Maternal

The client is a 16-year-old gravida 1 at 37 weeks' pregnancy with preeclampsia. The primary health care provider has prescribed a maintenance dose of 2 g/hr of magnesium sulfate. The premixed intravenous (IV) bag has 40 g of magnesium sulfate per 1000 mL lactated Ringer's solution. How many milliliters per hour of this solution should the nurse administer? Fill in the blank.

50 mL/hr

The client is a 39-year-old gravida 1, who has a busy life as a consultant, which requires frequent travel. She is at 28 weeks' pregnancy and has begun to have vaginal bleeding. She has just been told she has placenta previa and that she will need to be on bed rest in the hospital for the present time until all active bleeding ceases, and she will then be evaluated for possible home care. The client is crying and stating that she cannot follow this regimen of care because she has many responsibilities to fulfill at work this week, including travel to another city. She states the bleeding has decreased and she wants to go home. What action by the nurse can best assist the client to an understanding and acceptance of her diagnosis at this time?

Allow the woman to cry and listen to her express her feelings before reviewing the diagnosis with her.

The client is a 38-year-old woman at 15 weeks' pregnancy who is considering genetic amniocentesis. Which statement by the nurse represents accurate information regarding this procedure?

Amniocentesis can screen for some specific genetic conditions.

A newborn is diagnosed with imperforate anus, and the parents ask the nurse to describe this abnormality. The nurse bases the response on which characteristic of the disorder?

Absence of the anus in its normal position in the perineum

While caring for a client in labor, the nurse suspects an umbilical cord prolapse. What is the immediate nursing action?

Adjust the bed to Trendelenburg's position.

The client is a 19-year-old woman with a recent diagnosis of chlamydiosis. She is 10 weeks' pregnant at this time. Which client statement reflects an understanding of this condition?

Both she and her partner need treatment for chlamydiosis now.

The nurse is monitoring the status of a client in labor who is experiencing hypotonic uterine dysfunction. The nurse interprets that which findings are consistent with this type of dysfunctional labor? Select all that apply.

Contractions weaken during the active stage of labor. Contractions become inefficient or stop during the active stage of labor. The client initially makes normal progress into the active stage of labor and then contractions weaken.

The nurse in the postpartum unit notes that a new mother was given methylergonovine intramuscularly after delivery. The nurse should evaluate the client for which finding to determine that the medication was effective?

Decreased uterine bleeding

A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse should use which approach as the first step to support the client psychologically?

Determine how the client perceived the event.

The nurse is caring for a woman who has just undergone an emergency cesarean delivery. In preparing to discuss postoperative and home care measures, the nurse should take which action first?

Determine the client's ability to take in and process information

The home care nurse is visiting a postpartum client. The nurse reviews the information in the client's medical record and collects data on the client. The nurse should suspect endometritis if which finding is noted?

Fever that began 3 days postpartum

The client is a 42-year-old gravida 8 para 8 who had a vaginal delivery of a 9-pound, 4-ounce infant 30 minutes ago. The nurse is assessing the client and notes a large amount of vaginal bleeding and blood clots. What is the first action the nurse should take?

Firmly massage the uterine fundus

The client is in the first trimester of pregnancy. How should the nurse explain the rationale for folic acid supplementation in the first trimester of pregnancy?

Folic acid helps prevent fetal neural tube defects.

The client is at 6 weeks' pregnancy and has called the clinic to speak to the nurse. The client complains of light vaginal bleeding and new onset of severe left lower quadrant pain. What should the nurse advise the client to do?

Go to the emergency department to be evaluated immediately.

The nurse is admitting a client at 39 weeks' pregnancy who is in active labor. Which data would be most important in the immediate care of the client at this time? Refer to the chart.

Group B Streptococcus (GBS) positive at 36 weeks' pregnancy

The nurse working in a prenatal clinic is reviewing the records of clients scheduled for prenatal visits. The nurse interprets that the client most at risk for abruptio placentae is the one who presents which clinical picture?

Has maternal hypertension

The nurse is collecting data on a client with severe preeclampsia. Which sign would indicate an improvement in the client's condition?

Headache is no longer present

Which practices are used to provide a safe environment for the newborn? Select all that apply.

Identification bracelets placed on the newborn and parents Door alarms positioned on entrances to maternal-newborn units Identification badges worn by personnel that identify them as maternal-newborn staff Instruction to parents to never release their infant to anyone without proper identification

The client is a 26-year-old who is 12 weeks' pregnant and visiting with the nurse in the clinic. Her complete blood cell count shows the hemoglobin to be 10.1 g/dL (101 mmol/L). What would be the most appropriate nutrition education based on this information?

Increase amounts of meat and dried beans in the diet

Immediately after the delivery of a newborn, the nurse prepares to assist in the delivery of the placenta. What is the appropriate action to deliver the placenta?

Instruct the mother to push during a uterine contraction.

The nurse is caring for a pregnant client diagnosed with preeclampsia. What factors about pregnant women with preeclampsia are correct? Select all that apply.

Is a vasospastic, systemic disorder Occurs more often with preexisting diabetes Occurs more frequently with multifetal gestation More likely with history of chronic hypertension

The nurse is assessing the reflexes of a newborn. What assessment should be used to check the sucking reflex?

Placing a nipple or nonlatex-gloved finger in the mouth

A client at 10 weeks' gestation has type 1 diabetes mellitus and is receiving prenatal care at a high-risk clinic. The nurse teaches the client about the signs of hyperglycemia and should tell the client that which is an early sign?

Polyuria

A client in labor has been repositioned from side to side every 30 minutes. The client tells the nurse that she is tired of having to lie on her side and would like to lie on her back for a while. The nurse should take which most appropriate action?

Position the client supine and place a pillow under one hip to act as a wedge

Trimethoprim/sulfamethoxazole is prescribed for a hospitalized pregnant client. The nurse reviews the client's chart and should contact the primary health care provider regarding which documented finding to verify the prescription? Refer to the chart.

Pregnancy at 36 weeks' gestation

A client has just experienced a precipitate labor. The nurse notes that the mother is lying quietly in bed and is avoiding physical contact with her newborn. What is the most appropriate nursing action?

Provide support to the mother

The nurse is monitoring a client in the fourth stage of labor and notes that the uterine fundus is firmly contracted and is midline at the level of the umbilicus. Based on this finding, what is the most appropriate nursing action?

Record the findings

The nurse receives a report at the beginning of the shift about a client with an intrauterine fetal demise. When collecting data on assessment of the client, the nurse expects to note which finding?

Regression of pregnancy symptoms and absence of fetal heart tones

The nurse is monitoring a client who is receiving magnesium sulfate for preeclampsia and is monitoring the client every 30 minutes. Which finding indicates a need to immediately contact the primary health care provider?

Respirations of 10 breaths/minute

A client seen in the prenatal clinic is experiencing ankle edema. The nurse assesses the client and notes that the edema is nonpitting and the client's blood pressure is within normal limits. The nurse should provide which home care instruction to this client?

Rest periodically with the legs and hips elevated

The client has a prepregnancy body mass index (BMI) of 28 and comes to the clinic at 6 weeks' pregnancy. How should the nurse advise her regarding her total weight gain in pregnancy?

She should be advised to gain 15 to 25 pounds

The client is a 20-year-old woman who is taking combined oral contraception pills for birth control. She has been on the pill for 2 months. She calls the clinic and tells the nurse that she is spotting on and off between her periods. What would be the most appropriate information for this client?

Spotting is common in the first months of pill use

The client is a 28-year-old gravida 1 who has just been diagnosed with intrauterine fetal demise at 39 weeks' gestation and is in early labor. Her husband is at her bedside, and both are crying. What should the nurse do to care for this couple at this time?

Stay with the couple, acknowledge the loss, and provide support

Which is the most appropriate content for the nurse to include in first trimester education of the pregnant client?

Strategies for relief of common discomforts

The nurse provides instructions to a prenatal client with heartburn about measures to alleviate the discomfort. Which statement by the client indicates a need for further instruction?

"I need to lie down after eating."

The client is a 17-year-old gravida 2 para 2. She is successfully breast-feeding her newborn. She is preparing for discharge with her newborn. Her boyfriend and their 1-year-old are accompanying her. Which statement by the client indicates the need for further teaching?

"I plan to begin using birth control when I'm done breast-feeding."

The client is in active labor. She is 5 cm dilated and received 1 mg hydromorphone hydrochloride intravenously (IV) for labor pain 30 minutes ago. The nurse is assessing the response to the pain medication. Which response from the client demonstrates the normal effects of this medication at this time?

"I feel the pain still, but it is less."

A female who has recently immigrated to the United States from Sudan is being treated for depression related to her inability to become pregnant. The client volunteers that she has a history of urinary tract infections. Which statement by the nurse demonstrates an understanding of how culture can affect both physical and mental health?

"Does your culture support surgically altering female genitals?"

The nurse provides instructions to a pregnant woman in the second trimester regarding measures to relieve backache. Which statement by the client indicates an understanding of these measures?

"I will avoid getting tired, and I should work at maintaining a good posture."

The nurse is assessing the respiratory rate of a newborn infant. The nurse determines that the rate is normal if which finding is noted?

40 breaths per minute

Which of the clients who have come into the obstetrics triage area of the hospital should the nurse assess first?

A 42-year-old gravida 1 at 39 weeks' pregnancy complaining of a headache, visual changes, and epigastric pain

Which phone call from prenatal clients would require the nurse to immediately notify the primary health care provider?

A woman at 32 weeks' pregnancy who notes clear fluid leaking from the vagina

The client is a 30-year-old gravida 5 para 5 who is being seen for a postpartum visit 6 weeks after delivery. She has no medical, surgical, or gynecological problems. She is breast-feeding and tells the nurse she wants no more children and would like to use the most effective method of birth control, but she does not want sterilization. Which contraceptive method would be most appropriate for this client?

An intrauterine device (IUD)

The client had a cesarean section under spinal anesthesia 22 hours ago. She is now complaining of a severe headache. The headache becomes worse when she is upright and disappears when she is supine. The primary health care provider plans to administer a blood patch. How should the nurse explain this procedure to the client?

Blood is injected into the epidural space to seal a leak of cerebrospinal fluid.

Methylergonovine has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside?

Blood pressure cuff

The client is 7 weeks' pregnant and has chosen to have genetic testing, which reveals that she is a carrier of the cystic fibrosis gene. Because cystic fibrosis is an autosomal-recessive inheritance disorder, what would be the next step in the testing process?

Arrange testing of the father of the baby

The client is breast-feeding her first infant who is 6 hours old, and she complains of sore nipples. Which action by the nurse is most appropriate at this time?

Assess and assist with the newborn latch to the nipple.

The healthy newborn infant was born 30 minutes ago and is in the baby warmer in the labor and delivery room. The nurse had offered the infant to the mother to hold immediately after birth, but the mother had declined saying she was too tired. She still states she does not feel well and does not want to hold the infant. What action should the nurse take first?

Assist the mother to rest and become comfortable, and allow her to hold the infant when she is ready.

The client is a gravida 3 para 2 entering the second stage of labor. The primary health care provider delivers the fetal head and then encounters shoulder dystocia during her attempts to deliver the shoulders. What actions should the nurse assist to take at this time? Select all that apply.

Call for additional help. Apply suprapubic pressure Ensure that the neonatal resuscitation team and equipment are ready Place the woman into McRoberts' position (thighs flexed apart and pulled back).

Artificial rupture of the membranes is done to induce labor in a client. After this procedure, what is the immediate nursing action?

Check the fetal heart rate (FHR)

The nurse is reviewing the results of a newborn's Apgar score. What specific newborn categories are included in the Apgar scoring system? Select all that apply.

Color Crying Heart rate Muscle tone Reflex irritability Respiratory effort

The client is undergoing induction of labor at 41 weeks' pregnancy. The nurse midwife has placed dinoprostone in the posterior fornix of the vagina for cervical ripening. Which finding would require the nurse to notify the primary health care provider?

Contractions occurring every minute

A pregnant client is seen in the prenatal clinic with morning sickness. The nurse should provide which instruction to the client regarding dietary measures?

Eat 5 or 6 small meals per day

The nurse is caring for a client who has been diagnosed with hyperemesis gravidarum. What dietary instructions should the nurse teach the client? Select all that apply.

Eat protein after sweets Drink liquids from a cup with a lid In general eat what sounds good rather than trying to balance meals Follow the salty and sweet approach; even so-called junk foods are okay.

The nurse is preparing the parents of a newborn with respiratory distress syndrome for an initial visit to the neonatal intensive care unit. The nurse should plan which action that will best facilitate parent-infant bonding?

Encourage the parents to touch their newborn

The client is a 22-year-old gravida 1 at 39 weeks' pregnancy in active labor. She has stated that she prefers natural childbirth and does not want an epidural or opioid medications. She has been coping with labor by deep breathing and using differing positions, including walking, sitting on a birth ball, and positioning on her hands and knees. She states she feels tired and that the pain is now much more intense. The nurse midwife examines her and finds her to be 6 cm dilated or 100% effaced with the fetal head at station 0. What should the nurse do at this time to help the client cope with the pain of labor?

Encourage water immersion in a tub of warm water

The nurse is speaking to a couple about genetic testing and screening. What are the most important aspects of genetic testing and screening interventions? Select all that apply.

Equal access to all Voluntary participation Confidentiality in conducting tests and in handling records or results Education and counseling about tests and procedures as an integral part of screening

The nurse is monitoring a newborn diagnosed with congenital hypothyroidism. The nurse should expect to note which assessment finding?

Excessive sleepiness

An antepartum client is diagnosed with bacterial vaginosis. The nurse expects to note which finding on data collection of the client?

Itching and vaginal discharge

Which are consequences of cold stress the nurse may observe in a newborn infant? Select all that apply.

Jaundice Hypoglycemia Respiratory distress

A client tells the nurse that she is really worried about knowing how to care for her firstborn child. The nurse should identify which priority problem for this client?

Lack of knowledge

The client is in active labor at 41 weeks' pregnancy. Her membranes have just ruptured spontaneously. The nurse notes the presence of thick meconium. Which actions by the nurse are most appropriate at this time? Select all that apply.

Listen to the fetal heart tones Inform the neonatal team of the presence of meconium near the time of delivery Prepare wall suction, laryngoscope blade, and endotracheal tubes for possible use at delivery.

The nurse is collecting data during an assessment and notes that the fundus feels soft and spongy. Which nursing actions are most appropriate initially? Select all that apply.

Massage the fundus gently Observe for increased vaginal bleeding or clots Document fundal position, consistency, and height.

A client arrives at the prenatal clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period (LMP) was August 19, 2020. Using Naegele's rule, the nurse informs the client that the estimated date of delivery is which date?

May 26, 2021

A client in labor tells the nurse that she suddenly has a wet feeling in the vaginal area. The nurse quickly checks the client and notes a large amount of bright red blood. What is the immediate nursing action?

Notify the obstetrician

The nurse is collecting data on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. Based on this finding, what is the most appropriate nursing action?

Notify the primary health care provider.

A client in the third trimester of pregnancy seen in the clinic is experiencing urinary frequency. Which self-care measure should the nurse provide to the client?

Perform Kegel exercises.

The nurse is preparing to perform fundal massage on a client with uterine atony. How should the nurse perform this procedure?

Place 1 hand just above the symphysis pubis and gently but firmly massage the fundus in a circular motion

The client had a cesarean section 12 hours ago after a prolonged labor. Spinal anesthesia was used. Which finding indicates the need for immediate further assessment?

The client cannot move her legs freely

The nurse is assigned to care for an obstetric client with acquired immunodeficiency syndrome (AIDS). The nurse creates a plan of care for the client and should include which priority client goal in the plan?

The client will not develop an opportunistic infection during the remainder of the pregnancy.

The client is in active labor at 38 weeks' pregnancy. She has recently received a continuous lumbar epidural infusion. Which assessment finding would prompt the nurse to request the presence of the anesthesiologist?

The client's blood pressure is 80/40 mm Hg.

A client is hospitalized at 28 weeks' pregnancy for preterm labor. The primary health care provider has prescribed nifedipine 20 mg by mouth every 6 hours. Which assessment finding would require notification of the primary health care provider?

The client's contractions have increased in frequency to every 2 minutes

The labor room nurse is preparing to give report to the postpartum nurse about a client who had a normal vaginal birth complicated by postpartum hemorrhage. Which data are most relevant to the client's care at this time to include in the report to the postpartum nurse? Select all that apply.

The client's pulse is 112 beats/min The client has not yet voided since delivery. The client received methylergonovine 0.2 mg intramuscularly 1 hour ago.

The nurse is preparing to collect data on a client with placenta previa and should plan to check which item first?

The fetal heart rate (FHR)

The nurse is reviewing the fetal monitor record of a client who is in active labor at 37 weeks' pregnancy. Which finding would require the nurse to notify the primary health care provider immediately?

The fetal heart rate has been 175 beats/min for 20 minutes

After the delivery of an infant, the nurse assists to perform an initial assessment and determines that the Apgar score is 9. What does this score indicate about the infant?

The infant is adjusting well to extrauterine life.

The client gave birth yesterday, and the nurse is planning for her discharge today. Which data indicate the need for further assessment before discharge?

The maternal blood type is A negative.

What observations by the nurse of the mother-baby couplet indicate effective breast-feeding on day 2 of life? Select all that apply.

The newborn has voided 3 times today Audible swallowing by the newborn is noted The mother feels a firm tugging on her nipples as the baby feeds The newborn's nose, cheek, and chin are all touching the mother's breast.

The nurse is caring for a newborn infant at 6 hours of age. The mother had hepatitis B virus infection during pregnancy, and she is positive for hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBsAg e). Which practice is recommended to decrease the risks of transmission of hepatitis B to the newborn?

The newborn should receive hepatitis B vaccine and hepatitis B immunoglobulin.

The newborn infant is 5 days old. The mother asks questions about breast-feeding the infant. Which response to the nurse's assessment questions would require follow-up?

The newborn slept 7 hours last night.

The client is a 30-year-old who had a previous cesarean section (CS) and would like to have a vaginal birth after cesarean section (VBAC) with the current pregnancy. Which data would indicate increased risk of uterine rupture in labor?

The uterine incision was vertical

The nurse is evaluating the fetal monitor tracing of a 28-year-old client with diabetes undergoing induction of labor with oxytocin. With regard to the tracing shown, what are the appropriate nursing interventions? Select all that apply. Refer to the figure.

Turn off the oxytocin infusion Notify the primary health care provider Administer oxygen by face mask at 8 to 10 L/min

A client in the second trimester of pregnancy is admitted to the maternity unit with a diagnosis of abruptio placentae. The nurse expects to note which clinical manifestation associated with this disorder?

Uterine hypertonicity

A pregnant client with a suspected diagnosis of placenta previa arrives at the health care clinic for an examination. The nurse prepares the client for the examination and tells the client that which procedure will be deferred until the diagnosis is confirmed?

Vaginal speculum examination

A postpartum mother complains of severe pain and an intense feeling of swelling and pressure in the vaginal area. The nurse should check which anatomical area immediately?

Vulva for a hematoma