Maternity ATI 1

A nurse is caring for a newborn who weighs 4 lb. How many kilograms does the newborn weigh? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.)

1.8

A nurse is providing discharge instructions to the parent of a newborn. Which of the following statements should the nurse include? A. "Crib slats should be less than 2.25 inches apart." B. "Share your bed with your baby for the first few weeks." C. "Place your baby on his stomach for naps." D. "You can position your baby's crib next to a heating vent for warmth."

A. "Crib slats should be less than 2.25 inches apart." Crib slats should be no more than 5.7 cm (2.25 in) apart to prevent injuries due to falls or entrapment of the infant's head between the slats.

A nurse is providing teaching to a client who is 1 hour postpartum about using the perineal squeeze bottle. Which of the following instructions should the nurse include? A. "Fill the perineal bottle with warm water prior to use." B. "Squeeze the perineal bottle while standing up in the bathroom to cleanse the perineum." C. "Only use half of the perineal bottle for cleansing." D. "Wipe the perineum with toilet paper from back to front after using the perineal bottle."

A. "Fill the perineal bottle with warm water prior to use." The client should fill the squeeze bottle and use the entire contents each time she voids or has a bowel movement to cleanse her perineum. Warm water will promote healing and increase comfort to the perineal area. Cold water will be uncomfortable, and hot water could cause tissue trauma. - sit on the toilet when using the perineal bottle. Standing will not allow the client to cleanse the perineal area thoroughly. - use the entire contents of the perineal bottle. - gently blot her vulva and perineum dry with tissue paper and avoid vigorous rubbing with abrasive cloths. - wipe from front to back to prevent the spread of bacteria to the perineal area.

A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching? A. "I will place my baby on his back when putting him to sleep." B. "I will keep my baby's crib close to the heat vents to keep him warm." C. "I will use an infant carrier when I drive to places close to my house." D. "I will tie my baby's pacifier around his neck with a piece of yarn."

A. "I will place my baby on his back when putting him to sleep." Newborns should always sleep on the back to prevent sudden infant death syndrome. - should not place the newborn's crib close to a heat source due to the risk of the crib linen catching on fire. - should always place the newborn in an approved car seat while driving with the newborn. - should never tie any type of string or cord around the newborn's neck due to the risk of strangulation.

A provider tells a client at 12 weeks gestation who practices Hinduism that she needs more protein in her diet and suggests eating more meat. After the provider leaves the examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make? A. "Let's discuss other foods that are also high in protein that you could substitute for meat." B. "Eating meat during pregnancy provides necessary protein and does not cause miscarriage." C. "Why do you think that eating animal products will cause you to have a miscarriage?" D. "Your doctor is recommending what is best for you and your baby."

A. "Let's discuss other foods that are also high in protein that you could substitute for meat." Many cultures have beliefs about food that the nurse should respect. Discussing non-animal protein sources can help the client identify foods that do not conflict with her religious and cultural beliefs.

A nurse is caring for a client who is pregnant. The client asks, "Is it okay to have a few beers while I'm pregnant?" Which of the following responses should the nurse make? A. "Total abstinence from alcohol is recommended." B. "One occasional beer during pregnancy is okay." C. "High levels of alcohol consumption should be decreased." D. "A low-calorie liquor is safe to drink."

A. "Total abstinence from alcohol is recommended." Total abstinence is from alcohol is recommended. Alcohol can cross the placental barrier and transmit to the fetus. This can increase the fetus's risk of developing fetal alcohol syndrome and can increase the mother's risk of experiencing a miscarriage. There is no safe level of alcohol consumption for a client who is pregnant.

A nurse is caring for a client who asks, "How will I know if I'm having true or false labor contractions?" Which of the following responses should the nurse make? A. "True contractions will begin irregularly and then become regular in timing." B. "True contractions will go away with ambulation." C. "False contractions increase in frequency and duration the closer you are to your due date." D. "False contractions are first felt in the pelvic area and then in the lower back and abdomen."

A. "True contractions will begin irregularly and then become regular in timing." False contractions begin and remain irregular, but true contractions will begin irregularly and become regular and predictable. - False contractions will usually go away if the client ambulates or goes to sleep - False contractions do not increase in duration, frequency, or intensity no matter how close the client is to her due date. - False contractions are felt in the client's abdomen and remain in the abdominal and groin area

A nurse is caring for a pregnant client who reports nausea and vomiting. Which of the following instructions should the nurse share with the client? A. "You should eat some crackers before rising from bed in the morning." B. "You should eat foods served at warm temperatures." C. "You should sip whole milk with breakfast." D. "You should brush your teeth immediately after meals."

A. "You should eat some crackers before rising from bed in the morning." Morning sickness is caused by the buildup of human chorionic gonadotropin (hCG) in the mother's system. Dry foods eaten before rising in the morning tend to reduce the risk of nausea in clients who are pregnant.

A nurse is providing teaching about weight gain during pregnancy for a client who is a primigravida of normal pre-pregnancy weight. Which of the following statements should the nurse include? A. "You should plan to gain 25 to 35 pounds during your pregnancy." B. "You should plan to gain 11 to 20 pounds during your pregnancy." C. "Because you started pregnancy at a normal BMI and weight, your weight gain is not limited as long as you follow a healthy, balanced diet." D. "Because you are of normal weight prior to pregnancy, you are encouraged to gain 28 to 40 pounds during pregnancy."

A. "You should plan to gain 25 to 35 pounds during your pregnancy." A client of normal prepregnancy weight should plan to gain 11.3 to 15.9 kg (25 to 35 lb) during pregnancy. Weight gain is primarily for maternal tissue growth during the first and second trimesters and fetal tissue growth during the third trimester. - BMI >30 are instructed to gain 5 to 9.1 kg (11 to 20 lb) during pregnancy. - normal prepregnancy weight should plan to gain 11.3 to 15.9 kg (25 to 35 lb) during pregnancy. - underweight prior to pregnancy is encouraged to gain 12.7 to 18.1 kg (28 to 40 lb) during pregnancy.

A nurse is providing discharge teaching to the parent of a newborn. Which of the following statements should the nurse include in the teaching? A. "Your baby should be rear-facing in a car seat until 2 years of age." B. "Cover your baby with a light blanket during naps." C. "Set your hot water heater to no more than 140 degrees Fahrenheit." D. "Ensure your baby's crib has side rails that can be lowered."

