HESI-MATERNITY
Which client statement indicates that she understands the instructions of breastfeeding her newborn? (Select all that apply.)
"Breastfeeding my infant consistently every 3 to 4 hours decreases the likelihood of me ovulating." "I should avoid foods that usually give me gas." "When I feed my baby, I should start on the breast the baby stopped on last." "I should drink fluids when breastfeeding my baby, especially at night."
The nurse is performing an initial intake assessment for a newly pregnant client. Which questions will the nurse include in the assessment? (Select all that apply.)
"Do you have proof of your immunizations?" "Were your periods regular at every 28 days?" "Are you have any nausea at any time during the day?"
The clinic nurse takes a phone call from a client who reports she is at 12 weeks gestation. Which statements indicate to the nurse the client may be having a spontaneous abortion? (Select all that apply.)
"I am having severe abdominal cramping." "I am passing blood clots from my vagina."
The nurse is discussing the timing of the next prenatal visit for the client at 34 weeks gestation. If the current visit occurred on April 4, which statement indicates the client understands the teaching?
"I can come in on April 18."
The nurse is discussing many of the changes a pregnancy brings to a couple. Which of the father's statements concerns the nurse the most? (Select all that apply.)
"I do not want to be a father!" "I am sure I am not the father of this baby."
Which client statement indicates to the nurse that the she understands her pre-pregnancy instructions?
"I will take 400 mcg of folic acid daily."
The laboring client requests an epidural placement for labor pain. The standing order is for 1000 mL of LR to infuse over 15 minutes prior to the placement of the epidural. The client asks, "How come I have to have so much fluid so fast?" What is the nurse's best response?
"It is to help prevent low blood pressure."
The nurse is performing teaching for a pregnant client who has been an insulin dependent diabetic since she was 13 year old. Which statement indicates to the nurse that the teaching was effective?
"My insulin requirements will likely increase around 24 weeks gestation."
The health care provider states to the nurse, the baby is in a left occiput anterior (LOA) position. The laboring client asks, "What does that mean?" What descriptions will the nurse use when teaching the client about the LOA fetal position? (Select all that apply.)
"The baby's head is in your pelvis." "That is the ideal fetal birthing position." "The baby is looking down towards the floor"
A newly pregnant client is crying loudly and reports to the clinic nurse over the phone that she took a prescribed narcotic pain medication 4 weeks ago. What is the nurse's next response?
"When did your last period begin?"
A new mother asks the nurse, "How do I know that my baby is getting enough breast milk?" Which explanation is most appropriate?
"Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day."
A client in early labor is requesting pain medication. The health care provider prescribes butorphanol 0.5 mg IV × 1 now. The only butorphanol available is in a concentration of 2 mg/mL. How many mL will the nurse deliver to the client?
0.25
A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color. Which action should the nurse take next?
Explain this is a normal finding.
On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on February 15 and that previously her periods were regular (28-day cycle). Her pregnancy test is positive. What is this client's expected date of birth?
November 22
One hour following a normal vaginal delivery, a newborn infant's axillary temperature is 96° F/35.6 C, the lower lip is shaking, and when the nurse assesses for a Moro reflex, the baby's hands shake. Which nursing action should the nurse take first?
Obtain a serum glucose level.
A multigravida states to the nurse, "I have to push." The client had a cervical exam less than 10 minutes prior and she was 5/+1/100%. What is the nurse's next action?
Perform a cervical assessment.
The nurse calls a client who is 4 days postpartum to follow up about her transition with her newborn at home. The woman tells the nurse, "I don't know what is wrong. I love my baby, but I feel so let down. I seem to cry for no reason!" Which adjustment phase should the nurse determine the client is experiencing?
Postpartum blues
The nurse is reviewing the findings from a pregnant client's glucose challenge test. The results were 156 mg/dL. What is the best nursing action related to this finding?
Schedule the client for a return appointment in 1 week.
The nurse is preparing a newborn for discharge. There is an order for a hepatitis B vaccination prior to discharge. When planning to administer the vaccination, what information must the nurse obtain from the infants chart?
Site of the vitamin K injection
A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide?
Take your blood pressure now, and if it is seriously elevated, go to the hospital.
In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan?
The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.
