OB study guide #2
Nurse is assessing newborn that's 12 hrs old. Which manifestation requires intervention by nurse? Acrocyanosis of the extremities Murmur at the left sternal border Substernal chest retractions while sleeping Positive Babinski reflex
Acrocyanosis of the extremities: - an expected manifestation in newborns. Acrocyanosis is a bluish discoloration of the newborn's hands and feet. Murmur at the left sternal border: - an expected manifestation in newborns. ANS: Substernal chest retractions while sleeping: - can indicate resp distress syndrome in the newborn. This manifestation requires further assessment and intervention by the nurse. Positive Babinski reflex: - an expected manifestation in newborns. This reflex is elicited when a newborn's sole is stroked with a finger upward along the lateral aspect of the sole and then across the ball of the foot and, in response, the toes hyperextend, and the large toe dorsiflexes.
Nurse performing newborn assessment. Which images should the nurse ID as indication of spina bifida occulta?
External indications of this NTD include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area.
Nurse reviews medical record of postpartum client with preeclampsia. Which lab result should nurse report to HCP? Hct 39% Serum albumin 4.5 g/dL WBC 9,000/mm3 Platelets 50,000/mm3
Hct 39%: - within the expected reference range and does not indicate a postpartum complication. Serum albumin 4.5 g/dL: - within the expected reference range. This finding is consistent with mild preeclampsia and does not indicate a worsening of the condition. WBC 9,000/mm3: - within the expected reference range and does not indicate a postpartum complication. ANS: Platelets 50,000/mm3: - below the expected reference range, which can indicate DIC. The nurse should report this result to the provider.
Nurse caring for client who has preeclampsia and receiving continuous infusion of mag sulfate IV. Which actions should the nurse take? Restrict hourly fluid intake to 150 mL/hr. Have calcium gluconate readily available Assess DTRs Q 6 hr Monitor intake and output every 4 hr.
Restrict hourly fluid intake to 150 mL/hr: - The nurse should restrict hourly fluid intake to no more than 125 mL/hr. The client's UO should be 30 mL/hr or greater. ANS: Have calcium gluconate readily available: - The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity. Assess DTRs Q 6 hr: - The nurse should assess DTRs Q 1 - 4 hr during continuous infusion of magnesium sulfate. Monitor intake and output every 4 hr. - The nurse should monitor I&Os hourly for clients who are receiving a continuous infusion of magnesium sulfate.
Nurse speaks with client who's trying to make decision about tubal ligation. Client asks, " What effects will this procedure have on my sex life?". Which response should the nurse make? "I think that is something you should discuss with your doctor." "This procedure should have no effect on your sexual performance or adequacy." "You'll be fine. I can't imagine you and your partner will have any problems with sexual function." "If this concerns you, perhaps you should reconsider and use another form of contraception."
"I think that is something you should discuss with your doctor.": - The nurse is dismissing the client's question, providing no information to help the client make an informed decision. ANS: "This procedure should have no effect on your sexual performance or adequacy.": - The nurse is giving the client the information she is seeking. Sexual function depends on various hormonal and psychological factors. Therefore, tubal occlusion should have no physiological effect on sexual function. "You'll be fine. I can't imagine you and your partner will have any problems with sexual function.": - The nurse is giving the client unwarranted reassurance without addressing the information the client is seeking. "If this concerns you, perhaps you should reconsider and use another form of contraception.": - The nurse is giving the client unwarranted advice which might imply that there is a reason to be concerned about the effect of the procedure on sexual function.
Nurse on antepartum unit is caring for 4 clients. Which client should nurse ID as priority? A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL A client who is at 34 weeks of gestation and reports epigastric pain A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL A client who is at 39 weeks of gestation and reports urinary frequency and dysuria
A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL: - above the expected reference range for a client who has GDM, which is a nonurgent finding. Therefore, another client is the nurse's priority. ANS: A client who is at 34 weeks of gestation and reports epigastric pain: - When using the urgent vs nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL: - This finding is a manifestation of anemia in a client who is pregnant, which is a nonurgent condition. Therefore, another client is the nurse's priority. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria: - Dysuria can indicate a urinary tract infection, which can cause preterm labor. Dysuria in a client who is at 39 weeks of gestation is a nonurgent condition which will require antibiotics. Therefore, another client is the nurse's priority.
