Maternal Newborn Practice 2019 A***
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching?
"I can administer oxytocin 4 hours after the insertion of the medication" The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor.
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
"I should take 600 micrograms of folic acid every day" A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects.
A nurse is 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 the 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 providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include?
"You can still become pregnant if you are breastfeeding" The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a non-stress test. Which of the following instructions should the nurse include?
"You should press the handheld button when you feel your baby move." The nurse should instruct the client to press the handheld button when the fetus moves. This action will mark the fetal monitor tracing with the client's reports of fetal movement. This will assist in the interpretation of the nonstress test to determine if it is reactive or nonreactive.
A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many mL/hr?
50 ml/hr
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
A client who is at 11 weeks of gestation and reports abdominal cramping When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first.
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
A newborn who is 18 hr old and has an axillary temperature of 99.9° F An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider.
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed bethamethasone 12 mg IM. Which of the following outcomes should the nurse expect?
A reduction in respiratory distress in the newborn Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress.
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching?
"Ensure that the newborn has been receiving feeding for 24 hours prior to obtaining the specimen" "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr prior to testing.
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess?
Abruptio placenta Cocaine use increases the risk for vasoconstriction and possible abruptio placenta.
A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect?
Acrocyanosis Positive Babinski reflex Two umbilical arteries visible is correct Yellow sclera is incorrect. Yellow sclera is an indication of hyperbilirubinemia and is not an expected manifestation. Acrocyanosis is correct. Acrocyanosis is an expected finding for at least the first 24 hr following birth. Poor peripheral perfusion leads to bluish discoloration in the newborn's hands and feet.Posterior fontanel larger than the anterior fontanel is incorrect. The posterior fontanel is located on the back of the newborn's head and is a small triangular shape. The anterior fontanel is diamond shaped and approximately 5 cm (2 in) long. It is located on the top of the newborn's head and is larger than the posterior fontanel. Positive Babinski reflex is correct. Newborns should exhibit a positive Babinski sign following birth. The nurse should stroke the newborn's foot upward from the heel to the toes. The toes should hyperextend, and dorsal flexion of the big toe should occur. The absence of this finding requires neurological evaluation. The Babinski reflex is no longer present after 1 year of age .Two umbilical arteries visible is correct. The nurse should observe two arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly.
A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client head to the side, which of the following actions should the nurse take immediately after the seizure?
Administer oxygen via a nonrebreather mask When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask at 10 L/min to ensure adequate oxygenation to the fetus.
A nurse is preparing to administer magnesium sulfate 2 g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water (D5W).The nurse should set the IV infusion pump to administer how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Follow these steps for the Ratio and Proportion method of calculation: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 2 g Step 3: What is the dose available? Dose available = Have 20 g Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 500 mL Step 6: Set up an equation and solve for X. HaveDesired = QuantityX 20 g2 g = 500 mLX mL X mL = 50 mL Step 7: Round if necessary. Step 8: Determine whether the amount to administer makes sense. If there are 20 g of magnesium sulfate in 500 mL D5W and the prescription reads 2 g, it makes sense to administer 50 mL. The nurse should administer magnesium sulfate 50 mL/hr IV. Follow these steps for the Desired Over Have method of calculation: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 2 g Step 3: What is the dose available? Dose available = Have 20 g Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 500 mL Step 6: Set up an equation and solve for X. Desired × QuantityX = Have 2 g × 500 mLX mL = 20 g X mL = 50 mL Step 7: Round if necessary. Step 8: Determine whether the amount to administer makes sense. If there are 20 g of magnesium sulfate in 500 mL D5W and the prescription reads 2 g, it makes sense to administer 50 mL. The nurse should administer magnesium sulfate 50 mL/hr IV. Follow these steps for the Dimensional Analysis method of calculation: Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 500 mLX mL = 20 g Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 500 mL2 gX mL = × 20 g1 Step 4: Solve for X. X mL = 50 mL Step 5: Round if necessary. Step 6: Determine whether the amount to administer makes sense. If there are 20 g of magnesium sulfate in 500 mL D5W and the prescription reads 2 g, it makes sense to administer 50 mL. The nurse should administer magnesium sulfate 50 mL/hr IV.
