Maternal Newborn B Ati
A nurse is discussion the differences between true labor and false labor with a group of expectant parents. Which of the following characteristics should the nurse include when discussing true labor?
Contractions become stronger with walking -The contractions that occur during true labor become stronger and more regular with a change in activity, such as walking.
A nurse is performing a vaginal exam on a client who is in labor and reports severe pressure and pain in the lower back. the nurse notes that the fetal head is in a posterior position. The nurse should identify that which of the following is the best nonpharmacological intervention to perform to relieve the client's discomfort
Counter pressure
A nurse is caring for a newborn is undergoing phototherapy to treat hyperbilirubinemia. which of the following actions should the nurse take?
Cover the newborn's eye while under the phototherapy light. -Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light.
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
I will eat foods that appeal to my taste instead of trying to balance me meals. -clients with this condition should eat to taste to avoid nausea. -avoid going to bed with an empty stomach -should alternate liquids and solids every 2-3 hr to void an empty stomach and over filling at each meal.
A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within expected reference range. Which of the following client statements indicates an understanding of the teaching?
I will likely need to use alternative positions for sexual intercourse -The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This client statement indicates that she understands the nurse's teaching about the physiological changes that occur during pregnancy.
A nurse is caring for a client who has recently experienced a perinatal death. which of the following statements should the nurse make to the client?
I'm sad for you -the nurse is offering empathy to the client to facilitate further communication about the perinatal death.
A nurse is assessing a newborn who is 12 h old. Which of the following clinical manifestations requires interv. by the nurse?
Substernal chest retractions while sleeping -Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This clinical manifestation requires further assessment and intervention by the nurse. EXPECTED: A positive Babinski reflex, An audible murmur heard at the left sternal border, acrocyanosis of the extremities
A nurse is caring for a newborn who was transferred to the nursery 30 min after delivery. Which of the following actions should the nurse take first?
Verify newborns identification -The Apgar score is a physiologic assessment that occurs 1 min following birth and again at 5 min. The nurse should confirm the score when the newborn arrives in the nursery. However, there is another action the nurse should take first. -The nurse should administer IM vitamin K to the newborn soon after birth to increase clotting factors and prevent bleeding. However, the injection can be delayed until after initial bonding time and the first breastfeeding if necessary. Therefore, there is another action the nurse should take first. -The nurse should identify obstetrical risk factors to determine if interventions are required for the newborn. However, there is another action the nurse should take first.
A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the clients history should the nurse recognize as a contraindication to oral contraceptives?
Cholecystitis HTN migraine headaches
A nurse is preparing to perform Leopold maneuvers for a client. identify the sequence the nurse should follow.
1. palpate the fundus to ID fetal part 2. Determine location of fetal back 3. palpate fetal part presenting at the inlet 4. ID attitude of head
a nurse is assessing four newborns. Which of the following findings should the nurse report?
18 hr old and has an ax temp of 37.7 C (99.9 F) EXPECTED:Erythema toxicum is a transient rash that can appear anywhere on a newborn's body during the first 24 to 72 hr following birth -A newborn should pass the first meconium stool within the first 24 to 48 hr following birth. Failure to pass a meconium stool can indicate a bowel obstruction or congenital disorder. This finding is within the expected reference range. -Pink-tinged urine is an indication of uric acid crystals and is an expected finding for a newborn during the first week following birth.
A nurse is preparing to administer mag sulfate 2g/hr IV to a client who is in preterm labor. Available is 20g mag sulfate in 500 mL of dextrose 5% in water. the nurse should set the IV infusion pump to administer how many mL/hr?
50 mL/hr
A nurse is teaching a client who is at 24 weeks of gestation regarding a 1 hr glucose tolerance test. which of the following statements should the nurse include in her teaching?
A blood glucose of 130-140 is considered a positive screening result. -If a client receives a positive result, will need to undergo a 3 hr glucose tolerance test to confirm if she has gestational DM. -Glucose solution should be taken 1 hr to the test
A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions?
Administer terbutaline -The nurse should administer terbutaline to stop contractions because the laboratory results indicate that the fetus's lungs are not mature enough for delivery.
A nurse is providing discharge teaching to a parent whose newborn has just had circumcision. Which of the following instructions should the nurse include?
Apply slight pressure with a sterile gauze pad for mild bleeding. -The nurse should instruct the client to attempt to stop mild bleeding by applying pressure with sterile gauze. If bleeding continues, the client should notify the provider.
A nurse is assessing a client who is 12 hr postpartum. The client's fundus is two fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take?
Assist client to the bathroom to void -A distended bladder inhibits the uterus from contracting normally and can cause uterine atony. Therefore, the nurse should assist the client to void.
A nurse is caring for a client who is at 40 weeks gestation and is in early labor. the client has a platelet count of 75,ooo/mm3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate?
Attention-focusing -Attention-focusing and distraction techniques are types of nonpharmacological care that are effective in relieving labor pain.
A nurse is admitting a client to the labor and delivery unit when the client states, "my water just broke." which of the following interv. is the nurse's priority?
Begin FHR monitoring
A nurse is providing teaching about nonpharm pain management to a client who is breastfeeding and has engorgement. the nurse should recommend the application of which items?
Cold cabbage leave
A nurse is assessing a client who is in active labor and notes early decelerations in the FHR on the monitor tracing. The client is at 39 weeks of gestation and is receiving a continuous IV infusion of oxytocin. Which of the following actions should the nurse take?
Continue monitoring the client -Early decelerations in the FHR are considered benign. Early decelerations occur due to compression of the fetal head during contractions, vaginal examinations, and pushing during the second stage of labor. No interventions are necessary for early decelerations. Therefore, the nurse should continue to monitor the client.
A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following clinical manifestations should the nurse expect?
Creases molding lanugo
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura. Which of the following findings should the nurse expect?
Decreased platelet count INCORRECT: ESR is indication of chronic renal failure
A nurse is assessing a client who is at 26 weeks gestation. Which of the following clinical manifestations should the nurse report to the provider?
Decreased urine output -Decreased urine output, increased blood pressure, proteinuria, and decreased fetal activity can be indications of preeclampsia and should be reported to the provider.
A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?
Demonstrate to the client how to perform a newborn bath -Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new mother moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new mother confidence and promote maternal adjustment.
A nurse is caring for a client who is at 22 weeks of gest. and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?
Explain that this an expected outcome
A nurse is performing a newborn assessment. Which of the following images should the nurse ID as an indication of spina bifida occulta?
External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area.
A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect?
HTN -The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension.
A nurse is teaching a client who has pregestational type 1 DM about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
I will continue to take my insulin if i experience nausea and vomiting. -The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes. -The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes. -The nurse should teach the client to avoid exercise during periods of hyperglycemia and when positive urine ketones are present. -The nurse should teach the client to avoid snacks and foods that are high in refined sugar.
A nurse is teaching a group of parents about newborn safety. Which of the following statements by a parent indicates an understanding?
I will dress my baby in flame-retardant clothing. AVOID:The parents should avoid heating the formula in a microwave to prevent uneven warming of the formula. -placing plastic over the crib mattress to prevent suffocation. -bib around their newborns' necks at night to prevent choking and suffocation.
A nurse is caring for a client who is to receive oxytocin to augment her labor. which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported?
Late decelerations
A nurse is assessing fetal heart tones for a client who is pregnant. the nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abd. should the nurse apply the ultrasound transducer in order to assess the point of max intensity of the fetal heart?
Left lower quadrant. OTHER QUAD: The fetal heart tones of a fetus in the left sacrum anterior position are best heard in the left upper quadrant. -in the right sacrum anterior position are best heard in the right upper quadrant. -right occipital anterior position are best heard in the right lower quadrant.
A nurse is caring a client who has uterine hypotonicity and is experiencing postpartum hemorrhage. Which of the following actions is the nurses priority?
Massage the client's fundus -Uterine hypotonicity and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, causing death to occur. Therefore, the nurse's priority is to
A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. which of the following interventions should the nurse include in the plan?
Monitor HFR continuously -Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The FHR and uterine contractions should be monitored continuously while the client is receiving magnesium sulfate.
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
Monitor client's bp every 5 min following first dose of anesthetic solution. -The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution.
A nurse is caring for a client who is at 15 weeks gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurses's priority following the procedure?
Monitor the FHR. -Greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis.
A nurse is teaching clients in a prenatal class about the importance of taking folic acid during pregnancy. The nurse should instruct the clients to consume an adequate amount of folic acid from various sources to prevent which of the following fetal abnormalities?
Neural tube defect -The nurse should inform the clients that neural tube defects are more common in newborns born to mothers who had inadequate folic acid intake. Food sources of folic acid include fortified cereals and grain products, oranges, artichokes, liver, broccoli, and asparagus.
A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7 yr old child in accepting the new family member?
Obtain a gift from the newborn to present to the sibling -Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that he understands his role in the family.
A nurse is assessing a newborn who was delivered vaginally and experience a tight nuchal cord. Which of the following clinical manifestations should the nurse expect?
Petechiae over the head -Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck.
A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize pain of the procedure to the newborn?
Place the newborn skin to skin on the mother's chest -Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure.
A nurse is providing discharge teaching to the parents of a newborn about using a car seat properly. Which of the following instructions should the nurse include?
Position the car seat rear-facing in the back seat of the vehicle. place shoulder harness in the slots that are at or just below the newborns shoulders place the retainer clip at the level of the newborn's axillae position newborn at a 45 degree angle
A nurse in a provider's office is reviewing the medical record of a client who is in her first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia?
Pregestational diabetes mellitus -Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis.
A nurse is planning care for a client who is at 24 weeks of gestation and reports daily mild headaches. Which of the following instructions should the nurse include in the plan of care?
Recommend that the client perform conscious relaxation technique daily. -The nurse should include conscious relaxation technique in the plan of care as a way to relieve tension and reduce stress, which can help to decrease and eliminate headaches. INCORRECT: Daily ibuprofen administration can lead to increased bleeding and premature a closure of the ductus arteriosus in the fetus -ginseng tea is contraindicated in pregnancy
A nurse is assessing a late preterm newborn. Which of the following clinical manifestations is an indication of hypoglycemia?
Resp. distress
A nurse is assessing a full-term newborn 15 min after birth. Which of the following findings requires intervention by the nurse?
Resp. rate 18/min -During the first phase of a newborn's transition to extrauterine life, which is up to 30 min after birth, the respiratory rate can range between 20 to 100/min. A respiratory rate this low at this time requires further evaluation and intervention by the nurse.
A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include?
Stop suctioning when the newborn's cry sounds clear -The client should compress the bulb before inserting the syringe tip. Compressing the bulb after it is in the newborn's nares or mouth could push the secretions and mucus further inside. -The client should suction the mouth before suctioning the nares. Otherwise, the newborn could gasp and inhale pharyngeal secretions when the syringe tip touches the nares. -The client should insert the tip of the syringe into the side of the newborn's mouth. Inserting it into the center of the newborn's mouth can trigger the gag reflex.
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. which of the following information should the nurse include in the teaching?
Take the medication within 72 hrs following unprotected sexual intercourse
A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing to administer pain medications to a a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary identifies to identify the client?
The client's room number -Using the client's room number is not an acceptable identifier and places the client at risk for a medication error. Therefore, the charge nurse should intervene
A nurse is providing teaching for a client who gave birth 2 hr ago about the facility for newborn safety. Which of the following statements indicates an understanding of the teaching?
The person who comes to take my baby's pictures will be wearing a photo ID badge.
A nurse is speaking with a client who is trying to make a decision about uterine tube occlusion. The client asks, "what effects will this procedure have on my sex life?" which of the following responses should the nurse make?
