maternity1

A postpartum client with mastitis in the right breast complains that the breast is too sore for her to breastfeed her infant. Which should the nurse tell the client?

"Breastfeed from the left breast and gently pump the right breast."

A young 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, which is the best response by the nurse?

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

A client is pregnant, has a history of heart disease, and has been instructed on care at home. Which statement by the client indicates that she understands her needs?

"I should avoid stressful situations."

The nurse is reinforcing instructions to a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement

"I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."

The nurse is caring for a newborn in the nursery and notes that the primary health care provider has documented that the child has gastroschisis. The parents ask the nurse about the treatment for the disorder. Which statement should the nurse make to the parents?

"The defect will be closed surgically after all of the contents have been returned to the abdominal cavity."

A woman at 20 weeks of gestation calls the primary health care provider's office and speaks to the nurse. The client states that she is having subtle but persistent changes in her vaginal discharge, menstrual-like cramps, and diarrhea. Which is the least helpful response to the client?

"This is an emergency; you should come to the clinic within the hour."

The nurse is collecting data from a pregnant client who is currently at 28 weeks' gestation. At her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in centimeters and should expect which finding?

26 cm

It has been 12 hours since a client's delivery of a newborn. The nurse assesses the mother for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted at which level? Refer to figure.

A

The nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. Which instruction should the nurse provide to the client?

A cesarean section will be necessary if vaginal lesions are present at the time of labor.

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated?

A change in the uterine contour

The perinatal client is admitted to the obstetrical unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse should consult with the dietitian to ensure which dietary measure?

A diet that is high in fluids and fiber to decrease constipation

The nurse is collecting data from a prenatal client. The nurse determines that which situation places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?

A history of intravenous (IV) drug use in the past year

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated?

A manual pelvic examination

The nurse's assignment is to visit a new mother at home who was recently discharged from the hospital. Which finding should the nurse expect to note in a healthy breastfeeding mother and newborn?

A mother breastfeeding with the newborn in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow

A newborn has just been circumcised and is being discharged home in 2 hours. Which instructions should be provided by the nurse to the parents? Select all that apply.

Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days. 4. Change diaper every 4 hours or more often to inspect the penis for drainage or infection. 5. Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure.

The nurse performs a blood glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 50 mg/dL. Which action should the nurse implement based on this finding?

Document the finding because it is within the normal range.

The nurse in the labor room is caring for a client in the first stage of labor. When monitoring the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action?

Document the findings and continue to monitor the fetal patterns.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure?

Dorsiflex the client's foot while extending the knee

An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with what problem?

Drug withdrawal

After birth the nurse prevents hypothermia as a result of evaporation by performing which action?

Drying the baby with a warm blanket

The nurse suspects that the client has a pulmonary embolism when the client exhibits which signs and symptoms?

Dyspnea, tachypnea, and tachycardia

The nurse is collecting data from a client during the first prenatal visit at 12 weeks' gestation. The client is anxious to know what the fetus will look like at this time. The nurse correctly responds to the client by providing which information? Select all that apply.

Earliest taste buds present. 3. Kidneys able to secrete urine. Sex can be determined as internal and external organs are sex specific.

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

Encourage oral fluid intake.

A client is scheduled to have an elective cesarean delivery. How should the nurse allay the client's feelings of anxiety?

Encourage the client to discuss her concerns and desires regarding anesthesia options.

The nurse is caring for a postpartum client who is being treated for thrombophlebitis. The client is receiving an anticoagulant by intravenous infusion. The nurse monitors for adverse effects of the anticoagulant by checking the client for which signs/symptoms? Select all that apply

Epistaxis Hematuria 5. Ecchymosis

The goal for the postpartum client with deep thrombophlebitis is to prevent the complication of pulmonary embolism. In planning care to assist in meeting this goal, the nurse should perform which action?

Administer anticoagulants as prescribed

The clinic nurse is reviewing the records of the pregnant clients who will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection?

An adolescent with multiple heterosexual contacts

A woman diagnosed previously with gestational hypertension is returning to the clinic for her scheduled prenatal appointment. During the assessment, the nurse is concerned that she is developing signs/symptoms that indicate that her mild gestational hypertension is progressing. What assessment findings indicate to the nurse that the mild gestational hypertension is progressing? Select all that apply.

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

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply.

Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age

In order to prevent mastitis, which discharge instructions should the breastfeeding postpartum client receive from the nurse? Select all that apply.