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? Graphic RecordBlood pressure 130/78 mm HgRespiratory rate 20/minHeart rate 90/min Diagnostic ResultsHemoglobin 12 g/dLHematocrit 34%1-hr glucose tolerance test 120 mg/dL Progress NotesFundal height 30 cmGood fetal movementNot experiencing headache, dizziness, blurred vision, or vaginal bleedingFetal heart rate 110/min
Fundal Height Measurement A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider.
A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take?
Have the client change positions Having the client change position is an appropriate intervention for a variable deceleration to relieve umbilical cord compression.
A nurse is performing a physical assessment of a newborn. Which of the following clinical finding should the nurse expect?
Heart Rate 154/ min Respiratory rate 58/ min Weight 2,600 g (5lb 12 oz)
A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply.)
Heart rate 154/min is correct. The expected reference range for a newborn's heart rate is from 110/min to 160/min while awake. Axillary temperature 36° C (96.8° F) is incorrect. A healthy newborn's temperature averages 37° C (98.6° F), with a range of 36.5° to 37.5° C (97.7° to 99.5° F). Respiratory rate 58/min is correct. The expected reference range for a newborn's respiratory rate is from 30/min to 60/min. Length 43 cm (16.9 in) is incorrect. The expected reference range for a newborn's length is from 45 to 55 cm (17.7 to 21.7 in). Weight 2.6 kg (5 lb 12 oz) is correct. The expected reference range for a newborn's weight is from 2,500 to 4,000 g (5.5 lb to 8.8 lb).
A nurse is reviewing the prenatal laboratory value for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider
Hemoglobin 10 g/dL
A nurse is reviewing the prenatal laboratory results for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider?
Hemoglobin 10 g/dL A hemoglobin of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this finding to the provider to obtain a prescription for ferrous iron supplementation because of anemia.
A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication?
Hypertension The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension.
A nurse is performing a vaginal exam on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take?
Insert two gloved fingers into the vagina and apply upward pressure to the presenting part
A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next?
Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. MY ANSWER The nurse should quickly apply gloves and insert two fingers into the vagina toward the cervix, exerting upward pressure onto the presenting part to relieve umbilical cord compression and increase oxygenation to the fetus. Apply internal upward pressure to the presenting part using 2 gloved fingers.Using evidence-based practice, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
Jaundice Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider.
A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe?
Kleihauer-Betke test The nurse should expect the provider to prescribe a Kleihauer-Betke test for a client who has suspected placental abruption to determine if fetal blood is in maternal circulation. This test is useful to determine if Rho-(D) immune globulin therapy should be administered to a client who is Rh-negative.
A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the infusion of the oxytocin infusion and should be reported to the provider?
Late Decelerations Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider.
A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior?
Lays the newborn across her lap and gently sways This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn.
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take?
Maintain the client of bed rest The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended.
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse priority?
Massage the client's fundus
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority?
Massage the client's fundus. Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood loss.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
Minimal arm recoil The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil.
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 nurse's priority following the procedure?
Monitor the FHR The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis.
A nurse 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 the FHR continously 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 assessing a client who is receiving morphine via IV bolus for pain following a C-section. The nurse notes a respiratory rate of 8/min. Which of the following medications should be administered?
Naloxone
A nurse is assessing a client who is receiving morphine via IV bolus for pain following a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the following medications should the nurse administer?
Naloxone Morphine is a common opioid analgesic used for postoperative pain management that can cause central nervous system depression and can cause respiratory depression. The nurse should administer naloxone, an opioid antagonist, to reverse the opioid-induced respiratory depression in the client.
A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member?
Obtain a gift from the newborn to present to the sibling. Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that they understand their role in the family.
A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old in accepting the new family memeber?