A. "Your baby should be rear-facing in a car seat until 2 years of age." The parent should ensure the baby rides in a rear-facing car seat until at least 2 years of age, or longer if recommended by the car seat manufacturer. - place the baby in a lightweight sleeper or sleep sack. - set the hot water heater to no more than 120°F (48.9°C) to avoid burns and scalding injuries. - ensure the baby's crib rails are stationary to prevent injury.

A nurse in the labor and delivery suite is planning care for a group of 4 clients. Which of the following clients should the nurse see first? A. A client who is in active labor and has late decelerations on the fetal heart monitor strip B. A client who is in transition and screaming and disturbing other clients C. A client who has epidural analgesia and is reporting breakthrough pain D. A client who has received an oxytocin infusion and is experiencing contractions every 2 min lasting 60 sec

A. A client who is in active labor and has late decelerations on the fetal heart monitor strip Late decelerations are nonreassuring patterns that reflect impaired placental exchange or placental insufficiency. Because late decelerations indicate fetal hypoxia, the nurse should assess and intervene immediately by changing the client's position, administering oxygen, increasing IV fluids, and preparing for the possibility of an immediate cesarean birth.

A nurse in a provider's office is caring for a client who is in the first trimester of pregnancy. Which of the following psychological tasks should the nurse expect the client to accomplish during this trimester? A. Accepting the pregnancy B. Preparing for the end of pregnancy C. Preparing for parenthood D. Accepting the baby

A. Accepting the pregnancy Accepting the pregnancy is a psychological task that the client is expected to accomplish during the first trimester.

A nurse is assisting with an amniotomy for a client who is in active labor. Which of the following actions should the nurse take? A. Assess the fetal heart rate before and after the procedure B. Monitor the client's temperature every 4 hr after the procedure C. Medicate the client for pain 30 min prior to the procedure D. Perform cervical assessments every 2 hr after the procedure

A. Assess the fetal heart rate before and after the procedure The nurse should assess the fetal heart rate for the presence of variable decelerations or bradycardia, which can occur after rupturing of the membranes if the umbilical cord has prolapsed.

A nurse is caring for a client who is in labor. Which of the following assessment findings should the nurse report to the provider? A. Fetal heart rate baseline of 90 bpm B. Maternal temperature of 37.8°C (100°F) C. Uterine relaxation for 1 min between contractions D. Uterine contractions increasing in intensity

A. Fetal heart rate baseline of 90 bpm A fetal heart rate baseline of 90 bpm is considered bradycardia and should be reported to the provider. Fetal bradycardia is associated with fetal cardiac defects, maternal hypoglycemia, and fetal viral infections.

A nurse in a prenatal care clinic answers a phone call from a client who is at 37 weeks gestation and reports, "I became very dizzy while lying in bed this morning, but the feeling went away when I turned onto my side." Which of the following actions should the nurse take? A. Instruct the client about vena cava syndrome and measures to prevent it B. Arrange for the client to come to the clinic for an assessment C. Check the client's chart for gestational diabetes mellitus D. Schedule a nonstress test for the client

A. Instruct the client about vena cava syndrome and measures to prevent it This is a typical finding of vena cava syndrome or hypotension that occurs in clients who are pregnant upon assuming a supine position. It is caused by compression of the inferior vena cava by the gravid uterus with a consequent reduction in venous return. A side-lying position promotes uterine perfusion and fetoplacental oxygenation.

A nurse is monitoring a client who is receiving spinal anesthesia. The nurse should identify which of the following findings as a complication of the infusion? A. Maternal hypotension B. Fetal tachycardia C. Increased fetal heart rate variability D. Maternal hypothermia

A. Maternal hypotension Maternal hypotension is a common adverse effect of a spinal block. To prevent supine hypotension, the client should lie on a side or lie supine with a wedge under a hip to displace the uterus. - more likely to cause fetal bradycardia than fetal tachycardia. - more likely to cause minimal or a lack of fetal heart rate variability than increased fetal heart rate variability. - more likely to cause a fever than hypothermia.

A nurse is assessing a client who has placenta previa. Which of the following findings should the nurse expect? A. Painless, bright red bleeding B. Board-like uterus C. Persistent uterine contractions D. Abdominal pain

A. Painless, bright red bleeding Placenta previa is the placement of the placenta low in the uterus. Depending on the severity, manifestations include bright red vaginal bleeding and a fundal height higher than expected for the gestational age. The presenting part is higher due to the placenta taking up space inside the lower part of the uterus.

A nurse is caring for a newly admitted newborn who is large for gestational age. After 30 min, the newborn becomes jittery and lethargic with hypotonic muscles and a cry that is different from the time of admission. Which of the following actions should the nurse take? A. Perform a heel stick to check the newborn's glucose level B. Obtain a prescription for serum substance screening C. Provide a feeding of sterile water D. Screen the newborn for phenylketonuria (PKU)

A. Perform a heel stick to check the newborn's glucose level A newborn who is large for gestational age is at risk of hypoglycemia. The nurse should monitor the newborn for manifestations of this condition such as jitteriness, lethargy, hypotonia, an unusual cry, respiratory distress, poor feeding, and an unstable body temperature. Based on these manifestations, the nurse should perform a heel stick to check the newborn's serum glucose level and then implement interventions to correct hypoglycemia if present.

A nurse is initiating phototherapy for a newborn who has hyperbilirubinemia. Which of the following actions should the nurse take? A. Place an opaque mask over the newborn's eyes B. Apply lotion to the newborn's skin twice daily C. Dress the newborn in a diaper and t-shirt D. Check the newborn's temperature twice daily

A. Place an opaque mask over the newborn's eyes The nurse should cover the newborn's eyes with an opaque mask to prevent retinal damage from the ultraviolet light used in phototherapy. - should not apply lotions, creams, or ointments to the newborn's skin because they can absorb heat and cause burns. - dress the newborn in a diaper only to maximize skin exposure to the phototherapy light. - check the newborn's temperature frequently while receiving phototherapy.