Nurse reviews lab results of newborn who's 4 hrs old. Which findings should nurse report to HCP? Bilirubin 9 mg/dL Hemoglobin 18 g/dL Platelets 175,0000/mm3 Hematocrit 45%
Bilirubin 9 mg/dL: - above the expected reference range for a newborn who is 4 hr old. The expected reference range for a newborn who is less than 24 hr old is 2 to 6 mg/dL. The nurse should report this finding to the provider. Hemoglobin 18 g/dL: - within the expected reference range of 14 to 24 g/dL for a newborn and does not require reporting. Platelets 175,0000/mm3: - within the expected reference range of 150,000 to 300,000/mm3 for a newborn and does not require reporting. Hematocrit 45%: - within the expected reference range of 44% to 64% for a newborn and does not require reporting.
Nurse reviews lab report of newborn that's 24 hrs old. Which results should the nurse report to HCP? Hgb 20 g/dL Total bilirubin 5 mg/dL Blood glucose 30 mg/dL WBC count 20,000/mm3
Hgb 20 g/dL: - within expected reference range of 14 - 24 g/dL for a newborn that's 24 hr old. Total bilirubin 5 mg/dL: - within the expected reference range of 2 to 6 mg/dL for a newborn who is 24 hr old. ANS: Blood glucose 30 mg/dL: - Newborns < 24 hr old should have a BG of 40 - 60 mg/dL. Newborns who are >24 hr old should have a BG of 50 - 90 mg/dL. A BG level of 30 mg/dL is below the expected reference range for a newborn who is 24 hr old and should be reported to the provider. WBC count 20,000/mm3: - This value is within the expected reference range of 9,000 to 30,000/mm3 for a newborn who is 24 hr old.
Nurse calculating a patient's expected DOB using nagele's rule. Client tells nurse that her last menstrual cycle started on Nov 27th. Which dates is the patient expected DOB? September 3rd September 20th August 3rd August 20th
ANS: September 3rd: - When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd. September 20th: - When using Nägele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. Therefore, the correct date is September 3rd. August 3rd: - " August 20th: - "
Nurse is teaching client who has Pregestational T1DM about management during pregnancy. Which statements by client indicates understanding of teaching? "I should have a goal of maintaining my fasting blood glucose between 100 and 120." "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." "I will continue taking my insulin if I experience nausea and vomiting." "I will ensure that my bedtime snack is high in refined sugar."
"I should have a goal of maintaining my fasting blood glucose between 100 and 120.": - nurse should teach client to maintain fasting BG level between 60 - 99 mg/dL. "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater.": - The nurse should teach the client to avoid exercise during periods of hyperglycemia and when positive urine ketones are present. ANS: "I will continue taking my insulin if I experience nausea and vomiting.": - The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes. "I will ensure that my bedtime snack is high in refined sugar.": - The nurse should teach the client to avoid snacks and foods that are high in refined sugar.
Nurse is caring for client experiencing preterm labor at 29 weeks gestation and prescription for betamethasone. Which statements should nurse make about indication for med admin? "This medication will stop your labor." "This medication stimulates fetal lung maturity." "This medication will decrease your risk for uterine infections." "This medication will increase your baby's weight."
"This medication will stop your labor.": - Betamethasone is not a tocolytic and does not stop labor. ANS: "This medication stimulates fetal lung maturity.": - The nurse should inform the client that betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of enzymes that release lung surfactant. "This medication will decrease your risk for uterine infections.": - Betamethasone is not given to decrease the client's risk for uterine infections. "This medication will increase your baby's weight.": - Betamethasone does not increase fetal weight.
Nurse is caring for a newborn who was transferred to nursery 30 min after birth bc of mild resp distress. Which actions should the nurse take first? Confirm the newborn's Apgar score. Verify the newborn's identification. Administer vitamin K to the newborn. Determine obstetrical risk factors.
