Final 1A
A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching? "My sister will be able to carry my baby from the nursery to my room when she arrives." "The nurse will match my wrist band to my baby's crib card when they bring him to me." "The person who comes to take my baby's pictures will be wearing a photo identification badge." "My baby doesn't need to wear the electronic security bracelet when he's in my room."
"My sister will be able to carry my baby from the nursery to my room when she arrives." A newborn should always be transported in a bassinet when outside the parent's room. "The nurse will match my wrist band to my baby's crib card when they bring him to me." The nurse will match the newborn's identification number with the parent's identification number when they bring the newborn to the parent's room. ✅"The person who comes to take my baby's pictures will be wearing a photo identification badge." All personnel working on the unit should be wearing a photo identification badge. The nurse should instruct the parent to never allow anyone who is not wearing an identification badge to come in contact with the newborn. "My baby doesn't need to wear the electronic security bracelet when he's in my room." The newborn should wear the electronic security bracelet at all times. The bracelet is set to alarm if anyone removes the bracelet or if the newborn is brought near an exit door.
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching? "Obtain an informed consent prior to obtaining the specimen." "Collect at least 1 milliliter of urine for the test." "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." "Premature newborns may have false negative tests due to immature development of liver enzymes."
"Obtain an informed consent prior to obtaining the specimen." The universal newborn screening is mandated by law for all newborns. Therefore, the nurse does not need to obtain informed consent prior to obtaining the specimen. "Collect at least 1 milliliter of urine for the test." The nurse should collect a capillary blood sample via heel stick for the newborn screening. Urine is not collected for this test. ✅"Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr prior to testing. "Premature newborns may have false negative tests due to immature development of liver enzymes." Premature newborns have a delayed development of liver enzymes which can cause a false positive result.
A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member? Allow the sibling to hold the newborn during a bath. Make sure the sibling kisses the newborn each night. Obtain a gift from the newborn to present to the sibling. Switch the sibling's room with the nursery.
Allow the sibling to hold the newborn during a bath. Allowing the sibling to hold the newborn during a bath is not an appropriate activity for a school-age child because of the safety risk. However, the parents could let the sibling assist with other things in regard to caring for the newborn. Make sure the sibling kisses the newborn each night. Forcing interactions between the sibling and the adoptive newborn can cause anger on the part of the sibling. It is more important to allow feelings to evolve naturally as the family unit bonds. ✅Obtain a gift from the newborn to present to the sibling. Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that they understand their role in the family. Switch the sibling's room with the nursery. Switching the sibling's room with the newborn's room might cause jealousy of the newborn or cause the sibling to feel that the newborn is taking their belongings.
A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? Client reports nausea Urinary output of 40 mL/hr Respiratory rate 10/min Client reports feeling flushed
Client reports nausea Nausea is an expected adverse effect of magnesium sulfate. The nurse should reassure the client and provide comfort measures. Urinary output of 40 mL/hr Oliguria is a manifestation of magnesium toxicity. The nurse should report a urinary output of less than 25 to 30 mL/hr to the provider. ✅Respiratory rate 10/min MY ANSWER The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available. Client reports feeling flushed Flushing and feeling hot is an expected adverse effect of magnesium sulfate. The nurse should reassure the client and provide comfort measures.
A nurse is assessing a client who is receiving morphine via IV bolus for pain following a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the following medications should the nurse administer? Fentanyl Butorphanol Naloxone Meperidine
Fentanyl The nurse should administer fentanyl to the client for the relief of severe, recurrent, or persistent pain during labor. Fentanyl is most commonly administered via PCA pump or epidural, alone or with a local anesthetic agent. An adverse effect of this medication is respiratory depression. Butorphanol The nurse should administer butorphanol to the client for the relief of labor pain and severe postoperative pain after cesarean birth. An adverse effect of this medication is respiratory depression. ✅Naloxone Morphine is a common opioid analgesic used for postoperative pain management that can cause central nervous system depression and can cause respiratory depression. The nurse should administer naloxone, an opioid antagonist, to reverse the opioid-induced respiratory depression in the client. Meperidine The nurse should administer meperidine to the client for the relief of severe, persistent pain. An adverse effect of this medication is respiratory depression.