A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take? A. Place the unwrapped newborn on the mother's bare chest. B. Feed the infant 5 to 15 mL of 5% glucose water to assess the suck/swallow reflex. C. Bathe the newborn under running warm water before feeding. D. Administer vitamin K and eye prophylaxis prior to feeding.

A. Place the unwrapped newborn on the mother's bare chest. Skin-to-skin contact will maintain the newborn's temperature and illicit instinctive newborn feeding behaviors.

A nurse in a clinic is caring for a client who is pregnant and reports a last menstrual period (LMP) that began on December 7. Which of the following dates would be the client's estimated date of birth (EDB)? A. September 14 B. September 7 C. March 14 D. March 7

A. September 14 Naegele's rule involves subtracting 3 months and adding 7 days to the LMP to calculate the EDB. Subtracting 3 months from December (month 12) gives the month of September. Adding 7 days to the seventh day of the month equals 14. Therefore, September 14 is the EDB.

A nurse is caring for a client who is in labor and is receiving IV oxytocin. The nurse notes contractions lasting 3 min each. What action should the nurse take? A. Stop the oxytocin infusion B. Apply oxygen at 2 L/min via nasal cannula C. Administer methylergonovine intramuscularly D. Prepare for an emergent cesarean birth

A. Stop the oxytocin infusion A pattern of contractions lasting longer than 2 minutes or of more than 5 contractions in a 10-minute period is considered tachysystole. This pattern can decrease the placental perfusion of oxygen. The appropriate action is to discontinue the oxytocin infusion.

A nurse enters a postpartum client's room and notices many visitors in the room, conversing loudly and taking turns holding the newborn. The newborn intermittently cries and attempts to suck on her hand. After a few minutes, the newborn quiets, stares, and turns her head away when someone talks to her. What teaching should the nurse provide for this family? A. The newborn would benefit from skin-to-skin contact in a quiet environment. B. The newborn's blanket should be removed so her movements will not be restricted. C. The newborn's hat should be removed to avoid overheating. D. The newborn should be discouraged from sucking on her hand since this habit can interfere with feeding.

A. The newborn would benefit from skin-to-skin contact in a quiet environment. Staring and gaze aversion indicate the newborn is overstimulated and is "switching off" in an attempt to cope with excess stimuli. When these phenomena are observed, stimulation should be decreased, and supportive measures such as skin-to-skin contact should be increased.

A nurse is caring for a newborn who is receiving treatment for jaundice with traditional phototherapy lights. Which of the following interventions should the nurse perform? A. Turn the newborn every 2 hr B. Supplement with 5% glucose water between scheduled feedings C. Dress the infant lightly in a t-shirt and diaper D. Apply lotion to the skin every 4 hr

A. Turn the newborn every 2 hr Phototherapy lowers serum bilirubin levels by converting bilirubin accumulated in the skin to a form that is excreted in the newborn's urine and stools. The infant must be turned every 2 to 3 hours to maximize skin exposure, which promotes bilirubin breakdown. - Glucose water and plain water do not promote bilirubin excretion. - should be clothed only in a diaper to maximize skin exposure. - Ointments, creams, and lotions should be avoided because they have the potential to absorb heat and cause burns.

A nurse is providing teaching about newborn baths to a client who is 2 days postpartum. Which of the following pieces of information should the nurse include? A. Wash the newborn's face with plain warm water B. Wash the newborn's hair before the rest of the body C. Bathe the newborn once each day D. Bathe the newborn immediately after a feeding

A. Wash the newborn's face with plain warm water The parent should wash the newborn's face with plain warm water. Soap can irritate the eyes and skin. - wash the newborn's body from face to feet, then wash and dry the hair last. This prevents heat loss through the newborn's head, which has a large surface area. - bathe the newborn every 2 to 3 days. The genital area should be cleaned daily. - should not bathe the newborn immediately after a feeding, as this can cause the newborn to regurgitate.

A nurse is caring for a client who is receiving oxytocin to induce labor. Which of the following actions should the nurse take? A. Perform continuous fetal heart rate monitoring B. Measure maternal temperature every hour C. Evaluate the maternal contraction pattern every hour D. Check blood pressure every 5 min

A.Perform continuous fetal heart rate monitoring When oxytocin is administered to an antepartum client, the fetal monitor must be used to monitor the fetal heart rate and maternal contractions continuously.

A nurse is assessing a client who is at 20 weeks gestation and reports frequent episodes of indigestion and heartburn. Which of the following instructions should the nurse give to the client? A. "Limit your intake of food to twice per day." B. "Decrease your intake of spicy foods." C. "Rest in a supine position for a few minutes after eating." D. "Increase your intake of water and carbonated beverages."

B. "Decrease your intake of spicy foods." Spicy foods cause gastric irritation, which may increase during pregnancy as a result of various physiological changes. - Ingesting large amounts of food at once can cause bloating, distention, and nausea. The client should be counseled to eat small, frequent meals. - resting in supine position- cause heartburn and reflux of gastric contents. - water and carbonated drinks = contributes to feelings of fullness and nausea, and the carbonation unnecessarily adds gas to the digestive tract.

A nurse is caring for a client who experienced a fetal loss. When initiating communication with this client, which of the following statements should the nurse make? A. "I understand how you feel." B. "I'm here for you if you would like to talk." C. "It is better that the loss happened now, before you got to know your baby." D. "You are young and can have other children."

B. "I'm here for you if you would like to talk." This is a therapeutic statement because it acknowledges the client's loss and invites her to share her thoughts and feelings.

A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include? A. "Wear a loose-fitting bra to alleviate breast discomfort." B. "Place fresh cabbage leaves on your breasts." C. "Apply warm, moist compresses to your breasts." D. "Express small amounts of milk from your breasts frequently."

B. "Place fresh cabbage leaves on your breasts." After 3 days postpartum, the client's breasts can become swollen and distended because of congestion of the vascular structures of the breasts. Fresh cabbage leaves can be applied to engorged breasts to help relieve breast discomfort. The coolness of the leaves and the phytoestrogens exert a therapeutic effect on engorged breasts. Leaves should be replaced when they become wilted. - wear tight fitting bra - place an ice pack, warmth to breath stimulates milk production - do not express milk from breast, this increases milk production

A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which of the following instructions should the nurse include in the teaching? A. "Stand under a hot shower with your breasts exposed." B. "Place ice packs on your breasts." C. "Wear a loose-fitting, comfortable bra." D. "Limit fluid intake to 1 L per day."