Confirm the newborn's Apgar score: - The Apgar score is a physiological assessment that occurs 1 min following birth and again at 5 min. The nurse should confirm the score when the newborn arrives in the nursery. However, there is another action the nurse should take first. ANS: Verify the newborn's identification: - When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery. Administer vitamin K to the newborn: - The nurse should administer IM vitamin K to the newborn soon after birth to increase clotting factors and prevent bleeding. However, the injection can be delayed until after initial bonding time and the first breastfeeding if necessary. Therefore, there is another action the nurse should take first. Determine obstetrical risk factors: - The nurse should identify obstetrical risk factors to determine if interventions are required for the newborn. However, there is another action the nurse should take first.
Nurse teaches new mother how to use bulb syringe to suction newborn secretions. Which instructions should the nurse include? Insert the syringe tip before compressing the bulb. Suction each of the nares before suctioning the mouth. Insert the tip of the syringe into the center of the newborn's mouth. Stop suctioning when the newborn's cry sounds clear.
Insert the syringe tip before compressing the bulb: - The client should compress the bulb before inserting the syringe tip. Compressing the bulb after it is in the newborn's nares or mouth could push the secretions and mucus further inside. Suction each of the nares before suctioning the mouth: - The client should suction the mouth before suctioning the nares. Otherwise, the newborn could gasp and inhale pharyngeal secretions when the syringe tip touches the nares. Insert the tip of the syringe into the center of the newborn's mouth: - The client should insert the tip of the syringe into the side of the newborn's mouth. Inserting it into the center of the newborn's mouth can trigger the gag reflex. ANS: Stop suctioning when the newborn's cry sounds clear: - The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus.
Nurse is planning care for client in labor and needs an amniotomy. Which assessments should nurse ID as priority? O2 saturation Temperature Blood pressure Urinary output
O2 saturation: - Assessing the client's O2 saturation is important during labor. However, another assessment is the nurse's priority. ANS: Temperature: - The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature. Blood pressure: - Assessing the client's BP is important. However, another assessment is the nurse's priority. Urinary output: - Assessing the client's UO is important during labor. However, another assessment is the nurse's priority.
Nurse is providing dietary teaching to patient who has hyperemesis gravidarum. Which statements by client indicates understanding of teaching? "I will eat foods that taste good instead of balancing my meals." "I will avoid having a snack before I go to bed each night." "I will have a cup of hot tea with each meal." "I will eliminate products that contain dairy from my diet."
ANS: "I will eat foods that taste good instead of balancing my meals.": - Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet. "I will avoid having a snack before I go to bed each night.": - Clients who have hyperemesis gravidarum should avoid going to bed with an empty stomach. The nurse should instruct the client to eat a healthy snack before going to bed. "I will have a cup of hot tea with each meal.": - Clients who have hyperemesis gravidarum should alternate liquids and solids every 2 to 3 hr to avoid an empty stomach and over filling at each meal. "I will eliminate products that contain dairy from my diet.": - Clients who have hyperemesis gravidarum do not need to eliminate dairy products from their diet. The client should be encouraged to consume dairy products, because they are less likely to cause nausea than other foods.
Nurse is giving teaching about family planning to patient with new prescription for diaphragm. Which statements should nurse include in teaching? "You should replace the diaphragm every 5 years." "You should leave the diaphragm in place for at least 6 hours after intercourse." "You should use an oil-based product as a lubricant when inserting the diaphragm." "You should insert the diaphragm when your bladder is full."
"You should replace the diaphragm every 5 years.": - The client should replace the diaphragm every 2 years. ANS: "You should leave the diaphragm in place for at least 6 hours after intercourse.": - The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy. "You should use an oil-based product as a lubricant when inserting the diaphragm.": - The client should avoid using oil-based products because they can weaken the rubber in the diaphragm. "You should insert the diaphragm when your bladder is full.": - The client should have an empty bladder prior to inserting the diaphragm.
Nurse is teaching a client at 36 weeks gestation and has prescription for nonstress test. Which statements should the nurse include in teaching? "You will receive IV fluids prior to this test." "The procedure will take approximately 10 to 15 minutes." "You will be offered orange juice to drink during the test." "You will need to sign an informed consent form each time you have this test."
