diagnosed with perinatal depression. Which observation should the nurse report to the healthcare provider? A) The mother asks if she can have her partner on the phone. At the same time, the nurse speaks with her B) The mother attempts to put a pacifier in the infant's mouth C) The mother does not respond to the infant's cries D) The mother removes the infant from their carrier and rocks them

C) The mother does not respond to the infant's cries Rationale: If the mother of a crying baby appears withdrawn and is not responsive to the infant's cues, this is a sign of worsening perinatal depression and should be reported to the healthcare provider. The nurse should recognize signs of worsening perinatal depression, including decreased involvement with the baby, being emotionally withdrawn or unable to meet the baby's needs, and remaining isolated without adequate support.

A client five days postpartum calls her obstetrician's office and tells the nurse that she has been experiencing mild pelvic cramping. What is the nurse's most appropriate response? A) This is an emergency, and you need to call emergency medical services immediately. B) This is concerning, especially if your temperature remains normal. C) This is common and most likely due to the uterus returning to its normal position. D) This is abnormal and may indicate a postpartum infection.

C) This is common and most likely due to the uterus returning to its normal position. Rationale: After delivery, the uterus returns to its nonpregnant state of size and position, a process called uterine involution. It takes up to two weeks for the uterus to stabilize after delivery. Uterine contractions, often referred to as afterpains because they cause sharp pain in the lower abdomen, continue during the postpartum period to further aid uterine involution. Based on the client's complaint of mild pelvic cramps alone, the nurse should reassure the client and perform a further assessment before recommending an intervention.

A client has tachycardia 14 days after a vaginal delivery. Which laboratory test should the nurse prepare to draw to rule out postpartum infection? A) Progesterone B) Red blood cell count C) White blood cell count D) Creatinine

C) White blood cell count

The nurse is reviewing the electronic health record (EHR) of a newborn client with hyperbilirubinemia and notes that the skin is documented as being jaundice. Which skin color should the nurse visualize upon inspection of the client? A) Pink B) Red C) Yellow D) Blue

C) Yellow

A nurse is caring for a client born via vaginal delivery one hour ago. The client was born at 42.5 weeks gestation. Which statement is appropriate when the nurse is documenting for this client? A) "Client was born term at 42.5 weeks gestation." B) "Client was born prematurely at 42.5 weeks gestation." C) "Client was born preterm at 42.5 weeks gestation." D) "Client was born post-term at 42.5 weeks gestation."

D) "Client was born post-term at 42.5 weeks gestation." Rationale: A post-term infant is born after 42 weeks of gestation.

The nurse is providing instructions about measures to avoid postpartum mastitis to a pt who is breastfeeding the newborn. Which pt statement would indicate a *need for further instruction*? A) "I need to breastfeed every 2-3 hours." B) "I need to change the breast pads frequently." C) "I need to wash my hands well before breastfeeding." D) "I need to wash my nipples daily with soap and water."

D) "I need to wash my nipples daily with soap and water." Rationale: Soap is drying and could lead to cracking of the nipples, and the pt needs to be instructed to avoid using soap on the nipples.

The nurse has provided education to a postpartum client prescribed methylergonovine (methergine) for postpartum hemorrhage. Which client statement indicates further teaching is required? A) "I know this medicine comes in the form of an injection." B) "I should expect my uterine bleeding to decrease." C) "I will report any nausea to my healthcare provider." D) "I will stop breastfeeding because it is unsafe while taking this medication."

D) "I will stop breastfeeding because it is unsafe while taking this medication."

A nurse working in a community women's health clinic assesses a client who gave birth 10-days-ago. The client tells the nurse, "I feel like death is the only good option for my baby and me. I think I will drive my car off the road when I leave here." Which action should the nurse perform first? A) Ask the client to sign a suicide contract B) Schedule the client for a follow-up visit in two-weeks C) Encourage the client to express feelings of distress D) Call 911 immediately

D) Call 911 immediately Rationale: This client has expressed suicidal and homicidal ideation with a specific plan to kill herself and her child. The nurse is obligated to call 911 to ensure the safety of the client and the newborn. Expressing suicidal ideation is a sign of severe perinatal depression and psychological distress.

A week following cesarean section, a client presents to the emergency department with redness and purulent discharge at the incision site with no pain noted on assessment. The nurse anticipates the client will be prescribed which of the following? A) Docusate sodium B) Ibuprofen C) Fluoxetine D) Cephalexin

D) Cephalexin Rationale: Cephalexin is an antibiotic used to treat different kinds of infections, including those of the skin. Administration of this medication should be prioritized because, based on the client's symptoms, they may develop an infection of the surgical site.

A preterm infant born at 32-weeks gestation and diagnosed with hyperbilirubinemia has a total serum bilirubin (TSB) level of 17 mg/dL on day 2 after birth. The next day, the TSB level is 25 mg/dL despite phototherapy treatment and frequent breastfeeding. Which intervention should the nurse anticipate next? A) Autologous transfusion of whole blood B) Continuous infusion of heparin C) Transcutaneous bilirubin level D) Exchange blood transfusion

D) Exchange blood transfusion Rationale: Dangerous levels of serum bilirubin are greater than 25 mg/dL or an increase of more than 5 mg/dL per day. A client with severe jaundice should receive treatment with phototherapy. If the condition is severe or if phototherapy is ineffective, an exchange transfusion should be considered.