Change breast pads frequently Avoid the use of soap on your nipples. 5. Intermittently expose your nipples to the air.

The nurse is caring for a client during the immediate recovery phase or fourth stage of labor. Which action is most important for the nurse to take at this time?

Check the uterine fundus and lochia

The nurse is assisting in providing a class to new mothers on newborn care. In teaching cord care, the nurse makes which suggestion to the new mothers?

Clean around the cord with plain water as needed until the cord falls off.

The nurse assists the nurse-midwife in examining the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (-) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which activity for the client?

Complete bed rest

While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of which reason?

Compression of the vena cava

A 30-week gestational prenatal client with complaints of painless vaginal bleeding presents at the labor and birthing department of the hospital. The nurse prepares the client for which expected diagnostic procedure?

Contraction stress test

The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which is noted?

Presence of accelerations

The nurse is caring for a client with sickle cell disease who is in labor. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily accomplish which goal?

Prevent dehydration and hypoxemia.

The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings in the newborn should alert the nurse to the possibility of this syndrome?

Tachypnea and retractions

Which should be included in the plan of care for a pregnant teenager to reinforce instructions regarding dental care?

Tell the dental office staff that she is pregnant.

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note?

Red

The nurse assists a pregnant client with cardiac disease in identifying resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily to accomplish which tasks?

Reduce excessive maternal stress and fatigue

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 make which response?

Request to hold the infant following delivery

The nurse reviews the arterial blood gas report on a newborn with respiratory distress syndrome (RDS) who was recently weaned from the ventilator and placed in an oxygen hood at 50% oxygen. The results indicate a pH of 7.25, Pao2 of 80 mm Hg, Paco2 of 50 mm Hg, and HCO3- of 24 mEq. Which interpretation should the nurse make of these results?

Respiratory acidosis

The nurse working in a prenatal clinic reviews a client's chart and notes that the primary health care provider documents that the client has a gynecoid pelvis. The nurse plans care understanding that which findings are characteristic of this type of pelvis? Select all that apply.

Round shape Diagonal conjugate measures 12.5 cm to 13 cm 5. Blunt, somewhat widely separated ischial spines

The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client?

The bladder must be full during the examination.

A pregnant client is seen in the health care clinic and asks the nurse what causes the breasts to change in size and appearance during pregnancy. Which response is appropriate for the nurse to make?

The breast changes are a result of the secretion of estrogen and progesterone."

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make?

The bright red bleeding is abnormal and should be reported.

The nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which as the priority goal for the client?

The client exhibits no signs of fetal distress.

While a client is holding and talking to her newborn immediately following delivery, she begins to cry. How does the nurse interpret the client's behavior?

The client is experiencing a normal response to birth.

A client beginning week 30 of gestation comes to the clinic for a routine visit. Which observation by the nurse indicates a need for further teaching?

The client is wearing knee-high hose.

The nurse is preparing a pregnant client for a transvaginal ultrasound exam. The nurse should tell the client that which will occur?

The client will feel some pressure when the vaginal probe is moved

A client who has just been told that she is pregnant asks a clinic nurse when the fetus's heart will be developed and beating. The nurse tells the client that the fetal heart is beating at what gestational week?

Week 5

A pregnant client in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home for progression of the disease process. The home care nurse reinforces teaching the client about the signs that need to be reported to the primary health care provider (PHCP) and tells the client to call the PHCP if which occurs?

Weight increases by more than 1 pound in a week

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse should make?

Where fertilization occurs

The nurse observes that a client in the transition stage of labor is crying out in pain with pushing efforts. The nurse recognizes this behavior as indicative of which response?

Fear of losing control

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which occurrence indicates an abnormal physical finding that necessitates further testing?

Fetal heart rate of 180 beats per minute

The nurse is monitoring a client who is receiving oxytocin to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which is noted?

Fetal tachycardia

The nurse is instructing a pregnant client on dietary sources of iron. Which client food selection demonstrates an understanding of teaching?

Fresh spinach

The nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?

Have the client empty her bladder.

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, which nursing action is the most appropriate

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

The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has an android pelvic shape. The nurse understands that which characteristics are included with this pelvic shape? Select all that apply.

Heart shaped Convergent sidewalls Narrow interspinous diameter

The nurse provides home care instructions to a postpartum client following a vaginal birth with episiotomy. Which statement by the client indicates the need for further teaching?

I can resume sexual activity at any time."

The nurse is gathering data from a 16-year-old pregnant client during her initial prenatal clinic visit. The client is beginning week 18 of her first pregnancy. Which client statement indicates a need for further investigation?

I don't like my face anymore. I always look like I have been crying

The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement?

I will tell the nurse at the hospital that I had an Rh shot during pregnancy."

The nurse reinforces home care instructions to a postpartum client who had a cesarean delivery. Which statement by the client indicates an understanding of the instructions?

If I develop a fever, I will call my doctor."

The nurse is caring for a newborn diagnosed with hyperbilirubinemia. Which action is recommended for a newborn who is being breast-fed when diagnosed with hyperbilirubinemia?

Increase the frequency of breastfeeding.

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which nursing action should be appropriate?

Instruct the client that these are common and may occur throughout the pregnancy.

The nurse is assisting in administering beractant to a premature infant who has respiratory distress syndrome. The nurse understands that the medication should be administered by which route?

Intratracheal

The nurse is assigned to assist in preparing a woman who is gravida VI for delivery. In planning care for this client, the nurse places which item(s) at the client's bedside?

Intravenous (IV) supplies

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was October 20, 2019. Using Nägele's rule, the nurse determines the estimated date of birth is which date?

July 27, 2020

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action?

Keep the client and her family members informed of her progress.

The nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body areas, knowing that venous congestion is commonly noted in which areas? Select all that apply.

Legs 2. Vulva

Which findings indicate to the nurse that placental separation has occurred? Select all that apply

Lengthening of umbilical cord Sudden trickle or spurt of blood Fetal membranes are seen at the introitus

A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement?

Massage the breasts before feeding to stimulate let-down.

A pregnant woman who is 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, what does the nurse determine the client may be experiencing?

Placenta previa

The nurse is caring for a woman who has delivered a baby after a pregnancy complicated with placenta previa. Which complication is the client most at risk for developing?

Postpartum hemorrhage

The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action?

Prepare the client for surgery.

A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the client's behavior, the nurse should suspect the client is how far dilated?

8 to 10 cm

The nurse is assisting in developing a plan of care for a client preparing to breastfeed. In planning care, which factor is most significant in teaching a client to breastfeed?

A positive nurse-client relationship

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which change that occurs with pregnancy?

A softening of the cervix

A pregnant client in the second trimester of pregnancy is admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding should the nurse expect to note if this condition is present?

Abdominal pain

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS?

Abnormal palmar creases

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. The nurse analyzes the client's behavior as likely the result of which situation?

Acute anxiety and the need for support

A client in labor has an underlying diagnosis of sickle cell anemia. During labor the client is at high risk for sickling crisis. The nurse should take which action to assist in preventing a crisis from occurring during labor?

Administer oxygen as prescribed.

The nurse is monitoring a client in the active stage of labor. The nurse notes a late deceleration on the fetal monitor. Based on this observation, how should the nurse respond?

Administer oxygen via face mask to the mother

The nurse is providing health care information to a pregnant client who is human immunodeficiency virus (HIV) positive. The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to accomplish which goal?

Avoid further stress on the maternal immune system

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first?

Baseline fetal heart rate

The client is informed that she is now in the second stage of labor, the descent phase. Which observations should the nurse make to support this stage of labor? Select all that apply.

Bearing down with contractions 4. Making expiratory vocalizations 5. Changing body positions frequently

The nurse is assisting with caring for a client who has a placenta previa. The nurse understands that a cervical examination should not be performed on the client primarily because it could have which consequence?

Cause hemorrhage

The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which assessment finding most likely indicates a hematoma?

Changes in vital signs

A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint which should the nurse do first?

Check for signs of thrombophlebitis.

A client is brought to the labor unit. As the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. What should be the nurse's immediate action?

Check the fetal heart rate.

A client delivers a viable neonate who is given Apgar scores of 8 and 9 at 1 and 5 minutes. The nurse recognizes that this score is based on which factors? Select all that apply.

Color 2. Heart rate 3. Muscle tone 4. Reflex irritability 6. Respiratory effort

A primigravida's membranes rupture spontaneously. Which action should the nurse take first?

Determine the fetal heart rate.

The nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, "Why are all of these people in here? Is my baby going to be all right?" Which appropriately describes the mother's problem at this time?

Fear about what is happening

The nurse is collecting data on a client who is 6 hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action is appropriate?

Instruct the mother to request help when getting out of bed.

The nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which guideline

Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dL, which are not abnormal in a 2-day-old neonate.

The nurse is assisting in preparing to care for a client undergoing an induction of labor with an infusion of oxytocin. The nurse should include which in the plan of care?

Maintain continuous electronic fetal monitoring.

The nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which interventions are included in the plan of care? Select all that apply.

Maintaining bed rest 2. Elevating the affected extremity Applying warm compresses to the affected area as prescribed

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV)-positive. The nurse understands that which should be included in the plan of care?

Maintaining standard precautions at all times while caring for the neonate

The nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which is the most important information for the nurse to document on the strip?

Maternal vital signs

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate admitted to the newborn nursery. The nurse determines that which additional sign would be consistent with fetal alcohol syndrome (FAS)?

Microcephaly and increased respiratory effort

The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to document that the fundus of the uterus is located at which area?

Midway between the symphysis pubis and the umbilicus

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply.

Monitor the skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with shields or patches.

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). Which is the appropriate nursing action?

Notify the registered nurse (RN), who will then contact the primary health care provider (PHCP).

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

Notify the registered nurse.

The nurse is assisting in collecting data on a large-for-gestational age (LGA) newborn who was delivered in a vertex presentation. Which technique should the nurse anticipate being used to check for evidence of birth trauma?

Palpating the clavicles for a fracture

The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse should suspect DIC if which is observed?

Petechiae, oozing from injection sites, and hematuria

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should perform which action?

Prepare an ice pack for application to the area.

A client experiences subinvolution during the puerperium. The nurse recalls that which factors are the most common causes for this occurrence? Select all that apply.

Retained placental fragments 5. Maternal reproductive tract infections

A postpartum client asks the nurse when she may resume sexual activity. Which response should the nurse give to the client?

Sexual activity may be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped

The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has a platypelloid pelvic shape. The nurse recognizes which characteristics to be present in the platypelloid pelvis? Select all that apply.

Shallow depth 2. Wide suprapubic archCompatible with vaginal delivery 5. Flattened anteroposteriorly and wide transversely

The nurse is teaching a pregnant client how to perform Kegel exercises. The nurse should tell the client that these exercises are for which purpose

Strengthen the pelvic floor in preparation for delivery.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened?

Support the mother in her reaction to the newborn

A pregnant client asks the nurse about the type of exercises that are allowable during the pregnancy. The nurse should instruct the client that which is the safest exercise?

Swimming

A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently and requests to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because of which situation?

The client is required to stay on bed rest

Which action, if noted in the new mother, indicates the need for further data collection by the nurse for signs of postpartum depression?

The mother constantly complains of tiredness and fatigue.

The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates which

The presence of infection

The nurse is caring for a client who is being treated with antibiotics for mastitis. To reinforce instructions, what does the nurse tell the client

To complete the entire antibiotic regimen

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placentae is accompanied by which additional finding?

Uterine tenderness on palpation

A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement?

"I don't need birth control because I will be breastfeeding."

A client has been admitted to the maternity unit for a scheduled cesarean section. As she is getting into bed for preliminary preparation for surgery, the client states, "I don't need the cesarean section after all because I think my baby has moved around." Which is the appropriate response by the nurse?

"Tell me what you mean when you say that your baby has moved."

The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which statement indicates successful learning?

"The iron is needed for the red blood cells."

A pregnant woman in her second trimester calls the prenatal clinic nurse to report a recent exposure to a child with rubella. Which response by the nurse is appropriate?

"You were wise to call. I will check your rubella titer screening results, and we can identify immediately if interventions are needed."

The advantages of using spinal anesthesia for delivery of a fetus include which reasons? Select all that apply.

Ease of administration 2. Absence of fetal hypoxia 3. Immediate onset of anesthesia

The nurse assisting with monitoring a client in labor is told that the client's cervix is 3 cm dilated with contractions occurring every 2 to 3 minutes. When monitoring the client's psychological status, the nurse anticipates the client will reflect which attitudes? Select all that apply.

Alertness Excitement

The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing action should be to monitor which clinical parameter?

Blood glucose level

The nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan?

Circumcision has been delayed to save tissue for surgical repair."

The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure?

Drink decaffeinated coffee and tea

The nurse provides explanation to a client prescribed methylergonovine maleate in the immediate postpartum period. Which statement made by the client demonstrates understanding of the rationale for administration?

It will help prevent bleeding and control bleeding if it occurs."

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

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

The nurse is collecting data from a client with placenta previa during an office visit. The nurse should check which item as first priority?

Signs of fetal distress

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate?

Tell the client that these are common and they may occur throughout the pregnancy.

The nurse is monitoring a client with mild gestational hypertension (GH). Which data indicate that GH is a concern?

The client complains of a headache and blurred vision.

A client becomes increasingly more anxious and hyperventilates during the transition phase of labor. The nurse recognizes that the client needs what?

To regain her breathing pattern

Oxytocin is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for which effective response from the medication?

Uterine contractions

The nurse is assessing a 2-day postpartum mother. The mother complains of severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing these complaints, the nurse should check which as a priority?

Vulva for a hematoma

The nurse has reinforced instructions to a postpartum client who is hepatitis B positive on how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure?

Washes and dries her hands before feeding

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

Would you like to hold your baby?"

A nulliparous woman asks the nurse when she will feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately which week of gestation?

18

The postpartum nurse is collecting data from a client who delivered a viable newborn 2 hours ago. Which statement does the nurse anticipate that the client will make regarding her lochial flow?

"I am having a dark red discharge."

A pregnant client tests positive for hepatitis B virus (HBV). The nurse determines that the client understands this infection when the client makes which statement?

"I am so glad that I can breastfeed my baby after she has been vaccinated."

The nurse is reinforcing instructions to a postpartum cesarean delivery client who is preparing for discharge. Which statement by the client indicates a need for further teaching?

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

A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed?

"I will breastfeed, especially for the first 6 weeks postpartum."

A client asks, "What does it mean that the baby is at minus one?" The nurse should explain to the client that the fetal presenting part is which?

1 cm above the ischial spines

A pregnant client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse responds by telling the client that the gender of the fetus can usually be determined by which range of weeks?

12 to 16

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?

16 and 20 weeks' gestation

The nurse is assisting in caring for a newborn whose mother is Rh negative. Which is important for the nurse to include when planning the newborn's care?

Ask about the newborn's blood type and direct Coombs

A nursing student is conducting a clinical conference regarding the hormones related to pregnancy. The instructor asks the student about the function of thyroxine. Which statements by the student indicate an understanding of this hormone? Select all that apply.

It may play a role in the neural development of the fetus." 5. "It increases during pregnancy to stimulate basal metabolic rate."

The nurse is assisting in developing a plan of care for a newborn with spina bifida (myelomeningocele type). The nurse includes measures in the plan to monitor for increased intracranial pressure (ICP). Which action will detect the presence of an increase in ICP?

Monitoring the anterior fontanel for bulging

The nurse is assigned to care for a client who received methylergonovine maleate in the immediate postpartum period. The nurse determines the medication is effective when the client makes which statement?

My afterpains are really strong."

The nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client makes which statement?

My cervix is completely dilated."

The nurse is evaluating the effectiveness of meperidine hydrochloride for pain management for a client in labor. The client describes her pain level as "9" during contractions. The nurse determines that the medication was effective if the client exhibited which reasonable goal for pain relief?

Pain level is "4" while a progressive labor pattern continues.

The nurse is monitoring a new mother for signs of postpartum depression. Which observations in the mother indicate the need for further data collection related to this form of depression? Select all that apply.

Shows a lack of interest in eating 3. Lacks the ability to concentrate on tasks 4. Complains of feeling tired all of the time

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?

Side-lying

In caring for a preterm newborn, what knowledge related to skin care should the nurse consider when providing nursing care? Select all that apply.

Skin of the preterm baby is thinner than that of the full-term infant. 2. A preterm baby has less subcutaneous fat than the full-term infant. 3. The posture of the preterm infant will expose more skin to potential heat loss. 4. The preterm infant has a high body surface area in relation to their body weight.

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 is the nurse's priority action?

Stop the oxytocin infusion

The nurse is checking lochia discharge on a client in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. Which interpretation should the nurse make about this finding?

The finding is normal.

The nurse is reviewing the criteria for early discharge of a newborn infant with a new mother. Which data, if noted in the infant, indicate that the criterion for early discharge has not been met?

The infant has evidence of significant jaundice.

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

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

The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make which observation while caring for the neonate?

The neonate cries incessantly.

The nurse is preparing to reinforce instructions to a pregnant client about nutrition. The nurse plans to include which instruction in this client's teaching plan?

