OB atiii study guide

Nurse caring for patient who's experiencing preeclampsia and has a new prescription for IV mag sulfate. Which meds should the nurse anticipate adm. if client develops mag toxicity? Calcium gluconate Hydralazine Medroxyprogesterone acetate Methylergonovine

ANS: Calcium gluconate: - The nurse should anticipate admin. calcium gluconate if the client develops mag toxicity. Calcium gluconate is the antidote. Hydralazine: - an antiHTN med that can be admin. to clients who have HTN during pregnancy, rather than functioning as the antidote to mag toxicity. Medroxy-progesterone acetate: - an injectable contraceptive hormone, rather than functioning as the antidote to mag toxicity. Methylergonovine: - used to treat postpartum hemorrhage, rather than functioning as the antidote to magnesium toxicity.

Nurse is assessing patient who received carboprost for postpartum hemorrhage. Which findings is an adverse effect of this med? Hypertension Hypothermia Constipation Muscle weakness

ANS: Hypertension: - The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension. Hypothermia: - Fever is a common adverse effect of carboprost. Constipation: - Diarrhea is a common adverse effect of carboprost. Muscle weakness: - not an adverse effect of carboprost.

A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider? Late decelerations Moderate variability of the FHR Cessation of uterine dilation Prolonged active phase of labor

ANS: Late decelerations - indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider. Moderate variability of the FHR - an expected assessment finding associated with normal fetal acid-base balance. It is not a contraindication to the administration of oxytocin. Cessation of uterine dilation - an indication for the initiation of an oxytocin infusion to augment the client's labor progression. Prolonged active phase of labor - an indication for the initiation of an oxytocin infusion to augment the client's labor progression.

A nurse is caring for a patient that's 38 weeks gestation. Which actions should the nurse take prior to applying an external transducer for fetal monitoring? Determine progression of dilatation and effacement. Perform Leopold maneuvers. Complete a sterile speculum exam. Prepare a Nitrazine paper test.

ANS: Perform Leopold maneuvers: - The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer. Determine progression of dilatation and effacement. - The nurse should determine the client's dilation and effacement prior to applying an internal monitor. This action is not required prior to applying an external transducer for fetal monitoring. Complete a sterile speculum exam. - should be performed by the provider and is not required prior to applying an external transducer for fetal monitoring. Prepare a Nitrazine paper test: - performed to assess the components (pH level) of vaginal fluid to determine if the membranes have ruptured. This action is not required prior to applying an external transducer for fetal monitoring.

Nurse is caring for patient who's 15 weeks gestation, Rh-, and just had amniocentesis. Which interventions is the nurse's priority following the procedure? Check the client's temperature. Observe for uterine contractions. Administer Rho(D) immune globulin. Monitor the FHR.

ANS: Monitor the FHR: - The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis. Check the client's temp. - The nurse should check the client's temp to monitor for infection following an amniocentesis. However, this is not the priority nursing intervention. Observe for uterine contractions: - The nurse should observe for uterine contractions to identify preterm labor following an amniocentesis. However, this is not the priority nursing intervention. Administer Rho(D) immune globulin: - The nurse should administer Rho(D) immune globulin following an amniocentesis to prevent Rh sensitization. However, this is not the priority nursing intervention.

Nurse in a provider's office is reviewing the medical record of a client who is in the 1st trimester of pregnancy. Which findings should the nurse identify as a risk factor for development of preeclampsia? Singleton pregnancy BMI of 20 Maternal age 32 years Pregestational DM

ANS: Pregestational diabetes mellitus - increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis. Singleton pregnancy: - Multifetal gestation, rather than a single fetus pregnancy, increases a client's risk for the development of preeclampsia. BMI of 20 - Having a BMI greater than 30 increases a client's risk for the development of preeclampsia. Maternal age 32 years: A maternal age of younger than 19 or older than 40 increases the client's risk for the development of preeclampsia.

A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform leopold maneuvers. Which images indicates the first step of leopold maneuvers?

ANS: 1st - During this step, the nurse palpates the client's abdomen with the palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus. 2nd step of Leopold maneuvers: - During this step, the nurse uses the palms of the hands to determine the location of the smooth fetal back and the irregularly shaped, smaller fetal parts. 3rd step of Leopold maneuvers: - During this step, the nurse determines which fetal part is presenting in the pelvic inlet. The nurse gently grasps the lower uterine segment between the thumb and forefingers, pressing in slightly. 4th step of Leopold maneuvers: - During this step, the nurse faces the client's feet and uses the fingertips to palpate the cephalic prominence. This assessment allows the nurse to determine the attitude of the fetal head.

Nurse is assessing a newborn who has delivered vaginally and experienced a tight nuchal cord. Which findings should the nurse expect? Bruising over the buttocks Hard nodules on the roof of the mouth Petechiae over the head Bilateral periauricular papillomas

ANS: Petechiae over the head: - Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck. Bruising over the buttocks: - A breech birth can cause bruising over the buttocks and swollen genitalia. Hard nodules on the roof of the mouth: - Inclusion cysts, or whitish hard nodules on the gums or roof of the mouth, can be an expected finding. These are also called Epstein pearls. Bilateral periauricular papillomas: - are benign skin tags that can be an expected finding.

Nurse is admitting a patient to L&D unit when patient states, "my water just broke" which interventions is nurse's priority? Perform Nitrazine testing. Assess the fluid. Check cervical dilation. Begin FHR monitoring.

ANS: Begin FHR monitoring. - The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take. Perform Nitrazine testing. - The nurse should perform a Nitrazine test to determine the pH of the fluid. An alkaline pH can indicate rupture of membranes. However, this is not the first action the nurse should take. Assess the fluid: - The nurse should observe the characteristics of the fluid to document color, odor, and amount. However, this is not the first action the nurse should take. Check cervical dilation: - The nurse should check the client's cervical dilation to assess progress of labor. However, this is not the first action the nurse should take.