A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure? Monitor the FHR. Assess uterine activity. Administer oxygen via a nonrebreather mask. Start a bolus of IV fluids
✅Administer oxygen via a nonrebreather mask. When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask at 10 L/min to ensure adequate oxygenation to the fetus. Start a bolus of IV fluids. The nurse should start IV fluids following the seizure to ensure adequate hydration. However, this is not the action the nurse should take next. Monitor the FHR. The nurse should monitor the FHR to assess fetal well-being. However, this is not the action the nurse should take next. Assess uterine activity. The nurse should assess uterine activity for potential complications of the seizure. However, this is not the action the nurse should take next.
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? Biophysical profile Amniocentesis Cordocentesis Kleihauer-Betke test
✅Biophysical profile MY ANSWER A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound. Amniocentesis An amniocentesis is used to determine lung maturity, detect congenital anomalies, and diagnose fetal hemolytic disease. Cordocentesis A cordocentesis is used to identify fetal blood type and RBC when there is a risk of isoimmune hemolytic anemia. Kleihauer-Betke test The Kleihauer-Betke test is used to determine the amount of fetal blood in the maternal circulation when there is a risk of Rh-isoimmunization.
A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity? Calcium gluconate Hydralazine Medroxyprogesterone acetate Methylergonovine
✅Calcium gluconate The nurse should anticipate administering calcium gluconate if the client develops magnesium toxicity. Calcium gluconate is the antidote. Hydralazine Hydralazine is an antihypertensive medication that can be administered to clients who have hypertension during pregnancy, rather than functioning as the antidote to magnesium toxicity. Medroxyprogesterone acetate Medroxyprogesterone acetate is an injectable contraceptive hormone, rather than functioning as the antidote to magnesium toxicity. Methylergonovine Methylergonovine is used to treat postpartum hemorrhage, rather than functioning as the antidote to magnesium toxicity.
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? Depression Polyuria Hypotension Urticaria
✅Depression The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness. Polyuria Fluid retention can occur due to an excess of estrogen. Polyuria is not a common adverse effect of the medication. Hypotension Hypertension, rather than hypotension, is a common adverse effect of combined oral contraceptives. Urticaria Urticaria is not a common adverse effect of combined oral contraceptives.
A nurse is reviewing the prenatal laboratory results for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider? Hemoglobin 10 g/dL WBC count 10,000/mm3 Platelets 250,000/mm 3 Fasting blood glucose 90 mg/dL
✅Hemoglobin 10 g/dL A hemoglobin of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this finding to the provider to obtain a prescription for ferrous iron supplementation because of anemia. WBC count 10,000/mm3 This finding is within the expected reference range of 5,000 to 15,000/mm3 and does not require reporting to the provider. Platelets 250,000/mm3 This finding is within the expected reference range of 150,000 to 400,000/mm3 and does not require reporting to the provider. Fasting blood glucose 90 mg/dL This finding is within the expected reference range of 60 to 105 mg/dL and does not require reporting to the provider.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? Minimal arm recoil Popliteal angle of 90° Creases over the entire foot sole Raised areolas with 3 to 4 mm buds
✅Minimal arm recoil The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil. Popliteal angle of 90° A popliteal angle of 90° is an indicator of physical maturity with increasing gestational age after 26 weeks. Creases over the entire foot sole Creases over the entire sole of a newborn's foot are an indicator of physical maturity with increasing gestational age after 26 weeks. Raised areolas with 3 to 4 mm buds Raised areolas with 3 to 4 mm buds is an indicator of physical maturity with increasing gestational age after 26 weeks.
A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? Protect the client's head and feet from cold air. Bathe the client within 12 hr following birth. Ambulate the client within 24 hr following birth. Offer the client a glass of cold milk with her first meal.
✅Protect the client's head and feet from cold air. Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period. Bathe the client within 12 hr following birth. Bathing the client within 12 hr following birth should not be included in the plan of care because traditional Hispanic practices include delaying bathing for 14 days following birth. Ambulate the client within 24 hr following birth. Ambulating the client within 24 hr following birth should not be included in the plan of care because traditional Hispanic practices include bed rest for 3 days following birth. Offer the client a glass of cold milk with her first meal. Offering the client a glass of cold milk with her first meal should not be included in the plan of care because traditional Hispanic practices include drinking warm beverages following birth.
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take? Verify that the parent's identification band matches the newborn's identification band. Scan the newborn's identification band to verify their identity. Check the newborn's security tag number to ensure it matches the newborn's medical record. Match the newborn's date and time of birth to the information in the parent's medical record.
✅Verify that the parent's identification band matches the newborn's identification band. The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the information on the parent's identification band to the information on the newborn's identification band. Scan the newborn's identification band to verify their identity. Scanning the newborn's identification band to verify their identity does not ensure the newborn is being transferred to the correct parent. Check the newborn's security tag number to ensure it matches the newborn's medical record. Comparing the newborn's security tag number to the newborn's medical record does not ensure the newborn is being transferred to the correct parent. Match the newborn's date and time of birth to the information in the parent's medical record. It is not necessary for the nurse to check the parent's medical record. The nurse should match the information on the parent's identification band to the information on the newborn's identification band.
The quadruple marker screen is a blood test.
"The test is a screening tool for chromosomal syndromes." The quadruple marker screen measures alpha-fetoprotein, unconjugated estriol, hCG, and inhibin A to detect chromosomal anomalies. If the screening is abnormal, follow-up testing includes an amniocentesis
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? "I should increase my protein intake to 60 grams each day." "I should drink 2 liters of water each day." "I should increase my overall daily caloric intake by 300 calories." "I should take 600 micrograms of folic acid each day.
"I should increase my protein intake to 60 grams each day." A client who is pregnant should increase protein intake to 71 g each day during the second and third trimesters. "I should drink 2 liters of water each day." A client who is pregnant should consume 3 L of water each day. "I should increase my overall daily caloric intake by 300 calories." A client who is pregnant should increase caloric intake by 340 cal during the second trimester and by 452 cal during the third trimester. ✅"I should take 600 micrograms of folic acid each day." MY ANSWER A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include? "The test should take 10 to 15 minutes to complete." "You will lay in a supine position throughout the test." "You should not eat or drink for 2 hours before the test." "You should press the handheld button when you feel your baby move."
"The test should take 10 to 15 minutes to complete." The nurse should instruct the client that the nonstress will take approximately 20 to 30 min, but more time might be required if the fetus is in a sleep state when the testing begins. "You will lay in a supine position throughout the test." The nurse should instruct the client to be positioned in a reclining chair or semi-Fowler's position with a slight lateral tilt to ensure optimal uterine perfusion. "You should not eat or drink for 2 hours before the test." The client is not required to be NPO before or during the procedure. The nurse can suggest the client drink orange juice to increase her blood glucose level which will stimulate fetal movements. ✅"You should press the handheld button when you feel your baby move." The nurse should instruct the client to press the handheld button when the fetus moves. This action will mark the fetal monitor tracing with the client's reports of fetal movement. This will assist in the interpretation of the nonstress test to determine if it is reactive or nonreactive.
A nurse is teaching a client who is at 8 weeks of gestation about nutrition during pregnancy. Which of the following statements should the nurse include in the teaching?