B. "Place ice packs on your breasts." The nurse should instruct the client to place ice packs on her breasts using a "15 minutes on and 45 minutes off" schedule to decrease swelling of the breast tissue as the body produces milk. - Warm water running over the breasts can stimulate milk production. - The client should wear a well-fitting, supportive bra to provide comfort as the breasts fill with milk. - drink 2 to 3 L of fluid per day to promote normal bowel function.

A client at a routine prenatal care visit asks the nurse if developing vaginal yeast infections is common during pregnancy. Which of the following responses should the nurse make? A. "Have you discussed this with your doctor yet?" B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common." C. "Women who are already prone to vaginal yeast infections get them during pregnancy." D. "Why are you concerned about yeast infections during pregnancy?"

B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common." This is an information-seeking question; therefore, the therapeutic response is an answer that provides the client with the information she requested.

A nurse is assessing a pregnant client at 26 weeks of gestation who reports an episode of dizziness after lying on her back on the couch. Which of the following actions should the nurse take? A. Request a prescription for preeclampsia laboratory studies B. Advise the client to lie on her side C. Request an ultrasound to evaluate fetal wellbeing D. Advise the client to add a calcium supplement to her diet

B. Advise the client to lie on her side Dizziness after a pregnant client lies flat on her back is a sign of supine hypotension, which is caused by compression of the vena cava from the weight of the pregnant uterus. Pregnant women should be advised to avoid lying in a supine position. - Symptoms of preeclampsia include headaches, visual disturbances, swelling, and epigastric pain.

A nurse is caring for a recently delivered newborn whose mother had gestational diabetes. What action should the nurse take within 1 hr after birth? A. Administer the hepatitis B (HBV) vaccine B. Assess the newborn's blood glucose level C. Bathe the newborn D. Perform a screening for congenital heart disease

B. Assess the newborn's blood glucose level Newborns whose mothers have diabetes have a greater risk of developing hypoglycemia due to the cessation of the fetal blood glucose supply and fetal hyperinsulinemia. Blood glucose levels should be assessed within 1 hour after birth, followed closely, and treated promptly when needed.

A nurse is caring for a client who is at 38 weeks gestation and in the active phase of the first stage of labor. The nurse notes 2 late decelerations of the fetal heart rate during the last 5 contractions. Which of the following actions should the nurse take? A. Slow the IV infusion rate B. Assist the client to a lateral position C. Assess the bladder for urinary retention D. Initiate an oxytocin infusion

B. Assist the client to a lateral position A late deceleration is a variation in the fetal heart rate that results from uteroplacental insufficiency. Side-lying positioning helps improve uteroplacental blood flow

A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following medications should the nurse have available at the client's bedside? A. Naloxone B. Calcium gluconate C. Protamine sulfate D. Atropine

B. Calcium gluconate The nurse should have calcium gluconate available for a client who is receiving magnesium sulfate by continuous IV infusion in case of magnesium sulfate toxicity. The nurse should monitor the client for a respiratory rate of ≤12/min, muscle weakness, and depressed deep-tendon reflexes. - naloxone available for a client who is receiving opioid medication in case of respiratory depression. - protamine sulfate available for a client who is receiving heparin in case of hemorrhage. - atropine available for a client who is receiving medications that can lead to asystole or sinus bradycardia, such as beta-adrenergic blockers.

A nurse is teaching the guardians of a newborn about the facility's safety measures. Which of the following pieces of information should the nurse include? A. Expect staff to identify the newborn by verifying the information on the bassinet card B. Check for a photo identification badge before allowing a nurse to remove the newborn from the room C. Place the newborn in the bassinet when using the bathroom D. Hold the newborn securely when walking in the hallway

B. Check for a photo identification badge before allowing a nurse to remove the newborn from the room In maternal-newborn areas, all personnel should wear photo identification. Clients and their visitors should ensure the safety of the client and newborn by checking for photo identification on anyone who comes into the room.

A nurse is teaching a client who is at 10 weeks gestation about self-care management for common discomforts during pregnancy. Which of the following instructions should the nurse include? A. Douche every other day to minimize leukorrhea B. Consume frequent snacks to decrease episodes of nausea C. Refrain from scheduling dental procedures until the third trimester D. Decrease fluid intake to reduce urinary frequency

B. Consume frequent snacks to decrease episodes of nausea Clients with nausea during pregnancy should be instructed to ingest small snacks frequently. An empty or overloaded stomach can increase feelings of nausea.

A nurse is assessing a client who is at 12 weeks gestation and has a hydatidiform mole. Which of the following findings should the nurse expect? A. Hypothermia B. Dark brown vaginal discharge C. Decreased urinary output D. Fetal heart tones

B. Dark brown vaginal discharge A hydatidiform mole (a molar pregnancy) is a benign proliferative growth of the chorionic villi that gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grape-like clusters.

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider? A. Varicose veins B. Double vision C. Leukorrhea D. Flatulence

B. Double vision Double vision, blurred vision, or visual disturbances are signs of potential complications associated with preeclampsia. The nurse should report this finding to the provider.

A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1-2 hr of delivery? A. Naloxone B. Erythromycin ophthalmic ointment C. Poractant alfa D. Rotavirus immunization

B. Erythromycin ophthalmic ointment Every newborn born in the United States should receive erythromycin ophthalmic ointment to prevent gonorrheal or chlamydial infections that the newborn can contract during birth.

A nurse is assessing the respiratory status of a newborn who was born 2 hours ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress? A. Acrocyanosis B. Expiratory grunting C. Respiratory rate 56/min D. Irregular respirations

B. Expiratory grunting Expiratory grunting is an indication of respiratory distress that is caused by narrowing of the bronchi. The nurse should report this finding to the provider.

