Maternity and peds 16-21
A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder?
Mastitis
The nurse is admitting a newborn into the nursery and notes the newborn was born at 42 weeks' gestation. Which action should the nurse prioritize when caring for this infant?
Monitor the newborn's blood glucose levels.
The nurse is interacting with a young mother and her 2-week-old infant. Which behavior by the mother should the nurse prioritize and report to the RN or health care provider?
Not responding to the infant crying
A 21-year old client arrives at the prenatal clinical at 12 weeks' gestation and has a positive STI. Which of the following should the nurse be aware of that would indicate the client is at high risk for noncompliance with treatment for the STI?
noted to have history of substance abuse
The nurse is providing care for a child following a cardiac catheterization. Which nursing action should the nurse prioritize during the first 12 hours after the procedure?
observing the site and extremity
The nursing instructor is conducting a session with a group of nursing students researching potential respiratory difficulties in newborns. The instructor determines the session is successful after the students correctly choose which contributing factor for transient tachypnea of the newborn?
often seen with cesarean births
The nurse is assessing a client with type I diabetes who has just been informed she is 8 weeks' pregnant. The nurse should explain that her health care provider will probably refer her to which specialist to assist with this high-risk pregnancy
perinatologist
The nurse is leading a discussion with a group of pregnant women who have diabetes. The nurse should point out which situation can potentially occur during their pregnancy?
Polyhydramnios
A pregnant client with type I diabetes asks the nurse about how to best control her blood sugar while she is pregnant. The best reply would be for the woman to:
check her blood sugars frequently and adjust insulin accordingly.
A 38-year-old client, G4P3, at 10 weeks' gestation with an unplanned pregnancy, has concerns the fetus may have a genetic defect. The nurse should point out which test would be the best current choice to investigate the possibility of a chromosomal abnormality?
chorionic villus sampling (CVS)
A client who delivered approximately 18 hours ago suddenly reports pelvic pain that is unrelieved by comfort measures and medication. Assessment reveals HR 110, BP 96/68 mm Hg, firm fundus, and dark red, flowing lochia in moderate amounts with no pooling. The most recent hematocrit is 31.9% and hemoglobin 10.5 g/dl. Which complication should the nurse prioritize?
deep pelvic hematoma
A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize?
depressed deep tendon reflexes
The nurse is appraising the medical record of a pregnant client who is resting in a darkened room and receiving oxytocin and magnesium sulfate. The nurse will continue to monitor this client for progression to which condition?
eclampsia
A G2P1 woman with type 1 diabetes is determined to be at 8 weeks' gestation by her health care provider. The nurse should point out which factor will help the client maintain glycemic control
exercise
The nurse is preparing a postpartum nursing care plan for a single HIV-positive primigravida client. The nurse should prioritize in the plan how to acquire which resource?
formula
A woman at 8 weeks' gestation is admitted for ectopic pregnancy. She is asking why this has occurred. The nurse knows that which factor is a known risk factor for ectopic pregnancy?
history of endometriosis
At 31 weeks' gestation, a 37-year-old woman with a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals cervix 2.1 cm long; fetal fibronectin in cervical secretions, and cervix
hospitalization, tocolytic, and corticosteroids
The nurse is caring for a woman who delivered via a cesarean birth approximately 16 hours earlier. Which assessment finding should the nurse prioritize?
steadily decreasing volume of urine
Four weeks before the birth of a client's already large child, the health care provider has told the client that if the baby gets bigger and the baby's lungs are ready, a cesarean birth is preferred. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal birth. What is an appropriate response by the nurse?
"As the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress."
The nurse is teaching the caregivers of an infant diagnosed with hypospadias how to properly care for the infant. The nurse determines the session is successful when the caregivers make which statement?
"Being able to most likely correct this in one stage rather than several is reassuring."
The nurse is assessing a 4-year-old male born with a heart condition who is brought in for a routine well-child visit by his parents. The parents report he is very curious, active, and very social; however, they often see him take breaks in his play by squatting for a few minutes or sitting on the sidelines at which time they insist he take a nap. Assessment reveals a child small for his age, mildly cyanotic, and tires easily. What is the best response to the parents when they ask the nurse for suggestions on how to encourage their son to take the naps they insist on but he doesn't want to take?