This process should no effect on your sexual performance or adequacy
A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2-3 min part, each lasting 80-90 sec. and a vaginal exam reveals that her cervix is dilated to 9 cm. the nurse should identify that the client is in which of the following phases of labor?
Transition -The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds. ACTIVE:The active phase of labor is characterized by a cervical dilatation of 4 to 7 cm and contractions every 3 to 5 min, each lasting 40 to 70 seconds. LATENT: cervical dilation of 0 to 3 cm and contractions every 5 to 30 min, each lasting 30 to 45 seconds. DESCENT:active pushing with contractions every 1 to 2 min, each lasting for 90 seconds.
A nurse is providing discharge teaching to a client who is postpartum. For which of the following clinical manifestations should the nurse instruct the client to monitor and report to the provider?
Unilateral breast pain -Chills, fever, malaise, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this clinical manifestation to the provider.
a nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect?
Vaginal pressure. -A client who is 4 to 10 days postpartum will report lochia serosa. -A client who has a vaginal hematoma will report persistent vaginal or rectal pain. A client who is 1 day postpartum and has a vaginal hematoma will report lochia rubra.
A nurse is providing discharge teaching to a client who had a c-section 3 days ago. Which of the following instructions should the nurse include?
You can still become pregnant if you are breastfeeding. AVOID:abdominal exercises and sexual activity for 4 to 6 weeks
A nurse is teaching a client who is at 36 weeks of gest. and has a prescirption for a nonstress test. Which of the following statements should the nurse include in the teaching?
You will be offered OJ to drink during the test Procedure takes 20-40 minutes IV fluids are for oxytocin-stimulated contraction test
A nurse is teaching about effective breastfeeding to a client who is 3 days postpartum. Which of the following information should the nurse include?
Your newborn should appear content after each feeding. -The nurse should inform the client that a baby who is sated will appear content after feedings. A baby who continues to show indications of hunger (for example, rooting, sucking on the hands, or crying) might not be effectively emptying the breasts during feedings.
A nurse is performing a vaginal examination for a client who is in active labor and reports back pain. The nurse determines that the client is 8 cm dilated, 100% effaced, -2, and that the fetus is in the occiput posterior position. Which of the following actions should the nurse take?
assist the client to the hands and knees position. -assist to this position during contractions. This position can help relieve her back pain and it will enable the rotation of the fetus from the posterior to an anterior occiput position. INCORRECT: performing effleurage during contractions is done during first stage of labor. positioning client in the lithotomy position will prevent the rotation of the fetal head.
A nurse is developing an educational program for adolescents about nutrition during the third trimester of pregnancy. Which of the following statements should the nurse include in the program?
consume 3-4 servings of dairy each day -Calcium intake is especially important during an adolescent's pregnancy because bone absorption of calcium is still occurring. Therefore, the nurse should instruct the adolescents to consume three to four servings of dairy per day to meet their calcium needs. OTHER: the nurse should instruct the adolescents to increase their daily intake of protein to approximately 71 g during the second and third trimesters of pregnancy. -An adequate sodium intake is approximately 1.5 g per day. The nurse should instruct the adolescents that an adequate intake of sodium is required during pregnancy. -Consuming an additional 600 to 700 cal per day could lead to excessive weight gain, which increases the adolescent's risk for complications related to pregnancy, labor, and delivery. The nurse should instruct the adolescents that, if they have a BMI within the expected reference range prior to pregnancy, they should increase their daily caloric intake by 340 cal in the first trimester and 452 cal in the second and third trimesters.
A nurse in a woman's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients?
iron -The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old.
A nurse is providing prenatal teaching to a client who is at 26 weeks gest. which of the following positions should the nurse recommend for the client to increase circulation to the placenta?
side lying. -avoids the compression of the vena cava. INCORRECT: supine decreases blood return to the right atrium and the placenta. fowler's position compresses the vena cava, decreasing placental circulation.
A nurse is assessing a client who is at 38 weeks gest. during a weekly prenatal visit. which of the following findings should the nurse report to the provider?
wt gain of 2.2 kg -A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications
