Maternal Captsone questions exam 3

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?

"I should avoid exercise because of the negative effects on insulin production."

The nurse in a health care clinic is instructing a client on how to perform kick counts. Which statement made by the client indicates a need for further teaching?

"I should lie on my back to perform the procedure."

14. A client in the first trimester of pregnancy arrives at a health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse instructs the client regarding management of care. Which statement, if made by the client, indicates a need for further education?

"I will maintain strict bedrest throughout the remainder of the pregnancy.

323. The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume

1. Client pain level The priority nursing consideration for a client who delivered 2 hours ago and who has a midline episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?

2. Discontinue the infusion of oxytocin.

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply. 1. Bed rest as a necessary preventive measure may be prescribed 2.Routine administration of subcutaneous heparin may be prescribed 3. An overbed lift may be necessary if the client requires a cesarean section. 4. Less frequent cleansing of a cesarean present, may be prescribed. 5. Thromboembolism stockings or sequential compression devices may be prescribed.

2. Routine administration of subcutaneousheparin may be prescribed. 3. An overbed lift may be necessary if the clientrequires a cesarean section. 5. Thromboembolism stockings or sequential compression devices may be prescribed.

321. The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate? 1. Raise the head of the client's bed. 2. Obtain hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the client until the mother's symptoms have subsided. 3

3. Instruct the client to request help when getting out of bed. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a health care provider's prescription. Option 4 is unnecessary.

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply ?

3.The cervix is dilated completely. 5.The ferguson reflex is initiated from perineal pressure

331. The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra. ** 2. Rest during the acute phase. ** 3. Maintain a fluid intake of at least 3000 mL. ** 4. Continue to breast-feed if the breasts are not too sore. *** 5. Take the prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breast-feeding or breast pump.

331. 1, 2, 3, 4 Rationale: Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/ day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?

Administer oxygen via face mask.

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?

Perform a vaginal examination every shift.

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise?

Persistent nonreassuring fetal heart rate

The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicated that the client is at risk for preterm labor?

The client has a hx of cardiac disease

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?

The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

Which purposes of placental functioning should the nurse include in a prenatal class? SELECT ALL THAT APPLY. a. It cushions and protects the baby. b. It maintains the temperature of the baby. c. It is the way the baby gets food and oxygen. d. It prevents all antibodies and viruses from passing to the baby. e. It provides an exchange of nutrient ms and waste products between the mother and developing fetus.

answer: C. E.

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?

Hemmorhage

The home care nurse is monitoring a pregnant client who is at risk for preeclampsia. At each home care visit, the nurse assesses the client for which sign of preeclampsia?

Hypertension

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?

. "My contractions will increase in duration and intensity."

22. The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of delivery 4. Within 2 weeks postpartum

1. 3 days postpartum After birth, the nurse should auscultate the client's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.

The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)Select all that apply? 1.A client who has a history of intravenous drug use 2.A client who has a significant other who is heterosexual 3.A client who has a history of sexually transmitted infections 4.A client who has had one sexual partner for the past 10 years

1. A client who has a history of intravenous drug use 3. A client who has a history of sexually transmitted infections

338. The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation

1. Changes in vital signs Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?

1."I will begin abdominal exercises immediately."

The nurse in a maternity unit is reviewing the clients' records. Which clients should the nurse identify as being at the most risk for developing disseminated intravascular coagulation (DIC)? Select all that apply.

1.A primigravida with abruptio placenta 3.A gravida II who has just been diagnosed with dead fetus syndrome 5.A primigravida at 29 weeks of gestation who was recently diagnosed with severe preeclampsia

330. The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4 ° F 2. An increase in the pulse rate from 88 to 102 beats/ minute 3. A blood pressure change from 130/ 88 to 124/ 80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/ minute

2. An increase in the pulse rate from 88 to 102 beats/ minute During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply .1.Breast-feeding needs to be stopped for 3 months. 2.Pregnancy needs to be avoided for 1 to 3 months. 3.The vaccine is administered by the subcutaneous route. 4.Exposure to immunosuppressed individuals needs to be avoided. 5.A hypersensitivity reaction can occur if the client has an allergy to eggs. 6.The area of the injection needs to be covered with a sterile gauze for 1 week.

2.Pregnancy needs to be avoided for 1 to 3 months. 3.The vaccine is administered by the subcutaneous route. 4.Exposure to immunosuppressed individuals needs to be avoided. 5.A hypersensitivity reaction can occur if the client has an allergy to eggs.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery?

2.Support the mother in her reaction to the newborn infant.

333. The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3. Enlarged, hardened veins Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is a normal finding.

340. On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? 1. Elevate the client's legs. 2. Document the findings. 3. Massage the fundus until it is firm. 4. Push on the uterus to assist in expressing clots.

3. Massage the fundus until it is firm. If the uterus is not contracted firmly (i.e., it is soft and boggy), the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs would not assist in managing uterine atony. Documenting the findings is an appropriate action but is not the initial action. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.

335. The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the health care provider (HCP). 4. Place the client in Trendelenburg's position.

3. Notify the health care provider (HCP). If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function. Although the nurse would record the findings, the initial nursing action would be to notify the HCP.

339. The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Assess vital signs every 4 hours. 2. Measure fundal height every 4 hours. 3. Prepare an ice pack for application to the area. 4. Inform the health care provider of assessment findings.

3. Prepare an ice pack for application to the area. A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 4 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to *immediately* discontinue the oxytocin infusion? *Select all that apply*. 1. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Late decelerations of the fetal heart rate 5. Early decelerations of the fetal heart rate

3. Uterine hyperstimulation & 4. Late decelerations of the fetal heart rate Rationale: oxytocin stimulates uterine contractions and is a pharmacological method to induce labor. Late decelerations, a non reassuring fetal heart rate pattern, is an ominous sign indicating fetal distress period oxytocin infusion must be stopped when any signs of uterine hyperstimulation, late decelerations, or other adverse effects occur. Some healthcare providers prescribe the administration of oxytocin in 10-minute Post in fusions rather than as a continuous infusion. This post method, which is more like endogenous secretions of oxytocin, is reported to be effective for labor induction and requires significantly less oxytocin use period drowsiness and fatigue may be caused by the labor experience. Early decelerations fetal heart rate are a reassuring sign and do not indicate fetal distress.

332. The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction? 1. "I should breast-feed every 2 to 3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breast- feeding." 4. "I should wash my nipples daily with soap and water."

4. "I should wash my nipples daily with soap and water." Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand-washing and that she should breast-feed every 2 to 3 hours.

Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement?

4. Administer oxygen at 8 to 10 L/min via face mask.

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse should contact the healthcare provider who prescribed the medication if which condition is documented in the client's medical history? 1. Hypotension 2. Hypothyroidism 3. Diabetes mellitus 4. Peripheral vascular disease

4. Peripheral vascular disease Rationale: methylergonovine is in the ergot alkaloid used to treat postpartum Hemorrhage. Ergot alkaloids are contraindicated in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, pre-eclampsia, or a clamp Sia. These conditions are worsened by the basil constrictive effects of herbal alkaloids. Options 1, 2, and 3 are not contraindications related to the use of ergot alkaloids.

327. The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action? 1. The client with mild afterpains 2. The client with a pulse rate of 60 beats/ minute 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foul-smelling odor.

4. The client with lochia that is red and has a foul-smelling odor. Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

4. Variable decelerations

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the health care provider (HCP)?

Fetal heart rate of 180 beats/minute

Which assessment following an amniotomy should be conducted first?

Fetal heart rate pattern

An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placentae is present. Based on these findings, the nurse would prepare the client for:

Delivery of fetus

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate?

Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being.

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further teaching is needed if the client makes which statement?

I will need to increase my insulin dosage during the first 3 months of pregnancy."

A pregnant client is seen for a regular prenatal visit and tells the nurse that she is experiencing irregular contractions. The nurse determines that she is experiencing Braxton Hicks contractions. On the basis of this finding, which nursing action is appropriate?

Inform the client that these contractions are common and may occur throughout the pregnancy.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time?

Rest between contractions

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position?

Supine position with a wedge under the right hip

16. A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and who is being monitored for pregnancy induced hypertension (PIH). Which assessment finding indicates a worsening of the Preeclampsia and the need to notify the physician?

The client complains of a headache and blurred vision

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?

Uterine Tenderness

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief?

What can I do for you?"

The instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? SELECT ALL THAT APPLY. a. Allows for fetal movement b. Surrounds, cushions, and protects the fetus c. Maintains the body temperature of the fetus d. Can be used to measure fetal kidney function e. Prevents large particles such as bacteria from passing to the fetus f. Provides an exchange of nutrients and waste products between the mother and the fetus

answer: A, B, C, D

The nurse has assisted in performing a nonstress test on a pregnant client and is reviewing the documentation related to the results of the test. The nurse notes that the health care provider has documented the test results as reactive. How should the nurse interpret this result?

normal findings

The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area? Click on the image to indicate your answer.

3

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply.

1.Age 54 2.Body mass index of 28 3Previous difficulty with fertility

The nurse asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which statement indicates that *further teaching is needed* about administration of the eye medication? 1. "I will flush the eyes after instilling the ointment." 2. "I will clean the newborn's eyes before instilling the ointment." 3. "I need to administer the eye ointment within 1 hour of delivery." 4. "I will instill the eye ointment into each of the newborn's conjunctival sacs."

1. "I will flush the eyes after instilling the ointment." Rationale: eye prophylaxis protects newborns against gonorrhea and chlamydia. The eyes are not flush after installation of the medication because the flush would wash away the administered medication. Options two, three, and four are correct statements regarding the procedure for administering medication to the new born

1. The nurse is providing instructions to a pregnant client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurse?

"I should drink adequate fluids and increase my intake of high-fiber foods."

A 55 year old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response? a. "How often do you have sexual relations?" b. "Please share with me more about your concerns." c. "You are still young and have nothing to be concerned about." d. "You should not have a decline in testosterone until you are in your 80s."

"Please share with me more about your concerns."

334. A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/ minute, by face mask.

4. Administer oxygen, 8 to 10 L/ minute, by face mask. If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/ minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.

A pregnant client in the first trimester calls the nurse at a health care clinic and reports that she has noticed a thin, colorless vaginal drainage. The nurse should make which statement to the client?

"The vaginal discharge may be bothersome, but is a normal occurrence."

The nurse in a maternity unit is providing emotional support to a client and her husband who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?

"We want to attend a support group."

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

Evidence of bleeding, such as in the gums, petechiae, and purpura

The nurse should make which statement to a pregnant client found to have gynecologist pelvis? a. "Your type of pelvis has a narrow pubic arch." b. "Your type of pelvis is the most favorable for labor and birth." c. "Your type of pelvis is a wide pelvis, but it has a short diameter." d. "You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."

answer: B.

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? *Select all that apply*. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes

1. Flushing 4. Depressed respirations & 5. Extreme muscle weakness Rationale: magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. It did use to Halt preterm labor contractions and is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels.

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily accessible should respiratory depression occur? 1. Naloxone 2. Morphine sulfate 3. Betamethasone 4. Hydromorphone hydrochloride

1. Naloxone Rationale: opioid analgesics may be prescribed to relieve moderate to severe pain associated with labor. Opioid toxicity can occur and cause respiratory depression. Naloxone is an opioid antagonist, which reverses the effects of opioids and is given for respiratory depression. Morphine sulfate and hydromorphone hydrochloride are opioid analgesics. Betamethasone is a corticosteroid administered to enhance fetal lung maturity.

325. The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1. The diet should include additional fluids. 2. Prenatal vitamins should be discontinued. 3. Soap should be used to cleanse the breasts. 4. Birth control measures are unnecessary while breast-feeding.

1. The diet should include additional fluids. The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraception, so birth control measures should be resumed.

The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply. 1.Ballottement2.Chadwick's sign3.Uterine enlargement4.Positive pregnancy test 5. fetal heart rate detected by nonelectronic device 6.outline of fetus via radiography or ultrasound

1.Ballottement2.Chadwick's sign3.Uterine enlargement4.Positive pregnancy test

A client in preterm labor (31 weeks) who is dilated to 4 cm had been started on magnesium sulfate and contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? 1. Nalbuphine 2. Betamethasone 3. Rho (D) immune globulin 4. Dinoprostone vaginal insert

2. Betamethasone Rationale: betamethasone, a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered to clients in preterm labor at 28 to 32 weeks of gestation if labor can be inhibited for 48 hours. Now Buford is an opioid analgesic. Rho immune globulin is given to rh- clients to prevent sensitization. Dinoprostone vaginal insert is a prostaglandin given to ripen and soften the cervix and to stimulate uterine contractions.

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the *priority* assessment? 1. Uterine tone 2. Blood pressure 3. Amount of lochia 4. Deep tendon reflexes

2. Blood pressure Rationale: methylergonovine, and I go alkaloid comma is used to prevent or control postpartum Hemorrhage by Contracting the uterus. Methylergonovine causes continuous uterine contractions and may Elevate the blood pressure. A priority assessment before the administration of the medication is to check the blood pressure. The healthcare provider needs to be notified if hypertension is present. Although options one, three, and four may be components of postpartum assessment, blood pressure is related specifically to the administration of this medication

337. A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels

2. Encouraging fluid intake Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.

The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route? 1. Intradermal 2. Intratracheal 3. Subcutaneous 4. Intramuscular

2. Intratracheal Rationale: respiratory distress syndrome is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. It is common in premature infants and may be due to lung immaturity as a result of surfactant deficiency. The Mainstay of treatment is the administration of exogenous surfactant, which is administered by the intratracheal route. Options 1, 3, and 4 are not routes of administration for this medication

326. A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate? 1. Elevate the client's legs. 2. Massage the fundus until it is firm. 3. Ask the client to turn on her left side. 4. Push on the uterus to assist in expressing clots.

2. Massage the fundus until it is firm. If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony.

Rho (D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? 1. Having Rh-positive blood 2. Developing a rubella infection 3. Developing physiological jaundice 4. Being affected by Rh incompatibility

4. Being affected by Rh incompatibility Rationale: RH incompatibility can occur when an Rh negative mother become sensitized to the RH antigen. Sensitization May develop when an Rh negative woman becomes pregnant with a fetus who is RH positive. During pregnancy and at delivery, some of the fetus's RH positive blood can enter the maternal circulation, causing the mother's immune system to form antibodies against RH positive blood. Administration of rho immunoglobulin prevents the mother from developing antibodies against RH positive blood by providing passive antibody protection against the RH antigen.

A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year old child that was delivered at 37 weeks and tells the nurse that she doesn't have any history of abortion or fetal demise. The nurse would document the GTPAL for this client as:1.G = 3, T = 2, P = 0, A = 0, L =12.G = 2, T = 0, P = 1, A = 0, L =13.G = 1, T = 1. P = 1, A = 0, L = 14.G = 2, T = 0, P = 0, A = 0, L = 1

2. Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies. T is term births, the number born at term (38-41 weeks). P is preterm births, the number born before 38 weeks gestation. A is abortions or miscarriages (included in gravida if before 20 weeks gestation; included in parity if past 20 weeks gestation). L is live births, the number of live births or living children. Therefore, a woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 37 weeks, the number of preterm births is 1, and the number of term births is 0. The number of abortions is 0, and the number of live births is 1.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted on assessment? *Select all that apply*. 1. Protienuria of 3+ 2. Respirations of 10 breaths/minute 3. Presence of deep tendon reflexes 4. Urine output of 20 mL in an hour 5. Serum magnesium level of 4 mEq/L (2 mmol/L)

2. Respirations of 10 breaths/minute & 4. Urine output of 20 mL in an hour Rationale: magnesium toxicity can occur from magnesium sulfate therapy. signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal heart rate and maternal heart rate and blood pressure. Respiratory rate below 12 breaths per minute is a sign of toxicity. Urine output should be at least 25 to 30 milliliters per hour. Proteinuria of 3 + is an expected finding in a client with pre-eclampsia. Presence of deep tendon reflexes is normal and expected finding. Therapeutic serum levels of magnesium are for 27.5 mEq per liter

329. The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding? 1. Scant 2. Light 3. Heavy 4. Excessive

3. Heavy Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant = less than 2.5 cm (< 1 inch) on menstrual pad in 1 hour; light = less than 10 cm (< 4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (< 6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes. Test-Taking Strategy: Focus on the subject, a saturated perineal pad in 1 hour. The data and the use of guidelines to determine the amount of lochial flow will direct you to the correct option..