A nurse is caring for a term newborn 90 minutes after a scheduled cesarean birth. The newborn's 1-minute Apgar score was 9. The newborn's heart rate is 120/min, and his respiratory rate is 70/min. There are no indications of retractions, grunting, or nasal flaring. Which of the following actions should the nurse take? A. Request a prescription for continuous positive airway pressure (CPAP) B. Initiate close observation of the newborn for indications of respiratory distress C. Consult a respiratory therapist for chest physiotherapy D. Request an order for nitric oxide therapy

B. Initiate close observation of the newborn for indications of respiratory distress The newborn has manifestations of transient tachypnea of the newborn (TTN). This condition is thought to be a result of an incomplete clearance of fluid from the lungs at birth. Newborns born by cesarean are more likely to have TTN because the thoracic cavity is not compressed as in a vaginal birth. It usually resolves spontaneously, and close observation of the newborn is indicated.

A nurse is assessing a newborn. Which of the following findings suggests the newborn is post-mature? A. Pale, translucent skin B. Nails extending over fingers C. Weak gag reflex D. Thin covering of fine hair on shoulders and back

B. Nails extending over fingers This is an expected finding for a post-term infant.

A nurse is assessing a 12-hour-old newborn notes mild jaundice of the face and trunk. Which of the following actions should the nurse take? A. Administer phytonadione IM B. Obtain a stat prescription for a bilirubin level C. Obtain a bagged urine specimen D. Perform a gestational age assessment

B. Obtain a stat prescription for a bilirubin level Jaundice in the first 24 hours of life is pathologic. The nurse should notify the provider and obtain a stat prescription for a bilirubin level.

A nurse is assisting with the care of a client who is in labor. The nurse observes late decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Decrease the rate of the client's maintenance IV fluid B. Place the client in a left lateral position C. Apply oxygen at 2 L/min via nasal cannula D. Prepare the client for an amniocentesis

B. Place the client in a left lateral position The nurse should identify that decelerations of the fetal heart rate with an onset beginning after a contraction has started that persist beyond the end of the contraction are considered late decelerations. Later decelerations indicate an interruption in fetal oxygenation. A lateral position improves blood flow to the uterus and intervillous spaces. Repositioning the client is a component of intrauterine resuscitation.

A nurse is caring for a client who is in labor. The nurse observes late decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Decrease the rate of the client's maintenance IV fluid B. Place the client in a left lateral position C. Apply oxygen at 2 L/min via nasal cannula D. Prepare the client for an amniocentesis

B. Place the client in a left lateral position The nurse should identify that decelerations of the fetal heart rate with an onset beginning after a contraction has started that persist beyond the end of the contraction are considered late decelerations. Later decelerations indicate an interruption in fetal oxygenation. A lateral position improves blood flow to the uterus and intervillous spaces. Repositioning the client is a component of intrauterine resuscitation.

A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse perform first? A. Perform a detailed physical assessment B. Place the newborn directly on the client's chest C. Give the newborn IM vitamin K D. Administer erythromycin ophthalmic ointment

B. Place the newborn directly on the client's chest In this case, the greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client's chest will help maintain the newborn's temperature.

A nurse is assessing a client at 37 weeks gestation who has a suspected pelvic fracture due to blunt abdominal trauma. Which of the following findings should the nurse expect? A. Bradycardia B. Uterine contractions C. Seizures D. Bradypnea

B. Uterine contractions The nurse should expect the client to be experiencing uterine contractions due to abdominal trauma

This reflex is elicited by stroking upward along the lateral edge of the sole of the foot. In infancy, hyperextension of the toes with dorsiflexion of the great toe is expected. An absence of the response warrants neurological evaluation.

Babinski reflex

A nurse is teaching a client at 13 weeks gestation about the treatment of incompetent cervix with cervical cerclage. Which of the following statements by the client indicates an understanding of the teaching? A. "I am sad that I won't be able to get pregnant again." B. "I can resume having sex as soon as I feel up to it." C. "I should go to the hospital if I think I may be in labor." D. "I should expect bright red bleeding while the cerclage is in place."

C. "I should go to the hospital if I think I may be in labor." Cervical cerclage prevents premature opening of the cervix during pregnancy. The client should immediately go to a facility for evaluation if she experiences any manifestations of labor while the cerclage is in place. If the client experiences preterm uterine contractions, she might require tocolytic therapy.

A nurse is caring for a newborn who has a prescription for phototherapy. The mother asks why the newborn needs to lay under a special light. Which of the following responses should the nurse make? A. "The light helps your baby maintain his body temperature." B. "The light helps your baby establish a regular sleeping pattern." C. "The light will help lower your baby's bilirubin level." D. "The light will help regulate your baby's blood sugar."

C. "The light will help lower your baby's bilirubin level." Jaundice is caused by the breakdown of red blood cells, which release bilirubin. A newborn's immature liver is unable to filter and excrete the bilirubin efficiently, leading to accumulation of bilirubin in the tissues. The ultraviolet light in phototherapy assists in breaking down the bilirubin so that it can be excreted in the urine and feces.

A nurse is caring for a client who has a prescription for naloxone. Which of the following is the intended action of the medication in relation to the central nervous system (CNS)? A. Accentuate the effects of narcotics on the CNS B. Depress activity of the CNS C. Block the effects of narcotics on the CNS D. Stimulate activity of the CNS

C. Block the effects of narcotics on the CNS By blocking the effects of narcotics on the CNS, naloxone prevents CNS and respiratory depression in the newborn following delivery.

A nurse is caring for a client who is receiving magnesium sulfate IV. Which of the following medications should the nurse have available as an antidote to magnesium sulfate? A. Betamethasone B. Terbutaline C. Calcium gluconate D. Indomethacin

C. Calcium gluconate Calcium gluconate should be kept available as the antidote for magnesium sulfate toxicity. - Betamethasone is administered to help mature the lungs of the premature fetus before delivery - Terbutaline is a smooth muscle relaxer administered to inhibit uterine contractions in premature labor. - . Indomethacin relaxes uterine smooth muscle and is administered to stop preterm labor.