"You will receive IV fluids prior to this test.": - The nurse should state that IV fluids are initiated for an oxytocin-stimulated contraction test, rather than a nonstress test. "The procedure will take approximately 10 to 15 minutes.": - The nurse should instruct the client that the procedure will take 20 to 40 min. ANS: "You will be offered orange juice to drink during the test.": - A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate fetal movements during the procedure, helping to obtain results. "You will need to sign an informed consent form each time you have this test.": - A nonstress test is a noninvasive procedure. Therefore, the client does not need to provide informed consent.
Nurse in family planning clinic is caring for patient who requests an oral contraceptive. Which findings in patient's Hx should nurse recognize as a contraindication to oral contraceptives? (SATA) Cholecystitis Hypertension Human papillomavirus Migraine headaches Anxiety disorder
ANS: Cholecystitis is correct. - A history of gallbladder disease is a contraindication for the use of oral contraceptives. ANS: Hypertension is correct: - Hypertension is a contraindication for the use of oral contraceptives. ANS: Migraine headaches is correct: - history of migraine headaches is a contraindication for the use of oral contraceptives. Human papillomavirus is incorrect: - The presence of human papillomavirus is not a contraindication for the use of oral contraceptives. Anxiety disorder is incorrect: - The presence of an anxiety disorder is not a contraindication for the use of oral contraceptives.
Nurse assesses newborn after circumcision. Which findings should nurse ID as indication that newborn is experiencing pain? Decreased heart rate Chin quivering Pinpoint pupils Slowed respirations
Decreased HR: - The HR will increase when a newborn is experiencing pain. ANS: Chin quivering: - Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow. Pinpoint pupils: - When experiencing pain, a newborn's pupils typically dilate. Slowed respirations: - When experiencing pain, a newborn's resp are typically rapid and shallow.
Nurse is caring for client in active labor and has had no cervical changes in last 4 hrs. Which statements should the nurse make? "Let me help you into a comfortable pushing position so you can begin bearing down." "I am going to call the doctor to get a prescription for medication to ripen your cervix." "I will give you some IV pain medicine to strengthen your contractions." "Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions."
"Let me help you into a comfortable pushing position so you can begin bearing down.": - The nurse should not instruct the client to start bearing down until the second stage of labor. "I am going to call the doctor to get a prescription for medication to ripen your cervix.": - A cervical ripening agent is not used during the active stage of labor. "I will give you some IV pain medicine to strengthen your contractions.": - Administering IV pain medication can decrease the intensity of uterine contractions. ANS: "Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions.": - Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, frequency, and duration which will identify whether the contractions are adequate for progression of labor.
Nurse teaching postpartum client about steps nurses will take to promote security and safety of client's newborn. Which statements should the nurse make? "The nurse will carry your newborn to the nursery for procedures." "We will document the relationship of visitors in your medical record." "Your baby will stay in the nursery while you are asleep." "Staff members who take care of your baby will be wearing a photo identification badge."
"The nurse will carry your newborn to the nursery for procedures.": - The nurse should instruct the client that newborns will be transported in their bassinets and never carried outside the client's room to reduce the risk for falls. "We will document the relationship of visitors in your medical record.": - The nurse should instruct the client that they can have anyone visit them on the unit. There is no documentation of a visitor's relationship to the client entered into the medical record. "Your baby will stay in the nursery while you are asleep.": - The nurse should instruct the client to place the baby in the bassinet on the side of the bed furthest from the door while she is sleeping. ANS: "Staff members who take care of your baby will be wearing a photo identification badge.": - The nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs.
Nurse is assessing newborn for manifestations of hypoglycemia. Which findings should nurse expect? Jitteriness Hypertonia Abd. distension Mottling
ANS: Jitteriness: - Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability, apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia. Newborns who are small or large for gestational age and late preterm newborns are at an increased risk for hypoglycemia. Hypertonia: - Hypotonia, rather than hypertonia, is a manifestation of hypoglycemia. Hypertonia is a manifestation of opioid withdrawal. Abdominal distention: - not a manifestation of hypoglycemia. Abdominal distention is a finding in newborns who have hypocalcemia. Mottling: - not a manifestation of hypoglycemia. It can be a normal variation seen in newborns. Also, it is a manifestation of opioid withdrawal.