The nurse is reviewing the prenatal record for a client scheduled for a glucose challenge test. Which maternal findings place this client at an increased risk for developing gestational diabetes? (Select all that apply.)
The client is 37 years old. The client is having twins. The client's pre-pregnant weight was 190 pounds/86 kilograms.
The nurse is preparing a teaching session for a group of newly pregnant women and their significant other. When discussing fatigue early in pregnancy, which statements will the nurse include in the teaching plan? (Select all that apply.)
"Fatigue is a result from the hormonal changes early in pregnancy." "Highly caffeinated drinks need to be avoided in pregnancy." "Keep up your regular 45 minutes of stationary cycling per day."
The clinic nurse is performing an initial assessment. The client states to the nurse, "I must be pregnant. My breasts are tender; my last period was 5 weeks ago; and, I feel nauseous in the mornings. What is the nurse's best response?
"Have you done a home pregnancy test?"
A client at 34 weeks gestation reports to the clinic nurse that she has frequent indigestion. What should the nurse include in the client's teaching plan? (Select all that apply.)
"Have you tried taking Tums for your indigestion?" "The baby is getting big, which reduces the size of the stomach." "Try eating small meals, 6 times per day."
The client at 20 weeks gestation states to the nurse, "I feel dizzy when I go from a sitting to a standing position." What is the nurse's best response?
"Make sure you change positions slowly."
The client at 10 weeks gestation states to the clinic nurse, "I have to urinate all of the time!" What is the nurse's response to this client concern? (Select all that apply.)
"The weight of your uterus is pressing on your bladder." "This is an anticipated finding at this point in our pregnancy." "Do you have any itching or burning when you urinate?"
The nurse is providing care to a primipara's whose most recent cervical exam at 0700 was 6/+1/100. Assuming an expected progression of labor, approximately what time will the client enter into the second stage of labor?
1100
The nurse determines that a 22-year-old, pregnant client's normal intake of calcium is approximately 500 mg. The client states she prefers non-fat milk over 2% fat milk. How many additional 8-ounce (30 mL) glasses of non-fat milk will the nurse recommend to meet the minimum daily calcium requirements?
2
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. What is the next nursing action?
Put the newborn to the breast immediately.
An induction of labor is planned for the client with diabetes mellitus and dependent on insulin since the age of 10. The nurse is gathering supplies to care for the client during the induction. What supplies will the nurse gather? (Select all that apply.)
An fusion pump for 3 lines Normal saline 10% dextrose solution Glucose monitoring kit
The clinic nurse is performing an assessment on a client who is 20 weeks gestation, which was confirmed by ultrasound. When performing the fundal height assessment, where will the nurse start palpating the abdomen?
At the umbilicus
A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3 months of gestation. What will the nurse document in the client's chart regarding her GTPAL?
20010
The nurse is providing care to an infant at 24 hours old. Upon assessment, the nurse observes milia on the newborn's nose. What is the nurse's next action?
Document the findings in the newborn's chart.
A client is admitted to the hospital at 28 weeks of gestation in preterm labor. The nurse administers three doses of terbutaline sulfate, 0.25 mg subcutaneously. Which side effects will the nurse anticipate for this client? (Select all that apply.)
Feeling of nervousness Tachycardia Restlessness
The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the mother's teaching plan?
Avoid alcohol within two hours before the next feeding.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information?
Fetal heart rate (FHR)
The nurse is reviewing fetal circulation with a nursing student. The nurse concludes the student understands the teaching when which statements are made? (Select all that apply.)
Fetal oxygenation occurs through the placenta. The foramen ovale is open in the fetal state. Blood flows from the placenta to the fetal heart.
A prenatal client at 35 weeks gestation reports to the clinic for routine prenatal care. The nurse assesses the client and notices: constricted pupils, erratic behavior, and multiple injection marks along the veins of both of the client's arms. What is the nurse's next action?
Notify the health care provider.
The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. What is the best nursing action?
Notify the health care provider.
When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation?
Vernix is a white cheesy substance, predominantly located in the skin folds.
The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign?
5
The nurse is preparing to administer an IV pain medication to a client in labor. What will the nurse include in this client's plan of care related to the administration of the medication? (Select all that apply.)
Administer the medication only when the client is having a contraction. Assess the fetal heart rate (FHR) for 10 minutes prior to administering the pain medication.