"Children are often aware of their limitations, and because he has shown that he knows when he needs to take a break he should be encouraged to control his own activity level.
The nurse is working with an adult female who has PKU and desires to become pregnant. The nurse notes on her assessment her current serum phenylalanine level is 10 mg/dl. Which instruction should the nurse prioritize for this client?
"It will be best if you cut back on meat, fish, and dairy products before you become pregnant to get your serum phenylalanine level down under 8 mg."
The nurse is assessing a toddler at a well-child visit and notes the following: small in stature, appears mildly developmentally delayed; short eyelid folds; and the nose is flat. Which advice should the nurse prioritize to the mother in response to her questions about having another baby?
"It's a good idea to stop drinking alcohol 3 months before trying to get pregnant."
The nurse is working with a group of parents of children who have congenital heart disorders. Which statement made by the parents should the nurse prioritize for further assessment?
"She gets so tired when she is eating."
The nurse is accepting a new mother and her term infant into the unit after delivery and notes the newborn is documented as low-birth-weight. How much does the nurse expect the newborn to weigh?
2000 grams
The nurse is assessing a newborn and notes that the size of the infant will necessitate classification as large for gestational age. When questioned by the mother as to what this means, the nurse should point out the infant is at which percentile?
92nd percentile
The nurse is preparing a nursing care plan for a preterm infant in the newborn nursery. Which nursing diagnoses could the nurse determine to be appropriate for this infant? Select all that apply.
A. Ineffective breathing pattern B. Ineffective thermoregulation E. Risk for impaired skin integrity
The nurse has completed an assessment on a newborn and documents a score of 17 for the physical maturity in the records. Which elements has the nurse prioritized for this assessment? Select all that apply.
A. skin C. breast buds E. plantar creases F. lanugo
The nurse is preparing discharge instructions for a postpartum woman who has developed DVT after a long and difficult birthing process. The nurse will include instruction on which medication for this client?
Anticoagulants
The nurse is answering questions from the parents of a newborn diagnosed with clubfoot (congenital talipes equinovarus). When asked by the parents which treatment will be used, what would the nurse predict?
Application of a splint or cast
The nurse cares for preterm infants and assesses them for potential complications to provide adequate countermeasures to prevent father complications. Which complication should the nurse prioritize and initiate proper measures to protect the newborn?
B. loss of body heat
The nurse is assessing a newborn to establish a gestational age. Which factors will the nurse prioritize when assessing the newborn's neuromuscular maturity? Select all that apply
B. posture C. arm recoil D. heel to ear F. scarf sign
The nursing instructor is conducting a discussion centered on the various methods used to describe an infant. The instructor determines the session is successful when the students correctly choose which as an indication of gestational age?
B. the length of time between fertilization of the egg and birth
The nurse is monitoring the woman who is 1 hour postpartum and notes on assessment the uterine fundus is boggy, to the right, and approximately 2 cm above the umbilicus. The nurse would conclude this is most likely related to which potential complication?
Bladder distention
The nurse is caring for an infant in a hip spica cast. Which nursing intervention would the nurse prioritize to promote skin integrity?
C. Give daily sponge baths and clean around the edges of the cast.
A client presents to the clinic with her 3-week-old infant reporting general flulike symptoms and a painful right breast. Assessment reveals temperature 101°8F (38.8°C) and the right breast nipple with a movable mass that is red and warm. The client is diagnosed with mastitis. Which instruction should the nurse prioritize for this client?
Complete the full course of antibiotic prescribed, even if you begin to feel better.
The parents of a newborn are struggling with the news that their infant has spina bifida. Which technique should the nurse prioritize teaching to the parents that will help increase the infant's comfort and development?
Cuddle the baby in a chest-to-chest position.
A nurse is providing postoperative care to an infant who had a ventriculoarterial shunt placed. Approximately 8 hours after surgery, the nurse notes on assessment shrill crying and projective vomiting. Which response should the nurse prioritize at this time?
D. Notify the primary care provider immediately.
The nurse is caring for a newborn with congenital hip dysplasia. Which nursing diagnoses would the nurse prioritize for this infant after the application of a hip spica cast? Select all that apply.
D. Risk for delayed growth and development E. Risk for impaired skin integrity
The nurse is evaluating the neonate for gestational age. Which assessment finding will the nurse note when determining the infant is post-term?
Ear cartilage is thick and the pinna is stiff.
A client who underwent a cesarean birth suddenly complains of shortness of breath and pain approximately 2 hours after delivery. Which action should the nurse prioritize?
Ensure the head of the bed is at 45 degrees.
The nurse is monitoring a newborn who exhibited a large head at birth and is exhibiting an increasing head growth on continued assessment. Which additional findings on assessment should lead the nurse to suspect hydrocephalus in this infant?
Eyes appear to be pushed downward.
A 2-year old child has gone home following successful hip dysplasia surgery in a spica cast. Her caregiver calls 2 days later to report the child has been vomiting after eating, but has no fever. Which response should the nurse prioritize in response to this caregiver?
If there is no fever and the child wants to eat, the cast may be too tight; she should be brought back in for recasting."
The nurse caring for a newborn notes a distended abdomen approximately 24 hours after birth. Which action should the nurse take after review of the medical record reveals an apparent healthy newborn at birth but no documentation of a bowel movement?
Inform the health care provider immediately.
A caregiver brings a 13-year-old male for a pre-high school checkup and reports he has spent lots of time in the principal's office or serving detention during junior high, and questions if he is too immature to be in high school. The nurse's assessment reveals evident breasts, little underarm or chest hair, and a highpitched voice. Which condition should the nurse suspect and discuss with the primary care provider?
Klinefelter syndrome
The nurse is preparing pre- and postoperative instructions for a family whose 6- month-old infant is scheduled for an initial surgical repair of a cleft lip and palate. Which activity should the nurse prioritize in the instructions to the caregivers of this infant?
Let the infant become accustomed to being in elbow restraints.
The nurse is assessing a newborn and suspects developmental dysplasia of the hip (DDH). For which sign is the nurse prioritizing in this potential diagnosis?
Limited abduction of the affected hip
A nursing instructor is leading a group discussion on congenital hydrocephalus. The instructor determines the session is successful after the students correctly choose which factor that determines the noncommunicating type?
Obstruction that keeps CSF from passing between the ventricles and the spinal cord
The LPN has reported that uterine massage is ineffective on a client. The nurse anticipates the health care provider will prescribe which medication to address this issue?
Oxytocin
The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis?
Pad count
The nurse is monitoring a new mother changing her newborn's diaper and notices a musty smell to the infant's urine. Which condition should the nurse prioritize in further assessments to rule out?
Phenylketonuria
The nurse is preparing a nursing care plan for an infant who was born with spina bifida with myelomeningocele. Which nursing goal should the nurse prioritize for this child?
Preventing infection
The nurse is assessing a postpartum client at a 6-week well-care check and notes questionable behavior on assessment. Which behaviors should the nurse prioritize and report to the RN or health care provider?
Restless and agitated, concerned with self and not the infant
The nurse is caring for a preterm infant and notes frothing and excessive drooling. Which additional assessment finding should the nurse prioritize and report immediately?
Severe cyanosis
15. A nurse is caring for a newborn who is determined to be small-for-gestationalage with intrauterine growth restriction. Which finding would lead the nurse to also question if this infant has asymmetric growth restriction?
The head is large in comparison with the body.
The nurse is teaching new parents about their premature newborn who was born with respiratory distress syndrome (RDS). The nurse determines the teaching session is successful when the parents correctly choose which explanation as being the cause of their newborn's condition?
The lungs are immature and deficient in surfactant.
A nursing instructor is preparing a discussion which will illustrate the different forms of spina bifida. The instructor determines the session is successful after the students correctly choose which form as being spina bifida with myelomeningocele?
The spinal cord, meninges, and nerve roots protrude out the lower back.
The community health nurse is preparing a presentation which will illustrate the various forms of spina bifida for a health fair. Which explanation should the nurse use to explain spina bifida with meningocele?
The spinal meninges protrude through the bony defect and form a cystic sac.
The nurse is preparing to teach the young parents of a newborn who is diagnosed with spinal bifida occulta how to care for their newborn. Which information should the nurse prioritize when explaining this defect?
There is a bony defect that occurs without soft-tissue involvement.
A newborn is diagnosed with the communicating type of congenital hydrocephalus. Which explanation should the nurse prioritize when preparing a teaching session for the parents?
There is defective absorption of cerebrospinal fluid.
A nurse is providing information for a pregnant woman who has just discovered that the fetus she's carrying is likely to have Down syndrome. Which statement by the nurse is most accurate regarding the possible concerns for a child with Down syndrome?
They have a higher risk of developing leukemia than those in the general population.
The nurse is caring for a newborn who is receiving phototherapy for hemolytic disease. As the nurse explains the procedure to the mother, which instruction should the nurse prioritize?
Turn the newborn every 3 to 4 hours.
The nursing instructor is teaching a session on techniques that the nursing students can use to properly address concerns of parents with children who are born with a cleft lip and palate. The instructor determines the session is successful when the students correctly choose which nursing intervention as being the most effective in these situations?
Use reflective listening with nonjudgmental support
A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider?
Weak and rapid pulse
The nurse is preparing a presentation for a health fair presenting the risks which can lead to sudden infant death syndrome (SIDS). Which factors would the nurse include as increasing the risk for SIDS?
a low-birth-weight baby boy, November birth, wealthy, educated, 19-year-old G1P1 smoker
The nurse is caring for a pregnant woman who is struggling with controlling gestational diabetes mellitus. What effect does the nurse predict this situation may have on the fetus?
grow to an unusually large size
a low-birth-weight baby boy, November birth, wealthy, educated, 19-year-old G1P1 smoker
hemolytic disease
During a clinical conference, a group of nursing students are discussing a newborn that is large-for-gestational-age. The instructor determines the students have successfully differentiated the potential cause after choosing which contributing maternal factor?
being 30 pounds overweight before getting pregnant
The nurse is caring for a new infant and notes on assessment the newborn is small for gestational age and also has indications of intrauterine growth restriction. Which assessments should the nurse prioritize about the mother as a potential cause for the infant's condition?
blood glucose levels
The nurse is assessing a group of infants and notes one of the infants has chronic constipation and an enlarged abdomen. The nurse would determine this infant is showing indications of which condition?
congenital hypothyroidism
The nurse is preparing a presentation for a health fair that will illustrate various factors that contribute to preterm births. Which contributing factor should the nurse prioritize?
fertility treatments that are resulting in multiple births
The nurse is preparing to assess an infant who is diagnosed with a ventricular septal defect. Which assessment finding should the nurse be prepared to document?
development
The nurse is admitting to the nursery a newborn of a mother who continued to drink alcohol during her pregnancy. Which finding does the nurse predict to encounter on the newborn's assessment?
hyperactive and irritable
The nurse is examining the morning laboratory results of the newborns of mothers with diabetes. Which report finding should the nurse prioritize?
hypocalcemia
The nurse is caring for a newborn diagnosed with a diaphragmatic hernia. The nurse will prepare to teach the parents concerning which potential treatment modality?
immediate surgery to correct
The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation?
infection
The parents of an infant diagnosed with phenylketonuria are not sure they agree with the diagnosis and proposed treatment. The nurse should point out that this condition can result in which additional condition if left untreated?
intellectual disability
The nurse is weighing and measuring a term newborn. Which assessment findings would indicate that this newborn is suffering from asymmetrical growth restriction?
is pale with loose, dry skin
The nurse is assessing the newborn male of a teen mother who was afraid to seek appropriate prenatal care. Which assessment finding should lead the nurse to question if this infant is preterm?
lanugo on the back and shoulders
The nurse assesses preterm infants as they come for routine well-baby checkups. The nurse will carefully assess the infant's vision to assess for which potential complication related to their birth?
retinopathy
When assisting in the delivery of a postterm baby, as soon as the baby's head is delivered, the nurse is most likely to be called upon to help the physician perform what action?
suction the baby's mouth and nose
The nursing instructor is leading a discussion with a group of nursing students who are analyzing the preterm infant's physiologic immaturity and the associated difficulties the newborn and family must deal with. The instructor determines the session is successful when the students correctly choose which body system that presents with the most critical concerns related to this immaturity?
the respiratory system
The nurse is assessing a primigravida woman who reports vaginal itching, a great deal of foamy yellow-green discharge, and pain during intercourse. The nurse suspects the woman has contracted which disorder?
trichomoniasis
The nurse is giving discharge instructions to a client who experienced a complete spontaneous abortion (miscarriage). Which question should the nurse prioritize at this time?
"Do you have someone to talk to, or may I give you the names and numbers for some possible grief counselors?"
The nurse is comforting and listening to a young couple who just suffered a spontaneous abortion (miscarriage). When asked why this happened, which reason should the nurse share as a common cause?
Chromosomal abnormality
A 14-year-old client and her parents have presented at the obstetrician's office in the second trimester; the teen had been hiding the pregnancy. The nurse is helping them develop a plan of care. What is the best thing the nurse can say to the clearly angry parents?
"I know you must be very upset and angry about your daughter's pregnancy, but because she's still an adolescent herself, she'll need your guidance in making nutritional and health choices that will be good for the baby and for herself."
A 32-year-old woman with epilepsy mentions to the nurse during a routine wellvisit that she would like to have children and asks the nurse for advice. Which response is most appropriate from the nurse?
"I'll let the doctor know so you can discuss your medications. In the meantime, I'll give you a list of folate-rich foods you can add to your diet."
The nurse is teaching a client who is diagnosed with preeclampsia how to monitor her condition. The nurse determines the client needs more instruction after making which statement?
"If I have changes in my vision, I will lie down and rest."
The nurse is caring for a primipara with PROM who appears extremely anxious and reveals that she is scared her birthing process will be extremely painful because it will be "dry". Which is the best response from the nurse?
"No birth is ever really dry, because amniotic fluid continues to be manufactured."
The nurse is preparing discharge instructions for a client at 32 weeks' gestation who was admitted for PROM. What is the best response from the nurse when the client asks when she can have intercourse with her husband again?
"That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor."
A woman's baby is HIV positive at birth. She asks the nurse if this means the baby will develop AIDS. Which statement would be the nurse's best answer?
"The antibodies may be those transferred across the placenta; the baby may not develop AIDS."
A woman at 41 weeks' gestation is progressing well in labor; however, the nurse notes the amniotic fluid is greenish in color. When questioned by the client for the reason for this, which explanation should the nurse provide?
"This is meconium-stained fluid from the baby."
A client suffering a miscarriage at 12 weeks' gestation is very upset that the health care provider has ordered a dilatation and curettage (D&C). How should the nurse respond after the client states she didn't have a D&C the time she lost a previous baby at 5 weeks' gestation?
"This procedure is needed to adequately remove all the fetal tissue."
A 43-year-old, physically fit, healthy woman who is newly married tells the nurse that she and her husband would like to have a child. What is an appropriate first response?
"Well, I'm sure you know there are some risks involved so it's helpful that you've been taking such good care of yourself."
A multipara woman at a birthing center is becoming very discouraged that her labor is taking so long. She is confused when her nurse-midwife indicates she has developed dystocia and needs to be transferred to a more advanced facility. What is the best response from the nurse to answer the woman's questions?
"Your difficult labor needs treatment we cannot provide here."
A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize?
A dipstick value of 2+ for protein
A woman at 31 weeks' gestation presents to the emergency department with bright red vaginal bleeding, reporting that the onset of the bleeding was sudden and without pain. Which diagnostic test should the nurse prioritize?
A transvaginal ultrasound
The nurse is caring for several postpartum clients and notes various warning signs that are concerning. Which client should the nurse suspect is developing endometritis?
A woman with diabetes, vaginal birth, HR 110, temperature 101.7°F (38.7°C) on the third postpartum day. The next day, appears ill; temperature now 102.9°F (39.3°C); WBC 31,500/mm3; negative blood cultures.
A G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something "came out" when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina?
A. Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord.
A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication?
A. Uterine rupture
A postpartum mother has the following lab data recorded: a negative rubella titer. What is the appropriate nursing intervention?
Administer rubella vaccine before discharge
A G4P3 client with a history of controlled asthma is upset her initial prenatal appointment is taking too long, making her late for another appointment. What is the nurse's best response when the client insists she knows how to handle her asthma and needs to leave?
Acknowledge her need to leave but ask her to demonstrate the use of inhaler and peak flow meter before she goes; remind her to take regular medications.
The nurse is caring for a mother within the first four hours after a cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother?
Ambulate the client as soon as her vital signs are stable.
A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure?
Amniocentesis
A 28-year-old client and her current partner present for the first prenatal appointment with the ob/gyn. The client has no children but does question a possible miscarriage 2 years ago; however, she never sought medical attention because she felt fine. Labs reveal both client and partner are Rh negative. Which action should the nurse prioritize?
Assess client for anti-D antibodies.
The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?
Assess for warmth, erythema, and pedal edema.
The nurse is preparing a woman for discharge after a birth and notes the mother's record indicates Rh negative and rubella titer is positive. Which nursing intervention will the nurse prioritize?
Assess the Rh of the baby.
The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize?
Assess the woman's fundus.
A 28-year-old client with a history of endometriosis presents to the emergency department with severe abdominal pain and nausea and vomiting. The client also reports her periods are irregular with the last one being 2 months ago. The nurse prepares to assess for which possible cause for this client's complaints?
B. Ectopic pregnancy
The nurse is educating a client with type 1 diabetes about the complications associated with diabetes and pregnancy. Which problems would the nurse include in her teaching? Select all that apply.
B. Increased risk of spontaneous abortion (miscarriage) C. Polyhydramnios D. Hypertension
A multigravida client at 31 weeks' gestation is admitted with confirmed preterm labor. As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?
B. Respiratory depression, hypotension, absent tendon reflexes
A nurse working at the local health district clinic assists numerous adolescents who become pregnant. Which factor will the nurse tell the teens is crucial for a positive pregnancy outcome?
B. Support network
23. The nurse is caring for a pregnant client who has a class II heart disease. The nurse is prepared to intensify monitoring during which period of the pregnancy?
B. second trimester
The nurse is assisting a client who has just undergone an amniocentesis. Blood results indicate the mother has type O blood and the fetus has type AB blood. The nurse should point out the mother and fetus are at an increased risk for which situation related to this procedure?
Baby developing postbirth jaundice
A nurse is preparing a nursing care plan for a client who is admitted at 22 weeks' gestation with advanced cervical dilation (dilatation) to 5 cm, cervical insufficiency, and a visible amniotic sac at the cervical opening. Which primary goal should the nurse prioritize at this point?
Bed rest to maintain pregnancy as long as possible
A pregnant woman with sickle cell anemia is very concerned her infant will also develop the disease and questions the nurse about that possibility. Which is the best response from the nurse?
Both parents have to carry the trait
A woman with a positive history of genital herpes is in active labor. Assessment reveals vesicles in the perineum area, membranes are ruptured, dilated 5 cm, and effaced 70%. The nurse should prepare the client for which type of birth?
Cesarean
The nurse is assessing a 35-year-old woman at 22 weeks' gestation who has had recent laboratory work. The nurse notes fasting blood glucose 146 mg/dl (8.10 mmol/L), hemoglobin 13 g/dl (130 g/L), and hematocrit 37% (0.37). Based on these results, which instruction should the nurse prioritize?
Check blood sugar levels daily
An 18-year-old pregnant client is hospitalized as she recovers from hyperemesis gravidarum. The client reveals she wanted to have an abortion (elective termination of pregnancy) but her cultural background forbids it. She is very unhappy aboutbeing pregnant and even expresses a wish for a miscarriage. Which action by the nurse is most appropriate?
Contact the health care provider to report the client's feelings.
Between her regularly scheduled visits, a woman in her first trimester of pregnancy who is taking iron supplements for anemia calls the nurse at her obstetrician's office reporting constipation. She reports that she has never had this problem before and asks for some advice about how to get relief. What is the best advice the nurse can give her?
Continue taking iron supplements but increase fluids and high-fiber foods; exercise more.
A woman with cardiac disease at 32 weeks' gestation reports she has been having spells of light-headedness and dizziness every few days. Which instruction should the nurse prioritize?
Decrease activity and rest more often.+
The nurse is monitoring a primipara who has been receiving oxytocin and is now in hypertonic labor. If the nurse notes the fetal heart rate has suddenly dropped, which action should the nurse prioritize?
Decrease the oxytocin drip rate.
The nurse is monitoring a woman who is receiving IV oxytocin to assist with uterine irritability. Which action should the nurse prioritize if the woman's contractions are determined to be 80 seconds in length after 1 hour of administration of the oxytocin?
Discontinue the oxytocin infusion.
The nurse is caring for a client who has been diagnosed with a deep vein thrombosis. Which assessment finding should the nurse prioritize and report immediately?
Dyspnea
A G4P4 client is recovering from dystocia for which oxytocin was administered to assist with the contractions. On assessment 24 hours later, the nurse notes moderate to heavy lochia with numerous large clots and the uterus in the midline, above the umbilicus, and boggy. Which action should the nurse prioritize?
Ensure that her bladder is empty.
The nurse assesses that a fetus is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment?
Experience of additional back pain
Initial measures to stop a client's bleeding have not proved successful, and she is being transferred to the ICU. Her family is frightened by the IV lines and the nasal cannula. The client's brother suddenly says to her partner, "This is all your fault!" What is the best response by the nurse?
Explain the client's care, focus on signs of improvement, and acknowledge this is a difficult time.
The nurse is preparing discharge instructions for a client who has developed endometritis after a cesarean birth. As the client is to be discharged on antibiotic therapy, which instruction should the nurse prioritize?
Handwashing
A 24-year-old woman presents with vague abdominal pains, nausea, and vomiting. An urine hCG is positive after the client mentioned that her last menstrual period was 2 months ago. The nurse should prepare the client for which intervention if the transvaginal ultrasound indicates a gestation sac is found in the right lower quadrant?
Immediate surgery
An infant is born to a mother with gestational diabetes. Which long-term maternal complication is associated with this diagnosis?
Increased risk of development of type 2 diabetes
The nurse assesses the client who is 1 hour postpartum and discovers a heavy, steady trickle of bright red blood from the vagina in the presence of a firm fundus. Which potential cause should the nurse question and report to the RN or primary care provider?
Laceration
A woman with class II heart disease is experiencing an uneventful pregnancy and is now prescribed bed rest at 36 weeks' gestation by her health care provider. The nurse should point out that this is best accomplished with which position?
Lie in a semi-recumbent position.
The nurse is preparing information for a client who has just been diagnosed with gestational diabetes. Which instruction should the nurse prioritize in this information?
Maintain a daily blood glucose log
A pregnant woman at 38 weeks' gestation is receiving care for preeclampsia and suddenly complains of sharp abdominal pain. Which action should the nurse prioritize if the nurse notes a firm, distended, and painful abdomen and dark red vaginal bleeding?
Obtain a full set of vital signs
The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?
Palpate her fundus
At 33 weeks' gestation, a woman experiencing preterm PROM is being prepared to discharge home after successful treatment with magnesium sulfate. The nurse should prioritize which instruction to the woman and her partner?
Perform kick counts after each meal.
The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder?
Postpartum psychosis
A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?
Premature separation of the placenta
A 17-year-old primigravida at 37 weeks' gestation has been unable to maintain adequate control of her blood glucose throughout her pregnancy. The nurse should prioritize which action after the health care provider
Prepare for assessment of fetal lung maturity.
the nurse is assessing a multipara woman who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifying the RN and primary care provider, which action should the LPN prioritize?
Prepare to assist with external version.
A client at 27 weeks' gestation is admitted to the obstetric unit after reporting headaches and edema of her hands. Review of the prenatal notes reveals blood pressure consistently above 136/90 mm Hg. The nurse anticipates the health care provider will prescribe magnesium sulfate to accomplish which primary goal?
Prevent maternal seizures
The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 12 breaths/min, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity?
Reflexes
A woman at 28 weeks' gestation has been hospitalized with moderate bleeding that is now stabilizing. The nurse performs a routine assessment and notes the client sleeping, lying on the back, and electronic fetal heart rate (FHR) monitor showing gradually increasing baseline with late decelerations. Which action will the nurse perform first?
Reposition the client to left side.
A woman who had preterm labor and preterm PROM successfully halted has reached week 36 of pregnancy and is doing well on home care. Which of the following nursing diagnoses should the nurse prioritize for this client?
Risk for fetal infection related to early rupture of membranes
A 24-year-old client is brought to the emergency department complaining of severe abdominal pain, vaginal bleeding, and fatigue. On assessment, the nurse notes cool, clammy skin; confusion; and vital signs as the following: HR 130, RR 28, and BP 98/60 mm Hg. Which action should the nurse prioritize?
Rule out shock.
The nurse is caring for a postpartum woman who is diagnosed with endometritis. Which position should the nurse encourage the client to maintain?
Semi-Fowler
The nurse is assessing a 37-year-old woman who has presented in active labor and notes the client has an increased risk for placental abruption (abruptio placentae). Which assessment finding should the nurse prioritize?
Sharp fundal pain and discomfort between contractions
The nurse is conducting a class for pregnant women on problems associated with infections seen in women during gestation. One mother tells the nurse that she has never had chickenpox (varicella) and is worried she will contract it before she delivers. What would the nurse explain to this mother to ease her anxiety?
She can receive her varicella vaccine immediately after delivery, followed by a second dose at her 6-week postpartum visit.
A pregnant single mom living alone tells the nurse she is considering getting a cat for her 2-year-old daughter. Which is the best response by the nurse?
You should wait until after you give birth to obtain the cat for your daughter."
The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse?
Teach that adequate hydration helps clear the infection quicker.
A 39-year-old multigravida with diabetes presents at 32 weeks' gestation reporting she has not felt movement of her fetus. Assessment reveals the fetus has died. The nurse shares with the mother that the institution takes pictures after the birth and asks if she would like one. What is the best response if the mother angrily says no and starts crying?
Tell her that the hospital will keep the photos for her in case she changes her mind
Which statement describes why hypertonic contractions tend to become very painful?
The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells.
A client with asthma is confused by her primary care provider continuing her medication while she is pregnant, since she read online the medications can cause birth defects. What is the nurse's best response?
Your primary care provider will order safe doses of your medication."
The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging?
Use McRoberts maneuver.
The nurse notes the fetal heart rate has slowed in a woman in labor at 8 cm dilation (dilatation). Assessment reveals a prolapsed umbilical cord. Which action should the nurse prioritize?
Use fingers to press upward on the presenting part.
The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage?
Uterine atony
A woman at 39 weeks' gestation is brought to the emergency department in labor following blunt trauma from an vehicle accident. The labor has been progressing well after the epidural when suddenly the woman reports severe pain in her back and shoulders. Which potential situation should the nurse suspect?
Uterine rupture
The nurse is caring for a client who has remained in stable condition at 37 weeks' gestation. The client's condition suddenly changes. Which assessment change should the nurse prioritize?
Vaginal bleeding and no pain
The nurse is preparing discharge instructions for several clients after their admission for emergent care of a pregnancy complication. The nurse will stress the importance of frequent and continuous office visits to the client with:
a molar pregnancy.
A client at 36 weeks' gestation presents to the OB unit reporting continuous, heavy vaginal discharge and pelvic pressure. Assessment reveals no signs of labor and positive nitrazine test. The nurse prepares for which nursing intervention after admitting the client?
administering erythromycin IV
The nurse is admitting a woman at 32 weeks' gestation in preterm labor. The nurse should question the order for magnesium sulfate after noting which assessment finding?
cervical dilation (dilatation) of 5 cm
A 25-year-old client at 22 weeks' gestation is noted to have proteinuria and dependent edema on her routine prenatal visit. Which additional assessment should the nurse prioritize and convey to the RN or health care provider?
initial BP 100/70 mm Hg; current BP 140/90 mm Hg
When providing education to a prenatal care class for teenagers, the nurse states that infants born to teenage mothers are more likely to have which outcome?
low-birth-weigh
The nurse is preparing to teach a pregnant client with iron deficiency anemia about the various iron-rich foods to include in her diet. Which food should the nurse point out will help increase the absorption of her iron supplement
orange juice
The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss?
placental abruption
The nurse is assessing a multipara client at 28 weeks' gestation who may be experiencing labor. Which findings should the nurse prioritize?
positive fetal fibronectin
A 24-year-old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out?
prevent maternal D antibody formation.
A client at 37 weeks' gestation presents to the emergency department with a BP 150/108 mm Hg, 1+ pedal edema, 1+ proteinuria, and normal deep tendon reflexes. Which assessment should the nurse prioritize as the client is administered magnesium sulfate IV?
respiratory rate
A client with preterm labor is receiving terbutaline therapy. Which assessment will the nurse take?
serum potassium levels