Nurse is planning care for patient that's 2 hr postpartum. Which interventions should nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? Discuss contraceptive options with the client and her partner. Repeat information to ensure client understanding. Listen to the client and her partner as they reflect upon the birth experience. Demonstrate to the client how to perform a newborn bath.
Discuss contraceptive options with the client and her partner: - The discussing of contraceptive options occurs during the letting-go phase. This phase focuses on moving forward as a family with interchanging members. Repeat information to ensure client understanding: - The repeating of information to ensure client understanding occurs during the taking-in phase. During this phase, which is experienced on the first postpartum day, the client displays dependent and passive behaviors. Due to excitement and fatigue, the client is unable to retain information. Therefore, the nurse should repeat instructions to ensure that the client understands what is being said. Listen to the client and her partner as they reflect upon the birth experience: - Listening to the client and her partner reflect upon the birth experience occurs during the taking-in phase. During this phase, the new mother is focused on herself and meeting her basic needs. There is also much excitement about the newborn and the birth experience. Therefore, the nurse should allow the client to reflect, ensuring a healthy transition and a successful adaptation into the new family unit. ANS: Demonstrate to the client how to perform a newborn bath: - Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new parent moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new parent confidence and promote maternal adjustment.
Nurse is caring for a client following an amniocentesis at 18 weeks gestation. Which findings should the nurse report to HCP as potential complication? Increased fetal movement Leakage of fluid from the vagina Upper abdominal discomfort Urinary frequency
Increased fetal movement: - Decreased fetal movement is a potential complication that should be reported to the provider. ANS: Leakage of fluid from the vagina: - Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider. Upper abdominal discomfort: - not a potential complication associated with an amniocentesis. Urinary frequency: - not a potential complication associated with an amniocentesis.
Nurse is planning discharge for client 3 days postpartum. Which nonpharm interventions should the nurse include in POC for lactation suppression? Place warm, moist packs on the breasts. Apply cabbage leaves to the breasts. Wear a loose-fitting bra. Put green tea bags on the breasts.
Place warm, moist packs on the breasts: - The client can use cold compresses to decrease breast discomfort during lactation suppression. ANS: Apply cabbage leaves to the breasts.: - Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement. Wear a loose-fitting bra: - A tight-fitting bra will provide support to the breasts during engorgement, which can decrease pain. Put green tea bags on the breasts: - Tea bags are used to relieve nipple soreness in breastfeeding clients.
Nurse is caring for patient who's pregnant and at end of her 1st trimester. Nurse should place Doppler ultrasound stethoscope in which locations to begin assessing fetal heart tones (FHT)? Just above the umbilicus Just above the symphysis pubis The right lower quadrant The left lower quadrant
Just above the umbilicus: - The nurse should assess FHT using the Doppler stethoscope just above the umbilicus if the fetus is in a transverse or breech presentation and the client is at a minimum of 22 weeks of gestation. ANS: Just above the symphysis pubis: - At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHT just above the symphysis pubis. The right lower quadrant: - At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse might not hear FHT in the right lower quadrant. The left lower quadrant: - At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse might not hear FHT in the left lower quadrant.
Nurse assesses the newborn of a client who took selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which manifestations should the nurse ID as an indication of withdrawal from an SSRI? Large for gestational age Hyperglycemia Bradypnea Vomiting
Large for gestational age: - Low birth weight is an expected manifestation of fetal exposure to SSRIs. Hyperglycemia: - Hypoglycemia is an expected manifestation of fetal exposure to SSRIs. Bradypnea: - Tachypnea is an expected manifestation of fetal exposure to SSRIs. ANS: Vomiting: - Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.
Nurse is assessing FHT for pregnant patient. Nurse determined that the fetal position as left occipital anterior. Which areas of the abd. should nurse apply ultrasound transducer to assess point of max intensity of fetal heart? Left upper quadrant Right upper quadrant Left lower quadrant Right lower quadrant
Left upper quadrant: - The fetal heart tones of a fetus in the left sacrum anterior position are best heard in the left upper quadrant. Right upper quadrant: - The fetal heart tones of a fetus in the right sacrum anterior position are best heard in the right upper quadrant. ANS: Left lower quadrant: - The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant. Right lower quadrant: - The fetal heart tones of a fetus in the right occipital anterior position are best heard in the right lower quadrant.
