NCLEX Labor and Delivery, Problems with Labor and Delivery, Postpartum Period, Postpartum Complications, and Care of the Newborn Questions

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of the newborn? 1. Lethargy 2. Sleepiness 3. Constant crying 4. Cuddles when being held

3. Constant crying A newborn of a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation.

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1. Developmental delays because of excessive size 2. Maintaining safety because of low blood glucose levels 3. Choking because of impaired suck and swallow reflexes 4. Elevated body temperature because of excess fat and glycogen

2. Maintaining safety because of low blood glucose levels

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all the apply. 1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 4. "I will start my estrogen birth control pills again as soon as I get home." 5. "I know if my breasts get engorged I will limit my breast feeding and supplement the baby." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

1. "I should wear a bra that provides support." 2. "Drinking alcohol can affect my milk supply." 3. "The use of caffeine can decrease my milk supply." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? 1. "I will begin abdominal exercises immediately." 2. "I will notify the health care provider if I develop a fever." 3. "I will turn on my side and push up with my arms to get out of bed." 4. "I will lift nothing heavier than my newborn baby for at least two weeks."

1. "I will begin abdominal exercises immediately." The client must wait at least 3-4 week post-operatively to allow for healing of the incision.

An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription? 1. Delivery of the fetus 2. Strict monitoring on intake and output 3. Complete bed rest for the remainder of the pregnancy 4. The need for weekly monitoring of coagulation studies until the time of the delivery

1. Delivery of the fetus The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible.

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with a placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2. Hemorrhage In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining muscularture as the fundus of the uterus, and this site is more prone to bleeding.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full term newborn on admission to the nursery. the nurse suspects fetal alcohol syndrome and is aware of which additional sign would be consistent with this syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Birth weight of 6 lb, 14 oz 4. Head circumference appropriate for gestational age

2. Abnormal palmar creases Features of newborns diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar reflexes, and respiratory distress.

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4 2. An increase in the pulse rate from 88 to 102 beats/minutes 3. A blood pressure change from 130/88 to 124/80 4. An increase in the respiratory rate from 18-22 breaths/minute

2. An increase in the pulse rate from 88 to 102 beats/minute An increased pulse rate is an early sign of excessive blood loss because the heart pumps faster to compensate for the decreased blood flow.

Then nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the monitor, what is the next nursing action? 1. Identify the types of acceleration 2. Assess the baseline fetal heart rate 3. Determine the intensity of contractions 4. Determine the frequency of the contractions

2. Assess the baseline fetal heart rate Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified.

The nurse develops a plan of care for a woman with HIV and her newborn. The nurse should include which intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely 2. Maintaining standard precautions at all times while caring for the newborn 3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4. Instructing the breast-feeding mother regarding the treatment of the nipples with nyastatin ointment

2. Maintaining standard precautions at all times while caring for the newborn

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention would be most appropriate? 1. Elevate the client's legs 2. Massage the fundus until it is firm 3. Ask the client to turn on her left side 4. Push on the uterus to assist in expanding clots

2. Massage the fundus until it is firm If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus.

The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding? 1. Gently push the cord into the vagina 2. Place the client in the Trendelenburg position 3. Find the closest telephone and page the health care provider stat 4. Call the delivery room to notify the staff that the client will be transported immediately

2. Place the client in the Trendelenburg position The client should be positioned with the hips higher than the head to shift the presenting part towards the diaphragm. The nurse should push the call light to summon help.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1. Ambulation 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids

2. Rest between contractions Encouraging rest between contractions conserves maternal energy.

The nurse is reviewing the record of a client in the labor room and notes that the health care provider has documented that the fetal presenting part is at the -1 station. This documented finding indicates that the fetal presenting part is located at which area? 1. 1 inch below the coccyx 2. 1 inch below the illiac crest 3. 1 cm above the ischial spine 4. 1 fingerbreadth below the symphysis pubis

3. 1 cm above the ischial spine Station is the measurement of the progress of descent in centimeters above or below the midplane from the presenting part to the ischial spine. It is noted as a negative number above the line and as a positive number below the line.

The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

3. Drying the infant with a warm blanket Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying prevents hypothermia.

The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Assess vital signs every 4 hours 2. Measure fundal height every 4 hours 3. Prepare an ice pack for application to the area 4. Inform the health care provider of assessment findings

3. Prepare an ice pack application to the area Application of ice reduces swelling caused by hematoma formation in the vulvar area.

The nurse is caring for a client in labor. Which assessment finding indicates to the nurse that the client is beginning the second stage of labor? 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid.

3. The cervix is dilated completely. The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate.

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further teaching? 1. "I should breast feed every 2-3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breastfeeding." 4. "I should wash my nipples daily with soap and water."

4. "I should wash my nipples daily with soap and water." Soap is drying and could lead to cracks in the nipples.

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1. "I will place my baby's crib close to the door." 2. "Some health care personnel won't have name badges." 3. "It's OK to allow unlicensed assistive personnel to carry my newborn to the nursery." 4. "I will ask the nurse to attend to my infant if I am napping and my husband is not here."

4. "I will ask the nurse to attend to my infant if I am napping and my husband is not here."

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes what statement? 1. "I won't be in labor until my baby drops." 2. "My contractions will be felt in my abdominal area." 3. "My contractions will not be as painful if I walk around." 4. "My contractions will increase in duration and intensity."

4. "My contractions will increase in duration and intensity." True labor is present when contractions increase in duration and intensity.

Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? 1. Slow the IV flow rate 2. Place the client in a high Fowler's position 3. Continue the oxytocin drip if infusing 4. Administer oxygen, 8-10 L/minute via face mask

4. Administer oxygen, 8-10 L/minute via face mask Oxygen is administered to optimize oxygenation to the circulating blood.

The postpartum nurse is providing instructions to a client after delivery of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of delivery 4. Within two weeks postpartum

1. 3 days postpartum After birth, the nurse should auscultate all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2-3 days postpartum.

The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription? 1. Prepare the client for an ultrasound 2. Obtain equipment for a manual pelvic exam 3. Prepare to draw a hemoglobin and hematocrit blood sample 4. Obtain equipment for external electronic fetal heart rate monitoring

2. Obtain equipment for a manual pelvic exam Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os.

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is the most appropriate? 1. Apply gentle pressure 2. Reinforce the dressing 3. Document the findings 4. Contact the health care provider

3. Document the findings The penis is normally red during the healing process after circumcision. A yellow exudate may be noted in 24 hours, and this is part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage.

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is the most appropriate? 1. Notify the health care provider of the findings 2. Reposition the mother and check the monitor for changes in fetal tracing 3. Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen 4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well being

4. Document the findings and tell the mother that the pattern on the monitor indicates fetal well being Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen via face mask. 2. Place the mother in a supine position. 3. Increase the rate of the oxytocin IV infusion 4. Document the findings and continue to monitor the fetal patterns.

1. Administer oxygen via face mask. Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during uterine contractions. Hypoxemia results; administer 8-10 L/minute via face mask.

The mother of a newborn calls the clinic and reports when cleaning the umbilical cord, she noticed the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1. Bring the infant to the clinic 2. This is a normal occurrence 3. Increase the number of times that the cord is cleaned per day 4. Monitor the cord for another 24-48 hours and call the clinic if the discharge continues

1. Bring the infant to the clinic Symptoms of umbilical cord infection are moisture, oozing, discharge, and reddened base around the cord.

The nurse monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation

1. Changes in vital signs Since the client had an epidural, she cannot feel the pain, pressure, or tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with a vulvar hematoma.

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume

1. Client pain level Most clients experience some degree of discomfort during the immediate postpartum period.

The nurse is monitoring a client who is in the active stage of labor. The client has been experiencing contractions that are short, irregular, and weak. The nurse documents that the client is experiencing which type of labor dystocia? 1. Hypotonic 2. Precipitous 3. Hypertonic 4. Preterm labor

1. Hypotonic Hypotonic labor contractions are short, irregular, and weak and usually occur during the active phase of labor. Hypertonic usually occurs during the latent phase of labor and contractions are painful, frequent and usually uncomfortable. Precipitous labor is labor that lasts in its entirety for 3 hours or less.

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most important? 1. Notify the health care provider 2. Continue to monitor the fetal heart rate 3. Encourage the client to continue pushing with each contraction 4. Instruct the client's coach to continue to encourage breathing techniques

1. Notify the health care provider A normal fetal heart rate is 110-160 beats/minute, the fetal heart rate should be within the range between contractions.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1. Provide pain relief measures 2. Prepare the client for an amniotomy 3. Promote ambulation every 30 minutes 4. Monitor the oxytocin infusion closely

1. Provide pain relief measures Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Relief of the pain is the primary intervention to promote a normal labor pattern.

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position? 1. Supine position with a wedge under the right hip 2. Trendelenburg's position with the legs in stirrups 3. Prone position with the legs separated and elevated 4. Semi-Fowler's position with a pillow under the knees

1. Supine position with a wedge under the right hip Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would side lying, but since abdominal surgery requires a supine position a wedge should be placed under the right hip.

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. Presence of barrel chest and acrocyanosis

1. Tachypnea and retractions A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? 1. The diet should include additional fluids. 2. Prenatal vitamins should be discontinued. 3. Soap should be used to cleanse the breasts. 4. Birth control measures are unnecessary while breast-feeding.

1. The diet should include additional fluids

The nurse is preparing a list of self care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included in the list? Select all that apply. 1. Wear a supportive bra 2. Rest during the acute phase 3. Maintain a fluid intake of at least 3000 mL 4. Continue to breast feed if the breasts are not too sore 5. Take the prescribed antibiotics until the soreness subsides 6. Avoid decompression of the breast by breast feeding or breast pumping

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

The nurse in the NICU receives a telephone call to prepare the admission of a 43 week gestation newborn with an APGAR score of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? 1. Turn on the apnea and cardiorespiratory monitors 2. Connect the resuscitation bag to the oxygen outlet 3. Set up the IV line with 5% dextrose in water 4. Set the radiant warmer control to 97.6

2. Connect the resuscitation bag to the oxygen outlet The highest priority would be airway.

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast fed. The nurse should provide which most appropriate instruction to the mother? 1. Feed the newborn less frequently 2. Continue to breast-feed every 2-4 hours 3. Switch to bottle-feeding the infant for 2 weeks 4. Stop breast-feeding and switch to bottle feeding permanently

2. Continue to breast-feed every 2-4 hours

The nurse is assisting a client undergoing induction of labor at 41 weeks gestation. The client's contractions are moderate and occurring every 2-3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120-122 for the past hour. What is the priority nursing action? 1. Notify the health care provider 2. Discontinue the infusion of oxytocin 3. Place oxygen on at 8-10 L/minute via face mask 4. Contact the client's primary support person if not currently present

2. Discontinue the infusion of oxytocin Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability.

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing action in the care of the client? 1. Providing sitz bath 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels

2. Encouraging fluid intake Cystitis is an infection of the bladder. The client should drink 3000 mL of fluids per day if not contraindicated.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate the need to contact the health care provider? 1. Hemoglobin of 11 g/dL 2. Fetal heart rate of 180 beats per minute 3. Maternal pulse rate of 85 beats per minute 4. White blood cell count of 12,000 cells/mm3

2. Fetal heart rate of 180 beats per minute A normal fetal heart rate is 110-160 beats/minute. A fetal heart rate of 180 could indicate fetal distress.

The nurse has developed a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1. Providing comfort measures 2. Monitoring the fetal heart rate 3. Changing the client's position frequently 4. Keeping the significant other informed about the progress of the labor

2. Monitor the fetal heart rate Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate, the fetal status is the priority.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with her fingertips. What should the nurse do to help the woman process the delivery? 1. Encourage the mother to breast-feed soon after birth 2. Support the mother in her reaction to the new-born infant 3. Tell the mother that it is important to hold the newborn infant 4. Document a complete account of the mother's reaction on the birth record

2. Support the mother in her reaction to the new-born infant Precipitous labor lasts less than 3 hours. Women who experience this often describe a feeling of disbelief that their labor progressed so rapidly.

The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1. The client is a 35-year-old primigravida 2. The client has a history of cardiac disease 3. The client's hemoglobin level is 13.5 g/dL 4. The client is a 20-year-old primigravida of average weight and height

2. The client has a history of cardiac disease Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetric problems, substance and environmental factors, and substance abuse.

The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if the condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding

2. Uterine tenderness Abruptio placentae is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. Abdominal pain is present along with uterine tenderness.

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign would the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3. Enlarged, hardened veins Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including redness, tenderness, and warmth of the involved extremity.

Which assessment finding following an amniotomy should be conducted first? 1. Cervical dilation 2. Bladder distention 3. Fetal heart rate pattern 4. Maternal blood pressure

3. Fetal heart rate pattern Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse.

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding? 1. Scant 2. Light 3. Heavy 4. Excessive

3. Heavy Scant = less than 2.5 cm on a menstrual pad in one hour, light = less than 10 cm, moderate = less than 15 cm, heavy = saturated menstrual pad.

A client arrives at a birthing center in active labor. Her membranes are still intact, and the health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? 1. Less pressure on her cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased maternal blood pressure monitoring

3. Increased efficiency of contractions Amniotomy can be used to induce labor when the condition of the cervix is favorable or to augment labor if the progress begins too slow.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action would be most appropriate? 1. Raise the head of the clients bed 2. Obtain hemoglobin and hematocrit levels 3. Instruct the client to request help when getting out of bed 4. Inform the nursery room nurse to avoid bringing the newborn to the client until the mother's symptoms have subsided

3. Instruct the client to request help when getting out of bed Orthostatic hypotension may be evident during the first 8 hours after birth.

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? 1. Elevate the client's legs 2. Document the findings 3. Massage the fundus until it is firm 4. Push on the uterus to assist in expressing clots

3. Massage the fundus until it is firm

When performing a postpartum assessment on a client, a nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document the findings 2. Reassess the client in 2 hours 3. Notify the health care provider 4. Encourage increased oral intake of fluids

3. Notify the health care provider A few small clots may be noted in the lochia in the first 1-2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal.

The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings 2. Massage the fundus 3. Notify the health care provider 4. Place the client in the trendelenburg position

3. Notify the health care provider If bleeding is excessive, the cause may be laceration of the cervix of the birth canal.

The nurse is reviewing the health care providers prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question? 1. Monitor fetal heart rate continuously 2. Monitor maternal vital signs frequently 3. Perform a vaginal exam every shift 4. Administer ampicillin 1 g as an intravenous piggyback every 6 hours

3. Perform a vaginal exam every shift Vaginal examinations should not be done routinely on a client with premature rupture of the membranes because of the risk of infection.

The nurse is preparing to care for four assigned clients. Which client is the highest risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A primiparous client who delivered 6 hours ago and had epidural anesthesia 4. A multiparous client who delivered a large baby after oxytocin induction

4. A multiparous client who delivered a large baby after oxytocin induction Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, large neonate, infection, multiparity, dystocia, cesarean birth, forceps delivery, and intrauterine manipulation.

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an IV line 2. Asses the client's BP 3. Prepare to administer morphine sulfate 4. Administer oxygen, 8-10 L/minute by face mask

4. Administer oxygen, 8-10 L/minutes by face mask If pulmonary embolism is suspected, oxygen should be administered. Oxygen is used to decreased hypoxia. The client is also kept on bed rest with the head of the bed slightly elevated to reduce dyspnea.

The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment findings would the nurse expect to note? Select all that apply. 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright, red vaginal bleeding 5. Soft, relaxed, nontender uterus 6. Fundal height may be greater than expected for gestational age

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

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2. What is the priority nursing action? 1. Document the finding 2. Retake the temperature in 15 minutes 3. Notify the health care provider 4. Increase hydration by encouraging oral fluids

4. Increase hydration by encouraging oral fluids The clients temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4 in the first 24 hours after birth often are related to the dehydration effects of labor.

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1. Avoid stimulation 2. Decrease fluid intake 3. Expose all of the newborn's skin 4. Monitor skin temperature closely 5. Reposition the newborn every 2 hours 6. Cover the newborn's eyes with eye shield or patches

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

The nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? 1. Allow the newborn to establish own sleep-rest pattern 2. Maintain the newborn in a brightly lighted area of the nursery 3. Encourage frequent handling of the newborn by staff and parents 4. Monitor the newborn's response to feedings and weight gain pattern

4. Monitor the newborn's response to feedings and weight gain pattern

The nurse in the labor room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding would alert the nurse to a compromise? 1. Maternal fatigue 2. Coordinated uterine contractions 3. Progressive changes in the cervix 4. Persistent nonreassuring fetal heart rate

4. Persistent nonreassuring fetal heart rate Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium.

The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action? 1. The client with mild afterpains 2. The client with a pulse of 60 beats/minute 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foul smelling odor

4. The client with lochia that is red and has a foul smelling odor Lochia, is red for the first 1-3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul smelling lochia indicates infection.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Acceleration 3. Early decelerations 4. Variable decelerations

4. Variable decelerations Variable decelerations occur if the umbilical cord is compressed, reducing the blood flow between the placenta and the fetus.