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

After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother is discharged. The nurse determines that the mother needs further teaching if the new mother makes which statement?

The only medications that I will take are prenatal vitamins and stool softeners."

A pregnant woman visiting a health care clinic for the first prenatal visit hears the primary health care provider discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. What information should the nurse share related to this stage of development? Select all that apply.

The preembryonic period is the first 2 weeks of fetal development following conception." "The preembryonic period includes initial development of the embryonic membranes and establishment of the primary germ layers."

The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care?

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

In providing initial care to the newborn following delivery, what is the nurse's priority action?

Turn the infant's head to the side.

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which components?

Two umbilical arteries and one umbilical vein

The nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client's health record, knowing that which finding needs to be further investigated before delivery?

White blood cell count of 35,000 mm3

The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormonal changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?

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

The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta?

Provides an exchange of nutrients and waste products between the mother and the fetus

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers?

The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client?

The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

The nurse is providing information to a pregnant woman about food items high in folic acid. Which mid-afternoon snack should be recommended to supply folic acid?

Nuts and green, leafy vegetables

A pregnant client asks the nurse about the hormone that stimulates postpartum contractions. The nurse tells the client that which primary hormone stimulates postpartum contractions?

Oxytocin

The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn?

Tachypnea and retractions

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?

"It is the fetal movement that is felt by the mother."

During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted?

150 beats per minute

A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states which about the ductus venosus?

Connects the umbilical vein to the inferior vena cava

During a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client makes which statement?

"I need to increase the fiber in my diet to control my blood glucose and prevent constipation."

The nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy, and the instructor asks the student about the function of progesterone. Which response made by the student indicates an understanding of the function of this hormone? Select all that apply.

"It maintains the uterine lining for implantation. "It relaxes all smooth muscle, including the uterus."

The new breastfeeding mother has been seen in the clinic for the treatment of mastitis. Which comment by the mother indicates a need for further teaching?

"My left breast is sore, so I will offer only my right breast frequently for breastfeeding."

A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione). The nurse should make which statement to the client?

"Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding."

The nurse is talking to a pregnant client with human immunodeficiency virus (HIV) infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

"You will need to bottle-feed your newborn."

The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action?

Ambulate frequently.

After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note?

At the level of the umbilicus

A perinatal client is at risk for toxoplasmosis. Which instruction should the nurse reinforce with the client to prevent exposure to this disease?

Avoid exposure to litter boxes used by cats.

The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.

Ballottement Chadwick's sign Uterine enlargement Braxton Hicks contraction

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply

Bright red vaginal bleeding Soft, relaxed, nontender uterus

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action should the nurse take initially?

Determine the maternal and fetal vital signs.

The nurse is assisting in caring for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and parents?

Encourage the parents to touch their newborn.

The nurse-midwife is conducting a session on the process of conception with a group of nursing students. Which statements reflect that the nursing students understand the process of conception? Select all that apply.

Fertilization occurs in the outer third of the fallopian tube." 2. "Only 1 sperm will penetrate the ovum to produce fertilization." Implantation occurs in the anterior or posterior fundal region of the uterus." 5. "The ovary produces hormones to maintain the pregnancy before placental development."

The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document which as the GTPAL for this client?

G = 2, T = 1, P = 0, A = 0, L = 1

The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse should recommend which measure to help relieve both discomforts?

Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

A second-day postpartum client diagnosed with a stable cardiac condition has scant lochia with a foul odor and a temperature of 102.2° F. The primary health care provider suspects infection and writes prescriptions to treat the client. Which prescription written by the primary health care provider should the nurse implement first?

Obtain culture and sensitivity of lochia and urine.

A mother is breastfeeding her newborn. The mother complains to the nurse that she is experiencing severe nipple soreness. The nurse should provide which suggestion to the client?

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

The nurse is monitoring a pregnant client with gestational hypertension (GH) who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? Select all that apply.

Proteinuria Hypertension

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.

Rest during the acute phase. 2. Wear a supportive, nonunderwire bra. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breastfeed if the breasts are not too sore.

The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position?

Supine position with a wedge under the right hip

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse helps determine whether this method of family planning is appropriate?

"Do you plan to have any other children?"

The nurse has provided instructions about measures to clean the penis to the mother of a newborn who is not circumcised. Which statement by the mother indicates an understanding of this procedure?

"I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."

A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat a urinary tract infection. The mother expresses concern that her baby will be born with an infection. Which response should the nurse make to help reduce the maternal fears that the newborn will be born with an infection?

"Now that you have taken the medication as prescribed, we will continue to monitor you closely by repeating the urine culture before you leave today."

Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery?

"There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth."

A postpartum client who delivered at 32 weeks of gestation would like to breastfeed her preterm infant. At this time, the infant is receiving tube feedings only. What is the nurse's best response to the mother?

"You can begin pumping as soon as possible after delivery with an electric breast pump."

A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test?

A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test?

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for the presence of an infection. The nurse should tell the mother that which is a sign of infection?

A moist cord with discharge

The nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding indicates which condition?

Bladder distention

The nurse is collecting data on a pregnant client and is preparing to take the client's blood pressure. In which position should the nurse place the client?

In a sitting position

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes and the mother asks the nurse why this is done. The nurse should give which response to the client?

Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

A term client is being seen for a final prenatal appointment. The clinic nurse is making arrangements for the client to be 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?

Previous classical vertical uterine incision

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 progesterone. According to the nurse, what is the purpose of progesterone?

Progesterone maintains the uterine lining for implantation.

new mother is attempting to breastfeed for the first time. The nurse notices that the client has inverted nipples. What nursing action can the nurse take to assist the client in breastfeeding the newborn?

Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp

A client in labor has been pushing effectively for 1 hour and the presenting part is at a +2 station. The nurse determines which physiological need is primary to the client at this time?

Rest between contractions

The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is in a cephalic presentation. Which findings while performing Leopold's maneuvers support the identification of a cephalic presentation? Select all that apply.

Small parts are located on the left side of the uterus. 2. Small parts are located on the right side of the uterus. A soft, irregular non-ballottable shape is located just above the symphysis pubis

The nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented findings are associated with this disorder? Select all that apply.

Stenosis of the anorectal canal 2. Failure to pass meconium stool 3. The presence of stool in the vagina 4. The presence of an anal membrane

The nurse is caring for a client who had a cesarean section to deliver a nonviable fetus as a result of abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, "I lost my baby and now my wife! What am I going to do?" Which appropriately describes the situation?

The spouse lacks hope because of the loss of the baby and illness of his wife.

The nurse in the delivery room is assisting with the delivery of a newborn. Which observations indicate that the placenta has separated from the uterine wall and is ready for delivery? Select all that apply.

The umbilical cord lengthens 3. Changes in the shape of the uterusA trickle or gush of blood escapes from the introitus

An elective cesarean delivery is being planned for a pregnant client. The nurse is reviewing the plans for the surgery with the client. A low transverse uterine incision will be used. The client asks the nurse to explain why this approach is being used. The nurse's response is based on which premise?

This incision allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy.

The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which statement by the mother is most likely to occur at this time related to her birth experience?

I do not feel any urges yet to empty my bladder."

The nurse reinforces discharge instructions to the mother of a 5-day-old postterm newborn who required ventilatory support for 3 days for meconium aspiration. Which statement indicates that the mother needs further teaching?

I understand that my baby will be susceptible to contracting all respiratory infections throughout his childhood."

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

I will massage the breasts before feeding to stimulate let-down."

A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that this procedure will most likely have which effect?

Increased efficiency of contractions

The nurse is reinforcing instructions to a pregnant client about the warning signs in pregnancy that require the need to notify the primary health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the primary health care provider if which occurs?

Irregular, painless contractions

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action?

Keep the client in a side-lying position.

The nurse is preparing to monitor a fetal heart rate. The nurse locates a round, ballottable shape just above the symphysis pubis. Fetal small parts are located on the right side of the uterus with a concave shape located on the left side of the uterus. Where should the nurse listen to hear the strongest fetal heart tones?

Left lower quadrant

The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1.8. Which should the nurse anticipate to be prescribed by the primary health care provider?

Administration of a subcutaneous rubella virus vaccine

A client who is breastfeeding her newborn infant is experiencing nipple soreness. To relieve the soreness, which action should the nurse suggest to the client?

Begin feeding on the less sore nipple

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention?

Begin with the eyes and face

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

Breastfeeding my newborn will be the best option for my baby."

The nurse is reinforcing instructions to a maternity client on how to keep a fetal activity diary. Which instruction should the nurse provide the client?

Contact the primary health care provider if the baby's movements are fewer than 10 times in 2 hours.