A nurse is reviewing the laboratory report for a client with suspected HELLP syndrome. Which of the following findings should the nurse report to the provider as an indication of this disorder? A. Elevated hemoglobin B. Elevated creatinine clearance C. Elevated liver enzymes D. Elevated platelet count

C. Elevated liver enzymes The nurse should expect a client who has HELLP syndrome to have elevated liver enzymes. HELLP refers to hemolysis (H), elevated liver enzymes (EL), and low platelet count (LP). This syndrome is a severe form of preeclampsia. - decreased hemoglobin - decreased creatinine clearance - deceased platelet count

A nurse is planning care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care? A. Swaddle the newborn in a receiving blanket during the treatment B. Maintain NPO status until the newborn's bilirubin is within the expected reference range C. Ensure the newborn's eyes are closed before applying the eye shield D. Apply lotion to the newborn's skin twice per day

C. Ensure the newborn's eyes are closed before applying the eye shield Overexposure to the lights during treatment can cause damage to the newborn's corneas. Therefore, the nurse should gently close the newborn's eyes prior to applying the eye shield. - ensure that the newborn has as much skin exposed to the lights as possible. - encourage frequent feedings throughout the treatment to prevent dehydration and to help promote excretion of bilirubin in the stools. - Lotion can cause burn

A nurse is caring for a client who states, "I think I am pregnant." Which of the following findings should the nurse identify as a positive sign of pregnancy? A. Positive serum pregnancy test B. Amenorrhea C. Fetal heart tones auscultated by Doppler D. Chadwick sign

C. Fetal heart tones auscultated by Doppler Fetal heart tones heard by Doppler are a positive sign of pregnancy. The only possible explanation for hearing fetal heart tones is the presence of a fetus. - A positive pregnancy test is a probable sign of pregnancy. - Amenorrhea is a presumptive sign of pregnancy. - Chadwick sign is a probable indication of pregnancy

A nurse is caring for a client who is scheduled to receive a continuous IV infusion of oxytocin following a vaginal birth. Which of the following assessment findings should the nurse monitor to evaluate the effectiveness of the medication? A. Urinary output B. Blood pressure C. Fundal consistency D. Pulse rate

C. Fundal consistency Oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective. - identify water intoxication, which is an adverse effect of oxytocin. - identify hypertension, which is an adverse effect of oxytocin. - identify cardiac dysrhythmias, which are adverse effects of oxytocin.

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Pink-tinged urine B. Scant amount of nipple discharge C. Grunting with expiration D. Bluish discoloration of feet and hands

C. Grunting with expiration Grunting, nasal flaring, and substernal or intercostal retractions are signs of respiratory distress in a newborn. The nurse should report this finding to the provider.

A nurse is teaching a group of clients who are pregnant about vitamin K for newborns. Vitamin K helps prevent which of the following conditions in a newborn? A. Altered carbohydrate metabolism B. Hyperbilirubinemia C. Intracranial hemorrhage D. Hypoglycemia

C. Intracranial hemorrhage Vitamin K, which is necessary for blood clotting, is produced by the action of bacteria in the gastrointestinal system. A newborn's gastrointestinal system is sterile and therefore deficient in vitamin K at birth. It needs to be supplemented to protect the newborn from bleeding until the gastrointestinal system is colonized with flora.

A nurse is assessing a 7-month-old infant during a well-child visit and notes the presence of a full Moro reflex. For which of the following conditions should the nurse screen the infant? A. Congenital heart disease B. Hearing loss C. Neurological disorder D. Amblyopia

C. Neurological disorder The Moro reflex, also known as the startle reflex, is elicited by striking the surface next to the newborn to startle him/her. A classic pattern of abduction and extension of the arms is expected. This reflex should be gone by 4 months of age; its presence after 4 months of age is associated with a neurological disorder.

A nurse is calculating a pregnant client's estimated date of delivery using Naegele's rule. The client's last menstrual period started on January 20. Which of the following is the client's expected date of delivery? A. October 13 B. November 13 C. October 27 D. November 27

C. October 27 Naegele's rule involves subtracting 3 months from the first day of the last menstrual period and adding 7 days.

A nurse is assessing a 4-hour-old newborn prior to breastfeeding and notes hands and feet that are cool and slightly blue. Which of the following actions should the nurse take? A. Apply an oxygen hood over the newborn's head and neck B. Check the newborn's temperature using a temporal thermometer C. Place the naked newborn on the mother's bare chest and cover both with a blanket D. Give the newborn glucose water between feedings

C. Place the naked newborn on the mother's bare chest and cover both with a blanket Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with the mother helps stabilize the newborn's temperature and promotes bonding.

A nurse is teaching new parents about newborn reflexes. Which of the following reflexes facilitates infant feeding? A. Stepping B. Moro C. Rooting D. Babinski

C. Rooting The rooting reflex is elicited when the cheek is stroked and the newborn turns the head while making sucking motions with the mouth. This reflex supports effective sucking.

A nurse is teaching a client who is at 30 weeks gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching? A. Mild constipation B. Nasal congestion C. Vaginal bleeding D. 10 fetal movements per hour

C. Vaginal bleeding Vaginal bleeding can be an abnormal finding during pregnancy indicating a complication such as placental abruption, placenta previa, or preterm labor.

A nurse is providing counseling for a couple experiencing infertility issues. Which of the following statements by the nurse is appropriate? A. "Even though you can't have children biologically, you can always adopt a child." B. "You need to take a break from these attempts to conceive." C. "You might want to join our support group for couples who are experiencing similar problems." D. "Why didn't you get your immunizations when you were younger?"

C. You might want to join our support group for couples who are experiencing similar problems." An invitation to join a support group will promote emotional, social, and spiritual growth. Many positive results from peer support can occur.

A nurse is caring for a client who is at 39 weeks gestation and shows manifestations of labor. Which of the following findings will alert the nurse that the client is in true labor? A. Contractions felt in the upper abdomen B. A small amount of bloody discharge C. Contractions occurring every 2 to 10 min D. Changes in cervical dilation or effacement

D. Changes in cervical dilation or effacement Cervical changes are signs of true labor. - typically felt in the lower back and radiate to the lower abdomen. =MIrregular contractions are Braxton-Hicks contractions and are not a sign of true labor.

A nurse is caring for a client who is in labor. The client asks the nurse, "Why are you pressing on my abdomen?" Which of the following responses should the nurse make? A. "I can determine your baby's heart rate." B. "I can confirm that you have sufficient fluid around your baby." C. "I can confirm that your baby moves with stimulation." D. "I can determine the position of your baby."

D. "I can determine the position of your baby." Palpation of the abdomen can determine which fetal part is in the uterine fundus and where the back of the fetus is. Palpating the lower abdomen will help determine whether the fetus's head is down or if another extremity is the presenting part.

A nurse is providing teaching about newborn care to the parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will wash my baby's umbilical cord stump with antibacterial soap." B. "I will cover my baby with a lightweight blanket during nap time." C. "I will use a cotton-tipped swab to clean my baby's ear canals." D. "I will place a hat on my baby's head prior to going outside."

D. "I will place a hat on my baby's head prior to going outside." The parent should place a hat or bonnet on the newborn's head to protect the scalp, minimize heat loss, and protect against sunburn.

A nurse is teaching a client who is postpartum about keeping the newborn safe. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will put bumper pads in the crib." B. "I will warm my baby's formula in the microwave on a low setting." C. "I will place my baby on his stomach to sleep." D. "I will purchase a firm mattress for the crib."

D. "I will purchase a firm mattress for the crib." A firm mattress that leaves no gaps between it and the crib rails helps prevent suffocation and entrapment. -MBumper pads, pillows, stuffed toys, and blankets increase the risk of suffocation. -never use a microwave oven to heat refrigerated formula or breast milk. Heating in a microwave is inconsistent and can cause burns. Instead, the client should warm the formula in a pan of hot water and test the temperature with a few drops on the inner aspect of her wrist before feeding it to the newborn. - place the newborn on his back to sleep to reduce the risk of sudden infant death syndrome.

A nurse is caring for a client who delivered a stillborn child. Which of the following actions should the nurse take? A. Tell the parents that they should hold their child while they have the chance B. Stay with the parents as long as the child is still in the mother's room C. Discourage the parents from viewing any of the child's congenital anomalies D. Allow the parents to keep the child in their room for as long as they wish

D. Allow the parents to keep the child in their room for as long as they wish The parents should have unrestricted access to the child's body. This time allows them to process the traumatic event. Evidence shows that the risk of infection caused by having a deceased body in the room is minimal. Most parents will be ready to say goodbye to the body when it begins to show obvious signs of deterioration.

While caring for a client who is in active labor, a nurse notes late decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Administer methyl-prostaglandin IM B. Encourage the client to use the shower C. Place the client in a supine position D. Apply oxygen at 10 L/min via nonrebreather face mask

D. Apply oxygen at 10 L/min via nonrebreather face mask Late decelerations are caused by uteroplacental insufficiency and require intervention to increase oxygen flow to the fetus. Administering oxygen to the client will increase the amount of oxygen available to the fetus. - Methyl-prostaglandin is a uterotonic medication that will increase contractility of the uterus. It should never be administered to a pregnant client. - shower might decrease maternal discomfort, but it does not increase oxygen flow to the fetus. - supine position can decrease uteroplacental blood flow further due to compression of the vena cava.

A nurse is caring for a client whose last menstrual period (LMP) began on July 8. Using Naegele's rule, what is the client's estimated date of birth (EDB)? A. October 1 B. April 1 C. October 15 D. April 15

D. April 15. Explanation: Using Naegele's rule, the nurse determines the EDB by counting back 3 months from the first day of the LMP and adding 7 days.

A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) immune globulin? A. While the client is in labor B. Following an episode of influenza during pregnancy C. Prior to a blood transfusion D. At 28 weeks gestation

D. At 28 weeks gestation The nurse should administer Rh(D) immune globulin to a client who is pregnant and has Rh-negative blood at 28 weeks gestation. Rh(D) immune globulin consists of passive antibodies against the Rh factor, which will destroy any fetal RBCs in the maternal circulation and block maternal antibody production.

A nurse is providing teaching to a client who is at 8 weeks gestation about manifestations to report to the provider during pregnancy. Which of the following pieces of information should the nurse include in the teaching? A. Nausea upon awakening B. Leg cramps while sleeping C. Increased white vaginal discharge D. Blurred or double vision

D. Blurred or double vision A client who is pregnant should report experiencing blurred or double vision, as these could be a manifestation of gestational hypertension or preeclampsia.

A charge nurse is teaching newly licensed nurses about teratogens that affect fetal development. The nurses should recognize that which of the following is an example of a teratogen? A. Consuming caffeine during pregnancy B. A family history of a genetic disorder C. Gum disease in a pregnant client D. Drinking alcohol during pregnancy

D. Drinking alcohol during pregnancy Alcohol is an outside substance that, if ingested by a client who is pregnant, can cause abnormal fetal development. Alcohol consumption during pregnancy can cause central nervous system disorders, abnormal craniofacial features, and cognitive impairment.

A nurse is reviewing the provider's admission orders for a client who is at 37 weeks of gestation and is HIV positive. Which of the following orders should the nurse clarify with the provider? A. Intermittent auscultation B. Biophysical profile C. Non-stress test (NST) D. Fetal scalp electrode

D. Fetal scalp electrode The placement of a fetal scalp electrode is an invasive procedure that requires ruptured membranes. The electrode is inserted into the fetal scalp, which will increase the fetus's exposure to HIV and is contraindicated.

A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department? A. Bacterial vaginosis B. Trichomoniasis C. Candidiasis D. Gonorrhea

D. Gonorrhea Gonorrhea is often asymptomatic. The client might have purulent endocervical discharge. Gonorrhea is one of the infectious conditions on the Nationally Notifiable Infections list and should be reported by the nurse to the community health department, which will report the infection to the CDC.

A nurse is caring for a client who is 24 years old and at 13 weeks of gestation. The client's history includes a BMI of 31 prior to pregnancy, a prior post-term delivery, and a newborn birth weight of 4,167.38 g (9 lb 3 oz). Which of the following laboratory values should the nurse expect to collect? A. Maternal serum alpha-fetoprotein B. Pregnancy-associated plasma protein A C. Chorionic villus sampling D. HbA1c

D. HbA1c HbA1c measures average plasma glucose concentration over the 12 weeks preceding the test. A female client whose BMI is >30 and who has a history of delivering a baby weighing over 4,082.33 grams (9 lb) is at risk for impaired glucose metabolism and should be screened at the end of the first trimester.