"You should consume 2 cups of milk daily." The nurse should instruct the client to consume 3 cups of dairy daily. It is best to select fat free or low fat dairy products. "You should consume 4 ounces of grains each day." The nurse should instruct the client to consume 6 to 8 oz of grains. The client should consume at least half of the servings as whole grains. "You should consume 2 cups of vegetables each day." The nurse should instruct the client to consume 2.5 to 3 cups of vegetables daily. The client should vary the type of vegetables to obtain various amounts of different nutrients. "You should consume 6 ounces of protein foods daily." The nurse should instruct the client to consume 5.5 to 6.5 oz of protein foods each day. The client should select high-protein foods, such as legumes, nuts, eggs, and lean meat or poultry.
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? 2+ deep tendon reflexes Proteinuria of 200 mg in a 24-hr specimen Polyuria Blurred vision
2+ deep tendon reflexes The nurse should identify that a client who has severe preeclampsia can have hyperactive reflexes of 3+ or 4+. Deep tendon reflexes of 2+ is indicative of an active or expected response. Proteinuria of 200 mg in a 24-hr specimen The nurse should identify that a client who has severe preeclampsia can have increased amount of urinary protein that is greater than 500 mg in a 24-hr specimen. Polyuria The nurse should identify that a client who has severe preeclampsia can have decreased urine output or oliguria of 20 mL/hr or less than 400 to 500 mL in 24 hr. This is related to decreased perfusion of the kidneys and possible glomerular damage. ✅Blurred vision MY ANSWER The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field.
Hematocrit range for females
37-47% In pregnancy the expected reference range for this client. The level should be greater than 33%.
1-hr glucose tolerance test Range:
A glucose tolerance test result of 120 mg/dL is within the expected reference range for this client. A value of 130 to 140 mg/dL or greater for a 1-hr glucose tolerance test indicates a positive test result and should be reported to the provider.
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? A newborn who is 26 hr old and has erythema toxicum on his face A newborn who is 32 hr old and has not passed a meconium stool A newborn who is 12 hr old and has pink-tinged urine A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
A newborn who is 26 hr old and has erythema toxicum on his face Erythema toxicum is a transient rash that can appear anywhere on a newborn's body during the first 24 to 72 hr following birth and can last up to 3 weeks. This finding requires no treatment. A newborn who is 32 hr old and has not passed a meconium stool A newborn should pass the first meconium stool within the first 24 to 48 hr following birth. Failure to pass a meconium stool can indicate a bowel obstruction or congenital disorder. This finding is within the expected reference range. A newborn who is 12 hr old and has pink-tinged urine Pink-tinged urine is an indication of uric acid crystals and is an expected finding for a newborn during the first week following birth. ✅A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F) MY ANSWER An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider.
A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? Blood pressure 136/88 mm Hg Report of insomnia Weight gain of 2.2 kg (4.8 lb) Report of Braxton Hicks contractions
A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider. All other findings are expected
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? Acrocyanosis Transient strabismus Jaundice
Acrocyanosis Acrocyanosis is a bluish discoloration of the hands and feet and is an expected finding in a newborn 24 to 48 hr after birth. Transient strabismus Transient strabismus is a normal variation in the newborn's eyes that can persist until the third or fourth month of age. ✅Jaundice Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider. Caput succedaneum Caput succedaneum is a benign, edematous area of the scalp and is commonly found on the occiput.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider? BUN 25 mg/dL Serum creatinine 0.8 mg/dL Urine output of 280 mL within 8 hr Urine negative for ketones
BUN 25 mg/dL
Induction diagnostic test
Bishop score of 10 A bishop score is assigned by the provider to evaluate a client's readiness for labor induction. The best predictors for a successful induction is a ripe cervix. A bishop score of 8 or greater indicates the cervix is more favorable for a labor induction.
A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect? Bruising over the buttocks Hard nodules on the roof of the mouth Petechiae over the head Bilateral periauricular papillomas
Bruising over the buttocks A breech birth can cause bruising over the buttocks and swollen genitalia. Hard nodules on the roof of the mouth Inclusion cysts, or whitish hard nodules on the gums or roof of the mouth, can be an expected finding. These are also called Epstein pearls. ✅Petechiae over the head Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck. Bilateral periauricular papillomas Bilateral periauricular papillomas are benign skin tags that can be an expected finding.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? Deep tendon reflexes 4+ Fundal height 14 cm Urine protein 2+ FHR 152/min
Deep tendon reflexes 4+ MY ANSWER Deep tendon reflexes (DTRs) are an indication of the balance between the cerebral cortex and spinal cord. The nurse should expect the client's DTR to be 2+. Therefore, a DTR of 4+ indicates hyperreflexia. Fundal height 14 cm From gestational weeks 18 to 32, the height of the fundus is approximately equal to the number of weeks of gestation plus or minus 2 cm. Therefore, the nurse should expect the fundal height for this client should be 16 to 20 cm. Urine protein 2+ The nurse should expect the urine protein for this client to be less than 1+. A urine protein concentration of 2+ is an indication of preeclampsia. Therefore, the nurse should investigate this finding further. ✅FHR 152/min The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse.
A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? Give the client orange juice. Elevate the client's legs. Have the client change position. Establish IV access.
Give the client orange juice. Giving the client orange juice is not an appropriate intervention for a variable deceleration in the FHR. Elevate the client's legs. Elevating the client's legs is an acceptable intervention for late decelerations associated with maternal hypotension. ✅Have the client change position. Having the client change position is an appropriate intervention for a variable deceleration to relieve umbilical cord compression. Establish IV access. Establishing IV access is not indicated at this time.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? Determine progression of dilatation and effacement. Perform Leopold maneuvers. Complete a sterile speculum exam. Prepare a Nitrazine paper test.
Determine progression of dilatation and effacement. The nurse should determine the client's dilation and effacement prior to applying an internal monitor. This action is not required prior to applying an external transducer for fetal monitoring. Perform Leopold maneuvers. MY ANSWER The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer. Complete a sterile speculum exam. A sterile speculum examination should be performed by the provider and is not required prior to applying an external transducer for fetal monitoring. Prepare a Nitrazine paper test. A Nitrazine paper test is performed to assess the components (pH level) of vaginal fluid to determine if the membranes have ruptured. This action is not required prior to applying an external transducer for fetal monitoring.
A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications? Excessive bleeding Oligohydramnios Premature rupture of membranes Proteinuria
Excessive bleeding A client who is pregnant and has gonorrhea is not at an increased risk for excessive bleeding. Oligohydramnios A client who is pregnant and has gonorrhea is not at an increased risk for oligohydramnios. Oligohydramnios is a decrease in amniotic fluid and is associated with congenital anomalies such as renal agenesis and intrauterine growth restriction. ✅Premature rupture of membranes The nurse should identify that a client who is pregnant and has gonorrhea is at an increased risk for premature rupture of membranes, chorioamnionitis, preterm birth, neonatal sepsis, and intrauterine growth restriction. Proteinuria A client who is pregnant and has gonorrhea is not at an increased risk for proteinuria. Proteinuria is associated with preeclampsia
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? Feed the newborn 1 oz of water every 4 hr. Apply lotion to the newborn's skin three times per day. Remove all clothing from the newborn except the diaper. Discontinue therapy if the newborn develops a rash.
Feed the newborn 1 oz of water every 4 hr. The nurse should not feed the newborn any water or glucose water. Hydration can be maintained through regular breastfeeding or formula feeding. Water and glucose water do not increase the excretion rate of bilirubin in the stool or provide nutritional value. Apply lotion to the newborn's skin three times per day. The nurse should not apply lotion, ointments, or creams to a newborn who is undergoing phototherapy. Lotions, ointments, and creams can absorb heat and lead to burns. ✅Remove all clothing from the newborn except the diaper. The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin. Discontinue therapy if the newborn develops a rash. The nurse should not discontinue phototherapy if the newborn develops a rash. A temporary, fine rash can occur during therapy. This rash requires no treatment.
Fundal height measurement range
Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? Hypertonia Increased feeding Hyperthermia Respiratory distress
Hypertonia A newborn who has hypoglycemia can exhibit hypotonia. Increased feeding A newborn who has hypoglycemia can exhibit poor feeding behaviors. Hyperthermia A newborn who has hypoglycemia can exhibit hypothermia. ✅Respiratory distress Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.
A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider? Late decelerations Moderate variability of the FHR Cessation of uterine dilation Prolonged active phase of labor
Late decelerations ✅ Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider. Moderate variability of the FHR Moderate variability of the FHR is an expected assessment finding associated with normal fetal acid-base balance. It is not a contraindication to the administration of oxytocin. Cessation of uterine dilation Cessation of uterine dilation is an indication for the initiation of an oxytocin infusion to augment the client's labor progression. Prolonged active phase of labor A prolonged active phase of labor is an indication for the initiation of an oxytocin infusion to augment the client's labor progression.
A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect?
Lochia serosa vaginal drainage A client who is 4 to 10 days postpartum will report lochia serosa. ✅Vaginal pressure The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues. Intermittent vaginal pain A client who has a vaginal hematoma will report persistent vaginal or rectal pain. Yellow exudate vaginal drainage A client who is 1 day postpartum and has a vaginal hematoma will report lochia rubra.
Manifestations of hyperglycemia in patients with gestational diabetes
Manifestations of hyperglycemia include acetone or fruity breath odor; increased thirst; abdominal pain; polyuria; flushed, dry skin; rapid breathing; drowsiness; and a weak, rapid pulse rate.
A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take?
Offer the newborn glucose water between feedings. The nurse should provide breast milk or infant formula to maintain the newborn's hydration, which promotes the excretion of bilirubin in the stool. Supplemental feedings of glucose water or plain water can increase circulation to the liver and impede bilirubin excretion. Keep the newborn's eye patches on during feedings. The nurse should apply eye patches so the light does not damage the newborn's eyes. The nurse should remove the patches during feedings to observe the eyes and clean them. The parents can make direct eye contact with the newborn during this time. Apply barrier ointment to the newborn's perianal region. The nurse should avoid applying any type of topical substance to the newborn's skin because these substances can absorb heat and cause burns. ✅Use a photometer to monitor the lamp's energy. The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective.
Contraindications of induction of labor
Placenta previa, acute fetal distress, previous uterine incisions that prohibits a trial of labor, and uncontrolled hemorrhaging are contraindications for the administration of oxytocin.
The nurse should use the Apgar scoring system to perform a quick assessment of the newborn at 1 min and 5 min after birth. The nurse should assign a score of 0, 1, or 2 to each of five categories.
The nurse should assign a score of 2 for a heart rate greater than 100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well flexed extremities, which shows expected normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a score of 1 for blue hands and feet, known as acrocyanosis.
A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Wipe the newborn's eyes from the inner canthus outward. Wash the newborn's neck by lifting the newborn's chin. Wash the newborn's legs and feet. Cleanse the skin around the newborn's umbilical cord stump. Clean the newborn's diaper area.
The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus outward using plain water. The nurse should then wash the newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump followed by washing the newborn's legs and feet. The last step of the bath should be to clean the newborn's diaper area.
Fetal heart rate (FHR) range
This FHR is within the expected reference range of 110/min to 160/min for a client at 26 weeks of gestation.
hypertension risk in pregnancy
This value is below the expected reference range of 150,000 to 400,000 mm3. Clients who have hypertension are at increased risk for the development of HELLP syndrome. HELLP syndrome is characterized by low platelet count, elevated liver enzymes, and hemolysis. The nurse should notify the provider of this laboratory result.
A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound? To estimate the fetal weight To locate a pocket of fluid To determine multiparity To prescreen for fetal anomalies
To estimate the fetal weight This is not an indication for an ultrasound prior to an amniocentesis. ✅To locate a pocket of fluid An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus. To determine multiparity This is not an indication for an ultrasound prior to an amniocentesis. To prescreen for fetal anomalies This is not an indication for an ultrasound prior to an amniocentesis.
A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? (Select all that apply.) Yellow sclera Acrocyanosis Posterior fontanel larger than the anterior fontanel Positive Babinski reflex Two umbilical arteries visible
Yellow sclera is incorrect. Yellow sclera is an indication of hyperbilirubinemia and is not an expected manifestation. ✅Acrocyanosis is correct. Acrocyanosis is an expected finding for at least the first 24 hr following birth. Poor peripheral perfusion leads to bluish discoloration in the newborn's hands and feet. Posterior fontanel larger than the anterior fontanel is The posterior fontanel is located on the back of the newborn's head and is a small triangular shape. The anterior fontanel is diamond shaped and approximately 5 cm (2 in) long. It is located on the top of the newborn's head and is larger than the posterior fontanel. ✅Positive Babinski reflex is correct. Newborns should exhibit a positive Babinski sign following birth. The nurse should stroke the newborn's foot upward from the heel to the toes. The toes should hyperextend, and dorsal flexion of the big toe should occur. The absence of this finding requires neurological evaluation. The Babinski reflex is no longer present after 1 year of age. ✅Two umbilical arteries visible is correct. The nurse should observe two arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly.
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? "I can administer oxytocin 4 hours after the insertion of the medication." "You will need a full bladder prior to the insertion of the medication." "Remain in a side-lying position for 15 minutes after the medication is inserted." "An antacid will be given 20 minutes prior to the insertion of the medication
✅"I can administer oxytocin 4 hours after the insertion of the medication." The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor. "You will need a full bladder prior to the insertion of the medication." The nurse should instruct the client to void prior to the administration of the medication. "Remain in a side-lying position for 15 minutes after the medication is inserted." The nurse should instruct the client to remain in a side-lying position for 30 to 40 min after the insertion. "An antacid will be given 20 minutes prior to the insertion of the medication." The nurse should avoid administering aluminum hydroxide and magnesium-containing antacids with misoprostol.
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first? A client who is at 11 weeks of gestation and reports abdominal cramping A client who is at 15 weeks of gestation and reports tingling and numbness in right hand A client who is at 20 weeks of gestation and reports constipation for the past 4 days A client who is at 8 weeks of gestation and reports having three bloody noses in the past week
✅A client who is at 11 weeks of gestation and reports abdominal cramping When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand Tingling and numbness of the right hand is nonurgent because it is a common discomfort related to pregnancy for a client who is at 15 weeks of gestation. Therefore, there is another client that the provider should see first. A client who is at 20 weeks of gestation and reports constipation for the past 4 days Constipation is nonurgent because it is a common discomfort related to pregnancy for a client who is at 20 weeks of gestation. Therefore, there is another client that the provider should see first. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week Epistaxis is nonurgent because it is a common discomfort related to pregnancy for a client who is at 8 weeks of gestation. Therefore, there is another client that the provider should see first.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take? Administer penicillin G 2.4 million units IM to the client. Instruct the client to schedule an annual pelvic examination. Tell the client she will start medication for HIV immediately after delivery. Report the client's condition to the local health
✅Report the client's condition to the local health department. The nurse should report the condition to the local health department. HIV is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is required to be reported. Administer penicillin G 2.4 million units IM to the client. The nurse should administer penicillin G 2.4 million units IM to a client who has syphilis. Instruct the client to schedule an annual pelvic examination. The nurse should instruct the client to schedule a pelvic examination every 6 months. Tell the client she will start medication for HIV immediately after delivery. The nurse should tell the client that treatment for HIV will be during the prenatal and perinatal periods. Treatment with antiretroviral prophylaxis such as zidovudine, triple-drug antiretroviral therapy (ART), or highly active antiretroviral therapy (HAART) during pregnancy have been reported to decrease the transmission of the virus to the newborn.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider? Substernal retractions Acrocyanosis Overlapping suture lines Head circumference 33 cm (13 in)
✅Substernal retractions The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection or respiratory distress in the newborn. The nurse should report these findings to the provider for immediate intervention. Acrocyanosis Acrocyanosis is an expected finding in the newborn for the first 24 hr following birth. Overlapping suture lines Overlapping suture lines with molding are an expected variation for newborns who were delivered vaginally. Head circumference 33 cm (13 in) A head circumference of 33 cm is within the expected reference range for a newborn following birth.
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take? Administer aspirin for pain. Maintain the client on bed rest. Massage the affected leg every 12 hr. Apply cold compresses to the affected calf.
Administer aspirin for pain. A client receiving anticoagulant therapy, such as heparin, should not receive aspirin because it can lead to prolonged clotting times and increased risk of bleeding. ✅Maintain the client on bed rest. The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended. Massage the affected leg every 12 hr. The nurse should avoid massaging the affected leg to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Apply cold compresses to the affected calf. The nurse should apply warm compresses to the affected area to promote circulation and decrease edema.
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority?
Check the client's capillary refill. It is important for the nurse to monitor capillary refill to track baseline data for this client. Noninvasive assessments of cardiac output for clients who are experiencing postpartum hemorrhage include assessing: capillary refill; skin color, temperature, and turgor; level of consciousness; neck veins; and mucous membranes. However, another action is the nurse's priority. Massage the client's fundus. Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood loss. Insert an indwelling urinary catheter for the client. It is important for the nurse to insert an indwelling urinary catheter to assess the client for hypovolemia. The most objective assessment of oxygenation and organ perfusion is urinary output of at least 30 ml/hr. However, another action is the nurse's priority. Prepare the client for a blood transfusion. It is important for the nurse to prepare the client for a blood transfusion to replace the amount of blood lost from postpartum hemorrhage. It is crucial to restore circulating blood volume. However, another action is the nurse's priority.
A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure? Check the client's temperature. Observe for uterine contractions. Administer Rho(D) immune globulin. Monitor the FHR.
Check the client's temperature. The nurse should check the client's temperature to monitor for infection following an amniocentesis. However, this is not the priority nursing intervention. Observe for uterine contractions. The nurse should observe for uterine contractions to identify preterm labor following an amniocentesis. However, this is not the priority nursing intervention. Administer Rho(D) immune globulin. The nurse should administer Rho(D) immune globulin following an amniocentesis to prevent Rh sensitization. However, this is not the priority nursing intervention. ✅Monitor the FHR. The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis.
A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider? Fundal height 34 cm Report of decreased fetal movement Report of occasional ankle swelling BP 110/80 mm Hg
Fundal height 34 cm A client who is at 32 weeks of gestation should have a fundal height about the same as the number of weeks of gestation, plus or minus 2 cm. ✅Report of decreased fetal movement The nurse should identify that a client who reports decreased fetal movement could be experiencing a complication related to fetal well-being. A decrease in fetal movement can indicate fetal distress. Report of occasional ankle swelling The nurse should identify that occasional ankle edema is a common discomfort associated with a client who is at 32 weeks of gestation. BP 110/80 mm Hg The nurse should identify that during pregnancy the client's blood pressure should remain the same or be slightly decreased. A blood pressure of 110/80 mm Hg is within the expected reference range of less than 120 mm Hg systolic and less than 80 mm Hg diastolic.
Manifestations of abnormal breathing patterns, which can indicate a need for supplemental oxygen,
include tachypnea, nasal retractions, stridor, and gasping.