A client has just delivered a viable newborn. The first nursing action to initiate attachment is which?

Determine the parents' desires for contact with the newborn.

The nurse prepares to explain the purpose of effleurage to a client in early labor. Which explanation by the nurse describes effleurage?

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

The nursing student is preparing to administer a medication to a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication and placement for the prophylaxis of ophthalmia neonatorum caused by gonococcal or chlamydia infection. The student correctly identifies which medication and location?

Erythromycin, eyes

In the prenatal clinic, the nurse is gathering data from a new client for the health history information. Which action is the best way for the nurse to elicit correct responses to questions that refer to sexually transmitted infections?

Establish a therapeutic relationship between the nurse and pregnant client

The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing student to identify the functions of the vagina. The student correctly responds by identifying which functions? Select all that apply.

Female organ of coitus 2. Discharge of menstrual flow 3. Allows for fetal passage during the process of birth

Which statements made by a nursing student indicate that the student has an appropriate knowledge base regarding the pregnancy hormone human chorionic gonadotropin (hCG)? Select all that apply.

Human chorionic gonadotropin is the hormone responsible for a positive pregnancy test." 3. "Human chorionic gonadotropin may be present as early as 8 to 10 days following conception." 4. "Human chorionic gonadotropin is produced by the trophoblastic cells that surround the developing embryo." 5. "Human chorionic gonadotropin preserves the function of the ovarian corpus luteum so that estrogen and progesterone are produced before placental functioning."

A delivery room nurse collects data on a mother who just delivered a healthy newborn infant. The nurse checks the uterus to determine if the placenta has detached. Which findings indicate to the nurse that placental detachment has occurred? Select all that apply.

Lengthening of the umbilical cord Sudden gush of dark blood from the vagina 4. Appearance of fetal membranes at the introitus

The nurse is assisting in performing Leopold's maneuvers. The client asks the purpose of the procedure. How should the nurse respond to the client? Select all that apply

Leopold's maneuvers are used to determine fetal position." "Leopold's maneuvers assist in determining the degree of descent into the pelvis of the presenting part." 6. "Leopold's maneuvers assist in determining the point of maximal intensity of the fetal heart rate on the maternal abdomen."

The nurse is caring for a neonate with fetal alcohol syndrome (FAS). The nurse includes which priority intervention in the plan of care for this newborn?

Monitor neonate response to feedings and the weight gain pattern

The nurse is caring for a newborn with respiratory distress syndrome (RDS). Which data obtained by the nurse indicate potential complications associated with this disorder?

No audible breath sounds in left lung; heart sounds louder in right side of chest

The nurse is caring for a newborn whose mother had an elevated temperature during a prolonged labor. Which intervention should be important to include in the newborn's plan of care?

Observe vital signs and central nervous system status frequently during the first 2 days.

The nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure the nurse should take which action?

Place the client in a supine position and place a wedge under the right hip.

The nurse is assisting with care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by performing which?

Placing external fetal monitors so that each fetal heart rate is monitored separately

The pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects the client will indicate that which medication is prescribed?

Subcutaneous administration of heparin sodium 5000 units daily

A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table and the nurse places the client in which position?

Supine with a wedge under the right hip

a nursing instructor instructs the nursing students that surfactant is a substance needed to facilitate neonatal breathing. Which statements made by the nursing students indicate understanding regarding the presence of surfactant? Select all that apply.

Surfactant, which is needed for lung expansion, is present beginning at 28 weeks." 4. "With decreased surfactant, more pressure must be generated to produce inspiration." 5. "Surfactant lowers surface tension, reducing the pressure required to keep the alveoli expanded."

The postpartum nurse is caring for a mother following delivery of a newborn infant. The nurse performs a perineal assessment on the mother and notes a trickle of bright red blood coming from the perineum. The nurse checks the mother's fundus and notes that it is firm. On review of the mother's record, the nurse also notes that an episiotomy was performed. Which determination should the nurse make based on this information?

The bright red bleeding is abnormal and should be reported.

The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. Which clinical finding supports the documentation of Chadwick's sign?

Violet bluish color of vaginal mucosa and cervix

A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure?

What an efficient way to record my baby's heart rate.

The nurse reviews the results of a bilirubin level on a 2-day-old, jaundiced, term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. On which interpretation of the bilirubin result does the nurse base a response?

Within acceptable ranges

The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse should document which gravida and para status on this client?

Gravida II, para I