Maternity Q&A Review for the NCLEX Questions

The nursing student preparing to suction a tracheostomy on a newborn infant sets the suction setting at 120 mm Hg. How should the staff nurse reviewing the preparations made by the student nurse respond?

"Before you proceed, I think it is best for us to review the procedure together."

The nurse provides instructions to new parents regarding their newborn infant's nutritional needs. Which statement by the parents indicates an understanding of these needs?

"Breast milk or infant formula is all that is needed for the first 6 months."

A pregnant woman with diabetes mellitus has lost 10 pounds during the first 15 weeks of gestation. The client tells the nurse, "I do not eat regular meals." Based on the client's statement, what is the best response for the nurse to make?

"Can you tell me more about what you are eating?"

A new mother is trying to decide whether to have her baby boy circumcised. The nurse should make which statement to assist the mother with making the decision?

"Circumcision is a difficult decision. Here, read this pamphlet that discusses the pros and cons, and we will talk about any questions that you have after you read it."

The nurse conducts a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which statement by the client indicates an understanding of the purpose of and need for iron supplementation?

"The iron is needed to make red blood cells to supply my baby with food."

A pregnant client is positive for human immunodeficiency virus (HIV). The client asks the nurse whether the newborn will contract the virus. Which response should the nurse make to the client?

"The newborn infant has a risk of developing the disease."

The nurse is caring for an infant diagnosed with respiratory distress syndrome. The infant will require the instillation of surfactant replacement therapy via an endotracheal tube, and the parents will be present during the procedure. The father states that he is not sure about having this done to his baby. Which statement by the nurse before performing the procedure will aid in preparing the parents?

"You have concerns about this procedure for your baby?"

The mother of a newborn diagnosed with hydrocephalus is concerned about the complication of mental retardation. The mother states to the nurse, "I'm not sure if I can care for my baby at home." Which therapeutic response should the nurse make to the mother?

"You have concerns about your baby's condition and care?"

A neonatal intensive care nurse is caring for a newborn with a suspected diagnosis of erythroblastosis fetalis. Which therapeutic statement should the nurse make to the parents at this time?

"You must have many concerns. Please ask me any questions that you have so that I can explain your infant's care."

The nurse is assessing a pregnant client with a diagnosis of abruptio placentae. Which manifestations of this condition should the nurse expect to note? Select all that apply.

1. Uterine irritability 2. Uterine tenderness 4. Abdominal and low back pain 6. Nonreassuring fetal heart rate patterns

Most newborn infants who are human immunodeficiency virus (HIV)-positive are asymptomatic at birth. Which early finding should be noted in an HIV-positive infant?

Hepatosplenomegaly

The nurse is performing an assessment on a pregnant client and her partner. The nurse suspects intimate partner violence. Which clinical findings support the possibility of domestic abuse? Select all that apply.

*Physical bruising to breasts and abdomen is observed. *Pregnant client has made several prior clinic visits this month for GI distress. *Partner attends the prenatal visit and responds to questions asked to pregnant partner.

The nurse is preparing to assess the respirations of several newborns in the nursery. The nurse performs the procedure and determines that the respiratory rate is normal if which finding is noted?

A respiratory rate of 46 breaths per minute in an awake newborn

The nurse educating second-trimester pregnant clients about preterm labor should include which signs/symptoms in the teaching plan? Select all that apply.

2. Pelvic pressure or heaviness 3. Painful, menstrual-like cramps 5. Dull, intermittent; low back pain below the waist

A woman is 22 weeks pregnant. Her assessment history identifies that she had 1 full-term pregnancy that resulted in a live birth 2 years ago. What is her gravidity and parity, using the two-digit system?

2/2

Instructions for the self-care for a client with premature rupture of membranes should include which actions? Select all that apply.

3. Remain on modified bed rest. 5. Watch for foul-smelling vaginal discharge. 6. Report a temperature of more than 100.4 ° F (38° C).

A blood glucose 1-hour screen is measured on a pregnant client, and the results indicate that the blood glucose level is elevated. Which intervention should the nurse anticipate to be prescribed for the mother?

A 3-hour glucose tolerance test

Which newborn has the highest risk for developing physiological jaundice?

A preterm newborn

The nurse is caring for a client experiencing hypotonic labor contractions. The client is very discouraged with the progress she is making but adamantly refuses an amniotomy or oxytocin stimulation. The nurse determines that the client's behavior may be attributed to which?

A concern about her own and the baby's well-being

The nurse is conducting a home visit for a postpartum mother and her 1-week-old infant. The home care nurse concludes that the infant should be evaluated for acquired neonatal congenital syphilis if which signs/symptoms are observed in the infant at this time?

A copper-colored maculopapular dermal rash on the palms, soles, mouth, and anal areas

The nurse is preparing to attach an ultrasound transducer to obtain a continuous fetal heart rate (FHR) pattern on a client in active labor. The nurse performs Leopold's maneuvers. Which figure depicts the Leopold's maneuver that determines which side of the uterus the fetal back is on? Refer to figure.

B

The nurse working in a prenatal clinic is briefly reviewing the records of a number of clients scheduled for prenatal visits today. Which factor most likely places a woman at risk for abruptio placentae?

Continues to use illegal drugs

The nurse is caring for a client in active labor. Which natural and soothing techniques should the nurse plan to use during active labor to assist the client to effectively manage the labor process?

Counterpressure and effleurage

The nurse is interviewing a client on her first prenatal visit. She is 6 weeks pregnant, has three living children, and had one spontaneous abortion at 6 weeks. When the nurse asks about family history, the client reports that both her mother and grandmother died of complications from diabetes mellitus. The nurse should then gather information about which item?

How large her other children were at birth

The nurse in the newborn nursery is planning for the admission of a large for gestational age (LGA) infant. In preparing to care for this infant, the nurse should obtain equipment to perform which diagnostic test?

Heel stick blood glucose

A newborn is diagnosed with Hirschsprung's disease, based on the failure to pass meconium. The nurse observes that the parents are hesitant to hold their newborn. Based on this assessment, which action is an important nursing consideration in working with the parents?

Helping the parents adjust to the congenital disorder

The nurse uses standard precautions for contact with body fluids of the newborn and plans to wear gloves when performing which activity?

Providing cord care

Which nursing assessment findings indicate normal vital signs in a newborn infant?

Pulse, 144; respiratory rate, 48

The nurse caring for a postpartum client should suspect that the client is experiencing endometritis if which is noted?

Fever over 38° C (100.4° F), beginning 2 days postpartum

At the last vaginal exam, the client who is in the late first stage of labor was fully effaced, 8 cm dilated, vertex presentation, and station -1. Which observation would indicate that the fetus was in fetal distress?

Fresh, thick meconium is passed with a small gush of liquid, and the fetal monitor shows late decelerations with a variable descending baseline.

A newborn is documented as having a 1-minute Apgar score of 2. When considering the general distress the infant is experiencing, what term would be used?

Severe

The nurse employed in a primary health care provider's office is assessing a client with placenta previa. Which item should the nurse assess as a priority?

Signs of fetal distress

An 8-pound 15-ounce baby born at 36 weeks' gestation should be described using which terminology? Select all that apply.

Preterm LGA

The nurse is caring for a woman with a twin pregnancy. What is a priority concern of the nurse related to the twin pregnancy?

Preterm labor

On assessment of a newborn being admitted to the nursery, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition?

A normal finding

The nurse is preparing to teach a new mother to breast-feed. Which factor is important to promote an effective and positive learning experience?

A positive nurse-client relationship

The nurse is assessing a 3-day-old preterm neonate with a diagnosis of respiratory distress syndrome (RDS). Which assessment finding indicates that the neonate's respiratory condition is improving?

Urine output of 3 mL/kg/hour

A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse counsels the client and determines that there is a need for further teaching when the client makes which statement?

"Breast-feeding after delivery is best for my baby."

A pregnant client tests positive for the hepatitis B virus. The client asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which therapeutic response should the nurse communicate to the client?

"Breast-feeding is allowed if the baby receives prophylaxis treatment at birth and scheduled immunizations."

A pregnant client tests positive for hepatitis B virus (HBV). The client would like to breast-feed her newborn infant after delivery and asks the nurse whether this is possible. Which response should the nurse make to the client?

"Breast-feeding is considered safe as long as the newborn infant has been vaccinated."

The nurse is planning care for a client who presents in active labor with a history of a previous cesarean delivery. The client complains of a "tearing" sensation in the lower abdomen. She is upset, and she expresses concern for the safety of her baby. Which therapeutic response to the client should the nurse make?

"I can understand that you are fearful. We are doing everything possible for your baby."

During clinical conference, a nursing instructor asks a nursing student to explain the purpose of effleurage for a client in early labor. Which statement by the student indicates an understanding of why this procedure is performed?

"Effleurage is light stroking of the abdomen to facilitate relaxation during labor."

A newborn infant is diagnosed with hypospadias, and the mother asks the nurse about the disorder. After the nurse provides education to this mother, which statement by the mother indicates the teaching has been effective?

"Hypospadias is a congenital anomaly in which the actual opening of the urethral meatus is below the normal placement on the glans penis."

The clinic nurse is discussing the importance of the antenatal period with a pregnant client diagnosed with human immunodeficiency virus (HIV) and informs the client that the client's weight gain pattern will be plotted on a regular basis. The client asks the nurse why this is so important. What should the nurse tell the client?

"I can identify adequate weight gain throughout pregnancy to ensure appropriate fetal development."

A client has just delivered a large-for-gestational-age (LGA) infant by the vaginal route. The client verbalizes concern regarding the infant's facial bruising and causing pain to the site if touched. Which therapeutic statement should the nurse make to alleviate the client's concerns?

"I can show you how to gently stroke the face and not cause pain."

The nurse is preparing a postpartum client who had a cesarean delivery for discharge to home. Which statement by the client indicates a need for additional teaching before discharge?

"I can start doing abdominal exercises as soon as I get home."

A 17-year-old client is discharged to home with her newborn baby after the nurse provides information about home safety for children. Which statement by the client should alert the nurse that further teaching is required regarding home safety?

"I have a car seat that I will put in the front seat to keep my baby safe."

The nurse working in the prenatal clinic is providing dietary teaching to the pregnant client. Which statement by the client indicates a need for further instruction?

"I love to eat different cheeses, especially Brie."

The clinic nurse teaches a pregnant client with herpes genitalis about the measures that will be implemented during the pregnancy. Which statement by the client indicates an understanding of these measures?

"I may need a cesarean section if the lesions are present at the time of labor."

A maternity client is seen in the health care clinic and is complaining of ankle edema. After diagnostic evaluation, it has been determined that the blood pressure is within normal limits, and proteinuria is not present. The nurse provides home care instructions to the client. Which statement by the client indicates the need for further instructions?

"I need to avoid frequent rest periods."

The nurse teaches the mother of a newly circumcised infant about postcircumcision care. Which statement by the mother indicates an understanding of the care required?

"I need to check for bleeding every hour for the first 12 hours."

The nurse instructs a client with mild preeclampsia about home care measures. Which statement by the client indicates to the nurse that the teaching has been effective concerning the assessment of complications for preeclampsia?

"I need to check my urine with a dipstick every day for protein and call the doctor if it is 2+ or more."

A client is seen in the prenatal clinic complaining of heartburn, and the nurse provides instructions to the client regarding measures to alleviate the heartburn. Which statement by the client indicates a need for further instructions?

"I need to lie down after eating."

A client is prescribed mifepristone. Which statement by the client indicates a need for further teaching?

"I need to limit smoking cigarettes to 1 pack a day while taking this medication."

When a breast-feeding mother reports experiencing nipple soreness, the nurse provides teaching regarding measures to relieve the soreness. Which statement by the mother indicates an understanding of the teaching?

"I need to position my infant with her ear, shoulder, and hip in straight alignment and place her stomach against me."

The nurse has conducted a class for pregnant clients diagnosed with diabetes mellitus about the signs/symptoms of potential complications. The nurse determines that the teaching was effective if a client makes which statement?

"I need to watch my weight for any sudden gains because I could develop what they call gestational hypertension."

A perinatal client with a history of heart disease has been instructed on care at home. Which statement by the client indicates that the client understands her needs?

"I should avoid stressful situations."

A primigravida at 10 weeks' gestation is asking about experiencing fetal movement. The nurse validates the client's understanding of fetal movement (quickening) when the client makes which statement?

"I should experience fetal movement at 18 to 20 weeks of my pregnancy."

A primigravida at 16 weeks' gestation asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother when fetal movements will most likely be noted. Which response by the client indicates understanding of this information?

"I should experience fetal movement within the next few weeks."

A perinatal client has been instructed about the prevention of genital tract infections. Which statement by the client indicates an understanding of these preventive measures?

"I should wear underwear with a cotton panel liner."

The nurse is teaching a mother diagnosed with diabetes mellitus who delivered a large-for-gestational-age (LGA) infant about the care of the infant. The nurse tells the mother that LGA infants appear to be more mature because of their large size, but that, in reality, these infants frequently need to be aroused to facilitate nutritional intake and attachment. Which statement by the mother indicates the need for additional teaching about the care of the infant?

"I will allow my baby to sleep through the night because he needs his rest."

The nurse provides instructions to a pregnant woman regarding measures to relieve low back pain. Which statement by the client indicates an understanding of these measures?

"I will do the pelvic tilt exercises."

The nurse is instructing a pregnant client regarding measures to prevent a recurrent episode of preterm labor. Which statement by the client indicates the need for further teaching?

"I will limit my fluid intake to three 8-ounce glasses of fluid per day."

A new breast-feeding mother experiencing breast engorgement is provided with instructions regarding care for the condition. Which statement by the mother indicates to the nurse that she possesses an understanding of the measures that will provide comfort for the engorgement?

"I will massage my breasts before feeding to stimulate letdown."

The nurse provides instructions about measures that will provide comfort to a breast-feeding mother who is experiencing breast engorgement. Which statement by the mother indicates an understanding of these measures?

"I will massage the breasts before feeding to stimulate letdown."

The clinic nurse is collecting data on a client who has just been told that she is pregnant. Laboratory results indicate that the client is Rh negative and Coombs' antibody negative. The nurse instructs the client regarding the necessary measures related to the results of the laboratory report. Which statement by the client indicates an adequate understanding of the instructions?

"I will need a shot of RhoGAM when I am 28 weeks' pregnant."

During a prenatal visit, the nurse provides dietary instructions to a client diagnosed with diabetes mellitus. Which instruction should the nurse include in the teaching plan?

"It is important to increase fiber in the diet in order to control the blood glucose and prevent constipation."

A mother of an infant born at 42 weeks' gestation arrives at the neonatal intensive care unit to visit her infant. The mother notes that her infant is on a mechanical ventilator and states, "I don't understand. I thought my baby would be fine. Why is my baby on this machine?" What is an appropriate response by nurse?

"Many postterm babies aspirate meconium, and the mechanical ventilator helps the baby breathe easier."

The nurse teaches a pregnant client diagnosed with human immunodeficiency virus (HIV) about measures to prevent opportunistic infections. Which client statement indicates that the teaching has been effective?

"My husband is taking care of cleaning the fish tank."

A client has some concerns regarding chorionic villus sampling (CVS) and states to the nurse, "I'm not sure I should have this test done." Which appropriate response should the nurse make to the client?

"Tell me what concerns you have."

The nurse provides instructions to a client with mild preeclampsia regarding care at home. Which statement by the client indicates the need for further instructions?

"The purpose of having the home care nurse visiting is that I will not have to struggle to make it to my doctor's office."

A pregnant client who is anemic tells the nurse that she is concerned about her baby's condition after delivery. Which nursing response would best support the client?

"The effects of anemia on your baby are difficult to predict, but let's review the care needed to provide the best nutrition and growth potential."

A pregnant client reports that the iron supplement she is taking is causing nausea, constipation, and heartburn and that she plans to stop the medication. Which response by the nurse is appropriate?

"These gastric reactions are most intense during initial therapy and become less bothersome with continued use."

The initial assessment of a newborn notes petechiae on the infant's face, scalp, and neck. What response should the nurse provide the infant's mother when she asks "Are these spots something to worry about?"

"They're not serious if no new ones appear and they all fade within 2 days."

A client at 36 weeks' gestation has just been diagnosed with mild preeclampsia and is sent home on bed rest. The client has a husband who works out of town during the week and a 3-year-old child at home. Which question best ascertains the client's ability to maintain bed rest as prescribed?

"What type of problems will being on bed rest at home cause?"

During a difficult vaginal delivery, a large-for-gestational-age (LGA) infant sustained a fracture of the left clavicle. The infant is being discharged to home with an immobilizing sling, and the nurse is providing discharge instructions to the parents. Which statement made by a parent indicates that further teaching is necessary?

"Will the baby's arm always be paralyzed?"

A stillborn infant was delivered a few hours ago. After the birth, the family has remained together, holding and touching the baby. Which statement by the nurse should further assist the family in their initial period of grief?

"Would you like to name your baby?"

The nursing instructor is reviewing complications of the labor process with a nursing student. Instruction has been effective when the nursing student verbalizes which findings as complications of the labor process? Select all that apply.

1. Foul smelling vaginal drainage 2. Contraction duration 100 seconds 3. Persistent bright or dark red vaginal bleeding

A woman is being seen to confirm a possible pregnancy. When the nurse asks the woman how she has been feeling, which statement reflects the expected signs of pregnancy? Select all that apply.

1. "I have been so nauseous." 3. "I have not had a menstrual period in 2 months." 4. "It seems like I have to go to the restroom to urinate all the time."

The nurse is checking for the presence of pitting edema in a prenatal client. The nurse presses the tips of the index and middle fingers against the skin of the client and holds pressure for 2 to 3 seconds. On releasing the pressure, the nurse notes a slight indentation. Which determination should the nurse make based on this finding?

1+ edema

A maternity nurse asks a nursing student to present information regarding breast changes during pregnancy. Which statements, if made by the nursing student, indicate an understanding of breast changes during pregnancy? Select all that apply.

1. "Colostrum may appear as early as 16 weeks' gestation." 2. "Striae gravidarum may occur on the outer aspect of the breasts." 4. "Progressive breast enlargement occurs during the second and third trimesters due to growth of the mammary glands." 5. "Montgomery tubercles are sebaceous glands that are located in the areola and secrete substances that protect the nipple and areola when breast-feeding."

A maternity nurse asks a nursing student to present information regarding breast changes during pregnancy. Which statements, if made by the nursing student, indicate an understanding of breast changes during pregnancy? Select all that apply.

1. "Colostrum may appear as early as 16 weeks' gestation." 2. "Striae gravidarum may occur on the outer aspect of the breasts." 4. "Progressive breast enlargement occurs during the second and third trimesters due to growth of the mammary glands." 5. "Montgomery tubercles are sebaceous glands that are located in the areola and secrete substances that protect the nipple and areola when breast-feeding."

The nurse has completed teaching a client who is in the early stage of labor about what to expect when the labor progresses to the active stage. The nurse knows that there is a need for further teaching about the occurrences in the active stage if the client makes which statements? Select all that apply.

1. "I will be able to start pushing in this phase of labor." 3. "My contractions should be lasting only 30 seconds."

The nurse is counseling a couple after a stillbirth delivery. Which statements are appropriate for the nurse to share with the bereaved parents? Select all that apply.

1. "What can I do for you?" 3. "I'm here, and I want to listen." 4. "How are you doing with all of this?"

The nurse is teaching a lactose-intolerant, first-trimester pregnant client about foods that have approximately the same amount of calcium as a cup of milk. Which foods should the nurse include in the teaching plan? Select all that apply.

1. 11 dried figs 2. 1 cup of collards 5. A 3-oz can of sardines

The nurse is responsible for screening prenatal clients for potential complications and referring them to specific high-risk clinics. Which clients are at highest risk to develop gestational hypertension? Select all that apply.

1. A 16-year-old who is obese 3. A client with a previous history of gestational hypertension 4. A client who has been diagnosed with chronic hypertension 5. A client who was diagnosed with diabetes mellitus 10 years ago

The nurse is reviewing the records of recently admitted clients to the postpartum unit. The nurse determines that which clients would have an increased risk for developing a puerperal infection? Select all that apply.

1. A client with a history of previous infections 3. A client who had numerous vaginal examinations 6. A client who experienced prolonged rupture of the membranes

The nurse is admitting a newborn infant to the neonatal intensive care nursery and notes that the health care provider has documented that the newborn has gastroschisis. Which nursing interventions should be performed preoperatively? Select all that apply.

1. Administer IV fluids. 2. Administer antibiotics. 4. Maintain thermoneutral environment. 5. Keep abdominal contents covered with a bowel bag.

The nurse is admitting a newborn infant to the neonatal intensive care nursery and notes that the health care provider has documented that the newborn has gastroschisis. Which nursing interventions should be performed preoperatively? Select all that apply.

1. Administer IV fluids. 2. Administer antibiotics. 4. Maintain thermoneutral environment. 5. Keep abdominal contents covered with a bowel bag.

A client arrives at her primary health care provider's office 10 weeks pregnant with her first child. What are the presumptive signs of pregnancy that the client might be expected to have? Select all that apply.

1. Amenorrhea 3. Morning sickness 4. Changes to her breasts

The nurse creating a care plan for a postpartum client should include which interventions related to prevention of excessive bleeding in the immediate postpartum period? Select all that apply.

1. Assess for bladder distention. 3. Teach the client to massage her own fundus. 4. Gently massage the fundus if the uterus becomes "boggy."

A woman is scheduled for an amniocentesis. Which nursing interventions need to be initiated before and during the procedure? Select all that apply.

1. Assessing for a decrease in fetal heart rate 3. Instructing the woman to report any severe abdominal pain promptly 4. Preparing the client for the procedure to be performed under sterile technique

A pregnant client is receiving rehabilitative services for alcohol abuse. How should the nurse provide supportive care? Select all that apply.

1. Assist the client in identifying supportive strategies. 3. Stress the need for Alcoholics Anonymous (AA) meetings. 4. Encourage the client to continue counseling after the birth. 5. Encourage the client to participate in her rehabilitation care.

The clinic nurse is preparing to discuss cardiovascular changes of pregnancy in a prenatal class. Which information is appropriate for the nurse to include in this presentation? Select all that apply.

1. By term, heart rate increases by 15 to 20 beats per minute. 2. Number of red blood cells will be increased during pregnancy. 6. In a supine position, some degree of compression of the vena cava will occur.

The nurse is teaching the laboring client about the cardinal movements that a fetus in the vertex position makes through the pelvis during the labor process. Arrange those movements in order, beginning with the movement that occurs after engagement and ending with the movement that occurs at birth. All options must be used.

1. Descent 2. Flexion 3. Internal rotation 4. Extension 5. External rotation

A clinic client is reporting difficulty in "getting pregnant." The nurse knows that female infertility is associated with which of these factors? Select all that apply.

1. Endometriosis 2. Tubal adhesions 4. Reduced tubal motility 6. Endometrial and myometrial fibroid tumors

A woman in labor reports having attended childbirth classes and has learned techniques to help cope with the pain. The nurse determines that teaching has been effective when the client is observed engaging in what action during a contraction? Select all that apply.

1. Initiating a paced breathing pattern 2. Lightly massaging her uterus in a circular motion 3. Rocking slowly back and forth in a rhythmic motion 4. Visually focusing on a sonogram picture of her baby

A woman in labor reports having attended childbirth classes and has learned techniques to help cope with the pain. The nurse determines that teaching has been effective when the client is observed engaging in what action during a contraction? Select all that apply.

1. Initiating a paced breathing pattern 2. Lightly massaging her uterus in a circular motion 3. Rocking slowly back and forth in a rhythmic motion 4. Visually focusing on a sonogram picture of her baby

The nurse is caring for a 33-week pregnant client who has experienced a premature rupture of the membranes (PROM). Which interventions should the nurse expect to be part of the plan of care? Select all that apply.

1. Perform frequent biophysical profiles. 3. Monitor for manifestations of infection. 4. Teach the client how to count fetal movements. 5. Use strict sterile technique for vaginal examinations.

Which blood glucose levels during pregnancy are within normal range? Select all that apply.

1. Premeal 80 mg/dL (4.57 mmol/L) 3. Postmeal (1 hr) 114 mg/dL (6.5 mmol/L) 4. Postmeal (2 hrs) 110 mg/dL (6.0 mmol/L)

The nurse is conducting a prenatal session with a group of expectant parents. The nurse instructs the parents that an increase in which hormones is necessary to support the process of lactogenesis? Select all that apply.

1. Prolactin 2. Oxytocin

The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy, and the woman asks the nurse about the purpose of estrogen. The nurse is correct when she tells the client that which are the roles of estrogen? Select all that apply.

1. Relaxes pelvic ligaments and joints 2. Decreases mother's ability to utilize insulin 6. Stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation

The nurse is caring for a full-term infant who has been diagnosed with pathological jaundice. The nurse determines that which factors in the infant's history most likely impacted this diagnosis? Select all that apply.

1. Sepsis 2. Polycythemia 3. Rh incompatibility 4. Cephalohematoma

A woman is attending her first prenatal visit, and the nurse is teaching her about the optimum weight gain during pregnancy. During the assessment, the nurse finds that the woman is only slightly underweight. Which concepts should the nurse include in the teaching plan for the client? Select all that apply.

1. Severely underweight women are more likely to have preterm labor. 2. Inadequate weight gain during pregnancy could lead to intrauterine growth restriction (IUGR). 3. During the second and third trimesters, an additional 340 kcal is adequate for proper weight gain. 5. The risk of giving birth to a small-for-gestational-age (SGA) infant is greater if the weight gain is poor early in the pregnancy.

The nurse in the postpartum unit is assessing for signs of breast-feeding problems demonstrated by either the newborn or the mother. Which findings indicate a problem? Select all that apply.

1. The infant exhibits dimpling of the cheeks. 2. The infant makes smacking or clicking sounds. 5. The infant falls asleep after feeding less than 5 minutes.

The medication magnesium sulfate is started by intravenous (IV) infusion for a woman experiencing preterm labor. Which are the adverse effects of the medication? Select all that apply.

1. Tremors 2. Headache 4. Nervousness

The nurse is preparing to teach a pregnant client about the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to notify the primary health care provider. Which are warning signs that the nurse should place on the list? Select all that apply.

1. Vaginal bleeding 2. Rapid weight gain 3. Visual disturbances 4. Generalized or facial edema

The nurse is caring for a newborn delivered 10 minutes ago. Which prescribed medications will the nurse prepare to administer within the first hour of life? Select all that apply.

1. Vitamin K 6. Erythromycin eye drops

A client in the first trimester of pregnancy arrives at the health care clinic and reports that she has been experiencing vaginal bleeding. A threatened abortion is suspected, and the nurse provides a list of instructions for the client regarding management of care. Which instructions should the nurse place on the list? Select all that apply.

1. Watch for the evidence of the passage of tissue. 2. Count the number of perineal pads used on a daily basis. 3. Note the quantity and color of blood on each perineal pad. 6.Notify the primary health care provider if bleeding increases in amount.

The nursing instructor is reviewing the menstrual cycle with a nursing student and asks the student to describe the functioning of the follicle-stimulating hormone (FSH) and the luteinizing hormone (LH). Which statements indicate that the nursing student can differentiate between the purposes of these hormones? Select all that apply.

2. "FSH and LH stimulate growth of the Graafian follicle." 3. "FSH and LH assist in the production of progesterone." 4. "FSH and LH are released from the anterior pituitary gland."

A nursing student is asked to describe changes that the uterus undergoes during pregnancy. Which response by the student indicates an understanding of uterine changes? Select all that apply.

2. "In a primigravida, lightening typically occurs week 38 to 40." 3. "Fundal height is commonly used to determine the length of a pregnancy." 4. "Painless, irregular uterine contractions may be felt as early as 16 weeks' gestation." 5. "After 12 weeks' gestation, uterine enlargement occurs primarily due to mechanical pressure of the growing fetus."

The nursing student is assigned to care for a postpartum client. The registered nurse reviews the nursing care plan developed by the student and asks the student to describe the process of involution versus subinvolution. Which responses by the student indicate an understanding of the processes of involution and subinvolution? Select all that apply.

2. "The most common causes of subinvolution are retained placental fragments and infection." 4. "Involution begins immediately following the expulsion of the placenta with the contraction of the uterine muscle. 5. "Involution is a progressive descent of the uterus into the pelvic cavity occurring approximately 1 centimeter per day."

A hepatitis B screen is performed on a postpartum client and the results indicate the presence of antigens in the maternal blood. Which intervention should the nurse anticipate to be prescribed for the neonate? Select all that apply.

2. Administering hepatitis vaccine 5. Administering hepatitis B immune globulin

The nurse is planning care for a client in active labor. Which interventions should the nurse plan to implement if the client's amniotic fluid ruptures spontaneously? Select all that apply.

2. Assess fetal heart rate and pattern. 3. Assess the color, consistency, and odor of fluid. 4. Measure the client's temperature every 2 hours. 5. Document the date and time of the spontaneous rupture of the membranes.

The nurse is planning care for a client in active labor. Which interventions should the nurse plan to implement if the client's amniotic fluid ruptures spontaneously? Select all that apply.

2. Assess fetal heart rate and pattern. 3. Assess the color, consistency, and odor of fluid. 4. Measure the client's temperature every 2 hours. 5. Document the date and time of the spontaneous rupture of the membranes.

During each prenatal visit, the nurse assesses blood pressure and checks for proteinuria. Which results of blood pressure (BP) and proteinuria for a woman who is 26 weeks' gestation place the woman at risk for preeclampsia? Select all that apply.

2. Baseline BP 110/80 mm Hg, current BP 140/95 mm Hg, and 2+ for proteinuria 3. Baseline BP 130/75 mm Hg, current BP 165/90 mm Hg, and 2+ for proteinuria 4. Baseline BP 110/60 mm Hg, current BP 145/90 mm Hg, and 3+ for proteinuria

The client is told that she is in the second stage of labor, descent phase. What observations would the nurse make to support this stage of labor? Select all that apply.

2. Bearing down 4. Making expiratory vocalizations 5. Restless, changing body positions frequently

The nurse working in the prenatal clinic is conducting an in-service session and plans to provide information on ways to increase overall health in perinatal clients. Which topics should the nurse address during the in-service session? Select all that apply.

2. Decreasing the incidence of fetal alcohol spectrum disorder 3. Reducing low birth weight and very low birth weight in infants 5. Increasing the proportion of pregnant women who receive early and adequate prenatal care 6. Increasing the number of pregnant women receiving the Tdap immunization during pregnancy

The nurse working in the prenatal clinic is conducting an in-service session and plans to provide information on ways to increase overall health in perinatal clients. Which topics should the nurse address during the in-service session? Select all that apply.

2. Decreasing the incidence of fetal alcohol spectrum disorder 3.Reducing low birth weight and very low birth weight in infants 5.Increasing the proportion of pregnant women who receive early and adequate prenatal care 6. Increasing the number of pregnant women receiving the Tdap immunization during pregnancy

After the delivery of a newborn infant, the nurse performs an initial assessment and determines that the Apgar score is 9. What parameters has the nurse included in compiling this assessment score? Select all that apply.

2. Heart rate 3. Skin color 4. Muscle tone 5. Respiratory rate 6. Reflex irritability

The nurse includes which interventions in the plan of care for a newborn diagnosed with gastroschisis? Select all that apply.

2. Maintain intravenous site and fluids. 4. Position infant in a side-lying position with a blanket roll to support the viscera. 5. Keep exposed viscera covered with sterile moistened saline gauze and plastic wrap.

Which nursing interventions should be implemented for a newborn receiving phototherapy? Select all that apply.

2. Monitor the temperature frequently. 3. Protect the eyes with an opaque mask. 5. Monitor the number and consistency of stools.

The hemoglobin levels of a client in her first trimester of pregnancy are indicative of iron deficiency anemia. Which assessment findings support the diagnosis of this type of anemia? Select all that apply.

2. Reports of severe fatigue 5. Reports of frequent headaches

The nurse is teaching a group of pregnant clients about the function of the placenta during pregnancy. Which statements are accurate and should be included in the teaching session? Select all that apply.

2. The placenta functions as a lung for the baby. 4. Hormones necessary to maintain pregnancy are produced in the placenta. 5. Placental function depends on the maternal blood pressure to supply circulation.

The nurse should interpret the fetal heart tracing showing absent variability as indicative of which condition? Refer to figure.(Adapted from Tucker SM, Miller LA, Miller DA: Mosby's pocket guide to fetal monitoring: a multidisciplinary approach, ed 6, St. Louis, 2009, Mosby.)

A possible problem with the fetus that must be reported to the primary health care provider

Which safety measures should be implemented at delivery and when working in the newborn nursery? Select all that apply.

3. Adhere to standard precautions during delivery and in the nursery. 5. Instruct the parents not to release their newborn infant to anyone wearing improper identification. 6. Fingerprint the mother and footprint the infant on the identification card before removing the infant from the delivery room.

A client in the transition phase of labor is being supported by her labor coach. The client is complaining about how the coach is applying sacral pressure. Which actions should the nurse implement? Select all that apply.

3. Explain to the coach that this is expected behavior from the mother during the transition phase. 4. Suggest the technique of counterpressure on the back with the use of a tennis ball to the coach. 5. Reinforce that at this stage of labor the back discomfort is from the fetus moving further down in the pelvis.

The nurse is reviewing the antenatal history of a several clients in early labor. The nurse recognizes which factor documented in the history as having the potential for causing neonatal sepsis after delivery? Select all that apply.

3. Prenatal care began during the 3rd trimester 4. History of substance abuse during pregnancy 5. Dietary assessment identified poor eating habits 6. Spontaneous rupture of membranes 24 hours ago

At 28 weeks' gestation, the client's fundal height measured 26 cm; at 30 weeks the fundal height measured 29 cm. At the current 32-week visit, the nurse measures the fundal height in centimeters and expects which finding?

30 to 34 cm

The nurse is doing an assessment on a term newborn. Which depicts the tonic neck "fencing" reflex? Refer to figure.(From Lowdermilk D, Perry S, Cashion K: Maternity nursing, ed 8, St. Louis, 2010, Mosby.)

A

A pregnant client seen in the clinic has been given instruction regarding the management of hemorrhoids she has recently developed. Which statement by the client indicates the need for further teaching regarding appropriate interventions? Select all that apply.

4. "Avoiding bulk in my diet is very important in treating my hemorrhoids." 5. "After every bowel movement I clean from back to from of my perineum."

The registered nurse asks the nursing student assigned to work in the labor and delivery room about the purpose of the placenta. Which responses by the student nurse indicate an understanding of the purposes of the placenta? Select all that apply.

4. "It provides an exchange of nutrients and waste products between the mother and fetus." 5. "It produces human chorionic gonadotropin (hCG), which is the basis for pregnancy testing."

A woman diagnosed with gestational hypertension is scheduled for her next prenatal appointment. During the assessment, the nurse is concerned that she is developing signs/symptoms that indicate that her gestational hypertension is worsening. What would the nurse have assessed that indicates that the gestational hypertension is worsening? Select all that apply.

4. Blood pressure (BP) 165/120 mm Hg 5. Complaints of headache for the last 12 hours

A primigravida is admitted to the maternity unit with signs/symptoms of severe preeclampsia. The nurse is concerned that the client may be developing HELLP syndrome if which finding is noted?

A decrease in the platelet count

A perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements which dietary intervention should the nurse consult the dietitian about?

A diet adequate in fluids and fiber to decrease constipation

A prenatal client is being evaluated for possible gestational diabetes. Which data identified and documented after the client's initial nursing assessment would support that diagnosis?

A gravida 4, para 0, aborta 3

The community health nurse is providing an educational session regarding human immunodeficiency virus (HIV) to a group of prenatal clients at a local school. The nurse plans to discuss the risks associated with the transmission of HIV and includes which item in the discussion?

A history of IV drug use

A prenatal client has a suspected diagnosis of iron deficiency anemia. On assessment, which finding should the nurse expect to note as a result of this condition?

A low hemoglobin level

The nurse teaches a new mother how to perform cord care and to monitor for infection at home when the newborn infant is discharged. The nurse tells the mother that which signs indicate the presence of infection?

A moist cord with discharge

A nonstress test is performed on a client, and the results are documented in the chart as no accelerations during a 40-minute observation. The nurse interprets these findings as which result?

A nonreactive nonstress test

A client is being discharged after having a cesarean section to deliver her newborn infant, and the nurse provides discharge instructions to the client. The nurse determines that the client needs additional teaching about postdischarge complications if the client states that she will report which finding?

A temperature that increases to above 102° F (38.8° C)

The nurse has been encouraging the intake of oral fluids for a client in labor to improve hydration. Which indicates a successful outcome of this action?

A urine specific gravity of 1.020

A client in labor is experiencing dystocia. In delivering care to this client, the nurse should place priority on which ongoing nursing intervention?

Assessment of fetal status and the physical and emotional condition of the mother

A primipara is being evaluated in the clinic during her second trimester of pregnancy. The nurse checks the fetal heart rate (FHR) and notes that it is 190 beats/min. What is the appropriate initial nursing action?

Consult with the primary health care provider.

During a prenatal visit, a pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Which activity should the nurse determine is a harmful measure in preventing constipation?

Adding 1 tablespoon of mineral oil to a bowl of cereal daily

A goal for a postpartum client states, "The client will remain free of infection during her hospital stay." Which assessment data would support that the goal has been met?

Absence of fever

The nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative and is refusing any interventions until her husband arrives at the hospital. What is the most likely reason for client's behavior?

Acute anxiety and the need for support

The nurse is caring for a client who is in the active stage of labor. The nurse is monitoring the fetal status and notes that the monitor strip shows a late deceleration. Based on this observation, which action should the nurse plan to take immediately?

Administer oxygen via face mask.

A pregnant client at 8 weeks' gestation has a rubella titer of 1:6. The nurse anticipates which intervention?

Administer the rubella immunization during the postpartal stay at the birthing center.

A client in labor has a diagnosis of sickle cell anemia. Which action will the nurse take to assist in preventing the client from experiencing a sickling crisis during labor?

Administering oxygen

After birth, the nurse allows ample bonding time with the mother and family before administering the prescribed eye drops to the newborn. The nurse takes this sequence of action for which purpose?

Allow interaction before any temporarily effects on the infant's vision occur.

The nurse in the postpartum unit is reviewing the records of the clients on the unit. During the review, the nurse determines that which client is most at risk for developing endometritis after delivery?

An adolescent experiencing an emergency cesarean delivery for fetal distress

The nurse is monitoring a newborn infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F (38.1° C) and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which should be the priority nursing action?

Contact the PCP

The nurse observes for signs/symptoms of hypoglycemia in a large-for-gestational-age (LGA) newborn of a mother diagnosed with diabetes mellitus. Which clinical findings should the nurse assess for in this newborn? Select all that apply.

Apnea Jitteriness Seizures

The nurse provides a class to new mothers on newborn care. When teaching cord care, the nurse should instruct mothers to take which action?

Apply the prescribed cleansing agent to the cord, ensuring that all areas around the cord are cleaned two to three times a day.

The nurse performs an assessment on a postpartum client who is beginning to experience respiratory distress. The nurse should expect the client to exhibit which early neurological sign?

Apprehensiveness

The nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse should take which action?

Arrange to notify the primary health care provider of this physical finding.

A newborn diagnosed with respiratory distress syndrome (RDS) is prescribed surfactant replacement therapy. The nurse evaluates the infant 1 hour after the therapy and determines that the infant's condition has improved somewhat. Which finding indicates improvement?

Arterial blood pH increases to ≥7.35

The nurse is assisting in preparing a pregnant client for Leopold's maneuvers. Which should be included in the preprocedure plan of care?

Asking the client to empty her bladder

A primigravida is admitted to the labor unit. During the assessment of the client, her membranes rupture spontaneously. What is the priority nursing action?

Assess the fetal heart rate.

The nurse assists in creating a plan of care for a postpartum client and determines that which is the priority assessment in the fourth stage of labor?

Assessing the uterine fundus and lochia

The nurse is assigned to provide primary care to a client in labor and will care for the client throughout labor and into the postpartum period. When creating a plan of care for a client in the fourth stage of labor, what should the nurse determine is the initial priority nursing assessment?

Assessing vital signs and the uterine fundus and lochia

Twelve hours after delivery, the nurse assesses the client for uterine involution. The nurse determines that the uterus is progressing normally toward its prepregnancy state when palpation of the client's fundus is at which level?

At the umbilicus

After delivery, the postpartum nurse instructs the client with known cardiac disease to call for the nurse when she needs to get out of bed or when she plans to care for her newborn infant. Which rationale is the basis for these instructions?

Avoid maternal or infant injury caused by the potential for syncope or overexertion.

The community health nurse is providing a teaching session to a group of perinatal clients regarding the risks related to contracting toxoplasmosis. The nurse instructs the clients that which action is necessary to prevent exposure to this disease?

Avoiding exposure to litter boxes used by cats

The nurse is caring for a postterm infant who at 2 hours of age had a venous hematocrit level greater than 65% (0.65). The nurse monitors and prioritizes reviewing which laboratory test results over the next 24 hours?

Bilirubin

The nurse developing a plan of care for a postterm small-for-gestational-age (SGA) newborn should identify which assessment as the priority to monitor?

Blood glucose levels

The nurse is assessing a newborn infant with a diagnosis of congenital diaphragmatic hernia (CDH). Which assessment finding should the nurse specifically expect to note in the newborn?

Bowel sounds heard over the chest

The nurse is evaluating the obstetric pelvic measurements of a client. The nurse notes that the measurement of the narrowest part of the pelvis is at which landmark? Refer to figure.(From Lowdermilk D, Perry S, Cashion K: Maternity nursing, ed 8, St. Louis, 2010, Mosby.)

C

The nurse in the newborn nursery is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. In planning care for the newborn, what is the priority nursing action?

Obtain the newborn's blood type and direct Coombs' results.

Which action by the breast-feeding client should lead the nurse to determine that the client is at risk of developing mastitis?

Offering one breast per feeding

The nurse midwife instructs a pregnant client to keep a fetal activity diary of fetal movement and to bring the diary to the next scheduled prenatal appointment. How should the nurse midwife instruct the client to perform the fetal activity movement?

Call the midwife if the movements are fewer than 10 in a 12-hour period.

The nurse has provided instructions to a new mother with a urinary tract infection regarding foods and fluids to consume that will acidify the urine. The nurse determines that further teaching is needed if the mother indicates that which fluid will acidify the urine?

Carbonated drinks

During an exchange transfusion for an infant who has polycythemia and hyperviscosity, which assessment finding is considered significant?

Cardiac Irregularities

A prenatal client with a history of rheumatic heart disease is experiencing unusual episodes of a nonproductive cough on minimal exertion. The nurse interprets that this assessment finding may be an early manifestation of which potential complication?

Cardiac decompensation

During an exchange transfusion for an infant who has polycythemia and hyperviscosity, which assessment finding is considered significant?

Cardiac irregularities

The labor room nurse is assisting with a delivery and monitoring the client for placental separation following the delivery of a viable newborn. The nurse should monitor for which sign/symptom that indicates the placenta has separated?

Change in the uterine contour

The nurse is caring for a large-for-gestational-age (LGA) infant. The nurse assesses the infant for a major sign/symptom associated with LGA infants by performing which action?

Checking the infant's blood glucose level

The nurse is explaining physiological changes of pregnancy that are related to melanocyte-stimulating hormone (melanotropin). Which pregnancy changes are related to the effects of this hormone? Select all that apply.

Chloasma Linea nigra Darkening of the areola

The nurse is checking the reflexes on a neonate. In order to elicit the Moro reflex, which action should the nurse perform?

Clap hands or slap on the mattress.

The nurse is assessing a client with gestational hypertension who was admitted to the hospital 48 hours ago. Which current assessment data would indicate that the condition has not yet resolved?

Client complaints of blurred vision

Some risk factors for placental abruption relate to a client's lifestyle. In planning client education to prevent this complication, the nurse includes discussion about the use of which substance?

Cocaine

The father of a newly delivered full-term newborn is observing admission of the infant to the nursery. He asks the nursing student performing the admission why a cover is being placed on the baby scale to weigh and measure the newborn. This nurse should response that this intervention is designed to protect the newborn against which heat loss mechanism?

Conduction

The client is in the second stage of labor. As the baby begins to crown, the primary health care provider administers a pudendal nerve block in preparation for an episiotomy. What is the appropriate nursing intervention?

Continue to assess both vital signs and fetal heart rate as before the nerve block.

The maternity nurse is caring for a client in labor and performs an assessment on the client. The client is having moderate contractions that are occurring every 5 minutes and lasting 60 seconds. The fetal heart rate (FHR) is 150 beats/min and regular. Which nursing action has the priority based on the assessment data?

Continue to monitor the client.

A pregnant client with preeclampsia is admitted to the hospital with a blood pressure of 162/100 mm Hg and a urine protein of 2+. On assessment, which sign indicates to the nurse that the severity of the client's preeclampsia has increased?

Oliguria

The nurse is creating a plan of care for a pregnant client with a diagnosis of sickle cell anemia. Which client problem should the nurse determine is the priority?

Dehydration

A postpartum nurse caring for a client who delivered vaginally 2 hours ago palpates the fundus and notes the character of the lochia. Which characteristic of the lochia should indicate to the nurse that the client's recovery is normal?

Dark red-colored lochia

The mother of a preterm baby asks the nurse why the infant is receiving a caffeine-type medication. What should the nurse explain is the purpose of the medication?

Decrease the number of apnea occurrences.

The nurse is caring for a client who is having a precipitate delivery. For which abnormal assessment finding should the nurse monitor the client?

Decreased periods of uterine relaxation between contractions

A client diagnosed with severe preeclampsia is admitted to the hospital. The client is a student at a local college and insists on continuing her studies while in the hospital, despite being instructed to rest. The client studies approximately 10 hours a day and has numerous visits from fellow students, family, and friends. Which intervention should the nurse use to best assist the client with promoting rest?

Develop a routine with the client to balance her studies and her rest needs.

A full-term infant is admitted to the neonatal intensive care unit with a diagnosis of possible sepsis. The nurse caring for the infant should report which finding to the health care provider?

Diastolic BP of 32 mmHG

The nurse is evaluating the mother-infant bonding process during the postpartum period. What is an indication of a maladaptive interaction by the mother?

Encouraged the nurse to feed the baby because she continues to be too tired

The nurse is monitoring a pregnant woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which action should the nurse take as a result of this observation?

Document the finding.

The nurse is monitoring the vital signs of a client after delivery of a healthy newborn and notes that the mother's apical pulse is 50 beats/min. Which nursing action is appropriate?

Document the finding.

The nurse is monitoring a pregnant woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which action should the nurse take as a result of this observation?

Document the findings.

The nurse is performing an assessment on a client during her first prenatal visit to the clinic and takes the client's temperature and notes that the temperature is 99.2° F (37.3 ° C). Which nursing action is appropriate?

Document the temperature

The nurse is performing an assessment on a client during her first prenatal visit to the clinic and takes the client's temperature and notes that the temperature is 99.2° F (37.3 ° C). Which nursing action is appropriate?

Document the temperature.

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

Drink at least 2000 mL of fluid per day.

An 8-day-old infant is irritable and has a high-pitched persistent cry and a temperature of 99.4° F (37.4° C). The infant is also tachypneic, is diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. Which disease process should the nurse determine that these behaviors may be consistent with?

Drug withdrawal

The nurse is caring for a pregnant woman who has had ruptured membranes for longer than 24 hours. The client is receiving intravenous antibiotics and asks the nurse why the antibiotics are being given. The nurse understands the physiological risk associated with prolonged rupture of membranes (ROM) when the nurse tells the client that the use of antibiotics is to prevent which condition?

Early-onset neonatal group B Streptococcus (GBS) disease

A clinic nurse is caring for a client with a suspected diagnosis of gestational hypertension. The nurse assesses the client, expecting to note which set of findings if gestational hypertension is present?

Elevated blood pressure and proteinuria

A postpartum nurse obtains the vital signs on a mother who delivered a healthy infant 2 hours ago. The mother's temperature is 100° F (38° C). What should be the initial nursing action?

Encourage oral fluid intake.

The nurse is caring for a newly delivered breast-feeding infant. Which intervention performed by the nurse would best prevent jaundice in this infant?

Encourage the mom to breast feed ever 2-3 hours

The nurse is planning for the initial visit between the parents and a newborn infant diagnosed with respiratory distress syndrome. What actions should the nurse include in the plan to best facilitate bonding during the visit?

Encourage the parents to touch their infant.

The nurse is assessing a postterm infant born after the 42nd week of gestation. How should the nurse obtain significant information related to the infant's birth status?

Estimates true gestational age by recording the infant's weight, length, and head circumference on standard growth charts

When planning care for a woman with gestational hypertension, the nurse plans to encourage which maternal behavior?

Expression of hope for a positive outcome

The nurse is preparing a woman in labor for an amniotomy. Which priority data should the nurse assess before the procedure?

Fetal heart rate

On assessment, the nurse discovers that a client in early second-stage labor has a prolapsed umbilical cord. The nurse turns the client to a modified Sims' position, starts oxygen at 8 to 10 L/min by mask, increases the rate of the intravenous fluids, contacts the primary health care provider and other staff, and explains the situation to the client. The nurse monitors the client by using which criteria to determine if interventions are effective?

Fetal monitor indicates a normal baseline rate and variability of the fetal heart

The nurse is preparing to assess the fetal heart rate (FHR) of a pregnant woman who is at 20 weeks' gestation. Which piece of equipment will the nurse use to assess the FHR?

Fetoscope

A prenatal client is experiencing calf pain when she walks. Which action is appropriate for the nurse to implement?

Gather further data

An antenatal client who has experienced 2 episodes of bleeding as a result of a borderline placenta previa will be discharged to home care tomorrow. The nurse is planning the discharge instructions and is aware that there is a potential for fetal distress should the bleeding recur. Which intervention should be included in the plan in order to assist the client to identify fetal distress?

Give the mother instructions on how to perform daily fetal movement counts, and assist her to practice.

A client has just given birth to a newborn who has a cleft lip and palate. When planning to talk with the client, the nurse recognizes that the client needs to first work through which emotion before maternal bonding can occur?

Grief

A perinatal home care nurse has just assessed the fetal status of a client with a diagnosis of partial placental abruption of 20 weeks' gestation. The client is experiencing new bleeding and reports less fetal movement. The nurse informs the client that the primary health care provider will be contacted for possible hospital admission. The client begins to cry quietly while holding her abdomen with her hands. She murmurs, "No, no, you can't go, my little man." The nurse should recognize the client's behavior as an indication of which psychosocial reaction?

Grief due to potential loss of the fetus

The nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, "I can't even dress this baby!" After reassuring the client, the nurse determines that which is an appropriate nursing action?

Have the mother place the infant in the bassinet and assist the mother in dressing the baby.

The nurse is caring for a small-for-gestational-age (SGA) infant. To determine whether the infant is asymmetrically or symmetrically SGA, the nurse should assess which items?

Head circumference, length, and weight

The nurse is caring for a client at 30 weeks' gestation who is in preterm labor, and the primary health care provider prescribes betamethasone intramuscularly. The client asks the nurse why she is receiving corticosteroids. The nurse should tell the client that the betamethasone will do which action?

Help the baby's lungs mature faster.

Ferrous sulfate is prescribed for a pregnant client. Before the client begins this medication, the nurse determines that which laboratory result should be evaluated in order to identify the necessary baseline data for monitoring the therapeutic effect of the medication?

Hemoglobin level

The nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects that the umbilical cord is compressed. The nurse immediately places the client in what position?

Hips elevated

A primary health care provider has prescribed home care for a pregnant client. The nurse knows that home care is indicated for which condition during pregnancy?

Hypertension

A clinic nurse is caring for a client with a suspected diagnosis of gestational hypertension. The nurse assesses the client, expecting to note which set of findings if gestational hypertension is present?

Hypertension and proteinuria

On admission to the newborn nursery, the nurse notes jitteriness in a newborn who was born after 42 weeks' gestation. The newborn's vital signs are temperature, 98.0° F (36.6° C); pulse, 148 beats per minute; and respiration, 62 breaths per minute. The nurse interprets these data as being supportive of which problem?

Hypoglycemia

The nurse is assessing a 1-hour-old newborn. Which finding indicates that the newborn may be at risk for hypoglycemia?

Hypothermia and a weak, high-pitched cry

A home care nurse encourages a new, postpartum breast-feeding client to apply warm, moist compresses to her breast for 20 minutes before nursing. Which client response indicates the primary goal of the intervention has been met?

I have. a really good flow of breast milk

During the intrapartum and immediate postpartum period, which procedure places the newborn infant of a human immunodeficiency virus (HIV) mother at risk for exposure to the virus?

Immediate administration of phytonadione after delivery

A client in the third trimester of pregnancy arrives at the clinic and tells the nurse that she frequently has a backache. Which instructions should the nurse provide to the client to help alleviate the backache?

Perform pelvic rock exercises.

The nurse answers a call light to the room of a woman who was just admitted to the hospital in early latent labor. The client is lying flat on her back on the bed. The husband states worriedly, "I think my wife is going into shock or something! She was just lying there, and she turned so pale and her hands are so clammy. She's dizzy and sick to her stomach." The nurse notes on the noninvasive blood pressure machine that the client's pulse is 58 beats per minute and her blood pressure is 90/50 mm Hg. How should the nurse interpret the client's signs/symptoms?

Impaired tissue perfusion related to hypotensive syndrome (vena cava syndrome)

A newborn infant is diagnosed with imperforate anus. Which description of this disorder should the nurse provide to the parents?

Incomplete development of the anus

A client diagnosed with gestational hypertension has just been admitted and is in early active labor. Which assessment finding should the nurse most likely expect to note?

Increased blood pressure

A client who is diagnosed with type 1 diabetes mellitus is at 10 weeks' gestation and is receiving prenatal care at a high-risk clinic. The nurse tells the client about the early signs of hyperglycemia. Which response indicates that the client understands the early signs of hyperglycemia?

Increased urination

A newborn male infant is diagnosed with an undescended testicle (cryptorchidism), and these findings are shared with the parents. The parents ask questions about the condition. The nurse should respond to the parents that which condition can occur and have a psychosocial impact if the undescended testicle is not corrected?

Infertility

A pregnant client arrives at a prenatal clinic for a regularly scheduled prenatal visit. The client tells the nurse that she has been having a clear and slightly whitish vaginal discharge. Which action by the nurse is appropriate?

Inform the client that this is a common occurrence in pregnancy.

The nurse is reviewing the procedure for phytonadione injection in the newborn with a nursing student. Which information should the nurse provide to the student?

Inject into skin that has been cleansed thoroughly with alcohol.

The nurse is caring for a client who was diagnosed with complete placenta previa and is having contractions. In preparing the client for delivery, which procedure should the nurse perform?

Insert a Foley

The nurse prepares to admit a newborn born with spina bifida, myelomeningocele. Which nursing action is most important for the care for this infant?

Inspecting the anterior fontanel for bulging

During the initial prenatal visit, the nurse spends time with a client with known cardiac disease and explains the importance of an adequate diet and iron and folic acid supplementation during pregnancy. The nurse should instruct the client that these dietary supplements are important to prevent which condition?

Intrauterine fetal growth restriction

The nurse prepares to administer erythromycin ophthalmic ointment to a newborn infant immediately after delivery. Which information should be shared with the parent concerning the use of this medication?

Is effective in protecting the newborn from both Neisseria gonorrhoeae and Chlamydia trachomatis

A pregnant client in the third trimester of pregnancy is seen in the prenatal clinic and is complaining of constipation, and the nurse provides home care measures to the client to alleviate the problem. The nurse determines that the client needs additional teaching when the client states her lifestyle will need to change in which manner?

Limit regular exercise.

A pregnant woman reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. After an assessment, tuberculosis is suspected. A sputum culture identifies Mycobacterium tuberculosis in the sputum. What instructions should the nurse provide to the client regarding therapeutic management of the tuberculosis?

Isoniazid plus rifampin will be required for a total of 9 months.

The maternity nurse is teaching a pregnant client about the physiological effects and hormone changes that occur in pregnancy. Which information should the nurse provide to the client about the purpose of estrogen?

It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

During the transition period of labor, the nurse notes that a client is having difficulty concentrating on her breathing technique. Her coach anxiously states that he/she just doesn't know how to help her. What is an appropriate intervention by the nurse?

Keep them informed regarding the labor process and events using positive terms.

The nurse notes that a client is delighted with her newborn infant, but the client confides to the nurse that she is really worried about not knowing how to care for her first-born child. What can the nurse conclude is the client problem?

Lack of understanding

The nurse is performing a fetal assessment on a client in labor. The nurse determines that which finding indicates impaired fetal oxygenation?

Late decelerations

The nurse is reviewing the record of an infant admitted to the newborn nursery. The nurse notes that the health care provider has documented bladder exstrophy. Which nursing interventions should the nurse anticipate during the preoperative period? Select all that apply.

Latex precautions Administer IV fluids Emotional support Nonadhering plastic wrap

A newborn of a mother diagnosed with diabetes mellitus displays irregular respirations, grunting, substernal retractions, and lethargy. The nurse anticipated the respiratory distress noted in the newborn infant, based on assessment of which test results performed in the week before delivery?

Lecithin/sphingomyelin (L/S) ratio

The nurse is caring for an infant with physiological jaundice. Which intervention should the nurse perform to assess for a major sign associated with physiological jaundice?

Look for the presence of a cephalhematoma.

A prenatal client has a suspected diagnosis of iron deficiency anemia. On assessment, which finding should the nurse expect to note as a result of this condition?

Low hemoglobin

A woman diagnosed with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication?

Macrosomia

The nurse is caring for a client diagnosed with preeclampsia. When the client's condition progresses from preeclampsia to eclampsia, what should the nurse's first action be?

Maintain an open airway.

During the initial maternal-infant bonding period after the delivery of the placenta, what is the nurse's primary responsibility?

Make sure that the infant stays warm and is in no danger of slipping from the parent's grasp.

The nurse in the prenatal clinic is monitoring a client who is pregnant with twins. The nurse monitors the client closely for which priority complication that is associated with a twin pregnancy?

Maternal anemia

The nurse is caring for a woman who is human immunodeficiency virus (HIV)-positive and delivered a newborn infant. In the postpartum period, which psychosocial assessment should the nurse initially address?

Maternal fears related to the newborn's status

The nurse notes the fetal heart rate (FHR) pattern shown on the electronic fetal monitoring strip. The nurse understands that what is the most likely cause of this pattern? Refer to figure.(From Lowdermilk D, Perry S, Cashion K: Maternity nursing, ed 8, St. Louis, 2010, Mosby.)

Maternal fever

A client arrives at the prenatal clinic for the first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was August 19, 2019. Using Nägele's rule, what should the nurse determine as the estimated date of delivery?

May 26, 2020

A postterm infant, delivered vaginally, is exhibiting tachypnea, grunting, retractions, and nasal flaring. The nurse interprets that these assessment findings are indicative of which condition?

Meconium aspiration syndrome

A woman is hospitalized at 26 weeks' gestation with a possible diagnosis of early placental abruption. Which nursing assessment data best supports placental separation associated with this grade?

Mildly hypotension

The nurse is evaluating the effectiveness of meperidine for pain management for a client in labor. The nurse determines that the medication was effective if the client exhibited which signs/symptoms?

Moderate pain relief while a progressive labor pattern continues

The nurse in the labor room is assisting in performing an initial assessment on a newborn. On assessment of the newborn's head, the nurse notes that the ears are low set. Based on this finding, which nursing action is most appropriate?

Notify the PCP

The nurse is performing an assessment on a client in the third trimester of pregnancy and notes that the fetal heart rate (FHR) is 170 beats/min. What is the appropriate nursing action, based on the assessment finding?

Notify the primary health care provider.

A pregnant client reports that her last menstrual period was February 9, 2018. Using Näegele's rule, what will the nurse determine as the estimated date of birth?

November 16, 2018

The nurse is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. When planning care for the infant's arrival, which action should the nurse take?

Obtain the newborn infant's blood type and direct Coombs' results from the laboratory.

The nurse is evaluating a pregnant client for the presence of clonus. The nurse places one hand under the woman's knee and bends the knee slightly. The nurse places the other hand on the ball of the foot, encourages the woman to relax the foot, and then sharply dorsiflexes the foot. Which finding indicates that clonus is present?

One jerk or tap occurs against the nurse's hand.

Which medication prescription for the treatment of acne is contraindicated during pregnancy?

Oral tetracycline

A mother who is 2 days postpartum should be routinely assessed by the nurse for thrombophlebitis by specifically checking which parameter?

Pain in the calf area

A prenatal client has been diagnosed with a vaginal infection from the organism Candida albicans. What should the nurse expect to note on assessment of the client?

Pain, itching, and vaginal discharge

During a routine prenatal visit, a client in her third trimester of pregnancy reports having frequent calf pain when she walks. The nurse suspects superficial thrombophlebitis and checks for which sign associated with this condition?

Palpable hard thrombus

The nurse is performing an assessment on a postterm infant. Which physical characteristic should the nurse expect to observe in this infant?

Peeling of the skin

The nurse is creating a plan of care for a pregnant client that focuses on measures that will strengthen the pelvic floor and decrease the incidence of stress incontinence later in life. What should the nurse include in the plan to address these measures?

Perform Kegel exercises in 10 repetitions, 3 times per day.

A client in the late, active, first stage of labor has just reported a gush of vaginal fluid. The nurse observes a fetal monitor pattern of variable decelerations during contractions followed by a brief acceleration. After that, there is a return to baseline until the next contraction, when the pattern is repeated. On the basis of these data, what is the nurse's initial intervention?

Perform a manual sterile vaginal exam.

The nurse is monitoring a client with an abruptio placentae for signs of disseminated intravascular coagulopathy (DIC). Which symptom/signs indicate the occurrence of DIC? Select all that apply.

Petechiae Hematuria Oozing from injection sites

A term client is admitted to the labor and delivery unit for an oxytocin induction. The nurse reviews the client's chart and should contact the primary health care provider regarding which documented finding to verify the oxytocin induction? Refer to chart.

Previous classic vertical uterine incision

A pregnant woman at 38 weeks' gestation arrives at the emergency department. She reports the presence of bright red vaginal bleeding and denies the presence of any pain. Based on this information, the nurse determines that the client may be experiencing what adverse event?

Placenta previa

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

Placing one hand just above the symphysis pubis and gently, but firmly, massaging the fundus in a circular motion

A client who is breast-feeding her newborn is experiencing nipple soreness. What should the nurse suggest to the client to assist in relieving nipple soreness?

Position the infant with the ear, shoulder, and hip in straight alignment with the infant's stomach against the mother.

The nurse is caring for an antepartal client who has been diagnosed with placenta previa. For which potential postpartum complication associated with this high-risk condition should the nurse educate the client?

Postpartum hemorrhage

The nurse is observing the parents at the bedside of their small-for-gestational-age (SGA) infant, who was born at 27 weeks' gestation. The infant's mother states, "She is so tiny and fragile. I'll never be able to hold her with all those tubes." Considering this statement, which concern should the nurse identify for the mother?

Potential for compromised parenting

A clinic nurse is creating a plan of care for a pregnant client with acquired immunodeficiency syndrome (AIDS). The nurse determines that which is the priority consideration for this client?

Potential infection

A client at 35 weeks of gestation reports a sudden discharge of fluid from the vagina. Based on the data provided, which condition should the nurse suspect?

Premature rupture of the membranes

The nurse is caring for a client in labor. Immediately after delivering a normal healthy infant, the woman suddenly begins to complain of pain, and the nurse notes that the client is bleeding heavily from the vagina. The nurse suspects uterine inversion and should take which immediate action?

Prepare to administer a tocolytic.

The nurse is caring for a term newborn. Which assessment finding would predispose the newborn to the occurrence of jaundice?

Presence of a cephalhematoma

The nurse is assigned to assess a client with a suspected diagnosis of placenta abruptio. Which assessment data tends to support this possible diagnosis?

Presence of dark red uterine bleeding

The nurse is monitoring the status of a client in active labor. The nurse interprets that which finding is least consistent with dystocia?

Progressive changes in the cervix

A 30-week-gestation client admitted in preterm labor is prescribed betamethasone. What should the nurse tell the client is the purpose for this medication?

Promote fetal lung maturity.

The nurse is instructing a postpartum client on the use of a sitz bath. What reasons should the nurse tell the client that sitz baths are prescribed?

Promote healing and provide comfort.

The nurse is caring for a pregnant client who has been hospitalized for the stabilization of diabetes mellitus. The client tells the nurse that her husband is caring for their 2-year-old daughter. Which short-term psychosocial outcome should the nurse develop for the client?

Provide emotional support and education about interrupted family processes.

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

Respirations of 10 breaths per minute

The nurse reviews the pattern of a nonstress test performed on a pregnant client and interprets the finding as which result? (Refer to the figure.)

Reactive

The nurse teaches a postpartum client about postdelivery lochia. The nurse determines that the education has been effective when the client says that on the second day postpartum, the lochia should be which color?

Red

A breast-feeding mother has developed a temperature of 104° F (40° C) and is experiencing shaking chills. The nurse further assesses the client for signs/symptoms of mastitis and observes for which finding?

Reddened and extremely tender breast tissue

When instructing a postpartum client on the use of an ice pack, the nurse should tell the client that the ice pack will have which therapeutic effects?

Reduce the edema and numb the tissue.

The nurse receives a report at the beginning of the shift regarding a client with intrauterine fetal demise. On assessment of the client, which finding does the nurse expect to note?

Regression of pregnancy signs/symptoms and absence of fetal heart tones

The nurse is assisting with conducting a session about relaxation techniques for a group of pregnant women attending a childbirth class. The nurse informs the group that active relaxation techniques will assist them with coping with the discomfort of contractions. The nurse determines that teaching has been effective when a client says that active relaxation includes which activity?

Relaxing uninvolved muscles while the uterus contracts

A 3-week-old infant is brought to the well-baby clinic for a phenylketonuria (PKU) screening test. The nurse reviews the results of the serum phenylalanine levels and notes that the level is 1.0 mg/dL (60 mmol/L). What is the nurse's priority action?

Report test as inconclusive

A client is admitted to the hospital for an emergency cesarean delivery. Contractions are occurring every 15 minutes. The client has a temperature of 100° F (37.8° C), ate 2 hours ago, and indicates that she has had no preparation for the cesarean delivery. Which action should the nurse plan to take first?

Report the time of the last food intake to the obstetrician.

The nurse is performing a fetal heart rate assessment on a client who is in her third trimester of pregnancy. The nurse finds the fetal heart rate to be 185 beats/minute. What should be the priority nursing action at this time?

Report to the HCP

A client is admitted to the labor and delivery suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents take which actions?

Request to hold the infant after delivery

The nurse is caring for a pregnant client with a history of human immunodeficiency virus (HIV). Which problem identified by the nurse has the highest priority for this client?

Risk of infection

A client has some concerns regarding chorionic villus sampling (CVS) and states to the nurse, "I'm not sure I should have this test done." Which appropriate response should the nurse make to the client?

Tell me your concersn

A pregnant client diagnosed with diabetes mellitus arrives at the primary health care clinic for a follow-up visit. What best assessment should the nurse perform to assess insulin function?

Urine for glucose and ketones

An adolescent is admitted to the hospital with complaints of lower right abdominal pain. The surgeon prescribes laboratory tests to rule out ectopic pregnancy rather than appendicitis. Which is the most significant test in ruling out an ectopic pregnancy?

Serum human chorionic gonadotropin

The nurse is monitoring a postpartum client for signs of complications. Which finding indicates a sign of potential bleeding?

Soft or boggy uterus

The nurse caring for a client who is receiving oxytocin for the induction of labor notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, which action should the nurse do first?

Stop the infusion

The nurse is caring for a client in labor who is receiving an oxytocin infusion. The nurse notes the presence of tachycardia, decreased variability, and late decelerations on the fetal heart monitor. Which action should the nurse take immediately?

Stop the oxytocin infusion.

A delivery room nurse is preparing a client for a cesarean delivery. Which position will promote maximum uteroplacental perfusion during this surgery?

Supine position with a wedged right hip

The nurse is caring for a client during a precipitous labor. The nurse should anticipate that the client will require care for which emotional need?

Support in maintaining a sense of control

The nurse is reviewing the record of a newborn infant admitted to the nursery and notes that the health care provider has documented the presence of a caput succedaneum. Based on this documentation, what should the nurse expect to note?

Swelling of the soft tissues of the head and scalp

he newborn nursery nurse is performing an admission assessment on a newborn with the diagnosis of subdural hematoma. Which intervention should the nurse implement to assess for the primary symptom associated with subdural hematoma?

Test for equality of extremity reflexes.

The home care nurse is performing a 48-hour postpartum check on a client with gestational hypertension who was discharged from the hospital with mild preeclampsia. Which finding indicates that the preeclampsia is unresolved?

The client complains of a headache and blurred vision.

During a prenatal visit, the clinic nurse assesses a pregnant client diagnosed with iron-deficiency anemia for additional risk factors associated with the anemia. Which assessment finding supports a potential for further maternal compromise?

The client has experienced vaginal spotting twice since the last prenatal visit.

The nurse is developing goals for the postpartum client who is at risk for uterine infection. Which goal is most appropriate for this client?

The client will be able to identify measures to prevent infection.

A newborn is diagnosed with esophageal atresia, and the mother of the newborn asks the nurse to explain the diagnosis. On which description of this disorder should the nurse base the response?

The esophagus terminates before it reaches the stomach.

A clinic nurse is assessing a prenatal client who has been diagnosed with heart disease. The nurse carefully assesses the client's vital signs, weight, and fluid and nutritional status to detect for complications caused by which pregnancy-related concern?

The increase in circulating blood volume

After the delivery of an infant, the nurse performs an initial assessment on the newborn. The nurse obtains and documents an Apgar score of 8. The nurse determines that this score indicates which finding?

The infant is adjusting well to extrauterine life.

A newborn infant born to a mother with a drug addiction is ready for discharge from the hospital. The infant has been in the hospital for 2 weeks experiencing drug withdrawal. Which observation indicates that the infant has adjusted to the drug withdrawal?

The infant's face is calm and looks into the caregiver's face.

The nurse is caring for a client with a precipitous labor. What information should the nurse provide to the client regarding this type of labor?

The labor may last less than 3 hours.

The nurse is preparing to administer an injection of phytonadione to a newborn. When administering the injection, which injection site should the nurse select?

The lateral aspect of the middle third of the vastus lateralis muscle

The nurse employed in a newborn nursery is aware that medication toxicity is more likely to occur in the newborn because of which newborn characteristic?

The liver is immature.

The nurse is monitoring a new mother for signs/symptoms of postpartum depression. Which observation, if noted in the new mother, indicates the need for follow-up related to this form of depression?

The mother constantly complains of tiredness and fatigue.

The nurse is assessing the risk of transmission of perinatal infections in a prenatal client. Which correct item should the nurse use to guide this assessment?

The mother's immune system is depressed during pregnancy.

The nurse in the prenatal clinic is assisting in checking the deep tendon reflexes of a pregnant client. What is an accurate description of this assessment procedure?

The nurse places one hand under the knee to raise it slightly off the bed and uses a percussion hammer to strike the patellar tendon.

The clinic nurse is preparing to instruct a pregnant client about nutrition. What should the nurse include in the teaching plan?

The nutritional status of the mother significantly influences fetal growth and development.

The nurse is teaching a pregnant client about prenatal nutritional needs. The nurse should include which information in the client's teaching plan?

The nutritional status of the mother significantly influences fetal growth and development.

The nurse in the labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding should alert the nurse to a compromise?

The passage of meconium

The nurse is teaching umbilical cord care to a new mother. What information should the nurse provide to the mother related to cord care?

The process of keeping the cord clean and dry will decrease bacterial growth.

The nurse provides instructions to a new mother who is about to breast-feed her newborn infant. The nurse observes the new mother as she breast-feeds for the first time and determines the mother needs further teaching if the new mother applies which technique?

Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth

The nurse is providing information about health care to a pregnant client who has tested positive for human immunodeficiency virus (HIV). What is the primary reason that it is important for the client to avoid alcohol and cigarettes during pregnancy and to get adequate rest?

To avoid further stress on the maternal immune system

The nurse in the newborn nursery is preparing to feed a newborn the first feeding of sterile water. During the feeding, the newborn suddenly begins to cough, choke, and become cyanotic. These signs/symptoms support which diagnosis?

Tracheoesophageal fistula (TEF)

A pregnant client tells the nurse that she felt wetness on her peripad and found some clear fluid. The nurse inspects the perineum and notes the presence of the umbilical cord. What is the immediate nursing action?

Trendelenburg

The nurse is caring for a hospitalized client with a diagnosis of abruptio placentae. The nurse creates a nursing care plan and incorporates interventions to be implemented in the event of the development of shock. What is the initial nursing action that should be included in the plan if shock develops?

Turn mom on side

The nurse is assigned to care for a client with a diagnosis of preeclampsia. The nurse should plan to implement which action to provide a safe environment?

Turn off the room lights and draw the window shades.

The nurse is caring for a hospitalized client with a diagnosis of abruptio placentae. The nurse creates a nursing care plan and incorporates interventions to be implemented in the event of the development of shock. What is the initial nursing action that should be included in the plan if shock develops?

Turn the mother onto her side.

Which piece of equipment will the nurse routinely use to assess the fetal heart rate of a woman at 16 weeks' gestation?

Ultrasound fetoscope

A client in active labor calls the nurse to her bedside to report that when she went to the toilet to urinate, she passed a big gush of clear fluid and thinks that her water broke. The nurse performs a sterile vaginal examination and discovers a pulsating, ropelike object in the vaginal canal. Which is the priority nursing concern in this situation?

Umbilical cord compression

The nurse is monitoring a pregnant woman in labor and notes the presence of variable decelerations on the fetal monitor tracing. Which finding should the nurse suspect, based on this observation?

Umbilical cord compression

The nurse is assessing a pregnant woman with acquired immunodeficiency syndrome (AIDS) who is exhibiting nonspecific signs such as fever, weight loss, and signs of candidiasis. Which intervention should the nurse implement to ensure a safe environment?

Use disposable latex gloves when in contact with nonintact skin.

The nurse is preparing information regarding newborn safety interventions for a fathers' focused prenatal class. Which content area should the nurse view as having priority?

Use of infant car seats and carriers

The maternity nurse is monitoring a third-trimester pregnant client who is experiencing vaginal bleeding and is suspected of having abruptio placenta. On assessment, which sign/symptom should the nurse expect to note?

Uterine tenderness on palpation

The nurse is monitoring a fetal heart rate (FHR). The nurse documents that a reassuring FHR pattern is present if which sign is noted?

Variability averaging 6 to 10 beats per minute

After the delivery of a newborn infant, the nurse prepares to assist in the delivery of the placenta. What is the best method to deliver the placenta?

Wait for placental separation, and then pull gently on the cord as the mother bears down.

The postpartum nurse is monitoring the amount of lochial flow in a client after delivery. The nurse understands that the accurate assessment of the amount of flow is determined by using which method?

Weighing the perineal pad before and after use and the amount of time between pad changes

A pregnant woman is suspected of alcohol abuse. The nurse checks the client for clinical manifestations associated with alcohol abuse. Which clinical manifestation is least likely to be noted in the client?

Weight gain

The nurse explains to a mother that her newborn infant is being admitted to the neonatal intensive care unit with a probable diagnosis of fetal alcohol spectrum disorder-fetal alcohol syndrome (FAS). The nurse explains the expected effects of FAS to the mother and tells the mother which information?

Withdrawal symptoms include tremors, crying, seizures, and abnormal reflexes.

A client states, "It will be so hard to wait for the results of this amniocentesis. I don't know what I will do if something goes wrong." Which appropriate response should the nurse make to the client?

"You sound concerned about this test."

The nurse is assessing a client diagnosed with cardiac disease at the 30 weeks' gestation antenatal visit. The nurse assesses lung sounds in the lower lobes after a routine blood pressure screening. The nurse performs this assessment to elicit what information?

Assess for early signs of heart failure (HF).

A pregnant client has just been admitted to the maternity unit with a diagnosis of preeclampsia. The nurse knows that it is important to assess for complications at this time. As part of the plan of care for this client, which finding should the nurse regularly observe for?

Bleeding gums

The nurse is providing instructions to a mother of a newborn infant diagnosed with hyperbilirubinemia who is being breast-fed. What feeding procedure should the nurse teach the mother?

Breast-feed the infant every 2 to 4 hours.

The nurse caring for a client who recently received an epidural anesthesia for a vaginal delivery suspects the presence of a vaginal hematoma. Which finding would be the best indicator of the presence of this type of hematoma?

Changes in vital signs

The parents of a male newborn who is not circumcised request information on how to clean the newborn's penis. The nurse should make which statement to the parents?

"Cleanse the penis but allow natural separation of the foreskin rather than retracting because this may cause adhesions."

After receiving replacement surfactant therapy, the infant with respiratory distress syndrome (RDS) requires frequent arterial blood gas monitoring. Which statement by the infant's mother indicates that she understands the reason why frequent blood sampling is needed?

"Frequent blood gases help to monitor my baby's respiratory patterns."

A client diagnosed with diabetes mellitus delivered her infant an hour ago. Which statement by the client indicates a need for further teaching regarding care to the newborn?

"I don't think my baby needs to eat right now. It's only an hour old and is very sleepy."

The nurse in the prenatal clinic is taking a nutritional history from a 16-year-old adolescent. Which statement by the client indicates a need for follow-up?

"I need to gain only 7 to 10 pounds because I want a small, petite baby girl."

The nurse has provided instructions to a postpartum client regarding postpartum exercises. Which statement by the client indicates an understanding of the exercises?

"I should alternately contract and relax the muscles of the perineal area."

The home care nurse visits a 4-day-old, full-term, small-for-gestational-age (SGA) infant at home and notes that the infant is jaundiced and dehydrated. Which statement by the mother indicates that she understood the hospital discharge teaching for the infant?

"My baby looks so yellow. I am going to call the doctor."

A 10-day postpartum breast-feeding client telephones the postpartum unit reporting a reddened, painful breast and elevated temperature. Based on assessment of the client's complaints, which action should the nurse tell the client to do?

"Notify your health care provider because you may need medication."

During the discharge planning of a small-for-gestational-age (SGA) infant, the nurse makes an appointment for the infant to be evaluated by a developmental specialist. The mother says to the nurse, "I am not sure that going to a specialist is necessary just because the baby is small." The nurse should make which response to the mother?

"Would you like for me to clarify why I have made an appointment for your baby to be evaluated by the developmental specialist?"

The nurse reads the radiology report of the initial chest X-ray taken on an infant with respiratory distress syndrome (RDS) who has received surfactant replacement therapy. The report states that both lung fields have a "ground glass" appearance. How should the nurse interpret this report?

Characteristic of clinical findings in neonatal RDS

A multigravida woman with a history of multiple cesarean births is admitted to the maternity unit in labor. The client is having excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which finding is noted if complete uterine rupture occurred?

Decreasing blood pressure

Which procedure should be avoided in order to help prevent the transmission of the human immunodeficiency virus (HIV) from a positive pregnant mother to her fetus during the intrapartum period?

Direct (internal) fetal heart rate monitoring

The nurse is changing the diaper of a 1-day-old, full-term, female newborn and notes that the genitalia are red and swollen and that a thick white mucoid vaginal discharge is present. Based on these findings, the nurse determines that which is the best action?

Document the findings.

The nurse in the newborn nursery is caring for a preterm infant. Which is the best method the nurse can implement to assist the parents with developing attachment behaviors?

Encourage the parents to touch and speak to their infant.

The nursery-room nurse is reviewing the criteria for early discharge of a newborn infant. Which finding, if noted in the infant, indicates that the criteria for early discharge have not been met?

Has evidence of significant jaundice within the first 24 hours

The nurse is planning interventions for counseling a maternal client who has been newly diagnosed with sickle cell anemia. Which would be the most important psychosocial intervention at this time?

Help the client identify her concerns.

A postpartum client with a diagnosis of gestational diabetes is scheduled for discharge. During the discharge teaching, the client asks the nurse, "Do I have to worry about this diabetes anymore?" Which is the most appropriate response by the nurse?

"You will be at risk for developing gestational diabetes with your next pregnancy and also for developing diabetes mellitus."

Place in order the occurrence of the expected fetal developmental milestones, beginning with the milestone expected as early as 6 weeks' gestation and ending with the milestone seen at term (40 weeks). Arrange the developmental milestones in the order that they occur. All options must be used.

1. Fetal heart tones are detected by ultrasound examination. 2. Kidney is able to secrete urine. 3. Vernix caseosa and lanugo appear. 4. Lecithin/sphingomyelin (L/S) ratio is 1.2:1. 5. Testes are in scrotum; labia majora are well developed.

A pregnant client arrives at the prenatal clinic and is complaining that her breasts are very tender. The client is concerned about what is causing this discomfort. What should the nurse tell the client is causing this discomfort? Select all that apply.

1. Increased levels of estrogen 5. Increased levels of progesterone

A newborn has just been circumcised. Which postcircumcision interventions should the nurse implement? Select all that apply.

1. Observe for bleeding. 4. Note the time and amount of the first void after the circumcision. 5. Apply fresh petrolatum around the glans after each diaper change.

The nurse is monitoring a client in labor who is receiving oxytocin and notes that the fetal heart rate pattern is showing severe late decelerations. How should the nurse prioritize nursing actions? Arrange the actions in the order that they should be performed. All options must be used.

1. Perform a vaginal examination. 2. Reposition the client to her left side. 3. Stop the oxytocin infusion. 4. Administer oxygen by face mask at 8 to 10 L/min. 5. Call the primary health care provider if late decelerations continue.

The nurse is monitoring a laboring client who is receiving a fentanyl epidural block. The nurse monitors for which side/adverse effects of a fentanyl epidural? Select all that apply.

1. Pruritus 3. Hypotension 4. Urinary retention

The nurse assessing the apical heart rates of several different newborn infants notes that which heart rate is normal for this newborn population?

140 beats per minute

The nurse is planning care for a client with an intrauterine fetal demise. Which are appropriate goals for this client? Select all that apply.

2. The woman and her family will discuss plans for going home without the infant. 3. The woman and her family will express their grief about the loss of their desired infant. 5. The woman and her family will contact their pastor or grief counselor for support after discharge.

The health care provider informs the nurse that an infant with symptomatic polycythemia and hyperviscosity will undergo an exchange transfusion. Which fluid should the nurse prepare for use during the exchange transfusion?

5% Albumin

The nurse is performing a prenatal examination on a client in the third trimester. The nurse begins an abdominal examination that includes Leopold maneuvers. What information should the nurse be able to determine after performing the assessment's first maneuver?

Fetal lie and presentation

A pregnant client is seen in the clinic and reports that she has been experiencing pain caused by hemorrhoids. The nurse provides information to the client regarding the hemorrhoids. Which statement by the client indicates the need for further teaching?

"Hemorrhoids are caused by my changes in hormones and will disappear after my baby is born."

The nurse is assessing the respiratory rate of a newborn infant delivered vaginally 3 hours ago. The nurse determines that the rate is 70 breaths per minute. How should the nurse interpret this finding?

The newborn is experiencing tachypnea.

The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. The primary health care provider has documented the presence of Goodell's sign. What is an appropriate determination by the nurse regarding this sign?

This indicates softening of the cervix.

The nurse is performing an assessment on a primigravida client who has been a marathon runner for several years. The client verbalizes concern because she is no longer able to run in marathons and is concerned about the brown discoloration on her face and her increasing size. Which statements by the nurse are therapeutic? Select all that apply.

1. "I can see you're disappointed at not being able to run." 2. "Tell me how you are feeling about the changes in your body."

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. Which action should the nurse anticipate to be prescribed?

Administration of hepatitis immune globulin and a vaccine to the infant soon after birth

The nurse is preparing to care for the mother of a preterm infant. When should the nurse plan to begin discharge planning?

After stabilization of the infant during the early stages of hospitalization

After a newborn infant undergoes circumcision, which should the nurse include in the postprocedure plan of care?

Observing for bleeding and assessing for pain

The nurse is caring for a client in active labor. Which intervention should the nurse implement to prevent fetal heart rate decelerations?

Encourage upright or side-lying maternal positions.

Based on a complete assessment, the nurse has just instituted measures related to an occult prolapsed cord in a client just entering the second stage of labor. The sudden change of the labor plan has alarmed the client and her husband, who are anxiously asking what is happening and whether the baby is OK. Which response/action by the nurse will most likely reduce the fear and stress of the couple?

Explain to the couple what is happening, how it is being managed, and what they can do to help.

A 24-hour-old term infant had a confirmed episode of hypoglycemia when 1 hour old. Which observation by the nurse would indicate the need for follow-up?

High-pitched cry, drinking 10 to 15 mL of formula per feeding

The nurse is monitoring a small-for-gestational-age (SGA) infant. Which finding indicates a potential complication in this infant?

Intolerance of oral feedings

A primigravida client who came to the clinic has been diagnosed with a urinary tract infection. She repeatedly verbalizes concern regarding the safety of the fetus. Which should the nurse address first?

Maternal and infant safety

The nurse is comparing the use of nalbuphine versus meperidine for pain management for a pregnant client with dystocia. The nurse determines which statement is true with regard to the use of nalbuphine or meperidine?

Nalbuphine is less likely to cause significant respiratory depression.