Maternal-Newborn Test 1

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums?

Epstein pearls

Following delivery, a newborn has a large amount of mucus coming out of his mouth and nose. What would be the nurse's first action?

Using a bulb syringe, suction the mouth then the nose.

How long is the neonatal period for a newborn?

28 days

A nurse is performing a physical assessment of a woman in labor. As part of her assessment, she examines the outer and inner surfaces of her lips. What is the best rationale for this assessment?

Detection of herpes virus infection

The nurse teaches a primigravida client that lightening occurs about 2 weeks before the onset of labor. The mother will most likely experience which of the following at that time?

Urinary frequency

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents?

Anesthetic may not be effective during the procedure

A nurse is receiving a client from the postanesthesia unit to the recovery unit at the ambulatory surgery center. The client just had a laparoscopic tubal ligation. Which is the nurse's priority assessment?

Bleeding

A client at 39 weeks' gestation calls the OB triage and questions the nurse concerning a bloody mucus discharge noted in the toilet after an OB office visit several hours earlier. What is the best response from the triage nurse?

"A one time discharge of bloody mucus in the toilet might have been your mucus plug."

Which nursing action has a negative effect on fetal descent?

Administering narcotic pain medication

A nurse is observing a new parent bottle feeding the newborn. The nurse notices that the newborn begins to get fussy during the feeding. Which action by the nurse would be appropriate?

Encourage the parent to burp the newborn to get rid of air.

The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue?

The tint is due to jaundice.

The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding?

duration

The mother calls the nurse to check her baby after noting the right side of the body is dark red while the left side of the baby is pale. Which question to the mother should the nurse prioritize when assessing the situation?

"Was the baby recently crying?"

Uterus

"womb"- highly muscular, thick-walled, pear shaped organ situated between the bladder and rectum- where fetus develops

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period?

blood sugar

When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?

hypothermia

While performing a physical assessment of a newborn boy, the nurse notes diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse documents this finding as:

caput succedaneum.

When instructing a new mom on providing skin care to her newborn, which statement, made by the mother, indicates additional teaching is needed?

"I can use talc powders to prevent diaper rash."

A nurse is completing an informed consent on a client preparing for a tubal ligation. Which statement by the client would require the nurse to notify the health care provider?

"I will be able to have my third child in about a year from now."

The nurse is preparing a newborn male for circumcision. During the assessment, the nurse notes the newborn has a hypospadias. Which action made by the nurse is best?

Inform the practitioner and cancel the procedure.

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. a. Glucose water b. Suction equipment c. Identification bands d. Ophthalmoscope e. Warmer bed

b, c, e

A nurse is meeting with a group of pregnant clients who are in their last trimester to teach them the signs that may indicate they are going into labor. The nurse determines the session is successful after the clients correctly choose which signs as an indication of starting labor? Select all that apply. a. constipation b. bloody show c. lightening d. weight gain e. backache

b,c,e

The nurse places a warmed blanket on the scale when weighing a newborn to minimize heat loss via which mechanism?

conduction

The Apgar score is based on which 5 parameters?

heart rate, muscle tone, reflex irritability, respiratory effort, and color

A nurse is preparing to auscultate the fetal heart rate of a pregnant woman at term admitted to the labor and birth suite. Assessment reveals that the fetus is in a cephalic presentation. At which area on the woman's body would the nurse best hear the sounds?

in the woman's lower abdominal quadrant

A nurse is assessing a pregnant woman and suspects that the woman may be experiencing pica. To help support this suspicion, the nurse evaluates the woman for signs and symptoms of which condition?

iron-deficiency anemia

When explaining how a newborn adapts to extrauterine life, the nurse would describe which body systems as undergoing the most rapid changes?

respiratory and cardiovascular

The nurse is assessing a primigravida woman at a routine prenatal visit. Which assessment finding is reinforcing to the client that she is definitely pregnant?

ultrasound picture of her fetus

A nurse is instructing a client on birth control methods. The client asks about the cervical mucus method. When should the nurse tell the client she is fertile in relation to her mucus?

when it is thin, watery, and copious

A nurse has just taught a client about the signs of true and false labor. Which client statement indicates an accurate understanding of this information

"False labor contractions usually occur in the abdomen."