Nurse caring for client at 41 weeks gestation and has a positive contraction stress test. Which Dx tests should nurse prepare for client? Percutaneous umbilical blood sampling Amnioinfusion Biophysical profile (BPP) Chorionic villus sampling (CVS)
Percutaneous umbilical blood sampling: - AKA cordocentesis, is the most common method used for fetal blood sampling and transfusion. This is not a dx test used for clients who have a positive contraction stress test. Amnioinfusion: - An amnioinfusion of normal saline or LR is instilled into the amniotic cavity through a transcervical catheter introduced into the uterus to supplement the amount of amniotic fluid. The instillation reduces the severity of variable decelerations caused by cord compression for clients who are in labor. This is not a diagnostic test used for clients who have a positive contraction stress test. ANS: Biophysical profile (BPP): - The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. Chorionic villus sampling (CVS): - CVS is the assessment of a portion of the developing placenta, which is aspirated through a thin sterile catheter inserted through the abdominal wall or intravaginally through the cervix under ultrasound guidance. This procedure is done during the first trimester. This is not a diagnostic test used for clients who have a positive contraction stress test.
Nurse is providing discharge teaching to patient in postpartum. Which manifestations should nurse instruct patient to monitor and report to HCP? Persistent abdominal striae Temperature 37.8° C (100° F) Unilateral breast pain Brownish-red discharge on day 5
Persistent abdominal striae: - caused by the separation of the underlying connective tissue and are an expected postpartum finding. Temperature 37.8° C (100° F): - The nurse should instruct the client to report a temperature of 38° C (100.4° F) or higher because it could be an indication of infection. ANS: Unilateral breast pain: - Sudden onset of chills, fever, malaise, body aches, headaches, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this manifestation to the provider. Brownish-red discharge on day 5: - Brownish-red discharge is an expected manifestation during days 3 to 10. The client should report a large amount of lochia and large clots to the provider.
Nurse performing vag exam on client in labor and observes umbilical cord protruding from vagina. After calling for assistance, which action should nurse take next? Place a rolled towel beneath one of the client's hips. Apply internal upward pressure to the presenting part using two gloved fingers Administer oxygen to the client via a nonrebreather mask at 10 L/min. Increase the IV infusion rate.
Place a rolled towel beneath one of the client's hips.: - The nurse should place a rolled towel under the client's left or right hip to alleviate some of the pressure; however, EBP indicates that the nurse should take a different action first. ANS: Apply internal upward pressure to the presenting part using two gloved fingers: - Using EBP, the first action the nurse should take is to apply internal upward pressure to the presenting part. Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. After calling for assistance, the nurse should relieve the compression on the umbilical cord by applying upward internal pressure on the presenting part with two gloved fingers. The nurse should not move their hand. Administer oxygen to the client via a nonrebreather mask at 10 L/min.: - Prolapse of the umbilical cord during labor can result in decreased perfusion to the fetus, which can lead to hypoxia. The nurse should administer oxygen via a nonrebreather mask at 10 L/min; however, evidence-based practice indicates that the nurse should take a different action first. Increase the IV infusion rate.: - The nurse should increase the IV infusion rate; however, evidence-based practice indicates that the nurse should take a different action first.
Nurse is assessing patient who gave birth vaginally 12 hrs ago and palpates her uterus to right above umbilicus. Which interventions should the nurse perform? Reassess the client in 2 hr. Administer simethicone. Assist the client to empty her bladder. Instruct the client to lie on her right side.
Reassess client in 2 hr: - The nurse should assess the client more frequently after birth to determine the position of the uterus and to intervene as soon as possible if necessary. Administer simethicone: - The nurse should administer simethicone to reduce bloating, discomfort, or pain caused by excessive gas. ANS: Assist the client to empty her bladder: - The nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage. Instruct the client to lie on her right side: - Lying on her right side will not resolve the client's displaced uterus.