Nurse is assessing patient who's 1 day postpartum and has vaginal hematoma. Which manifestations should nurse expect? Lochia serosa vaginal drainage Vaginal pressure Intermittent vaginal pain Yellow exudate vaginal drainage

ANS: Vaginal pressure: - The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues. Lochia serosa vaginal drainage: - A client who is 4 to 10 days postpartum will report lochia serosa. Intermittent vaginal pain: - A client who has a vaginal hematoma will report persistent vaginal or rectal pain. Yellow exudate vaginal drainage: - A client who is 1 day postpartum and has a vaginal hematoma will report lochia rubra.

Nurse is assessing a patient that's 38 weeks gestation during weekly prenatal visit. Which findings should the nurse report to HCP? Blood pressure 136/88 mm Hg Report of insomnia Weight gain of 2.2 kg (4.8 lb) Report of Braxton Hicks contractions

ANS: Weight gain of 2.2 kg (4.8 lb): - A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider. Blood pressure 136/88 mm HgA: - Is within the expected reference range for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provider. Report of insomnia: - A regular occurrence of insomnia can be expected for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provider. Report of Braxton Hicks contractions: - Can be expected for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provider.

Nurse in an antepartum clinic is providing care for patient who's 26 weeks gestation. Upon review, which findings should the nurse report to HCP? Exhibit: BP 130/78, RR 20, HR 90, Hb 12 g/dL, Hct 34%, 1-hr glucose tolerance test 120 mg/dL, Fundal height 30 cm, Good fetal mvt, Not experiencing headache, dizziness, blurred vision, or vaginal bleeding, FHR 110/min 1-hr glucose tolerance test Hematocrit Fundal height measurement Fetal heart rate (FHR)

ANS: Fundal height measurement: - A fundal height measurement of 30 cm should be reported to HCP. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider. 1-hr glucose tolerance test - A GTT of 120 mg/dL is within the expected reference range for this client. A value of 130 to 140 mg/dL or greater for a 1-hr glucose tolerance test indicates a positive test result and should be reported to the provider. Hematocrit: - Hct 34% is within the expected reference range for this client. The level should be greater than 33%. Fetal heart rate (FHR)This FHR is within the expected reference range of 110/min to 160/min for a client at 26 weeks of gestation.

Nurse is caring for patient that's 35 weeks gestation and undergoing a nonstress test that reveals variable deceleration in FHR. Which actions should the nurse take? Give the client orange juice. Elevate the client's legs. Have the client change position. Establish IV access.

ANS: Have the client change position: - an appropriate intervention for a variable deceleration to relieve umbilical cord compression. Give the client orange juice: - not an appropriate intervention for a variable deceleration in the FHR. Elevate client's legs: - an acceptable intervention for late decelerations associated with maternal hypotension. Establish IV access: - not indicated at this time.

Nurse is caring for a patient who's 36 weeks gestation and has a prescription for amniocentesis. For which reasons should the nurse prepare the patient for an ultrasound? To estimate the fetal weight To locate a pocket of fluid To determine multiparity To prescreen for fetal anomalies

ANS: To locate a pocket of fluid: - An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus. To estimate the fetal weight: - This is not an indication for an ultrasound prior to an amniocentesis. To determine multiparity: - This is not an indication for an ultrasound prior to an amniocentesis. To prescreen for fetal anomalies: - This is not an indication for an ultrasound prior to an amniocentesis.

Nurse is assessing a patient that's 36 weeks gestation. Which findings should the nurse report to HCP? Report of visual disturbances Report of tingling of the fingers Report of urinary frequency Report of leg cramps

ANS: Report of visual disturbances: - Visual disturbances such as blurred vision are a potential prenatal complication associated with HTN. The nurse should report this finding to HCP so that additional fetal and maternal evaluation can be performed. Report of tingling of the fingers: - Tingling or numbness of the fingers is called brachial plexus traction syndrome resulting from drooping of shoulders during pregnancy. This is a common discomfort that occurs during the second trimester. Report of urinary frequency: - a common discomfort that occurs during the 3rd trimester b/c of the reduction in bladder capacity due to the enlarged uterus. Report of leg cramps: - Leg cramps are a common discomfort that occurs during the 3rd trimester because the nerves that supply lower extremities are compressed due to the enlarging uterus.

Nurse creating a POC for patient who's postpartum and adheres to traditional Hispanic cultural beliefs. Which cultural practices should the nurse include in POC? Protect the client's head and feet from cold air. Bathe the client within 12 hr following birth. Ambulate the client within 24 hr following birth. Offer the client a glass of cold milk with her first meal.

ANS: Protect the client's head and feet from cold air: - this is a traditional Hispanic practice during the postpartum period. Bathe the client within 12 hr following birth: - traditional Hispanic practices include delaying bathing for 14 days following birth. Ambulate the client within 24 hr following birth: - traditional Hispanic practices include bed rest for 3 days following birth. Offer the client a glass of cold milk with her first meal: - traditional Hispanic practices include drinking warm beverages following birth.

Nurse in an antepartum clinic is assessing a patient tha's 32 weeks gestation. Which findings should the nurse report to HCP? Fundal height 34 cm Report of decreased fetal movement Report of occasional ankle swelling BP 110/80 mm Hg

ANS: Report of decreased fetal movement: - The nurse should identify that a client who reports decreased fetal movement could be experiencing a complication related to fetal well-being. A decrease in fetal movement can indicate fetal distress. Fundal height 34 cm: - A client who is at 32 weeks of gestation should have a fundal height about the same as the number of weeks of gestation, plus or minus 2 cm. Report of occasional ankle swelling: - The nurse should identify that occasional ankle edema is a common discomfort associated with a client who is at 32 weeks of gestation. BP 110/80 mm Hg: - The nurse should identify that during pregnancy the client's blood pressure should remain the same or be slightly decreased. A blood pressure of 110/80 mm Hg is within the expected reference range of less than 120 mm Hg systolic and less than 80 mm Hg diastolic.

A nurse is caring for a patient that's 32 weeks gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications? Excessive bleeding Oligohydramnios Premature ROM Proteinuria

ANS: Premature rupture of membranes - The nurse should identify that a client who is pregnant and has gonorrhea is at an increased risk for premature rupture of membranes, chorioamnionitis, preterm birth, neonatal sepsis, and intrauterine growth restriction. Excessive bleeding - A client who is pregnant and has gonorrhea is not at an increased risk for excessive bleeding. Oligohydramnios - A client who is pregnant and has gonorrhea is not at an increased risk for oligohydramnios. Oligohydramnios is a decrease in amniotic fluid and is associated with congenital anomalies such as renal agenesis and intrauterine growth restriction. Proteinuria - A client who is pregnant and has gonorrhea is not at an increased risk for proteinuria. Proteinuria is associated with preeclampsia.

Nurse is caring for prenatal patient with parvovirus B19 (5th disease). Which actions should the nurse take? Administer antiviral medication. Schedule an ultrasound examination. Administer Haemophilus influenzae type b vaccine. Schedule an indirect Coombs' test.

ANS: Schedule an ultrasound examination: - The nurse should schedule serial U/S exam to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth. Administer antiviral medication: - Currently, there are no antiviral medications available to treat fifth disease. Administer Haemophilus influenzae type b vaccine: - The vaccine is given during infancy and childhood to protect against multiple infections caused by Haemophilus influenzae type b, not fifth disease. Currently, there are no vaccines to protect against fifth disease. Schedule an indirect Coombs' test: - determines whether the client has antibodies to the Rh antigen. The titer determines the prenatal client's sensitization and if there is Rh incompatibility.

Nurse providing discharge teaching to patient with c-section 3 days ago. Which instructions should the nurse include? "You can resume sexual activity in 1 week." "You won't need to do Kegel exercises since you had a cesarean." "You can still become pregnant if you are breastfeeding." "You are safe to start adding sit-ups to your exercise routine in 2 weeks."

ANS: "You can still become pregnant if you are breastfeeding.": - The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding. "You can resume sexual activity in 1 week." - The nurse should instruct the client that it is safe to resume sexual activity once all vaginal bleeding has stopped and the incision has healed, which can take 2 to 6 weeks. However, it is highly recommended that the client wait until after her 6-week follow-up with the provider because the incision and healing process should be assessed before sexual activity is resumed. "You won't need to do Kegel exercises since you had a cesarean." - The nurse should instruct the client to continue to perform Kegel exercises to maintain tone of the pelvic muscles. Maintaining tone of the pelvic floor muscles helps to maintain urinary continence in the future. "You are safe to start adding sit-ups to your exercise routine in 2 weeks." - The nurse should instruct the client to avoid abdominal exercises for 4 to 6 weeks following a cesarean birth. The nurse can instruct the client to perform other exercises such as walking, arm raises, and leg rolls.

Nurse is teaching patient of 37 weeks gestation and has a prescription for a nonstress test. Which instructions should the nurse include? -Test should take 10-15 min to complete -You will lay in supine position throughout the test -You should not eat or drink for 2 hours before the test -You should press the handheld button when you feel your baby move

ANS: "You should press the handheld button when you feel your baby move." - The nurse should instruct the client to press the handheld button when the fetus moves. This action will mark the fetal monitor tracing with the client's reports of fetal movement. This will assist in the interpretation of the nonstress test to determine if it is reactive or nonreactive. The test should take 10 to 15 minutes to complete." - The nurse should instruct the client that the nonstress will take approximately 20 to 30 min, but more time might be required if the fetus is in a sleep state when the testing begins. "You will lay in a supine position throughout the test." - The nurse should instruct the client to be positioned in a reclining chair or semi-Fowler's position with a slight lateral tilt to ensure optimal uterine perfusion. "You should not eat or drink for 2 hours before the test." - The client is not required to be NPO before or during the procedure. The nurse can suggest the client drink orange juice to increase her blood glucose level which will stimulate fetal movements.

A nurse in a prenatal clinic is assessing a group of patients. Which of the following clients should the nurse see first? A client who is at 11 weeks of gestation and reports abdominal cramping A client who is at 15 weeks of gestation and reports tingling and numbness in right hand A client who is at 20 weeks of gestation and reports constipation for the past 4 days A client who is at 8 weeks of gestation and reports having three bloody noses in the past week

ANS: A client who is at 11 weeks of gestation and reports abdominal cramping: - When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand: - is nonurgent because it is a common discomfort related to pregnancy for a client who is at 15 weeks of gestation. Therefore, there is another client that the provider should see first. A client who is at 20 weeks of gestation and reports constipation for the past 4 days: - nonurgent because it is a common discomfort related to pregnancy for a client who is at 20 weeks of gestation. Therefore, there is another client that the provider should see first. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week - Epistaxis is nonurgent because it is a common discomfort related to pregnancy for a client who is at 8 weeks of gestation. Therefore, there is another client that the provider should see first.

Nurse is caring for a patient who has hyperemesis gravidarum and is receiving IV fluid replacement. Which findings should the nurse report to HCP? BUN 25 mg/dL Serum creatinine 0.8 mg/dL Urine output of 280 mL within 8 hr Urine negative for ketones

ANS: BUN 25 mg/dL: - The nurse should report an elevated BUN to the provider since it can indicate dehydration. Serum creatinine 0.8 mg/dL: - A serum Cr 0.8 mg/dL is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. UO of 280 mL within 8 hr: - A UO of 280 mL within 8 hr is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. Urine negative for ketones: - Testing the urine for ketones is the most important laboratory test for a client who has hyperemesis gravidarum. Urine testing positive for ketones is an indication of dehydration, which increases the risk of preterm labor. A negative test result is an expected finding. Therefore, the nurse does not need to report this finding to the provider.