A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of bloating. Which nursing action takes the highest priority? (Select all that apply.)
Administer the ordered magnesium hydroxide. Encourage her to change position every 30 minutes.
Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home?
Allow the cord to air-dry as much as possible.
The nurse is teaching a group of teen girls about their reproductive system and pregnancy. What risk factors for an unplanned pregnancy will the nurse include in the teaching plan for these girls? (Select all that apply.)
Poverty Family problems Early onset of menarche Sexual exploration Group think
Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." What is the next nursing action?
Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
A pregnant teen says to the nurse, "I hope nothing happens to my breasts while I am pregnant!" What will the nurse include in the client's plan of care regarding breast changes in pregnancy? (Select all that apply.)
Areola darkening Veins easier to see under the skin
The nurse is providing care to a postpartum client with O negative blood who is antibody positive. The newborn is O negative. What is the best nursing action for this client?
Ask the mother if she desires any more children.
A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. What is the nurse's best action?
Asking the client and her partner if they would like the nurse to stay in the room
A client at 36 weeks gestation presents to labor and delivery and states to the nurse, "I have been leaking fluid for about 2 days now. At first I thought it was urine. Now, I am not so sure." Which nursing actions are most appropriate for this client? (Select all that apply.)
Assess maternal vital signs. Place an electronic fetal monitor. Assess the fluid for a foul odor. Obtain a complete blood count.
When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?
At 30 weeks of gestation
As the placenta is delivered during a cesarean section the health care provider states, "It looks like at least a 25% abruption." Which concerning signs will the postpartum nurse include in the client's assessment? (Select all that apply.)
Bleeding gums Petechia Oozing blood from IV site(s)
When reviewing a prenatal record for a client at 32 weeks gestation, the nurse notes that the client was recently diagnosed with chlamydia. What will the nurse include in the client's teaching plan? (Select all that apply.)
Call the clinic immediately if you feel any gush of fluid from your vagina. Call the clinic immediately if you have contractions every 5 minutes for an hour. Do not have sex for 7 days after you take your antibiotics.
Twenty-four hours after admission to the newborn nursery, the nurse assesses a full-term infant who has developed localized swelling on the right side of the head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line?
Cephalohematoma, which is caused by forceps trauma
A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?
Come to the clinic today for an ultrasound.
When returning for the results of her maternal serum alpha-fetoprotein (MSAFP), a primigravida asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to best describe how the test is interpreted?
If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect.
Which findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.)
Increased heartburn that is not relieved with doses of antacids Chronic headache that has been lingering for a week behind the client's eyes
The nurse is preparing a memory box of items from the care of an infant who died in utero. What items will the nurse plan on including in the box? (Select all that apply.)
Measuring tape Infant hat Infant blanket
The labor and delivery nurse is admitting a client at 32 weeks gestation. She reports epigastric pain, weight gain of 10 pounds in 1 week, and spots in front of her eyes. What nursing actions will the nurse include in this client's plan of care? (Select all that apply.)
Dipstick urine for protein Assess the patellar reflex bilaterally Determine the presence of clonus
The labor and delivery nurse is providing care to a client at term with known cardiac disease. Which focused assessments will the nurse include in the client's plan of care? (Select all that apply.)
Cough Dyspnea Chest pain
Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.)
Cramping with bright red spotting Lack of tenderness of the breast Increased right-side flank pain
A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being prepared for discharge. Which nursing action should be included in this infant's discharge teaching plan?
Observe the parents applying a Pavlik harness.
An expectant father tells the nurse he is concerned about some of his wife's behaviors. He states that she is constantly rubbing her abdomen and talking to the baby. Which recommendation should the nurse make to this expectant father?
Reassure him that normal maternal-fetal bonding is occurring.
The nurse is just starting the shift and is proving care to a laboring woman at term. The fetal heart rate by internal monitor has been 120 to 122 for the past 30 minutes. What are the best nursing actions? (Select all that apply.)
Reposition the client. Administer oxygen by facemask. Increase the rate of the mainline IV fluids. Assess the client's blood pressure. Assess for recent administered medications. Ask the support person to leave the room.
An 18-year-old client states to the nurse that she wants to understand all of her options for birth control. What assessments will the nurse include in the client's intake interview? (Select all that apply.)
Sexual frequency History of blood clots Comfort in touching her genitalia Preferences for different methods Religious beliefs Allergies
The nurse is providing care to an infant born 2 minutes ago with an Apgar of 8 at one minute. What nursing actions must the nurse include in the newborn's plan of care over the next 30 minutes? (Select all that apply.)
Temperature Heart rate Apgar score
Client teaching is an important part of the perinatal nurse's role. Which factor has the greatest influence on successful teaching of the pregnant client?
The client's investment in what is being taught
The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct?
Two weeks before menstruation
The postpartum client is preparing for discharge. She states to the nurse, "I have not had a bowel movement yet." What are the nurse's recommendations for this client? (Select all that apply.)
"Drink no less than 5, 8-ounce glasses of water or non-caffeine beverages per day." "Make sure you eat 4 to 5 servings if high fiber foods a day, like broccoli and pears." "Since it is nice outside, take a 15-minute walk two to three times a day."
The pregnant client at 28 weeks gestation complains to the nurse about hemorrhoid pain. What suggestions should the nurse offer the client? (Select all that apply.)
"Find a soft pillow when you are sitting at your desk at work." "Walk for 30 minutes at least twice a day." "Eat one cup of raspberries or a medium pear every day."
The clinic nurse is reviewing signs of pre-term labor with a client at 28 weeks gestation. Which client statements indicate to the nurse further teaching is necessary? (Select all that apply.)
"I expect the discharge from my vagina will change from thick to brown over the next two weeks." "The baby's movements will decrease and be almost still from here on out." "I should expect low back pain and diarrhea as the baby grows."
The nurse is providing care to a laboring client at term. Which client statement indicates to the nurse that the client is entering stage two of labor?
"I feel like I have to push down."
The nurse is interviewing a newly pregnancy client who is 16-years old. Which client statement indicates teaching is necessary for a safe pregnancy? (Select all that apply.)
"I hate milk." "I only want to gain 10 pounds." "I refuse to wear maternity clothes."
The clinic nurse is providing care to a client at 20 weeks gestation. They are reviewing literature about gestational diabetes mellitus (GDM). Which statement indicates to the nurse the client understands the information?
"I will have to drink the sweet syrup at my next appointment."
A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. The head is really funny looking." Which response by the nurse is best?
"That is normal. The head will return to a round shape within 7 to 10 days."
The nurse is teaching a prenatal class about the structure of the pelvis and is using a model of a pelvis in the presentation. Which statements will the nurse include in the teaching plan? (Select all that apply.)
"The baby has to pass through the true pelvis." "The pelvis consists of three distinct features." "The true pelvis is below the pelvic brim." "The ischial spines determine how low the baby is located."
The clinic nurse is providing care to a client at 28 weeks gestation. The client asks, "What does my baby look like now?" How will the nurse respond? (Select all that apply.)
"Your baby weighs about 2.5 pounds." "The baby's arms are bent at the elbows." "Your baby can open and close its eyes now."
A client at 39 weeks gestation overhears her health care provider say to the nurse, "Her Bishop score is 10." The client asks the nurse, "What does that mean?" What is the nurse's best response?
"Your cervix is ready for labor."
The nurse is providing care to a laboring client with a GTPAL of 75015. The client reports contractions every 2 to 8 minutes, of moderate intensity, for the past 6 hours. Her cervical exam upon admission is 4/0/75%, and membranes are intact. In the next 20 minutes, what supplies will the nurse gather for this client? (Select all that apply.)
Amnihook 1000 mL of D5LR Oxytocin
The postpartum client has a rubella vaccine ordered prior to discharge. The nurse reviews with the student nurse the proper technique to use when administering this immunization. Which student statement indicates to the nurse the correct technique is planned?
At a 45 degrees angle
A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide?
Breastfeed the infant every 2 hours.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client?
Breastfeed the infant, ensuring that both breasts are completely emptied.
A client presents to the emergency department with complaints of severe lower left abdominal pain and vaginal spotting. Her last menstrual period was 5 weeks ago. What are the nurse's next actions? (Select all that apply.)
Check the results of the HCG test. Ask the client to describe the color of the vaginal bleeding. Ask the client if she has ever been diagnosed with pelvic inflammatory disease. Draw the client's blood for a type and cross match.
The nurse is providing care to a client at term undergoing an oxytocin induction. At last check she was 6/+1/100%. For the most recent five contractions, the fetal heart rate has fallen below the baseline after the onset of the contraction, and returns to baseline 20 to 30 seconds after the end of the contraction. What actions must the nurse take? (Select all that apply.)
Contact the health care provider. Stop the infusion of oxytocin. Increase the infusion of the mainline IV fluid. Apply oxygen by facemask. Reposition the client.
The labor and delivery nurse is providing care to a mother who has experienced a fetal demise in utero at 36 weeks gestation. What will the nurse include in this client's plan of care? (Select all that apply.)
Contact the hospital chaplain. Ask about the last fetal movements. Ask about plans for labor pain management. Ask the parents if they want to hold the baby after birth.
The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take next?
Continue to monitor labor progress.
A new mother who has been insulin dependent for eight years just delivered spontaneously an 8 pound, 4 ounce infant/3740 grams infant. The nurse obtains a blood glucose reading of 112 mg/dL when the infant is 8 hours old. What is the best nursing action for this client?
Document the finding in the client's chart.
A primigravida at term presents to the labor and delivery unit smiling and states to the nurse, "I am in labor." The nurse assesses the client's cervical dilation and finds it is 2/50%/-1. The fetal heart rate is stable at 135 to 145 beats/min, and membranes are intact. Maternal vital signs are stable. What are the nursing actions for this phase/stage of labor? (Select all that apply.)
Encourage the mother to ambulate. Have the mother use slow, deep breathing with contractions. Encourage the mother to urinate every 1 to 2 hours.
A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement?
Encourage the mother to stop feeding for a few minutes and comfort the infant.
An insulin-dependent client with gestational diabetes mellitus is in the second stage of labor. What supplies will the delivery nurse gather for care of the newborn? (Select all that apply.)
Erythromycin ointment Scale Measuring tape Blood glucose testing kit
During stage two of labor, what assessments must the labor nurse perform? (Select all that apply.)
Fetal heart rate before the contraction Fetal heart rate during the contraction Fetal heart rate after the contraction Frequency of contractions Duration of contractions Uterine tone between contractions
The nurse is providing care for a laboring client with a GTPAL of 65005 at term. Which assessments will the nurse include in this client's plan of care for after delivery? (Select all that apply.)
Fundal assessment should be made every 5 minutes for 30 minutes after delivery of the placenta. Assess for lochia every 5 minutes for 30 minutes after delivery of the placenta. Place the infant to breast immediately after delivery
The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? (Select all that apply.)
Gonorrhea Chlamydia
The nurse is teaching a nursing student about the abbreviation GTPAL to note pregnancy outcomes. The nurse determines the teaching was successful when the students relates the abbreviation GTPAL to which terms? (Select all that apply.)
Gravidity Living
A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV infected. Which explanation should the nurse provide?
HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present.
The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take next?
Have the client breathe into her cupped hands.
When a new mother receives her infant for the first time, which behavior is most reassuring to the nurse?
Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.
The nurse is providing care to a 1-hour-old neonate born to mother who took insulin throughout her pregnancy. Which conditions will the nurse include in the infant's assessment throughout its hospitalization? (Select all that apply.)
Hypoglycemia Respiratory distress syndrome Congenital anomalies
A 41-week multigravida is receiving oxytocin to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. What is the next nursing action?
Increase the rate of the oxytocin infusion.
The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur?
January 29 to 30
During a prenatal visit, the nurse discusses with a pregnant client the effects of smoking on the fetus. Which statement is most characteristic of an infant whose mother smoked during pregnancy?
Lower initial weight documented at birth
A mother who is breastfeeding her baby receives instructions from the nurse. Which instructions are most effective in preventing nipple soreness? (Select all that apply.)
Massage a small amount of medical-grade lanolin into the nipple. Ensure that the baby is positioned correctly for latching on.
The nurse is providing care for a woman who just delivered. The umbilical cord extends from the vagina accompanied by a gush of blood. What is the next nursing action?
Massage the fundus.
A 38-week primigravida works as an office assistant and sits at a computer 8 hours each day. She tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities?
Move about every hour.
The nurse is teaching the pregnant client about fetal growth and development. Which client statements indicate understanding of the teaching? (Select all that apply.)
My baby gets oxygen through the placenta. The amniotic fluid helps with muscle development. My baby will gain about a half a pound per week after 36 weeks.
A client at term presents to labor and delivery in spontaneous labor; contractions are occurring every 3 to 4 minutes and they are 60 seconds in duration. The client states to the nurse, "I think I have a break out of my genital herpes." What actions will the nurse take next? (Select all that apply.)
Observe the client's perineum. Contact the health care provider. Assess ongoing acyclovir treatment.
The client comes to the hospital assuming she is in labor. Which assessment findings by the nurse would indicate that the client is in true labor? (Select all that apply.)
Pain in the lower back that radiates to abdomen Progressive cervical dilation and effacement Regular and rhythmic painful contractions
The labor and delivery nurse is admitting a client at 34 weeks gestation who reports contractions every 3 to 4 minutes for the past hour. What will the nurse include in the client's plan of care? (Select all that apply.)
Place an electronic fetal monitor. Collect a urine sample Left lateral position. Administer fluids.
A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan?
Place petroleum ointment around the glans with each diaper change and cleansing.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60 mm Hg. Which actions should the nurse take immediately? (Select all that apply.)
Place the client in a lateral position. Increase the rate of the main line IV. Place oxygen by facemask.
Six hours after an oxytocin induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement?
Place the client in a slight Trendelenburg position.
The laboring client at term states to the nurse, "I think my water just broke." The nurse observes a shiny, gelatinous, rope-like structure protruding from the client's vaginal area. What is the next nursing action?
Place the client in knee-chest position.
The nurse is providing care to a newborn just delivered from a mom who is positive for Hepatitis B. What additional care will the nurse plan for this neonate? (Select all that apply.)
Remove any maternal blood from the infant immediately after birth. Bathe the neonate prior to administering the vitamin K injection.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding?
Skin color that is slightly jaundiced
A client at 34 weeks gestation arrives to the clinic and says to the nurse that she thinks she is having contractions. What actions will the nurse include in this client's plan of care? (Select all that apply.)
State to her, "Let me know if you have a contraction during your visit today." Ask the client, "Are the contractions painful?" Ask her, "Do they come a frequently as every 5 minutes?" Inform her, "Those could be Braxton-Hicks contractions."
The clinic nurse is reviewing phone messages left from postpartum clients during the lunch break. Which calls will the nurse return before the others? (Select all that apply.)
The mother who reports her vaginal discharge went from brown to bright red. The mother who reports her vaginal flow smells "like a chicken farm." The breast-feeding mother who reports redness and a painful right breast.
The nurse is preparing an infusion of oxytocin to induce labor for a newly admitted client. The order reads, place 30 units of oxytocin in 500 mL of normal saline and start at 1 mL/hour. Increase by 1 mL every 30 minutes until contractions are every 3 to 4 minutes. Oxytoxin is packaged in a glass vial that reads, 1 mL contains 10 units. What supplies will the nurse need to gather to start the infusion? (Select all that apply.)
Three vials of oxytocin Alcohol wipe IV start kit One or three mL syringe
The clinic nurse is performing a fundal height assessment on a client in her third trimester. The client states to the nurse, "I am feeling very dizzy when you are pressing on my belly." What are the nurse's best actions to this comment? (Select all that apply.)
Turn the client to her left side. State, "That is from your baby pressing down on your blood vessels."
What specific instructions will the nurse include in the pregnancy client's teaching plan who is also human immunodeficiency virus (HIV) positive? (Select all that apply.)
Use condoms when having sex. Zidovudine prescription helps decrease risk of fetal exposure Breastfeeding is not recommended.
The nurse is providing care to a 1-hour-old infant. An assessment of gestational age is performed and the nurse estimates the age at 39 to 40 weeks. What findings will the nurse document in the infant's chart? (Select all that apply.)
Vernix in the creases of the neck Labia majora covers the labia minora.
The nurse is providing care to a client who just delivered her sixth term infant. In addition to routine postpartum care, what additional priority nursing action will the nurse include in this client's plan of care?
Weigh the peri pads before and after placement to the peri area.