Obtain an gift from the newborn to present to the sibling
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
Perform Leopold Maneuvers The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer.
A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect?
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 charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopoid maneuvers. Which of the following images indicates the first step of Leopoid maneuvers?
Picture of nurse palpating top of belly; where bottom is
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 the pain of the procedure for the newborn
Place the newborn skin to skin on the mothers 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 in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following 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 caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications?
Premature rupture of membranes The nurse should identify that a client who is pregnant and has gonorrhea is at an increased risk for premature rupture of membranes, chorioamnionitis, preterm birth, neonatal sepsis, and intrauterine growth restriction.
A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care?
Protect the client's head and feet from cold air. Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period.
A nurse is creating a plan of care who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care?
Protects the client's head and feet from cold air
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbillirubinemia. Which of the following actions should the nurse include in the plan?
Remove all clothing form the newborn except the diaper
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
Remove all clothing from the newborn except the diaper. The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin.
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider?
Report of visual disturbances Visual disturbances such as blurred vision are a potential prenatal complication associated with hypertension. The nurse should report this finding to the provider so that additional fetal and maternal evaluation can be performed.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
Report the client's condition to the local health department The nurse should report the condition to the local health department. HIV is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is required to be reported.
A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect?
Reports increased urinary output Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain, constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations include weak rapid pulse, fruity breath odor, urine positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL.
A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider?
Reports of decreased fetal movement The nurse should identify that a client who reports decreased fetal movement could be experiencing a complication related to fetal well-being. A decrease in fetal movement can indicate fetal distress.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
Respiratory distress Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.
A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects?
Respiratory rate 10/min The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available.
A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?
Schedule an ultrasound examination The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
Substernal Retractions A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching?
The person who come sin to take my baby's pictures will be wearing a photo ID badgeR: All personnel working on the unit should be wearing a photo identiication badge. The nurse should teach the mother to never allow anyone who is not wearing an identification badge to come in contact with her newborn.
A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound?
To locate the pocket of fluid An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus.
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 The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues.
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take?
Verify that the parent's identification band matches the newborn's identification band. The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the information on the parent's identification band to the information on the newborn's identification band.
A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider?
Weight gain of 2.2 kg (4.8 lb) A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider.
A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions?
Wipe eyes Wash Neck Cleanse skin around umbilical cord stump Wash legs and feet Clean diaper area The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus outward using plain water. The nurse should then wash the newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump followed by washing the newborn's legs and feet. The last step of the bath should be to clean the newborn's diaper area.
A nurse is providing teaching about nonpharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items?a. cold cabbage leavesb. purified lanolin creamc. a snug-fitting support brad. breast shells
a. cold cabbage leaves The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement. The nurse should instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the application for two to three sessions as needed. More frequent applications could decrease the client's milk supply.
A nurse is providing teaching for a client who have birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching?
the person who comes to take my baby's pictures will be wearing a photo identification badge
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
BUN 25 mg/dL The nurse should report an elevated BUN to the provider since it can indicate dehydration. The normal BUN level is between about 7 and 21 milligrams per deciliter (mg/dL).
A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke". Which of the following interventions is the nurse's priority?
Begin FHR monitoring The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take.
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic test?
Biophysicial profile A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound.
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect?
Blurred Vision The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field. The nurse should identify that a client who has severe preeclampsia can have increased amount of urinary protein that is greater than 500 mg in a 24-hr specimen.
A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity?
Calcium Gluconate The nurse should anticipate administering calcium gluconate if the client develops magnesium toxicity. Calcium gluconate is the antidote.
A nurse is providing teaching about nonpharmological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items?
Cold cabbage leaves
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?
Depression The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness.
A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following images indicates the first step of Leopold maneuvers?
Evidence-based practice indicates the nurse should perform this step first when performing Leopold maneuvers. During this step, the nurse palpates the client's abdomen with the palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
FHR 152/min The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse.