OB ATI

a nurse is preparing to administer vitamin K by IM injection to a newborn. the nurse should administer the medication into which of the following muscles?

Vastus lateralis The nurse should administer vitamin K, or phytonadione, into the vastus lateralis muscle in the thigh. This medication prevents and treats hemorrhagic disease of the newborn, as newborns are born with vitamin K deficiency.

a nurse is caring for a newborn and auscultates an apical heart rate of 130/min. which of the following actions should the nurse take?

Document this as expected finding The expected reference range for an apical pulse in a newborn who is awake is 120 to 160/min. The nurse should document this as an expected finding.

a nurse is assessing a newborn who was born at 42.5 weeks of gestation. which of the following findings should the nurse expect?

Dry, cracked skin A newborn who is postmature has dry, cracked skin.

a nurse is caring for a client who is 12 hr postpartum. which of the following findings should alert the nurse to the possibility of a postpartum complication?

Heart rate 110/min A rapid or increasing heart rate can be a manifestation of fluid volume depletion related to hemorrhage. The nurse should further evaluate the client for evidence of postpartum hemorrhage.

a nurse is caring for a client who experienced a vaginal birth 12 hr ago. the nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. which of the following findings should the nurse expect during this phase?

Expressions of excitement Expressing excitement and being talkative are characteristic of this phase.

a nurse is admitting a term newborn following a cesarean birth. the nurse observes that the newborn's skin is slightly yellow. this finding indicates the newborn is experiencing a complication related to which of the following?

Maternal/newborn blood group imcompatibility Maternal/newborn blood group incompatibility is the most common form of pathologic jaundice and the jaundice appears within the first 24 hr of life.

a nurse in the newborn nursery is caring for a group of newborns. which of the following newborns requires immediate intervention?

a newborn who is 12 hr post-delivery and has a temperature of 37.5 (99.5 F) Hyperthermia in the newborn requires immediately intervention. Hyperthermia is typically caused by increased heat production related to sepsis or decreased heat loss.

a nurse is discussing postpartum depression with a newly licensed nurse. which of the following statements indicates an understanding of this disorder?

it's common for clients who have postpartum depression to exhibit psychotic behavior Psychotic behavior is a common finding in clients who have postpartum psychosis.

a nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. the nurse observes variable decelerations in the fetal heart rate on the monitor strip. which of the following is a correct interpretation of this finding?

variable decelerations are due to umbilical cord compression Variable decelerations are decreases in the fetal heart rate with an abrupt onset, followed by a gradual return to baseline. Variable decelerations coincide with umbilical cord compression, which decreases the oxygen supply to the fetus.

A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make?

"We can time your pain medication so that you have an hour or two before the next feeding" This answer provides the client an option that allows for administration of pain medication but minimizes the effect it will have on the newborn while breastfeeding.

a nurse on the labor and delivery unit is caring for a newborn immediately following birth. which of the following actions by the nurse reduces evaporative heat loss by the newborn?

Drying the newborn's skin thoroughly Heat loss through evaporation occurs when moisture on the skin is converted to a vapor. This process is the most significant cause of heat loss in the first few days of life but is minimized by quickly and thoroughly drying the infant

a nurse is caring for a client who had a vaginal delivery 2 hr ago. which of the following actions should the nurse anticipate in the care of this client?

A. Document fundal height. C. Observe the lochia during palpation of fundus. D. Determine whether the fundus is midline. E. Administer methylgonovine maleate if uterus is boggy.

a nurse is caring for a client who is postpartum and received methylergonovine. which of the following findings indicates that the medication was effective?

Fundus firm to palpation Methylergonovine is an oxytocic medication that is administered to promote uterine contractions. This medication is indicated for treatment of postpartum hemorrhage caused by uterine atony or subinvolution; the desired effect is an increase in uterine tone.

A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first?

Place the client in the lateral position. This is a late deceleration and is associated with fetal hypoxemia due to insufficient placental perfusion. Placing the client in the lateral position is the first action the nurse should take.

a nurse is caring a client who is 3 days postpartum and is attempting to breastfeed. which of the following findings indicate mastitis?

Red and painful area in one breast Mastitis often appears as a red, hard, and painful area on the breast, commonly in the upper outer quadrant. Although mastitis can occur in both breasts, it is usually unilateral. A client who has mastitis can also influenza-like manifestations, such as fever, chills, headache, and myalgia. After delivery, the nurse should instruct the client to observe the breasts for indications of mastitis and to notify her provider if they occur.

a nurse is assisting a client who is postpartum with her first breastfeeding experience. when the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make?

"You should place your nipple and some of the areola into her mouth" Placing the nipple and 2 to 3 cm of areolar tissue around the nipple into the baby's mouth aids in adequately compressing the milk ducts. This placement decreases stress on the nipple and prevents cracking and soreness.

A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, "How will I know if my baby gets enough breast milk?" Which of the following responses should the nurse make?

"Your baby should wet 6 to 8 diapers per day." Newborns should wet 6 to 8 diapers per day. This is an indication that the newborn is getting enough fluids.

a nurse is caring for a client who just delivered a newborn. following the delivery, which nursing action should be done first to care for the newborn?

Clear the respiratory tract Clearing the airway of the infant is the first action the nurse should take immediately following delivery.

a nurse is preparing to assess a newborn who is postmature. which of the following findings should the nurse expect

Cracked, peeling skin is correct. Physical findings that indicate postmaturity in a newborn (gestational age of greater than 42 weeks) include cracked, peeling skin. Positive Moro reflex is correct. Reflexes that are present in a postmature newborn are the same as those that are present in a mature newborn. These reflexes include a positive Moro reflex.

A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, lasting 90 seconds, and are strong to palpation. The baseline fetal heart rate is 150/min, with a uniform deceleration beginning at the peak of the contraction and a return to baseline after the contractions is over. Which of the following actions should the nurse take?

Discontinue the infusion of the IV oxytocin Discontinue the oxytocin infusion immediately if a client is experiencing late decelerations due to uterine hyperstimulation.

a nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. the fundus is midline and firm at the umbilicus. which of the following actions should the nurse take?

Document the findings and continue to monitor the client These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. Small clots are common. The nurse should document the findings and continue to monitor the client.

a nurse is assessing a client who is 8 hr postpartum and multiparous. which of the following findings should alert the nurse to the client's need to urinate?

Fundus three fingerbreadths above the umbilicus A full bladder can raise the level of uterine fundus and possibly deviate it to the side.

a nurse is teaching a newborn's parent to care for the umbilical cord stump. which of the following instructions should the nurse include?

Give a sponge bath until the cord stump falls off Immersing the umbilical cord stump in water can delay the process of drying, separation, and healing. Sponge baths are appropriate until the stump falls off.

a nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. the nurse should recognize which of the following newborn complications as the priority focus of care?

Hypoglycemia Newborns of mothers who have diabetes are at high risk for hypoglycemia due to the loss of high levels of glucose after the umbilical cord is cut. This results in fetal hyperinsulinemia. It can take several days for the newborn to adjust to secreting appropriate amounts of insulin for the lower level of blood glucose. Because severe hypoglycemia can lead to cyanosis and seizures, prevention of hypoglycemia becomes the nurse's priority focus of care.

a nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." which of the following responses should the nurse make?

In 3 to 5 days By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milk.

a nurse is caring for a newborn 4 hr after birth. which of the following actions should the nurse include in the plan of care to prevent jaundice?

Initiate early feeding Prevention of jaundice can be facilitated best by early and frequent feeding, which stimulates intestinal activity and passage of meconium. Jaundice occurs due to elevated serum bilirubin, which is excreted primarily in the newborn's stool. Physiologic jaundice manifests after 24 hr and is considered benign. However, bilirubin may accumulate to hazardous levels and lead to a pathologic condition.

a nurse is teaching a client who is postpartum and has a new prescription for an injection of RHo (D) immunoglobulin. which of the following should be included in the teaching?

It prevents the formation of Rh antibodies in mothers who are Rh negative. Rho (D) immunoglobulin prevents the immune system of a client who is Rh negative from reacting to accidental exposure to fetal blood during pregnancy or delivery. If the client has another Rh positive fetus in the future, these antibodies can destroy the blood cells of the fetus. Rho (D) immunoglobulin is administered routinely to Rh negative mothers at 28 weeks of gestation and following any pregnancy outcome (including birth or any planned or unintentional fetal loss).

a nurse is planning care for a newborn who is small for gestational age (SGA). which of the following is the priority intervention the nurse should include in the newborn's plan of care?

Monitor blood glucose levels Decreased stores of glycogen and a lower rate of gluconeogenesis place newborns who are SGA at higher risk for hypoglycemia. Monitoring of blood glucose levels is a priority intervention.

a nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. which of the following actions should the nurse take?

Obtain blood glucose by heel stick The newborn is exhibiting early signs of hypoglycemia. The nurse should obtain blood by heel stick to check glucose. A therapeutic serum glucose level for a newborn is 40 to 60 mg/dL. Less than 40 mg/dL indicates hypoglycemia. Other findings of hypoglycemia include poor feeding, tremors, hypothermia, flaccid muscle tone, irregular respirations, apnea, cyanosis, and a weak, shrill cry. Early breastfeeding also should be encouraged to prevent hypoglycemia.

a nurse on the postpartum unit is caring for a group of clients with an assistive personnel (AP). which of the following tasks should the nurse plan to delegate to the AP?

Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum. Providing comfort measures is an appropriate task that can be delegated to the AP since it does not require nursing judgment.

a nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. to determine the client's tolerance of the procedure, which of the following assessments should the nurse perform?

Pulse rate A sitz bath causes vasodilation; therefore, the nurse should monitor the client's pulse rate. Orthostatic hypotension can occur upon standing causing the client to feel faint.

a nurse is caring for a client who is breastfeeding her newborn and asks the nurse about the changes she should make in her diet. which of the following dietary changes should the nurse suggest?

Reduce her intake of iron Recommendations for some nutrients, such as iron and folic acid, are less during lactation than during pregnancy. Because maternal blood volume decreases after childbirth, the client's need for these nutrients also diminishes.

a nurse is assessing a client who is 12 hr postpartum and received spinal anesthesia for a cesarean birth. which of the following findings requires immediate intervention by the nurse?

Respiratory rate 10 per min A client who has received spinal anesthesia is at risk for respiratory depression and hypotension. A respiratory rate of 10/min indicates bradypnea and requires immediate intervention.

a nurse is assisting a client with breastfeeding. the nurse explains that which of the following reflexes will promote the newborn to latch?

Rooting The rooting reflex is elicited when the client strokes the newborn's lips, cheek, or corner of the mouth with her nipple. The newborn will turn his head while making sucking motions with his mouth and latch onto the nipple.

a nurse is caring for a client who has just delivered a newborn. the nurse notes secretions bubbling out of the newborn's nose and mouth. which of the following actions is the nurse's priority?

Suction the mouth with a bulb syringe The greatest risk to the newborn is aspiration of secretions. Removing the secretions from the mouth first is the priority action.

a nurse is assessing a newborn for manifestations of a large patent ductus arteriosus. which of the following findings should the nurse expect?

Systolic murmur A patent ductus arteriosus is failure of the artery connecting the aorta and pulmonary artery to close after birth, causing a left-to-right shunt. A systolic murmur is a clinical manifestation found in newborns who have a large patent ductus arteriosus.

a nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252 g). the nurse should recognize that this client is at risk for which of the following postpartum complications?

Uterine atony A uterus that is over distended, such as from a macrosomic fetus, has an increased risk of uterine atony.

A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

Variable decelerations Variable decelerations occur when the umbilical cord becomes compressed and disrupts the flow of oxygen to the fetus.* Think VEALCHOP

a nurse places a newborn under a radiant heat warmer after birth. the purpose of this action is to prevent which of the following in the newborn?

cold stress When an infant is stressed by cold exposure, oxygen consumption increases and pulmonary and peripheral vasoconstriction occurs. Metabolic demands for glucose increase. If the cold stress continues, hypoglycemia and metabolic acidosis can result.

a nurse is caring for a client who is 6 hours postpartum and asks the nurse to feed her newborn. which of the following responses should the nurse provide?

feeding an infant can feel a little intimidating at first, but i'll stay and help you The nurse, while recognizing and acknowledging the client's apprehension, offers assistance and a sense of presence, with the intention of boosting client confidence.

a nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

Change the client's position The first action the nurse should take is to change the client's position in an attempt to increase blood flow to the fetus.

a nurse is preparing to administer 1 mg vitamin K to a newborn. the medication is available in 1 mg/0.5 ml. how much should the nurse administer?

0.5

a nurse is providing teaching to the mother of a newborn born small for gestational age. which of the following should the nurse include as a possible cause of this condition?

Placental insufficiency Placental insufficiency is a cause of small for gestational age. It can result from maternal infections, embryonic placental deficiency, teratogens, or chromosomal abnormalities.

a nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the plastibell technique. which of the following client statements indicates understanding of circumcision care?

"I'll call the doctor if I see any bleeding" is a correct statement. The client should report any bleeding immediately. "I'll make sure his diaper is loose in the front" is a correct statement. Applying a loose diaper prevents pressure over the circumcision area. "I'll expect the plastic ring to fall off by itself within a week" is a correct statement. With the Plastibell procedure, the plastic ring detaches in about 5 to 8 days.

A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?

"The rate and rhythm of breath are irregular in newborns." Newborns have an irregular respiratory rate and rhythm. Therefore, counting the respiratory rate for a complete minute is recommended to obtain an accurate rate.

A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and lightheaded. After applying oxygen via nonrebreather face mask at 10 L/min, which of the following actions should the nurse take next?

Massage the client's fundus to promote contractions A soaked perineal pad in less than 15 min, ashen skin color, and report of weakness and light headedness can indicate that the client is at greatest risk for hypovolemic shock. Therefore, the next action the nurse should take is to massage the client's fundus to expel blood clots and promote uterine contraction to stop the bleeding.

a nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. the client reports feeling "down" and sad, having no energy, and wanting to cry. which of the following is a priority action by the nurse?

Ask the client if she has considered harming her newborn When using the nursing process in caring for a client, the first action should focus on assessment of the client's mood, ability to concentrate, thought processes, and if the client has had thoughts of self-harm or of injuring her newborn.

a nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. which of the following statements by the client indicates a need for further teaching?

I should apply hot packs to my breasts during feeding The application of heat promotes increased blood flow to the breasts, which are already engorged. This is not an appropriate intervention.

a nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. which of the following is the priority nursing action?

Position the client on her side Late decelerations stem from decreased blood perfusion to the placenta or compression of the placenta. A position change should increase perfusion or decrease compression, and it is the first intervention the nurse should try. The greatest risk to the client is fetal hypoxia, so the priority action is the one that has the best chance of improving fetal perfusion.

a nurse is assisting with the care of a newborn immediately following birth. which of the following medications should the nurse anticipate administering?

Vitamin K injection Hep B immunization antibiotic oitments to both eyes

a nurse is caring for a client who is postpartum. the client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. which of the following statements should the nurse make?

we do routine hearing screenings on newborns. you'll know the results before you leave the hospital Most states mandate hearing screening for all newborns. The two tests in use do not diagnose hearing loss, but determine whether or not a newborn requires further evaluation.

A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?

"A caput succedaneum occurs due to compression of blood vessels." A caput succedaneum is an area of edema on the newborn's occiput, often seen where the cup of the vacuum was applied. It is present at birth and will disappear within 3 to 4 days.

A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn's Apgar score.

6 The Apgar score is 6 out of a possible 10. It is based on 5 signs evaluated at 1 and 5 min after delivery that indicate the physiologic state of the newborn as he transitions from intrauterine life to extrauterine life: heart rate over 100/min = 2; slow, weak cry = 1; some flexion of extremities = 1; grimace in response to suctioning of the nares = 1; body pink in color with blue extremities = 1. A score of 4 to 6 indicates moderate difficulty adjusting to life outside of the womb.

a nurse is caring for a client who is in labor and has an external fetal monitor. the nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

Uteroplacental insufficiency The pattern of the fetal heart rate during labor is an indicator of fetal well-being. Late decelerations are the result of uteroplacental insufficiency and the fetus becomes hypoxemic. They are an ominous sign if they cannot be corrected and place the fetus at risk for a low Apgar score.

a nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. which of the following measures should the nurse suggest to reduce discomfort during breastfeeding?

Apply breast milk to the nipples before each feeding is correct.The application of colostrum and breast milk to the nipples moistens them and prepares them for breastfeeding. This can prevent and reduce nipple tenderness. The client who is breastfeeding should start with the nipple that is less sore, as the newborn's initial sucking motions are the strongest. Change the infant's position on the nipples is correct. Changing the newborn's position on the nipples reduces discomfort and prevents nipple soreness. Repositioning of the mother can also prevent nipple discomfort.

a nurse is assessing a newborn the day after delivery. the nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. how should the nurse document this finding?

Cephalohematoma A cephalhematoma is a swelling, indicating bleeding under the subcutaneous tissues of the newborn's scalp. The collection of blood is beneath the periosteum of the cranial bone and therefore does not cross the suture line.

A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a durtiong of 1min and a frequency of 3min. The nurse obtains the following vitals: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54mmHg. Which of the following is the priority action for the nurse to take?

Position the client with one hip elevated Based on Maslow's hierarchy of needs, the client's need for an adequate blood pressure to perfuse herself and her fetus is a physiological need that requires immediate intervention. Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By turning the client on her side and retaking her blood pressure, the nurse is attempting to correct the low blood pressure and reassess.

a nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. the father of the newborn asks the nurse why this is necessary. which of the following responses should the nurse make?

Preterm newborns lack adequate temperature control mechanisms Preterm newborns have poor body control of temperature and need support to avoid losing heat. They require an external heat source, such as an incubator.

a nurse is assessing a newborn immediately following a scheduled cesarean delivery. which of the following assessments is the nurse's priority?

Respiratory distress Shortly before labor, there is a decreased production of fetal lung fluid and a catecholamine surge that promotes fluid clearance from the lungs. Newborns born by cesarean, in which labor did not occur, can experience lung fluid retention, which leads to respiratory distress. The priority assessment when using the airway, breathing, circulation (ABC) approach to client care is to monitor the newborn for respiratory distress.

A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons?

The client's blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in the newborn. If the Rh-negative client has been exposed to Rh-positive fetal blood, she will produce antibodies against Rh factor. These antibodies can cross the placenta and destroy the red blood cells of the Rh-positive fetus. This accelerated rate of red blood cell destruction results in the increased release of bilirubin. The newborn's serum bilirubin level can rise quickly.