The nurse working in a free health clinic assesses a 17-year-old client interested in contraceptives. Which statement by the client would indicate that female or male condoms would be the appropriate recommendation?

"Last year I was diagnosed with HPV."

The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means?

"The opening of his urethra in located on the under surface of the tip of the penis."

A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective?

"We will fold down the front of her diaper under the umbilical cord until it falls off."

A parent asks the nurse how to swaddle the newborn because the parent heard that it helps newborns calm down. Which statement will the nurse include in the teaching?

"Wrapping the newborn too tightly can impair breathing."

A client in her second trimester of pregnancy arrives at the health care facility for a routine follow-up visit. The nurse is required to educate the client so that the client knows what to expect during her second trimester. Which information should the nurse offer?

"You will experience quickening, and you will actually feel the baby."

Which documentation in the health record is most correct for the third stage of labor?

Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta.

A newborn's vital signs are documented by the nurse and are as follows: HR 144, RR- 36, BP- 128/78, and T- 98.6℉ (37℃). Which finding would be concerning to the nurse?

Blood Pressure

The nurse notices while holding him upright that a 1-day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate?

Dehydration

A 3-hour old newborn is assessed and is tachypneic with a respiratory rate of 44. Heart rate is 168, temperature is 97.3°F (36.3°C) and blood glucose is 90. What is the first action the nurse should take?

Document normal findings.

The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience?

Evaporative

The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?

Fetal position

The nurse is discussing the various positions for delivery with a client and her partner. The client mentions she would like a position which speeds up the process, decreases stress to her baby, and reduces the possibility of needing an episiotomy. Which positions should the nurse point out will best meet the client's desires?

Hands and knees

A 22-year-old client comes to the walk-in clinic complaining of fatigue, breast heaviness and extreme tenderness, and a clear vaginal discharge. What question would the nurse ask this client?

Have you been sexually active in the past 2 months?

During a vaginal exam, the nurse notes that the lower uterine segment is softened. The nurse documents this finding as:

Hegar sign.

A laboring mother requests that she be allowed to participate in "kangaroo care" following the birth. The nurse understands that this involves what action?

Placing the diapered newborn skin-to-skin with the mother and covering them both with a blanket.

A nurse is explaining to a group of new parents about the changes that occur in the neonate to sustain extrauterine life, describing the cardiac and respiratory systems as undergoing the most changes. Which information would the nurse integrate into the explanation to support this description?

Pulmonary vascular resistance (PVR) is decreased as lungs begin to function.

A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time?

Push with contractions and rest between them.

The new mother is holding her infant, speaking softly and gently stroking the baby's face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex?

Rooting

The nursing instructor is teaching students about normal changes of pregnancy. The instructor talks about diastasis recti. What is the instructor presenting?

Separation of the muscles of the abdominal wall

The nurse is assessing a 2-hour-old newborn and notes that the infant has irregular patterns of breathing rate, depth, and rhythm. Which is the best action made by the nurse?

Taking no action because these are normal findings in a newborn

The nurse-midwife is performing a pelvic examination on a client who came to her following a positive home pregnancy test. The nurse checks the woman's cervix for the probable sign of pregnancy known as Goodell sign. Which description illustrates this alteration?

The cervix softens.

What important information should the nurse give a client about the use of a diaphragm during menstruation?

Toxic shock syndrome is possible.

Which of the following changes, with highest priority, should the nurse teach a pregnant client to report to the health care provider as soon as possible?

abdominal pain coming and going during the third trimester

A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure?

allowing the woman time to be alone

The nurse is teaching a primigravida who does not speak the dominant language. The nurse will teach about the most common type of fetal presentation. Which presentation will the nurse prepare?

cephalic presentation using preprinted materials in the client's language

Which intervention would be least effective in caring for a woman who is in the transition phase of labor?

encouraging the woman to ambulate

A nurse notes a pregnant woman has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client?

encouraging the woman to push when she has a strong desire to do so

The nurse is conducting an annual examination on a young female who reports her last menses was 2 months ago. The client insists she is not pregnant due to a negative home pregnancy test. Which assessment should the nurse use to assess confirm the pregnancy?

fetal heartbeat

The nurse is discussing the insulin needs of a primiparous client with diabetes who has been using insulin for the past few years. The nurse informs the client that her insulin needs will increase during pregnancy based on the nurse's understanding that the placenta produces:

hPL, which deceases the effectiveness of insulin.

Many changes occur in the body of a pregnant woman. Some of these are changes in the integumentary system. What is one change in the integumentary system called?

melasma (chloasma)

Assessment of a newborn reveals tiny white pinpoint papules on a newborn's nose. The nurse documents this finding as:

milia.

A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. Which factor would the nurse integrate into the response?

relaxed cardiac sphincter

A young woman says she needs a temporary contraceptive but has a latex allergy. She mentions that she has a papillomavirus infection. Also, she says she is terrible about remembering to take pills. Which method should the nurse recommend?

transdermal contraception

A client calls the prenatal clinic and tells the nurse, "I think I am in labor." The nurse determines that the client is in true labor based on which client statement?

"I feel pressure in my vagina when I have the contraction."

A woman in labor has chosen to use hydrotherapy as a method of pain relief. Which statement by the woman would lead the nurse to suspect that the woman needs additional teaching?

"The temperature of the water should be at least 105℉ (40.5℃)."

The nurse is meeting with a 36-year-old client who wishes to begin using contraceptives. The client reports being in a long-term, monogamous relationship, runs 2 miles per day, and smokes a pack of cigarettes each day. Which method will the nurse be least likely to suggest to the client?

oral contraceptive pills (OCPs)

In a client's seventh month of pregnancy, she reports feeling "dizzy, like I'm going to pass out, when I lie down flat on my back." The nurse explains that this is due to:

pressure of the gravid uterus on the vena cava.

A maternity nurse is aware that the fetal head is the presenting part in complete extension position. Which type of birth should the maternity nurse anticipate?

prolonged labor and possible cesarean birth

Prior to discharging a 24-hour-old newborn, the nurse assesses the newborn's respiratory status. What would the nurse expect to assess?

respiratory rate 45 breaths/minute, irregular

A couple has chosen fertility awareness as their method of contraception. The nurse explains that the unsafe period for them during the menstrual cycle would be at which time?

three days before and three days after ovulation

A nurse is providing follow-up teaching to a client regarding the medically induced termination of her pregnancy. Which assessment finding should the nurse tell the client to report to the health care provider? Select all that apply. a. Mild cramping b. Severe depression or sadness c. Severe abdominal pain d. Vaginal bleeding of more than two pads per hour e. Oral temperature of 101.5°F (38.6℃)

b, c, d

The nurse is teaching a young couple who desire to start their family the various methods for determining fertility. After discovering the woman regularly travels internationally for work, deals with a lot of job anxiety, and frequently uses an electric blanket at home, the nurse will discourage the use of which method?

basal body temperature method

A nurse is conducting a class for a group of young adults at the health clinic about contraceptive options. The nurse determines that the teaching was successful when the group identifies which type as protective against sexually transmitted infections?

condom

The Ballard scoring system evaluates newborns on which two factors?

physical maturity and neuromuscular maturity

The nurse cares for a pregnant client in labor and determines the fetus is in the right occiput anterior (ROA) position. Which action by the nurse is best?

Continue to monitor the progress of labor

The school nurse is counseling a sexually active 16-year-old adolescent about the various forms of contraception. She is afraid of getting pregnant or contracting a sexually transmitted infection because her boyfriend refuses to use a condom. In answering the client's questions as to which option will be best suit her needs, which form should the nurse recommend?

Female Condom

The nurse has assessed several clients who have arrived for routine appointments. The nurse predicts the health care provider will prioritize a bone density scan for which client?

a 55-year-old white client who smokes and has family history of osteoporosis

A client in the latent phase of the first stage of labor is noted to be uncomfortable with intact membranes and mild contractions on assessment. The nurse should encourage the client to pursue which action?

Ambulation ad lib

The nurse is assessing a pregnant client at 12 weeks' gestation and the client reports some new bumps on the dark part of her nipples. What is the best response from the nurse when questioned by the client as to what they are?

Montgomery glands (Montgomery tubercles); secrete lubricant for the nipples

The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize?

Cover the glans generously with petroleum jelly.

The nurse has administered erythromycin ointment to a newborn. What outcome indicates this nursing intervention has been effective?

The newborn does not contract ophthalmia neonatorum.

A labor nurse is caring for a client who is 7 cm dilated, 100% effaced, at a +1 station, and has a face presentation on examination. The nurse knows that teaching was understood when the birth partner makes which statement?

"Our baby will come out face first."

The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action?

Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented.

The nurse explains the hospital's home visitation program for new families after discharge from the hospital. Which information will the nurse include regarding this program?

Caregivers can demonstrate competency in caring for the infant and ask questions.

The nurse is caring for a newborn with a mother who has a positive hepatitis B surface antigen (HBsAg) test. Which of the following can the nurse expect the newborn to receive? Select all that apply. a. Hepatitis B immune globulin b. Hepatitis A vaccination c. Intravenous immune globulin G d. Hepatitis B vaccination

a, d

During pregnancy a woman has many psychological adaptations that must be made. The nurse must remember that the baby's father is also experiencing the pregnancy and has adaptations that must be made. Some fathers actually have symptoms of the pregnancy along with the mothers. What is this called?

couvade syndrome

Which assessment finding in the pregnant woman at 12 weeks' gestation should the nurse find most concerning? The inability to:

detect fetal heart sounds with a Doppler.

A urinalysis is done on a client in her third trimester. Which result would be considered abnormal?

2+ Protein in urine

A woman in scrubs enters a mother's room while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do?

Ask to see the woman' hospital identification badge.

The nurse is caring for a client whose fetus is noted to be in the position shown. For which fetal lie would the nurse provide client teaching?

Longitudinal

A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate?

Notify the health care provider about possible meconium.

The nurse is assessing a 1-month-old male infant during a routine examination at a family health center. Which method does the nurse use to test for Babinski's sign?

Stroke the bottom of the foot to determine if there's fanning and dorsiflexion of the big toe

A client is beginning to take a combined oral contraceptive. Which of the following side effects will the nurse caution the client might be expected? Select all that apply. a. Nausea b. Breast tenderness c. Frequent urinary tract infections d. Headache e. Weight loss

a, b, d

A nurse is preparing a client for intrauterine device (IUD) insertion. Which education will the nurse provide to the client?

"Checking the strings is recommended following insertion."

Fetal heart rate monitoring reveals baseline tachycardia in the fetus. Which rate would be most likely?

164 beats per minute

A nurse is providing care to a woman during the third stage of labor. Which finding would alert the nurse that the placenta is separating?

sudden gush of dark blood from the vagina

Fundus

top of the uterus

A woman has opted to use medroxyprogesterone injections for birth control. The client receives the first injection today. The nurse instructs the woman to return to the clinic in how many months for the next injection?

3

A client at 16 weeks' gestation comes to the office for a routine exam. At what location within the abdomen would the nurse anticipate the uterus to be found?

Halfway between the symphysis pubis and the umbilicus

What is the expected range for respirations in a newborn?

30 to 60 breaths per minute

The client is at 36 weeks' gestation. Which report requires immediate additional assessment by the nurse?

"I have been leaking clear, vaginal fluid."

After assessing a woman who has come to the clinic, the nurse suspects that the woman is experiencing abnormal uterine bleeding. Which statement by the client would support the nurse's suspicions?

"I've been having bleeding off and on that's irregular and sometimes heavy."

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the woman?

"It is a normal skin finding in a newborn."

A new mother asks the nurse why her newborn must get a vitamin K injection. Which response made by the nurse is best?

"Newborns need vitamin K to prevent hemorrhage. They cannot produce it themselves right after birth because of the lack of normal flora in their intestines."

The nurse is preparing an injection of a narcotic to relieve a pregnant woman's pain. As the nurse is about to give it, the client asks for a bedpan because she has to move her bowels. The nurse's best action would be to:

hold the injection until you evaluate her labor progress.

Which change in the musculoskeletal system would the nurse mention when teaching a group of pregnant women about the physiologic changes of pregnancy?

increased lordosis

A 28-year-old primigravida client with diabetes mellitus, in her first trimester, comes to the health care clinic for a routine visit. The client reports frequent episodes of sweating, giddiness, and confusion. What should the nurse tell the client about these experiences?

increased secretion of insulin occurs in the first trimester

A couple is deciding about contraceptive measures. The male partner has decided to undergo a vasectomy. After teaching the client about this procedure, which client statement indicates the need for additional teaching?

"Right after surgery, my semen will be sperm-free."

The nurse has provided information to a client about oral contraceptive pills (OCPs). Which statement by the client would indicate a need for further education?

"Some oral contraceptive pills protect against STIs."

A woman is diagnosed with primary dysmenorrhea and is prescribed ibuprofen as part of her treatment plan. When teaching the woman about using this medication, which instruction would be important for the nurse to emphasize?

"Start taking the medication when you first get your period."

The nurse is teaching a prenatal class about preparing for their expanding families. What is helpful advice from the nurse?

"The hormones of pregnancy may cause anxiety or depression postpartum."

The nurse is caring for a client who is a primigravida. Which statement is best to improve the client's psyche?

"You are doing a great job"

A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress?

"You are still 2 cm dilated, but the cervix is thinning out nicely."

The nurse is caring for a client requesting oral contraceptives who has multiple sexual partners. The nurse recommends condoms to the client, but the client states, "I cannot use condoms because I am allergic to latex." Which response by the nurse is appropriate?

"You can still use condoms because they make latex-free condoms."

The client is being rushed into the labor and delivery unit. At which station would the nurse document the fetus immediately prior to birth?

+4

A fetus is assessed at 2 cm above the ischial spines. How would the nurse document the fetal station?

-2

A woman is admitted to the labor and birthing suite. Vaginal examination reveals that the presenting part is approximately 2 cm above the ischial spines. The nurse documents this finding as:

-2 station.

To indicate that the infant is making a successful transition immediately after birth, the nurse checks the heart rate. The newborn is 4 hours old. Which rate would the nurse identify as a cause for concern?

108 beats/minute

The nurse is assessing a pregnant woman who has just completed her first trimester. The woman's BMI was 27 prior to becoming pregnant. Her prepregnancy weight was 175 lb (79.4 kg). On reviewing the woman's medical record, which measurement would the nurse determine as appropriate weight gain for the woman during her first trimester?

177 lb (80.3 kg)

The nurse has completed assessing the blood glucose levels of several infants who are 24 hours old. Which result should the nurse prioritize for intervention?

30 mg/dL (1.67 mmol/L)

The nurse obtains a human chorionic gonadotropin (hCG) level from a woman who thinks that she is pregnant. Which result would the nurse identify as a positive pregnancy result?

32 mIU/mL (32 IU/L)

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is:

7.15 or less.

A client gave birth to a child 3 hours ago and noticed a triangular-shaped gap in the bones at the back of the head of her newborn. The attending nurse informs the client that it is the posterior fontanel (fontanelle). The client is anxious to know when the posterior fontanel will close. Which time span is the normal duration for the closure of the posterior fontanel?

8 to 12 weeks

A 17-year-old client arrives for an annual examination and reports no changes since the last exam; however, the nurse assesses a positive Chadwick sign, slightly enlarged uterus, and subsequent positive urine pregnancy test. Which task should the nurse prioritize to assist this client who is denying any possibility that she is pregnant?

Accepting the pregnancy

A woman at 38 weeks' gestation is in labor and oxytocin is prescribed to augment her labor. When preparing to administer this medication, what action by the nurse would be appropriate?

Administer the medication piggybacked into a primary IV line using a pump.

A client who delivered her baby 3 months ago is seen in the clinic and tells the nurse that she and her husband have yet to resume a sexual relationship. The nurse notes that no contraception is currently being used. What is the most appropriate nursing diagnosis for this client?

Altered sexual pattern related to fear of pregnancy

The licensed practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the LPN do first?

Assess and reposition the woman.

The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery?

Bathe the newborn thoroughly

A nurse is caring for an infant with an elevated bilirubin level who is under phototherapy. What evaluation data would best indicate that the newborn's jaundice is improving?

Bilirubin level went from 15 to 11.

A pregnant client in her third trimester, lying supine on the examination table, suddenly grows very short of breath and dizzy. Concerned, she asks the nurse what is happening. Which response should the nurse prioritize?

Blood is trapped in the vena cava in a supine position.

The nurse is assessing a woman at 37 weeks' gestation who has presented with possible signs of labor. The nurse determines the membranes have ruptured based on which color of the Nitrazine paper?

Blue

Braxton Hicks contractions are termed "practice contractions" and occur throughout pregnancy. When the woman's body is getting ready to go into labor, it begins to show anticipatory signs of impending labor. Among these signs are Braxton Hicks contractions that are more frequent and stronger in intensity. What differentiates Braxton Hicks contractions from true labor?

Braxton Hicks contractions usually decrease in intensity with walking.

There are four essential components of labor. The first is the passageway. It is composed of the bony pelvis and soft tissues. What is one component of the passageway?

Cervix

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?

Check the identification badge of any health care worker before releasing baby from room.

The nurse is documenting the length of time in the second stage of labor. Which data will the nurse use to complete the documentation?

Complete cervical dilation (dilatation) and time of fetal birth

The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism?

Convection

The LPN assists the RN while performing the Ortolani maneuver on a newborn. When asked by the mother the reason for this maneuver, which is the best response from the nurse?

Hip for dislocation

Which complication occurs as a result of ineffective breathing patterns?

Hyperventilation

The nurse is assessing a pregnant client at her 20-week visit. Which breast assessment should the nurse anticipate documenting?

Darkened breast areolae

Which cardinal movement of delivery is the nurse correct to document by station?

Descent

The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding?

Dilation (dilatation) of cervix

The nurse cares for a pregnant client at the first prenatal visit and reviews expected changes that will occur during pregnancy. Which information will the nurse include in the education?

During pregnancy blood volume can increase by 40% to 50%.

A pregnant mother may experience constipation and the increased pressure in the veins below the uterus can lead to development of what problem?

Hemorrhoids

The nurse is explaining to new parents the various vaccinations their newborn will receive before being discharged home. Which immunization should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life?

Hep B

A client is requesting information on the various available contraceptives. When explaining a vaginal spermicide, which information should the nurse prioritize?

Insert the product by applicator in the vagina prior to intercourse.

A newborn's cord begins to bleed 1 day following birth. What measures would the nurse take to address this problem?

Inspect the clamp to insure that it is tightly closed and applied correctly.

A patient asks the nurse if a cervical cap is better than a diaphragm for contraception. What is the advantage of a cervical cap?

It can be left in place longer.

A black couple are spending time with their newborn after the nurse brings the baby back from the transition nursery. The parents are horrified to note that their infant's buttocks appears bruised and demand to know what happened. The nurse should explain this is related to which factor?

Mongolian spots

During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse interprets this finding as:

Mongolian spots.

A nurse is providing care to a pregnant woman in her first trimester who has come to the clinic for a follow-up visit. During the visit, the nurse teaches the woman about some of the changes that she will be experiencing during her pregnancy. Which information would the nurse include when describing changes in the breast?

Montgomery glands (Montgomery tubercles) become more prominent.

The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response?

Moro

The nurse enters the room and notes the infant is in its bed sleeping, close to the outside window. Which action should the nurse prioritize?

Move the infant away from the window.

What is the first action taken by a nurse caring for a newborn with suspected hypoglycemia?

Perform a heel stick to obtain a blood sample for testing for glucose level.

The nurse is assessing a client who believes she is pregnant. The nurse points out a more definitive assessment is necessary due to which sign being considered a probable sign of pregnancy?

Positive home pregnancy test

The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system?

Pressure changes occur and result in closure of the ductus arteriosus.

The client at 18 weeks' gestation states, "I feel a fluttering sensation, kind of like gas." The nurse understands that the client is describing what occurrence?

Quickening

According to Brazelton's Neonatal Behavioral Assessment Scale, a newborn would be in what state if the eyes are open and looking at people nearby, and the newborn has minimal activity or body movement?

Quiet alert

Just after birth, a newborn's axillary temperature is 94°F (34.4°C). What action would be most appropriate?

Rewarm the newborn gradually.

A young newly married woman comes to the clinic and asks about ways to prevent pregnancy. When the nurse begins to talk about oral contraceptives, the client says that her religion does not allow oral contraceptives. What can the nurse recommend for this client?

Rhythm method

A pregnant client at 33 weeks' gestation is in the office for a routine visit. She lies down on her back and while the nurse is listening for fetal heart tones, the client tells the nurse that she feels lightheaded; her blood pressure is 82/58 mm Hg. What is the most likely explanation for this problem?

She is experiencing supine hypotension syndrome

The client pushes and the baby's head emerges. External rotation begins, but the baby's chin is drawn back just inside the vagina. The nurse recognizes that additional providers are needed in the delivery room. What emergency protocol does the nurse call?

Shoulder dystocia

The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?

Sudden infant death syndrome

The nurse identifies from a client's prenatal record that she has a documented gynecoid pelvis. Upon the client entering the labor and delivery department, which nursing action is best?

Take no extra measures; prepare for a standard labor.

The nurse is preparing to teach a client how to conduct the basal body temperature method to determine her fertile window. Which instruction should the nurse prioritize?

Temperature should be taken prior to any activity every morning.

A heel stick blood glucose on a 6-hour-old newborn is 44 but the venous blood sample shows a glucose of 89. What could cause this discrepancy?

The bedside glucometer is not calibrated for newborns.

A 1-day-old newborn is being examined by the nurse practitioner, who makes the following notation: face and sclera appear mildly jaundiced. What causes this finding?

The breakdown of RBCs release bilirubin, which the liver cannot excrete.

A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor?

The client reports back pain, and the cervix is effacing and dilating.

What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor?

The client's cervix is fully dilated.

A couple is considering vasectomy as a contraception option. However, the husband is nervous about how such a procedure would affect his sexual functioning. Which information should the nurse mention to the man?

The man will still have full erection capacity.

Which statement is true regarding fetal and newborn senses?

The rooting reflex is an example that the newborn has a sense of touch.

Which statement is false regarding bathing the newborn?

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.

During an examination, a client at 32 weeks' gestation becomes dizzy, lightheaded, and pale while supine. What should the nurse do first?

Turn the client on her left side.

The nurse prepares to give the first bath to a newborn and notes a white cheese-like substance on the skin. The nurse should document this as which substance?

Vernix

What measure(s) will the nurse implement to help ensure that a newborn is not misidentified in the hospital? Select all that apply. a. Place an identification band on both the mother and the newborn immediately after birth, before separating them. b. Keep the newborn with the parent 24 hours per day until discharge. c. Ask the parents to look at the newborn each time the newborn is brought to the room to be sure that the newborn is theirs. d. Have identifying data on the newborn's chart and compare information to that in the mother's chart. e. Obtain the newborn and the mother's thumbprint on the mother's chart.

a

Upon assessing the newborn's respirations, which finding would cause the nurse to notify the primary care provider?

a respiratory rate of 15 breaths per minute with nasal flaring

The nurse is examining a woman who came to the clinic because she thinks she is pregnant. Which data collected by the nurse are presumptive signs of her pregnancy? Select all that apply. a. breast changes b. amenorrhea c. fetal heartbeat d. hydatidiform mole e. ultrasound pictures f. morning sickness

a, b, e

A nurse is conducting education classes at the local high school on reproductive life planning. Which would be appropriate for the nurse to implement during the teaching? Select all that apply. a. Encouragement of abstinence b. Various religious viewpoints c. Her personal opinion on abortion d. Sexually transmitted infection statistics e. Proper condom application

a, d, e

A woman who is using an intrauterine system for contraception comes to the clinic. When assessing the woman, which finding(s) would alert the nurse to a possible complication? Select all that apply. a. oral temperature of 101°F (38.3°C) b. absence of pain with intercourse c. menstrual flow lighter and shorter d. string length shorter than on initial visit e. reports of abdominal pain

a, d, e

A client prescribed a combined oral contraceptive (COC) has presented for a routine visit. Which finding if reported by the client upon assessment should the nurse prioritize?

abdominal pain

A nurse is caring for a client in her fourth stage of labor. Which nursing assessments would indicate normal physiologic changes occurring during the fourth stage of labor? Select all that apply. a. Increase in the blood pressure b. Mild uterine cramping and shivering c. Decrease in the pulse rate d. Well-contracted uterus in the midline e. Decreased intra-abdominal pressure

b, c, e

A nurse is conducting a parenting class on infant skin care. What information should the nurse include when preparing materials on the characteristics of the skin of infants? Select all that apply. a. The epidermis is thicker than in adults. b. Sweat glands are fully functioning at birth. c. Substances are easily absorbed. d. It is thinner and more fragile than an adult's e. Skin is less susceptible to the sun.

c, d

A woman is to receive methotrexate and misoprostol to terminate a first-trimester pregnancy. When preparing the teaching plan for this client, the nurse understands that misoprostol works by:

causing uterine contractions to expel the uterine contents.

A nurse is providing care to a pregnant woman in labor. The woman is in the first stage of labor. When describing this stage to the client, which event would the nurse identify as the major change occurring during this stage?

cervical dilation (dilatation)

After discussing various methods of contraception with a client and her partner, the nurse determines that the teaching was successful when they identify which contraceptive method as providing protection against sexually transmitted infections (STIs)?

condoms

A pregnant client comes to the prenatal clinic complaining of urinary frequency and lower back pain on the right, stating that this has never happened before. An exam validates the diagnosis of pyelonephritis. Which factor would contribute to this condition?

decreased peristalsis of urinary tract

When teaching a group of nursing students about the stages of labor, the nurse explains that softening, thinning, and shortening of the cervical canal occur during the first stage of labor. Which term is the nurse referring to in the explanation?

effacement

A woman is 10 weeks' pregnant and tells the nurse that this pregnancy was unplanned and she has no real family support. The nurse's most therapeutic response would be to:

encourage her to identify someone that she can talk to and share the pregnancy experience.

A woman is using depot medroxyprogesterone acetate (Depo-Provera) as a method of birth control. Which side effect would the nurse most likely include as common?

irregular menstruation

Assessment of a pregnant client reveals that she is experiencing Braxton Hicks contractions. Which finding would support this assessment?

irregular pattern

The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn?

lack of subcutaneous fat

The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?

nasal flaring

In which newborn should the nurse suspect hypoglycemia?

newborn with a heart rate of 60 after a prolonged deceleration in utero

A client desires protection from unwanted pregnancies. However, the client does not enjoy sex when her partner wears a male condom. Also, the client experiences breast tenderness, headache, and nausea after taking oral contraceptive pills (OCPs). Which method would be the most likely choice for the couple to help them enhance their sexual experience as well as prevent any side effects?

transdermal contraceptive