Hesi practice exam

When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.)

"Postpartum blues" is a common emotional response related to the rapid decrease in placental hormones after delivery and include mood swings, tearfulness, feeling low, emotional, and fatigued.

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?

A 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia, which is an indication of an impending seizure.

A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurse's response should be based on what information?

According to the laws of inheritance, an autosomal dominant disorder has a 50% chance of being transmitted with each pregnancy, and if transmitted, the disorder will appear in the child. Males do not inherit autosomal dominant disorders more frequently than females.

A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best?

Home urine tests are based on the chemical detection of human chorionic gonadotrophin, which begins to increase 6 to 8 days after conception, and is best detected at 2 weeks gestation or immediately after the first missed period.

An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father?

Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement. These behaviors are positive signs of maternal/fetal bonding.

Which nursing intervention is helpful in relieving "afterpains" (postpartum uterine contractions)?

Periodic contraction and relaxation of the uterus causes "afterpains." Relaxation breathing techniques provide distraction, reducing the perception of pain.

A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin?

Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the client is at risk for hyperstimulation which can lead to tetanic contractions, uterine rupture, and fetal distress or demise.

The nurse is planning preconception care for a new female client. Which information should the nurse provide the client?

Planning for pregnancy begins with healthy lifestyles in the family which is an intervention in preconception care that targets an overall goal for a client preparing for pregnancy.

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." Which intervention is best for the nurse to implement first?

Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery.

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. Which intervention has the highest priority?

Putting the newborn to breast will help contract the uterus and prevent a postpartum hemorrhage--this intervention has the highest priority.

A 30-year-old multiparous woman who has a 3-year-old boy and an newborn girl tells the nurse, "My son is so jealous of my daughter, I don't know how I'll ever manage both children when I get home." How should the nurse respond?

Regression in behaviors in the older child is a typical reaction so he needs attention at this time. Preschool-aged children frequently regress in habits or behaviors, such as toileting and sleep habits, as a method of seeking attention, so the parents should distribute their attention between the children and include the preschooler during infant care.

A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is:

Respiratory tract infections commonly occur in the pediatric population. However, the child with AIDS has a decreased ability to defend the body against these infections and often the presenting symptom of a child with AIDS is a persistent cold.

A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nägele's rule, what is the estimated date of delivery?

Since this woman's first day of her last normal menstrual period occurred on August 2, 2006, the estimated date of delivery is May 9, 2007. Nägele's rule is used to calculate the expected date of delivery, and is obtained by subtracting 3 months and adding 7 days beginning from the first day of the last normal menstrual period.

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as..

a cephalhematoma, caused by forceps trauma and may last up to 8 weeks. Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and the skull.

In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the..

anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month. In the normal infant the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel by the end of the second month. These growth and development milestones should be memorized to prepare for the NCLEX.

What action should the nurse implement to decrease the client's risk for hemorrhage after a cesarean section?

A client's risk of postpartal hemorrhage is deceased when the uterus is firm after delivery of the infant. Assessment of fundus consistency q15 minutes provides frequent intervals to stimulate the fundus to contract and prevent bleeding.

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next?

A firm uterus is needed to control bleeding from the placental site of attachment on the uterine wall. The nurse should first assess for firmness and massage the fundus as indicated.

The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention?

A full bladder can impair the efficiency of the uterine contractions and impede descent of the fetus during labor. Also, because of the close proximity of the bladder to the uterus, the bladder can be traumatized by the descent of the fetus.

A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement?

Diet modifications are effective in managing Type 2 diabetes during pregnancy, and describing the necessary diet changes is the most important intervention for the nurse to implement with this client.

A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client?

Do you have a history of rheumatic fever? Clients with a history of rheumatic fever may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the increased blood volume that occurs during pregnancy, so obtaining information about this client's health history is a priority.

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period is..

January 30-31. This woman can expect her next period to begin 36 days from the first day of her last menstrual period--the cycle begins at the first day of the cycle and continues to the first day of the next cycle. Her next period would, therefore, begin on February 13. Ovulation occurs 14 days before the first day of the menstrual period. Therefore, ovulation for this woman would occur January 31

A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first?

To reduce direct contact with the human immuno-virus in blood and body fluids on the newborn's skin, a bath with an antimicrobial soap should be administered first.

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately?

Total (complete) placenta previa involves the placenta covering the entire cervical os (opening). The onset of uterine contractions places the client at risk for dilation and placental separation, which causes painless hemorrhaging.

A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first?

When possible, the nurse should first obtain measurable objective data; an oxygen saturation rate provides such information. FYI. The pediatrician should be notified if the oxygen saturation rate is below 90%

the Silverman-Anderson Index

A Silverman-Anderson Index has five categories with scores of 0, 1, or 2. The total score ranges from 0 to 10. A total score of 0 means the infant has no dyspnea, a total score of 10 indicates maximum respiratory distress.

A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next?

A vaginal exam should be performed after the rupture of membranes to determine the presence of a prolapsed cord.

The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding?

The normal umbilical cord contains three vessels--two arteries and one vein.

The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is recommended for which purpose?

Alpha-fetoprotein (AFP) is a screening test used in pregnancy. Elevated AFP may indicate an increased rish of neural tube defects such as anencephaly and spinal bifida.

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?

Attachment/bonding theory indicates that most mothers will demonstrate behaviors described in during the first visit with the newborn, which may be at delivery or later.

The nurse is calculating the estimated date of confinement (EDC) using Nägele's rule for a client whose last menstrual period started on December 1. Which date is most accurate?

Calculation of a client's EDC provides baseline data to monitor fetal gestation. Nägele's rule uses the formula: subtract 3 months and add 7 days to the first day of the last normal menstrual period, so December 1 minus 3 months + 7 days is September

While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother?

Caput succedaneum is edema of the fetal scalp that crosses over the suture lines and is caused by pressure on the fetal head against the cervix during labor; it subside in a few days after birth without treatment.

The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider?

Cephalohematomas are characterized by bleeding between the bone and its covering, the periosteum. Due to the breakdown of the red blood cells within a hematoma, the infant is at a greater risk for jaundice, so a yellowish tinge to the skin should be reported.

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client?

Complete bedrest decreases oxygen needs and demands on the heart muscle tissue. To help preserve cardiac reserves, the woman may need to restrict her activities and complete bedrest is often prescribed.

Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take?

The nurse should immediately turn the woman to a lateral position, place a pillow or wedge under the right hip to deflect the uterus, increase the rate of the main line IV infusion, and administer oxygen by face mask at 10-12 L/min. If the blood pressure remains low, especially if it further decreases, the anesthesiologist/healthcare provider should be notified immediately.

A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse implement?

Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is capable), and putting the heel of the foot on the floor is the best means of relieving leg cramps.

The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern?

Edema, basilar rales, and an irregular pulse indicate cardiac decompensation and require immediate intervention.

A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement?

Erythema toxicum (or erythema neonatorum) is a newborn rash that is commonly referred to as "flea bites," but is a normal finding that is documented in the infant's record.

The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant?

Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmica neonatorum, an infection caused by gonorrhea, and inclusion conjunctivitis, an infection caused by chlamydia.The infant may be exposed to these bacteria when passing through the birth canal.

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation should the nurse provide?

The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if the infant is adequately hydrated.

The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.)

Frontal occipital circumference of 12.5 inches (31.25 cm) Head to heel length of 17 inches (42.5 cm) Admission weight of 4 pounds, 15 ounces (2244 grams) The normal full-term, appropriate for gestational age (AGA) newborn should fall between the measurement ranges of weight, 6-9 pounds (2700-4000 grams); length, 19-21 inches (48-53 cm); FOC, 13-14 inches (33-35 cm). This neonate's parameters plot below the 10% percentile, which indicate that the infant is SGA.

A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child?

The use of lubricants has the potential to affect fertility because some lubricants interfere with sperm motility.

A full term infant is transferred to the nursery from labor and delivery. Which information is MOST important for the nurse to receive when planning immediate care for the newborn?

Immediate care is most dependent on the infant's current status (i.e., Apgar scores at 1 and 5 minutes) and any treatment or resuscitation that was indicated.

A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge?

It is difficult to consume 18 mg of additional iron by diet alone. Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and to meet the demands of pregnancy is difficult so iron supplements are often recommended.

The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding AFTER it changes?" What should the nurse instruct the client to do?

Lochia should progress in stages from rubra (red) to serosa (pinkish) to alba (whitish), and not return to red. The return to rubra usually indicates subinvolution or infection. If such a sign occurs, the mother should notify the clinic/healthcare provider and reduce her activity to conserve energy

Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?"

Lying prone keeps the fundus contracted and is especially useful with multiparas, who commonly experience afterpains due to lack of uterine tone.

One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse take immediately?

Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?

Monitoring bleeding from peripheral sites is the priority intervention. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruptio, characterized by abnormal bleeding.

A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first?

Obtaining a urine analysis should be done first because preterm clients with uterine irritability and contractions are often suffering from a urinary tract infection, and this should be ruled out first.

The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take?

The client should be asked if she has felt the fetus move. An NST is used to determine fetal well-being, and is often implemented when postmaturity is suspected. A "reactive" NST occurs if the FHR accelerates 15 bpm for 15 seconds in response to the fetus' own movement, and is "nonreactive" if no FHR acceleration occurs in response to fetal movement.

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take?

Parent-infant bonding or attachment is based on a mutual relationship between parent and infant and is commonly established by the "enface position," which is demonstrated by the mother's and infant's eyes meeting in the same plane. To assess for other attachment behaviors, continued observation of the new mother's interactions with her infant helps the nurse determine problems in attachment.

A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement?

The discomfort of back labor can be minimized by the application of firm pressure to the sacral area.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness?

The most common cause of nipple soreness is incorrect positioning of the infant on the breast, e.g., grasping too little of the areola or grasping only the nipple. Manually express a small amount of milk before nursing helps soften an engorged breast and encourages correct infant attachment, but is NOT the BEST answer.

A 23-year-old client who is receiving Medicaid benefits is pregnant with her first child. Based on knowledge of the statistics related to infant mortality, which plan should the nurse implement with this client?

Teach the client why keeping prenatal care appointments is important. Regular prenatal visits should begin early in pregnancy to monitor health of the mother and development of the fetus

A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate?

Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of "nervousness".

A client with gestational hypertension is in active labor and receiving an infusion of magnesium sulfate. Which drug should the nurse have available for signs of potential toxicity?

The antidote for magnesium sulfate is calcium gluconate, which should be readily available if the client manifest signs of toxicity.

The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?

Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands.

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client?

To accurately measure the fundal height, the bladder must be empty to avoid elevation of the uterus.

During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Arrange in order.)

To stabilize the fetus, intrauterine resuscitation is the first priority, and to enhance fetal blood supply, the laboring client should be repositioned (1) to displace the gravid uterus and improve fetal perfusion. Secondly, to optimize oxygenation of the circulatory blood volume, oxygen via face mask (2) should be applied to the mother. Next, the IV fluids should be increased (3) to expand the maternal circulating blood volume. Then, the primary healthcare provider should be notified (4) for additional interventions to resolve the fetal stress.

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client?

When teaching any client, readiness to learn is the most important criterion. For example, the client with severe morning sickness in the first trimester may not be "ready to learn" about labor and delivery, but is probably very "ready to learn" about ways to relieve morning sickness.

A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions?

Transition labor with contractions every 2 minutes, lasting 90 seconds each. Contraction pattern describes hyperstimulation and an inadequate resting time between contractions to allow for placental perfusion.

A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?

Urine outputs of less than 100 ml/4 hours, absent DTRs, and a respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.

When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation?

Vernix is a white, cheesy substance, predominantly located in the skin folds. Vernix, found in the folds of the skin, is a characteristic of term infants. Also, Meconium (first stool) is tarry black, Milia (milk dots) is white, pinpoint spots usually found over the nose and chin which represent blockage of the sebaceous glands, and Pseudostrabismus (crossed eyes) is normal at birth but should be corrected if it persists after 6 to 9 months of age.

The nurse should encourage the laboring client to begin pushing when..

the cervix is completely dilated. Pushing begins with the second stage of labor, i.e., when the cervix is completely dilated at 10 cm (C). If pushing begins before the cervix is completely dilated the cervix can become edematous and may never completely dilate, necessitating an operative delivery. Many primigravidas begin active labor 100% effaced and then proceed to dilate.

The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class?

Breastfeeding infants should be kept in the room with the mother and fed every 2 to 3 hours or on demand--whichever comes first.

The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?

A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged. When the presenting part is ballottable, it is floating out of the pelvis. In such a situation, the cord can descend before the fetus causing a prolapsed cord, which is an emergency situation.

A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client?

A client who has had a spontaneous abortion or still birth in the last 1½ years should take multivitamin and mineral supplements and maintain a balanced diet because the previous pregnancy may have left her nutritionally depleted.

A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider?

A platelet count of 67,000/mm3. Thrombocytopenia (low platelet count) should be reported to the healthcare provider because it places the client at risk for bleeding when an epidural is administred.

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside?

A single sterile glove, an amniotic hook, and Doppler to check fetal heart tones are the necessary equipment for performing an amniotomy.

Which assessment finding should the nursery nurse report to the pediatric healthcare provider?

An infant who demonstrates central cyanosis when crying is manifesting poor adaptation to extrauterine life which should be reported to the healthcare provider for determination of a possible underlying cardiovascular problem.

A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status?

BPP provides data regarding fetal risk surveillance by examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate. The client's gestation has progressed past the estimated date of confinement, so the major concern is fetal well-being related to an aging placenta, not screening for fetal anomalies.

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?

Between the time the temperature falls and rises. In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone. Therefore, intercourse between the time of the temperature fall and rise is the best time for conception. The human ovum can be fertilized 16 to 24 hours after ovulation.

A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective?

Changes in apical heart rate from the 180s to the 140s. Epogen, given to prevent or treat anemia, stimulates erythropoietin production, resulting in an increase in RBCs. Since the body has not had to compensate for anemia with an increased heart rate, changes in heart rate from high to normal is one indicator that Epogen is effective

A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited?

Choking, coughing, and cyanosis. the "3 Cs" of esophageal atresia caused by the overflow of secretions into the trachea.

A client with NO prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain?

Date of last normal menstrual period. Evaluating the gestation of the pregnancy takes priority. If the fetus is preterm and the fetal heart pattern is reassuring, the healthcare provider may attempt to prolong the pregnancy and administer corticosteroids to mature the lungs of the fetus.

A client in active labor complains of cramps in her leg. What intervention should the nurse implement?

Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is capable) (B), and putting the heel of the foot on the floor is the best means of relieving leg cramps.

The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement?

Encourage the mother to breastfeed frequently. The normal total bilirubin level is 6 to 12 mg/dl after Day 1 of life. This infant's bilirubin is beginning to climb and the infant should be monitored to prevent further complications. Breast milk provides calories and enhances GI motility, which will assist the bowel in eliminating bilirubin.

The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition?

Gestational diabetes. The nurse should evaluate the client for gestational diabetes because terbutaline (Brethine) increases blood glucose levels.

The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate?

Grief/loss response occurs at all stages of pregnancy loss.

A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complaint indicates that the fallopian tubes are patent?

If the tubes are patent (open), pain is referred to the shoulder from a subdiaphragmatic collection of peritoneal dye/gas.

A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?

Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory rate indicates that the drug is effective. (Respiratory rate below 12 indicates toxic effects.) Urinary output must be monitored when administering magnesium sulfate and should be at least 30 ml per hour. (The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl.)

A female client with insulin-dependent diabetes arrives at the clinic seeking a plan to get pregnant in approximately 6 months. She tells the nurse that she want to have an uncomplicated pregnancy and a healthy baby. What information should the nurse share with the client?

Maintaining blood sugar within a normal range during pregnancy has a strong correlation with a good outcome. Insulin requirements normally change during pregnancy.

At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next?

The client is demonstrating symptoms of blood loss, probably the result of an ectopic pregnancy, which occurs at approximately 14-weeks gestation when embryonic growth expands the fallopian tube causing its rupture, and can result in hemorrage and hypovolemic shock. Increasing the IV infusion rate provides intravascular fluid to maintain blood pressure.

A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best?

That is normal; the head will return to a round shape within 7 to 10 days. This reassures the mother that this is normal in the newborn and provides correct information regarding the return to a "normal" shape. A little tidbit from Evolve "Any implied or spoken "don't worry" is usually the wrong answer!"!

A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take?

The client is experiencing engorgement even though she is bottle-feeding her infant, and cold compresses may help reduce discomfort. Lactation begins about the third day after delivery, so the mother should avoid any breast stimulation, which further stimulates milk production. To aid in suppressing lactation, a well-fitting bra, should be worn to support and bind the breasts.

The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?

The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fractured clavicle should be suspected if an infant has limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex, crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.

The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching?

The mother should be instructed to avoid placing the infant prone which is associated with an increased incidence of sudden infant death syndrome (SIDS).

After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil® Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac® Soy Isomil® Formula, a soy protein isolate based infant formula. What information should the nurse provide to the mother about the newly prescribed formula?

The nurse should explain that the newborn's feeding intolerance may be related to the lactose found in cow's milk formula and is being replaced with the soy-based formula that contains sucrose, which is well-tolerated in infants with milk allergies and lactose intolerance.

A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply.)

The symptoms of abruptio placentae include dark red vaginal bleeding, increased uterine irritability, and a rigid abdomen.

A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?

Three plus deep tendon reflexes and hyperclonus are indicative of an impending convulsion and requires immediate attention.

When assessing a client who is at 12-weeks 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 gestation is closest (of the options) to the time parents would be ready for such classes. Learning is facilitated by an interested pupil! The couple is most interested in childbirth toward the end of the pregnancy when they are psychologically ready for the termination of the pregnancy, and the birth of their child is an immediate concern.

During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have..

lower birth weights Smoking is associated with low-birth-weight infants (B). Mothers are encouraged not to smoke during pregnancy. To date, significant relationships have NOT been found between smoking and lower Apgar scores, respiratory distress, a higher rate of congenital anomalies.

The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs..

two weeks before menstruation. Ovulation occurs 14 days before the first day of the menstrual period. While ovulation can occur in the middle of the cycle, or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of their menstrual cycle varies.

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?

These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed will increase venous return and provide blood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrose solution and ensuring that the client is in a lateral position are also appropriate interventions, and then checking the patients blood pressure.

A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?

Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound.

A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks' gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous. Which assessment is the highest priority for the nurse to monitor during the administration of this drug?

Monitoring maternal and fetal heart rates is most important when terbutaline is being administered. Terbutaline acts as a sympathomimetic agent that stimulates both beta 1 receptors (causing tachycardia, a side effect of the drug) and stimulation of beta 2 receptors (causing uterine relaxation, a desired effect of the drug).

On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) is..

November 22 correctly applies Nägele's rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15+7=22).

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client?

There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair. provides correct information and attempts to alleviate anxiety related to knowledge deficit. The anterior fontanel or "large soft spot" has a strong epidermal membrane present, which can be touched. The anterior fontanel normally closes at 12 to 18 months of age. The posterior fontanel closes at 8 to 12 weeks of age.

A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide?

It is important that you want to take part in your care. The emphasis of alternative and complementary therapies, such as herbal therapy, is that the client is viewed as a whole being, capable of decision-making and an integral part of the health care team, so recognizes the client's request.

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?

Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will straighten out the pelvic veins and increase venous return.

Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse perform next?

The nurse should immediately begin positive pressure ventilation because this infant's vital signs are not within the normal range, and oxygen deprivation leads to cardiac depression in infants. (The normal newborn pulse is 100 to 160 beats/minute and respirations are 40 to 60 breaths/minute.)

A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?

It is most important to meet the mother's requirement for attention to her needs so that she can begin infant care-taking. Nurse theorist Reva Rubin describes the initial postpartal period as the "taking-in phase," which is characterized by maternal reliance on others to satisfy the needs for comfort, rest, nourishment, and closeness to families and the newborn.

A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the nurse document in this client's record?

THIS QUESTION WAS CONTRAINDICATED. EVOLVE SAYS THIS BUT CORRECTLY IT IS SUPPOSE TO BE 3-1-2-0-3 The client has been pregnant 3 times including the current pregnancy (G-3). She had one full-term infant (T-1). She also had a preterm (P-1) twin pregnancy (a multifetal gestation is considered one birth when calculating parity). There were no abortions (A-0), so this client has a total of 3 living children.