A nurse is caring for a client in the early stage of labor who has preeclampsia with severe features. Which of the following interventions should the nurse perform? A. Assess the fetal heart rate and contractions hourly B. Encourage oral intake of clear, low-sodium fluids C. Instruct the client to ambulate during the early phase of labor D.Implement seizure precautions

D. Implement seizure precautions Clients who have preeclampsia with severe features are at risk for seizures. The nurse should keep the side rails of the client's bed up and ensure oxygen and suction equipment are readily available.

A nurse is assisting with monitoring the fetal heart rate tracings of a client who is in labor. Which of the following findings should the nurse report to the provider? A. Baseline fetal heart rate of 110 to 130/min B. Moderate baseline variability C. Accelerations in response to fetal stimulation D. Late decelerations with fetal bradycardia

D. Late decelerations with fetal bradycardia The nurse should identify that a fetal monitor showing recurrent late decelerations and bradycardia indicates that the fetus is not tolerating labor and may be compromised. These findings should be assessed in relation to the clinical picture of the progression of labor. The nurse should notify the provider to update the plan of care for the client and her baby.

A nurse is using Naegele's rule to determine the estimated date of birth (EDB) for a client whose first day of her last menstrual period was February 2, 2018. The nurse should identify which of the following as the client's EDB? A. November 16, 2018 B. October 19, 2018 C. October 26, 2018 D. November 9, 2018

D. November 9, 2018 This would be the correct EDB because Naegele's rule involves counting backward 3 calendar months from the first day of the client's last menstrual period and then adding 7 days.

A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? A. Anemia B. Frequent urinary tract infections C. Previous cesarean birth D. Pelvic inflammatory disease (PID)

D. Pelvic inflammatory disease (PID) An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and the placenta, and the fetus begin to develop in this area. The most common site is within a fallopian tube, but ectopic pregnancies can occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, PID places the client at risk of an ectopic pregnancy.

A nurse is providing education for the parent of a premature infant on interventions to promote optimal development. Which of the following actions should the nurse instruct the parent to perform? A. Maintain bright lighting to enable close observation of the infant at all times B. Place the infant in a prone position with arms and legs extended C. Rouse the infant every 1-2 hr to provide auditory and visual stimulation D. Provide kangaroo care for the infant

D. Provide kangaroo care for the infant Studies show that premature infants who are held skin-to-skin ("kangaroo care") demonstrate improved thermostability, oxygen saturation, interest in feeding, and maintenance of an organized, relaxed state.

A client who is pregnant tells the nurse that she is financially unable to buy the food and vitamins recommended during pregnancy. Which of the following actions should the nurse take? A. Explain to the client that improper nutrition could lead to birth defects in her baby. B. Instruct the client to return to the clinic for weekly weigh-ins for the remainder of the pregnancy. C. Provide the client with sample menus to promote nutritious meal preparation. D. Refer the client to a community resource that could assist with providing nutrition.

D. Refer the client to a community resource that could assist with providing nutrition. Federal and state programs are available to provide financial assistance that allows pregnant women and families with young children to purchase nutritious foods.

A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement? A. Self-hypnosis B. Biofeedback C. Acupuncture D. Slow-paced breathing

D. Slow-paced breathing Slow-paced breathing is an easy technique for the client to learn quickly and practice immediately. It provides distraction, which can help reduce the perception of pain. The pattern is In-2-3-4/Out-2-3-4/In-2-3-4/Out-2-3-4. Repeating this cycle slows the client's breathing to about half of its usual rate, which can help relax the client and improve oxygenation.

A nurse is caring for a client in the third trimester of pregnancy who reports difficulty sleeping. Which of the following instructions should the nurse provide? A. Eat a high-fat snack before bed. B. Exercise in the evening before bed. C. Sleep in the supine position. D. Use additional pillows to support extremities and abdomen.

D. Use additional pillows to support extremities and abdomen. Finding a comfortable position for sleeping during the last 3 months of pregnancy can be difficult due to fetal growth. Using additional pillows promotes a more comfortable sleeping position.

A nurse is caring for a client who is pregnant and whose last menstrual period (LMP) began on April 8. Using Naegele's rule, which of the following dates would be the client's estimated date of birth (EDB)? A. July 15 B. July 11 C. January 11 D. January 15

D.January 15 According to Naegele's rule, the nurse should subtract 3 months and add 7 days to the first day of the client's LMP to determine the EDB, plus or minus 7 days. April (month 4) minus 3 months yields January. After adding 7 days to the date of the client's LMP, the EDB is January 15.

This reflex, also known as the startle reflex, is elicited by striking the surface next to the newborn. The pattern of abduction and extension of the arms that follows is expected.

Moro relfex

This is a reflex of the lower extremities. When the newborn is held vertically, he or she will make leg movements that look like walking.

Stepping reflex

Obtain a prescription for serum substance screening

The nurse should expect a newborn who was exposed to substances in utero to be small for gestational age and should identify hypertonic muscles and hyperactivity as manifestations of neonatal abstinence syndrome

Screen the newborn for phenylketonuria (PKU)

The nurse should perform routine screening for PKU according to state law. A capillary sample to check for PKU is typically obtained 24 hours after birth.

Provide a feeding of sterile water

This newborn is at risk of and is exhibiting manifestations of hypoglycemia. Therefore, the nurse should administer a feeding that provides glucose rather than sterile water.

Trichomoniasis

can be asymptomatic. Manifestations include greenish to yellowish mucopurulent, frothy, malodorous discharge. This vaginal infection does not require reporting.

Chorionic villus sampling

indicated for women older than 35 years of age at the time of pregnancy, as well as those who have a history of spontaneous abortions, previous pregnancies of infants with chromosomal defects, or an abnormal ultrasound finding.

Candidiasis also known as a yeast infection

is the second-most common vaginal infection. Manifestations include a client report of thick, cottage cheese-like discharge and vaginal itching. This vaginal infection does not require reporting.

Maternal serum alpha-fetoprotein

part of the screening for open neural tube defects which takes place at 16 to 18 weeks of gestation

Pregnancy-associated plasma protein

part of the screening for potential birth defects at 16 to 18 weeks

Bacterial vaginosis' also known as vaginitis

the most common vaginal infection. Manifestations include client report of a "fishy odor" and vaginal discharge that appears thin, watery, gray, white, or milky. The client might also report pruritus. This vaginal infection does not require reporting; however, it should be treated with metronidazole or clindamycin cream.