Nurse assessing a patient who has severe preeclampsia. Which manifestations should the nurse expect? 2+ deep tendon reflexes Proteinuria of 200 mg in a 24-hr specimen Polyuria Blurred vision

ANS: Blurred vision: - The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field. 2+ deep tendon reflexes: - The nurse should identify that a client who has severe preeclampsia can have hyperactive reflexes of 3+ or 4+. DTRs of 2+ is indicative of an active or expected response. Proteinuria of 200 mg in a 24-hr specimen: - The nurse should identify that a client who has severe preeclampsia can have increased amount of urinary protein that is >500 mg in a 24-hr specimen. Polyuria: - The nurse should identify that a client who has severe preeclampsia can have decreased UO or oliguria of 20 mL/hr or less than 400 to 500 mL in 24 hr. This is related to decreased perfusion of the kidneys and possible glomerular damage.

Nurse giving teaching about nonpharm pain management to patient who's breastfeeding and has engorgement. Nurse should recommend application of which items? Cold cabbage leaves Purified lanolin cream A snug-fitting support bra Breast shells

ANS: Cold cabbage leaves: - The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement. The nurse should instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the application for two to three sessions as needed. More frequent applications could decrease the client's milk supply. Purified lanolin cream: - an over-the-counter product that is recommended for the treatment of sore nipples. A snug-fitting support bra: - recommended to suppress lactation for a client who is not breastfeeding. The bra prevents strain on the breast muscles and places the breasts in proper alignment to decrease engorgement. Breast shells: - recommended for clients who are postpartum and have sore nipples. They are used as a barrier to keep clothing away from the nipples and to allow air to circulate.

Nurse is performing a vag exam on a patient who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which actions should the nurse take? -Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. -Wrap the visible cord tightly with sterile, dry gauze. -Apply oxygen to the client at 2 L/min via nasal cannula. -Place the client in the lithotomy position and apply fundal pressure.

ANS: Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. - The nurse should quickly apply gloves and insert two fingers into the vagina toward the cervix, exerting upward pressure onto the presenting part to relieve umbilical cord compression and increase oxygenation to the fetus. Wrap the visible cord tightly with sterile, dry gauze. - The nurse should wrap the visible cord with a loose sterile towel saturated with warm 0.9% sodium chloride solution, rather than with sterile, dry gauze. Apply oxygen to the client at 2 L/min via nasal cannula. - The nurse should apply oxygen to the client at 8 to 10 L/min via nonbreather mask. Place the client in the lithotomy position and apply fundal pressure. - The nurse should place the client into a modified Sims position, knee-chest position, or extreme Trendelenburg to attempt to relieve the compression of the umbilical cord.

Nurse observing a new parent caring for crying newborn who is bottle feeding. Which actions by patent should the nurse recognize as a positive patenting behavior? Lays the newborn across her lap and gently sways Places the newborn in the crib in a prone position Offers the newborn a pacifier dipped in formula Prepares a bottle of formula mixed with rice cereal

ANS: Lays the newborn across her lap and gently sways: - This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn. Places the newborn in the crib in a prone position: - The parent should place the infant in the supine position, not a prone position, in the bassinet or crib because of the risk of SIDS. Offers the newborn a pacifier dipped in formula: - Pacifiers may be used for a newborn who needs extra sucking for self-soothing. However, formula should not be placed on the tip of the pacifier because the newborn might become accustomed to it and refuse to take the pacifier in the future without added supplement. Prepares a bottle of formula mixed with rice cereal: - Rice cereal should not be added to the bottle of a newborn because solids should not be introduced until 4 to 6 months of age.

Nurse is caring for a postpartum patient who is receiving heparin via continuous IV infusion for thrombophlebitis in left calf. Which actions should the nurse take? Administer aspirin for pain. Maintain the client on bed rest. Massage the affected leg every 12 hr. Apply cold compresses to the affected calf.

ANS: Maintain the client on bed rest - The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended. Administer aspirin for pain: - A client receiving anticoagulant therapy, such as heparin, should not receive aspirin because it can lead to prolonged clotting times and increased risk of bleeding. Massage the affected leg every 12 hr: - The nurse should avoid massaging the affected leg to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Apply cold compresses to the affected calf: - The nurse should apply warm compresses to the affected area to promote circulation and decrease edema.

Nurse caring for patient who has uterine atony and is experiencing postpartum hemorrhage. Which actions is the nurse's priority? Check the client's capillary refill. Massage the client's fundus. Insert an indwelling urinary catheter for the client. Prepare the client for a blood transfusion.

ANS: Massage the client's fundus: - Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood loss. Check the client's capillary refill: - It is important for the nurse to monitor capillary refill to track baseline data for this client. Noninvasive assessments of cardiac output for clients who are experiencing postpartum hemorrhage include assessing: capillary refill; skin color, temperature, and turgor; level of consciousness; neck veins; and mucous membranes. However, another action is the nurse's priority. Insert an indwelling urinary catheter for the client.It is important for the nurse to insert an indwelling urinary catheter to assess the client for hypovolemia. The most objective assessment of oxygenation and organ perfusion is UO of at least 30 ml/hr. However, another action is the nurse's priority. Prepare the client for a blood transfusion: - It is important for the nurse to prepare the client for a blood transfusion to replace the amount of blood lost from postpartum hemorrhage. It is crucial to restore circulating blood volume. However, another action is the nurse's priority.

Nurse is assessing a newborn who was born 26 weeks gestation using new ballard score. Which findings should nurse expect? Minimal arm recoil Popliteal angle of 90° Creases over the entire foot sole Raised areolas with 3 to 4 mm buds

ANS: Minimal arm recoil: - The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil. Popliteal angle of 90°: - an indicator of physical maturity with increasing gestational age after 26 weeks. Creases over the entire foot sole: - an indicator of physical maturity with increasing gestational age after 26 weeks. Raised areolas with 3 to 4 mm buds: - an indicator of physical maturity with increasing gestational age after 26 weeks.

Nurse is developing a POC for a patient who has preeclampsia and is receiving mag sulfate via continuous IV infusion. Which interventions should the nurse include in the plan? Monitor the client's blood pressure every hour. Restrict the total hourly intake to 200 mL. Monitor the FHR continuously. Administer protamine sulfate for manifestations of toxicity.

ANS: Monitor the FHR continuously. - Mag sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The FHR and uterine contractions should be monitored continuously while the client is receiving mag sulfate. Monitor the client's BP Qhour: - The nurse should monitor the client's VS, including BP, every 15 to 30 min. Mag sulfate, which is used to prevent seizures in clients w/ preeclampsia, is a high-alert med that requires close monitoring. Restrict the total hourly intake to 200 mL. - The nurse should restrict the client's total hourly intake to no more than 125 mL. Clients who have preeclampsia can have an alteration in kidney function, leading to increases in edema. Administer protamine sulfate for manifestations of toxicity: - The nurse should administer calcium gluconate if the client shows manifestations of mag sulfate toxicity. Findings of toxicity include loss of DTRs, resp depression, slurred speech, and cardiac arrest.

Nurse is assessing patient who's receiving morphine via IV bolus for pain following c-section. Nurse notes RR of 8/min. Which meds should the nurse administer? Fentanyl Butorphanol Naloxone Meperidine

ANS: Naloxone: - Morphine is a common opioid analgesic used for postop pain management that can cause CNS depression & can cause resp depression. The nurse should administer naloxone, an opioid antagonist, to reverse the opioid-induced resp depression in the client. Fentanyl: - The nurse should administer fentanyl to the client for the relief of severe, recurrent, or persistent pain during labor. Fentanyl is most commonly administered via PCA pump or epidural, alone or with a local anesthetic agent. An adverse effect of this medication is respiratory depression. Butorphanol: - The nurse should administer butorphanol to the client for the relief of labor pain and severe postoperative pain after cesarean birth. An adverse effect of this medication is respiratory depression. Meperidine: - The nurse should administer meperidine to the client for the relief of severe, persistent pain. An adverse effect of this medication is respiratory depression.

Nurse is providing education about family bonding to patents who recently adopted a newborn. Nurse should make which suggestions to aid family's 7 y/o child in accepting the new family member? Allow the sibling to hold the newborn during a bath. Make sure the sibling kisses the newborn each night. Obtain a gift from the newborn to present to the sibling. Switch the sibling's room with the nursery.

ANS: Obtain a gift from the newborn to present to the sibling: - Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that they understand their role in the family. Allow the sibling to hold the newborn during a bath: - Allowing the sibling to hold the newborn during a bath is not an appropriate activity for a school-age child because of the safety risk. However, the parents could let the sibling assist with other things in regard to caring for the newborn. Make sure the sibling kisses the newborn each night: - Forcing interactions between the sibling and the adoptive newborn can cause anger on the part of the sibling. It is more important to allow feelings to evolve naturally as the family unit bonds. Switch the sibling's room with the nursery: - Switching the sibling's room with the newborn's room might cause jealousy of the newborn or cause the sibling to feel that the newborn is taking their belongings.

Nurse is preparing to collect blood specimen from a newborn via heel stick. Which techniques should the nurse use to help minimize pain of procedure for newborn? Apply a cool pack for 10 min to the heel prior to the puncture. Request a prescription for IM analgesic. Use a manual lance blade to pierce the skin. Place the newborn skin to skin on the mother's chest.

ANS: Place the newborn skin to skin on the mother's chest: - Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure. Apply a cool pack for 10 min to the heel prior to the puncture: - A cool pack will constrict the blood vessels, making it more difficult to obtain an adequate specimen. The nurse should apply a warm pack prior to the puncture. Request a prescription for IM analgesic: - The pain experienced from a heel stick is too brief to warrant risking the adverse effects of parenteral analgesia. Use a manual lance blade to pierce the skin: - A spring-loaded, automatic puncture device is recommended to minimize pain by ensuring that the depth of the puncture is not too deep, avoiding injury to the newborn.

Nurse is developing POC for newborn undergoing phototherapy for hyperbilirubinemia. Which actions should the nurse include in plan? Feed the newborn 1 oz of water every 4 hr. Apply lotion to the newborn's skin three times per day. Remove all clothing from the newborn except the diaper. Discontinue therapy if the newborn develops a rash.

ANS: Remove all clothing from the newborn except the diaper: - The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin. Feed the newborn 1 oz of water Q4 hr: - The nurse should not feed the newborn any water or glucose water. Hydration can be maintained through regular breastfeeding or formula feeding. Water and glucose water do not increase the excretion rate of bilirubin in the stool or provide nutritional value. Apply lotion to the newborn's skin 3x/ day: - The nurse should not apply lotion, ointments, or creams to a newborn who is undergoing phototherapy. Lotions, ointments, and creams can absorb heat and lead to burns. Discontinue therapy if the newborn develops a rash: - The nurse should not discontinue phototherapy if the newborn develops a rash. A temporary, fine rash can occur during therapy. This rash requires no treatment.

Nurse caring for a patient that's 22 weeks gestation and is HIV positive. Which actions should the nurse take? Administer penicillin G 2.4 million units IM to the client. Instruct the client to schedule an annual pelvic examination. Tell the client she will start medication for HIV immediately after delivery. Report the client's condition to the local health department.

ANS: Report the client's condition to the local health department.: - The nurse should report the condition to the local health department. HIV is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is required to be reported. Administer PCN G 2.4 million units IM to the client: - The nurse should administer PCN G 2.4 million units IM to a client who has syphilis. Instruct the client to schedule an annual pelvic exam: - The nurse should instruct the client to schedule a pelvic examination every 6 months. Tell the client she will start medication for HIV immediately after delivery: - The nurse should tell the client that treatment for HIV will be during the prenatal and perinatal periods. Treatment with antiretroviral prophylaxis such as zidovudine, triple-drug antiretroviral therapy (ART), or highly active antiretroviral therapy (HAART) during pregnancy have been reported to decrease the transmission of the virus to the newborn.

Nurse is assessing a patient with GDM and experiencing hyperglycemia. Which findings should the nurse expect? Reports increased urinary output Diaphoresis Reports blurred vision Shallow respirations

ANS: Reports increased urinary output: - Increased UO, N/V, reports of thirst, abd. pain, constipation, drowsiness, & headaches are s/sx of hyperglycemia. Other s/sx include weak rapid pulse, fruity breath odor, urine positive for sugar and acetone, and a BG > 200 mg/dL. Diaphoresis: - or clammy skin is a finding of hypoglycemia. Flushed, dry skin is a manifestation of hyperglycemia. Reports blurred vision: - or double vision is a finding of hypoglycemia. A report of dim vision is a manifestation of hyperglycemia. Shallow respirations: - a finding of hypoglycemia. Rapid breathing is a manifestation of hyperglycemia.

Nurse caring for a patient who's 30 weeks gestation and has a prescription for mag sulfate IV to treat preterm labor. The nurse should notify the HCP of which adverse effects? Client reports nausea Urinary output of 40 mL/hr Respiratory rate 10/min Client reports feeling flushed

ANS: Respiratory rate 10/min: - The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available. Client reports nausea: - Nausea is an expected adverse effect of magnesium sulfate. The nurse should reassure the client and provide comfort measures. Urinary output of 40 mL/hr: - Oliguria is a manifestation of magnesium toxicity. The nurse should report a urinary output of less than 25 to 30 mL/hr to the provider. Client reports feeling flushed: - Flushing and feeling hot is an expected adverse effect of magnesium sulfate. The nurse should reassure the client and provide comfort measures.

Nurse is assessing a newborn who is 16 hr old. Which findings should the nurse report to HCP? Substernal retractions Acrocyanosis Overlapping suture lines Head circumference 33 cm (13 in)

ANS: Substernal retractions: - The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection or respiratory distress in the newborn. The nurse should report these findings to the provider for immediate intervention. Acrocyanosis: - an expected finding in the newborn for the first 24 hr following birth. Overlapping suture lines: - Overlapping suture lines with molding are an expected variation for newborns who were delivered vaginally. Head circumference 33 cm (13 in): - A head circumference of 33 cm is within the expected reference range for a newborn following birth.

Nurse is performing a physical assessment of newborn. Which clinical findings should the nurse expect? (SATA) HR 154/min Axillary temp 36° C (96.8° F) RR 58/min Length 43 cm (16.9 in) Weight 2,600 g (5 lb 12 oz)

HR 154/min is correct. - The expected reference range for a newborn's HR is from 110/min to 160/min while awake. RR 58/min is correct. - The expected reference range for a newborn's respiratory rate is from 30/min to 60/min. Weight 2.6 kg (5 lb 12 oz) is correct. The expected reference range for a newborn's weight is from 2,500 to 4,000 g (5.5 lb to 8.8 lb). Axillary temp 36° C (96.8° F) is incorrect. - A healthy newborn's temp averages 37° C (98.6° F), with a range of 36.5° to 37.5° C (97.7° to 99.5° F). Length 43 cm (16.9 in) is incorrect. The expected reference range for a newborn's length is from 45 to 55 cm (17.7 to 21.7 in).

Nurse is assessing a late preterm newborn. Which manifestations is an indication of hypoglycemia? Hypertonia Increased feeding Hyperthermia Respiratory distress

Respiratory distress: - Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures. Hypertonia: - A newborn who has hypoglycemia can exhibit hypotonia. Increased feeding: - A newborn who has hypoglycemia can exhibit poor feeding behaviors. Hyperthermia: - A newborn who has hypoglycemia can exhibit hypothermia.

Nurse is caring for a client who's 36 weeks gestation and positive contraction stress test. Nurse should plan to prepare client for which dx test? Biophysical profile Amniocentesis Cordocentesis Kleihauer-Betke test

ANS: Biophysical profile: - A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound. Amniocentesis: - An amniocentesis is used to determine lung maturity, detect congenital anomalies, and diagnose fetal hemolytic disease. Cordocentesis: - A cordocentesis is used to identify fetal blood type and RBC when there is a risk of isoimmune hemolytic anemia. Kleihauer-Betke test: - used to determine the amount of fetal blood in the maternal circulation when there is a risk of Rh-isoimmunization.

Nurse prepares to adm. mag sulfate 2 g/hr IV to patient in preterm labor. Available is 20 g mag sulfate in 500 ml of dextrose 5% in H2O (D5W). Nurse should set IV infusion pump to adm how many ml/hr?

50 ml/hr

Nurse is teaching newly licensed nurse about collecting a specimen for universal newborn screening. Which statements should the nurse include in teaching? "Obtain an informed consent prior to obtaining the specimen." "Collect at least 1 milliliter of urine for the test." "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." "Premature newborns may have false negative tests due to immature development of liver enzymes."

ANS: "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen.": - The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr prior to testing. "Obtain an informed consent prior to obtaining the specimen.": - The universal newborn screening is mandated by law for all newborns. Therefore, the nurse does not need to obtain informed consent prior to obtaining the specimen. "Collect at least 1 milliliter of urine for the test.": - The nurse should collect a capillary blood sample via heel stick for the newborn screening. Urine is not collected for this test. "Premature newborns may have false negative tests due to immature development of liver enzymes.": - Premature newborns have a delayed development of liver enzymes which can cause a false positive result.

Nurse teaching the patient that's 10 weeks gestation about nutrition during pregnancy. Which statements by patient indicates an understanding of teaching? "I should increase my protein intake to 60 grams each day." "I should drink 2 liters of water each day." "I should increase my overall daily caloric intake by 300 calories." "I should take 600 micrograms of folic acid each day."

ANS: "I should take 600 micrograms of folic acid each day.": - A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects. "I should increase my protein intake to 60 grams each day.": - A client who is pregnant should increase protein intake to 71 g each day during the second and third trimesters. "I should drink 2 liters of water each day.": - A client who is pregnant should consume 3 L of water each day. "I should increase my overall daily caloric intake by 300 calories.": - A client who is pregnant should increase caloric intake by 340 cal during the second trimester and by 452 cal during the third trimester.

Nurse caring for patient who's anemic at 32 weeks gestation and in preterm labor. HCP prescribes betamethasone 12 mg IM. Which outcomes should nurse expect? Decreased uterine contractions An increase in the client's hemoglobin levels A reduction in respiratory distress in the newborn Increased production of antibodies in the newborn

ANS: A reduction in resp distress in the newborn: - Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent resp distress. Decreased uterine contractions: - This is not an expected outcome of betamethasone. An increase in the client's Hb levels: - This is not an expected outcome of betamethasone. Increased production of antibodies in the newborn: - This is not an expected outcome of betamethasone.

Nurse is caring for patient that's 24 weeks gestation and has suspected placental abruption. Which lab tests should the nurse expect the HCP to prescribe? Kleihauer-Betke test Progesterone serum level Lecithin/sphingomyelin (L/S) ratio Maternal Alpha-fetoprotein (AFP)

ANS: Kleihauer-Betke test: - The nurse should expect the provider to prescribe a Kleihauer-Betke test for a client who has suspected placental abruption to determine if fetal blood is in maternal circulation. This test is useful to determine if Rho-(D) immune globulin therapy should be administered to a client who is Rh-negative. Progesterone serum level: - helps to determine if a client is pregnant and if the pregnancy is ectopic. Lecithin/sphingomyelin (L/S) ratio: - is done as a part of an amniocentesis to evaluate fetal lung maturity. Maternal Alpha-fetoprotein (AFP): - a lab test used to assess for NTDs or chromosome disorders.

Nurse is demonstrating how to bathe their newborn. Which order should the nurse perform actions?

The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus outward using plain water. The nurse should then wash the newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump followed by washing the newborn's legs and feet. The last step of the bath should be to clean the newborn's diaper area.

Nurse is providing teachings to patient about physiological changes that occur during pregnancy. patient is 10 weeks gestation and has BMI WDL. Which statements indicates an understanding of teaching? "I will not gain more than 15 to 20 pounds during my pregnancy." "I will likely need to use alternative positions for sexual intercourse." "I'm glad I had a breast reduction years ago, so they will not enlarge with my pregnancy." "I'm glad I have a light complexion and will not get any stretch marks."

ANS: "I will likely need to use alternative positions for sexual intercourse.": - The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This client statement indicates that she understands the nurse's teaching about the physiological changes that occur during pregnancy. "I will not gain more than 15 to 20 pounds during my pregnancy.": - The recommended weight gain during pregnancy for a client who has a BMI within the expected reference range is 25 to 35 lb (11.3 to 15.9 kg). The recommended weight gain during pregnancy for a client who has a BMI above the expected reference range is 15 to 20 lb (6.8 to 9.1 kg). "I'm glad I had a breast reduction years ago, so they will not enlarge with my pregnancy.": - The mammary glands of the breasts grow during pregnancy, causing progressive enlargement during the 2nd & 3rd trimesters of pregnancy. A breast reduction will not prevent this from occurring. "I'm glad I have a light complexion and will not get any stretch marks.": - Stretch marks can occur as a response to pregnancy regardless of the client's complexion.

Nurse is giving teaching for a patient who has a new prescription for combined oral contraceptives. Which findings should the nurse include as an adverse effect of this med? Depression Polyuria Hypotension Urticaria

ANS: Depression: - The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness. Polyuria: - Fluid retention can occur due to an excess of estrogen. Polyuria is not a common adverse effect of the medication. Hypotension: - HTN, rather than hypotension, is a common adverse effect of combined oral contraceptives. Urticaria: - Urticaria is not a common adverse effect of combined oral contraceptives.

Nurse is admitting a patient who's in labor. Patient admits to cocaine use. Which complications should the nurse assess? Abruptio placenta Placenta previa Preeclampsia Maternal bradycardia

ANS: Abruptio placenta: - Cocaine use increases the risk for vasoconstriction and possible abruptio placenta. Placenta previa: - This is not a common complication associated with cocaine use. Preeclampsia: - This is not a common complication associated with cocaine use. Maternal bradycardia: - This is not a common complication associated with cocaine use.

Nurse is reviewing prenatal lab results for patient at 12 weeks gestation following initial prenatal visit. Which lab findings should nurse report to HCP? Hemoglobin 10 g/dL WBC count 10,000/mm3 Platelets 250,000/mm3 Fasting blood glucose 90 mg/dL

ANS: Hb 10 g/dL: - below the expected reference range of >11 g/dL for a client who is pregnant. The nurse should report this finding to the provider to obtain a prescription for ferrous iron supplementation because of anemia. WBC count 10,000/mm3: - This finding is within the expected reference range of 5,000 to 15,000/mm3 and does not require reporting to the provider. Platelets 250,000/mm3: - This finding is within the expected reference range of 150,000 to 400,000/mm3 and does not require reporting to the provider. Fasting blood glucose 90 mg/dL: - This finding is within the expected reference range of 60 to 105 mg/dL and does not require reporting to the provider.

Nurse is transporting newborn back to parent's room following procedure. Which actions should the nurse take? Verify that the parent's identification band matches the newborn's identification band. Scan the newborn's identification band to verify their identity. Check the newborn's security tag number to ensure it matches the newborn's medical record. Match the newborn's date and time of birth to the information in the parent's medical record.

ANS: Verify that the parent's ID band matches the newborn's ID band: - The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the info on the parent's ID band to the info on the newborn's ID band. Scan the newborn's ID band to verify their identity: - does not ensure the newborn is being transferred to the correct parent. Check the newborn's security tag number to ensure it matches the newborn's medical record: - does not ensure the newborn is being transferred to the correct parent. Match the newborn's date and time of birth to the info in the parent's medical record: - It is not necessary for the nurse to check the parent's medical record. The nurse should match the info on the parent's ID band to the info on the newborn's ID band.

Nurse performing physical assessment of a newborn upon admission to nursery. Which manifestations should the nurse expect? (SATA) Yellow sclera Acrocyanosis Posterior fontanel larger than the anterior fontanel Positive Babinski reflex Two umbilical arteries visible

Acrocyanosis is correct. - an expected finding for at least the first 24 hr following birth. Poor peripheral perfusion leads to bluish discoloration in the newborn's hands and feet. Positive Babinski reflex is correct: - Newborns should exhibit a positive Babinski sign following birth. The nurse should stroke the newborn's foot upward from the heel to the toes. The toes should hyperextend, and dorsal flexion of the big toe should occur. The absence of this finding requires neurological evaluation. The Babinski reflex is no longer present after 1 year of age. Two umbilical arteries visible is correct: - The nurse should observe two arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly. Yellow sclera is incorrect. Yellow sclera is an indication of hyperbilirubinemia and is not an expected manifestation. Posterior fontanel larger than the anterior fontanel is incorrect: - The posterior fontanel is located on the back of the newborn's head and is a small triangular shape. The anterior fontanel is diamond shaped and approximately 5 cm (2 in) long. It is located on the top of the newborn's head and is larger than the posterior fontanel.

Nurse is providing teaching to patient that's 40 weeks gestation and has new prescription for misoprostol. Which instructions should the nurse include in teaching? "I can administer oxytocin 4 hours after the insertion of the medication." "You will need a full bladder prior to the insertion of the medication." "Remain in a side-lying position for 15 minutes after the medication is inserted." "An antacid will be given 20 minutes prior to the insertion of the medication."

ANS: "I can administer oxytocin 4 hours after the insertion of the medication.": - The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor. "You will need a full bladder prior to the insertion of the medication.": - The nurse should instruct the client to void prior to the administration of the medication. "Remain in a side-lying position for 15 minutes after the medication is inserted.": - The nurse should instruct the client to remain in a side-lying position for 30 to 40 min after the insertion. "An antacid will be given 20 minutes prior to the insertion of the medication.": - The nurse should avoid administering aluminum hydroxide and magnesium-containing antacids with misoprostol.

Nurse is giving Teaching to patient who gave birth 2 hrs ago about facility policy for newborn safety. Which patient statements indicates an understanding of teaching? "My sister will be able to carry my baby from the nursery to my room when she arrives." "The nurse will match my wrist band to my baby's crib card when they bring him to me." "The person who comes to take my baby's pictures will be wearing a photo identification badge." "My baby doesn't need to wear the electronic security bracelet when he's in my room."

ANS: "The person who comes to take my baby's pictures will be wearing a photo identification badge.": - All personnel working on the unit should be wearing a photo ID badge. The nurse should instruct the parent to never allow anyone who is not wearing an ID badge to come in contact with the newborn. "My sister will be able to carry my baby from the nursery to my room when she arrives.": - A newborn should always be transported in a bassinet when outside the parent's room. "The nurse will match my wrist band to my baby's crib card when they bring him to me.": - The nurse will match the newborn's ID number with the parent's ID number when they bring the newborn to the parent's room. "My baby doesn't need to wear the electronic security bracelet when he's in my room.": - The newborn should wear the electronic security bracelet at all times. The bracelet is set to alarm if anyone removes the bracelet or if the newborn is brought near an exit door.

Nurse is assessing 4 newborns. Which findings should the nurse report to HCP? A newborn who is 26 hr old and has erythema toxicum on his face A newborn who is 32 hr old and has not passed a meconium stool A newborn who is 12 hr old and has pink-tinged urine A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)

ANS: A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F): - An axillary temp. >37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider. A newborn who is 26 hr old and has erythema toxicum on his face - Erythema toxicum is a transient rash that can appear anywhere on a newborn's body during the first 24 to 72 hr following birth and can last up to 3 weeks. This finding requires no treatment. A newborn who is 32 hr old and has not passed a meconium stool: - A newborn should pass the first meconium stool within the first 24 to 48 hr following birth. Failure to pass a meconium stool can indicate a bowel obstruction or congenital disorder. This finding is within the expected reference range. A newborn who is 12 hr old and has pink-tinged urine: - Pink-tinged urine is an indication of uric acid crystals and is an expected finding for a newborn during the first week following birth.

Nurse is caring for a client who's 26 weeks gestation and has epilepsy. Nurse enters the room and observes the patient having a seizure. After turning patient's head to one side, which actions should the nurse take immediately after the seizure? Monitor the FHR. Assess uterine activity. Administer oxygen via a nonrebreather mask. Start a bolus of IV fluids.

ANS: Administer oxygen via a nonrebreather mask: - When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask at 10 L/min to ensure adequate oxygenation to the fetus. Monitor the FHR: - The nurse should monitor the FHR to assess fetal well-being. However, this is not the action the nurse should take next. Assess uterine activity: - The nurse should assess uterine activity for potential complications of the seizure. However, this is not the action the nurse should take next. Start a bolus of IV fluids.The nurse should start IV fluids following the seizure to ensure adequate hydration. However, this is not the action the nurse should take next.

Nurse is performing routine assessment on patient that's 18 weeks gestation. Which findings should the nurse expect? Deep tendon reflexes 4+ Fundal height 14 cm Urine protein 2+ FHR 152/min

ANS: FHR 152/min: - The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse. Deep tendon reflexes 4+: - DTRs are an indication of the balance between the cerebral cortex and spinal cord. The nurse should expect the client's DTR to be 2+. Therefore, a DTR of 4+ indicates hyperreflexia. Fundal height 14 cm: - From gestational weeks 18 to 32, the height of the fundus is approximately equal to the number of weeks of gestation plus or minus 2 cm. Therefore, the nurse should expect the fundal height for this client should be 16 to 20 cm. Urine protein 2+: - The nurse should expect the urine protein for this client to be less than 1+. A urine protein concentration of 2+ is an indication of preeclampsia. Therefore, the nurse should investigate this finding further.

Nurse is assessing a newborn 12 hr after birth. Which manifestations should the nurse report to HCP? Acrocyanosis Transient strabismus Jaundice Caput succedaneum

ANS: Jaundice: - Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider. Acrocyanosis: - a bluish discoloration of the hands and feet and is an expected finding in a newborn 24 to 48 hr after birth. Transient strabismus: - a normal variation in the newborn's eyes that can persist until the 3rd-4th month of age. Caput succedaneum: - a benign, edematous area of the scalp and is commonly found on the occiput.