328. When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings. 2. Reassess the client in 2 hours. 3. Notify the health care provider. 4. Encourage increased oral intake of fluids.

3. Notify the health care provider. Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the HCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.

A client arrives at a birthing center in active labor. Following examination, it is determined that her membranes are still intact and she is at a -2 station. The health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply.

3.Increased efficiency of contractions 5.The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

324. The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statement( s)? Select all that apply. 1. "I should wear a bra that provides support." ** 2. "Drinking alcohol can affect my milk supply." ** 3. "The use of caffeine can decrease my milk supply." ** 4. "I will start my estrogen birth control pills again as soon as I get home." 5. "I know if my breasts get engorged I will limit my breast-feeding and supplement the baby." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."**

324. 1, 2, 3, 6 Rationale: The postpartum client should wear a bra that is well-fitted and supportive. Breasts may leak between feedings or during coitus, and the client is taught to place a breast pad in the bra. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding, but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or other medications.

336. The nurse is preparing to care for four assigned clients. Which client is at highest risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A primiparous client who delivered 6 hours ago and had epidural anesthesia 4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction

4. A multiparous client who delivered a large baby after oxytocin (Pitocin) induction The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than the other clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 3 that present the risk for hemorrhage.

320. The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2 ° F. What is the priority nursing action? 1. Document the findings. 2. Retake the temperature in 15 minutes. 3. Notify the health care provider (HCP). 4. Increase hydration by encouraging oral fluids.

4. Increase hydration by encouraging oral fluids. The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4 ° F (38 ° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the HCP is not necessary.

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply.

4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide?

An informed consent needs to be signed before the procedure.

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action?

Assess the baseline fetal heart rate.

A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue. After assessment of the client, tuberculosis is suspected. A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan?

Isoniazid plus rifampin (Rifadin) will be required for 9 months.

A client arrives at the clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period was October 19 2020. Use Niagele's rule which expected date of delivery should the nurse document in the clients chart?

July 26 2021 Subtract 3 months add 7 days to first day of the last menstrual period and then add one year to that date.

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action?

Monitoring the fetal heart rate

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate?

Notify the health care provider (HCP).

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?

Obtain equipment for a manual pelvic examination.

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action?

Place the client in Trendelenburg's position.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action?

Provide pain relief measures.

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30cm. How should the nurse interpret this finding?

The client is measuring normal for gestational age

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be MOST APPROPRIATE? a. "Did you ever had surgery?" b. "Do you plan to have any other children?" c. "Do either of you have diabetes mellitus?" d. "Do either of you have problems with high blood pressure?"

answer: B.

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1."You will need to bottle-feed your newborn." 2."You will need to feed your newborn by nasogastric tube feeding." 3."You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." 4."You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

You will need to bottle-feed your newborn

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs that the client that she should be able to find out the sex at 12 weeks' gestation because of which factor? a. The appearance of the fetal external genitalia b. The beginning to differentiation in the fetal groin c. The fetal testes are descended into the scrotal sac d. The internal differences in males and females become apparent

answer: A.

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's BEST response? a. "It promotes the fertilized ovum's chances of survival." b. "It promotes the fertilized ovum's exposure to estrogen and progesterone." c. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." d. "It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone."

answer: C.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the priority nursing action? a. Document the finding. b. Check the mother's heart rate. c. Notify the health care provider (HCP). d. Tell the client that the fetal heart rate is normal.

answer: C.

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venous. Which statement by the student indicates an understanding of the ductus venousus? a. "It connects the pulmonary artery to the aorta." b. "It is an opening between the right and left atria." c. "It connects the umbilical vein to the inferior vena cava." d. "It connects the umbilical artery to the inferior vena cava."

answer: C.

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? SELECT ALL THAT APPLY. a. "The ductus arteriosus allows blood to bypass the fetal lungs." b. "One vein carries oxygenated blood from the placenta to the fetus." c. "The normal fetal heart tone range is 140 to 160 beats per minute in early pregnancy." d. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." e. "Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta."

answer: a, b, d