Nurse teaches client at 35 weeks gestation about manifestations of potential pregnancy complications to report to HCP. Which manifestations should nurse include? Shortness of breath when climbing stairs Swelling of feet and ankles at the end of the day Headache that is unrelieved by analgesia Braxton Hicks contractions
SOB when climbing stairs: - SOB is related to the enlarging uterus interfering with the expansion of the diaphragm and is an expected manifestation at 35 weeks of gestation. Swelling of feet and ankles at the end of the day: - due to the enlarging uterus interfering with blood return to the heart and is an expected manifestation at 35 weeks of gestation. ANS: Headache that is unrelieved by analgesia: - A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider. Braxton Hicks contractions: - an indication that the uterus is preparing for labor and is an expected manifestation at 35 weeks of gestation.
Nurse caring for a client at 22 weeks gestation and reports concern about blotchy hyper-pigmentation on forehead. Which actions should the nurse take?
Tell the client to follow up with a dermatologist: - *An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an increase in the pigmentation of the skin during pregnancy. Treatment by a dermatologist will not affect the client's condition. ANS: Explain to the client this is an expected occurrence: - Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery. Instruct the client to increase her intake of vitamin D: - *, Increasing her vitamin D intake will not affect the client's condition. Inform the client she might have an allergy to her skin care products: - *, Changing skin care products will not affect the client's condition.
Nurse in women's health clinic is giving teaching about nutritional intake to client at 8 weeks gestation. Nurse should instruct client to increase daily intake of which nutrients? Calcium Vitamin E Iron Vitamin D
Calcium: - The recommendation for calcium intake during pregnancy is the same as that for women who are not pregnant: 1,300 mg/day for women younger than 19 years old and 1,000 mg/day for women between the ages of 19 and 50 years old. Vitamin E: - The recommendation for vitamin E intake during pregnancy is 15 mg/day, the same as that for women who are not pregnant. ANS: Iron: - The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old. Vitamin D: - The recommendation for vitamin D intake during pregnancy is 600 IU/day, the same as that for women who are not pregnant.
Nurse is planning care for patient who is undergoing nonstress test. Which actions should the nurse include in POC? Maintain the client NPO throughout the procedure. Place the client in a supine position. Instruct the client to massage the abdomen to stimulate fetal movement. Instruct the client to press the provided button each time fetal movement is detected.
Maintain the client NPO throughout the procedure: - There is no indication for the client to be NPO. Sometimes clients are encouraged to drink liquids to promote adequate hydration. Place the client in a supine position: - The client should be placed in a semi-Fowler's or sitting position and tilted to the right or left to promote uterine perfusion and prevent supine hypotension. Instruct the client to massage the abdomen to stimulate fetal movement: - Massaging the abdomen does not stimulate fetal movement. ANS: Instruct the client to press the provided button each time fetal movement is detected: - Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.
Nurse prepares to perform Leopold maneuvers for client. List steps nurse should follow.
The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.
Nurse is teaching client in preterm labor about terbutaline. Which statements by client indicates understanding of teaching? "I will get injections of the medication once daily until my labor stops." "My blood sugar may be low while I'm on this medication." "I will have blood tests because my potassium might decrease." "My blood pressure may increase while I'm on this medication."
"I will get injections of the medication once daily until my labor stops.": - Terbutaline is admin. SQ, Q4 hr for no longer than 24 hr. "My blood sugar may be low while I'm on this medication.": - An adverse effect of terbutaline is hyperglycemia. ANS: "I will have blood tests because my potassium might decrease.": - An adverse effect of terbutaline is hypokalemia. "My blood pressure may increase while I'm on this medication.": - An adverse effect of terbutaline is hypotension.
Nurse is teaching patient who's Rh- about Rh0 (D) immune globulin. Which statements by client indicates an understanding of teaching? "I will receive this medication if my baby is Rh-negative." "I will receive this medication when I am in labor." "I will need a second dose of this medication when my baby is 6 weeks old." "I will need this medication if I have an amniocentesis."
"I will receive this medication if my baby is Rh-negative.": - Rho(D) immune globulin is administered to a client who is Rh-negative and gives birth to an Rh-positive newborn. "I will receive this medication when I am in labor.": - Rho(D) immune globulin is administered at 28 weeks of gestation or after birth if the newborn is Rh-positive. "I will need a second dose of this medication when my baby is 6 weeks old.": - Rho(D) immune globulin is administered at 28 weeks of gestation to clients who are Rh-negative and following the birth of a newborn who is Rh-positive. ANS: "I will need this medication if I have an amniocentesis.": - Rho(D) immune globulin is given to clients who are Rh negative following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.
Nurse is teaching patient who is at 24 weeks gestation regarding a 1 hr glucose tolerance test. Which statements should nurse include in teaching? "You will need to drink the glucose solution 2 hours prior to the test." "Limit your carbohydrate intake for 3 days prior to the test." "A blood glucose of 130 to 140 is considered a positive screening result." "You will need to fast for 12 hours prior to the test."
"You will need to drink the glucose solution 2 hours prior to the test.": - The nurse should instruct the client to drink the glucose solution 1 hr prior to the test. "Limit your carbohydrate intake for 3 days prior to the test.": - The nurse should instruct the client that she should not limit her carbohydrate intake. ANS: "A blood glucose of 130 to 140 is considered a positive screening result.": - The nurse should instruct the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus. "You will need to fast for 12 hours prior to the test.": - The nurse should instruct the client that fasting is not required for a 1-hr glucose tolerance test.
Nurse in prenatal clinic is caring for client who reports menstrual period is 2 weeks late. Client appears anxious and ask nurse if she's pregnant. Which responses should nurse make? "You can miss your period for several other reasons. Describe your typical menstrual cycle." "If you have been sexually active and haven't used protection, it is likely that you are pregnant." "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" "Because you have missed your period, you should try taking a home pregnancy test before you start worrying."
ANS: "You can miss your period for several other reasons. Describe your typical menstrual cycle.": - Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions. "If you have been sexually active and haven't used protection, it is likely that you are pregnant.": - The nurse's response is assuming and confirming that the client is pregnant based only on the client's statement, which can increase the client's anxiety level. "Let's check to see if you have any other signs of pregnancy. Have you noticed any abdominal enlargement yet?" - The nurse's response is making a false assumption that the client is pregnant based only on the client's statement. The nurse should gather more information from the client before making any false assumptions. "Because you have missed your period, you should try taking a home pregnancy test before you start worrying.": - The nurse's response dismisses the client's concerns and does not answer or address the client's question, which can increase the client's anxiety level.
Nurse teaching a new parent about newborn safety. Which instructions should the nurse include in the teaching? "You can share your room with your baby for the next few weeks." "Cover your baby with a light blanket while sleeping." "Check the temperature of your baby's bath water with your hand." "Your baby can nap in the car seat during the daytime."
ANS: "You can share your room with your baby for the next few weeks.": - The nurse should recommend room-sharing during the first few weeks. This allows the parent to be readily available to the newborn and learn the newborn's cues. However, nurse should instruct the parent to avoid placing the newborn in their bed as it increases risk for SIDS. "Cover your baby with a light blanket while sleeping.": - The nurse should instruct the parents to place the newborn in a sleep sack or a one-piece sleeper. Covering the newborn with a blanket or quilt increases the risk for SIDS. "Check the temperature of your baby's bath water with your hand.": - The nurse should instruct the parents to check the temperature of the newborn's bath water with their elbow, which is more sensitive to temp than the hand. The hot water heater should be set at or below 49° C (120.2° F) to prevent burns. "Your baby can nap in the car seat during the daytime." - The nurse should instruct the parents to lay the newborn in a bassinet or crib on her back to sleep. Sleeping in a supine position on a firm mattress decreases the risk of SIDS.
School nurse is teaching an adolescent about levonorgestrel contraception. Which info should nurse include in teaching? "You should take the medication within 72 hours following unprotected sexual intercourse." "You should avoid taking this medication if you are on an oral contraceptive." "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test." "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it."
ANS: "You should take the medication within 72 hours following unprotected sexual intercourse.": - Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse. "You should avoid taking this medication if you are on an oral contraceptive.": - Levonorgestrel, an emergency contraceptive, has no effect on the other oral contraceptive the adolescent might be taking. To prevent pregnancy, this medication should be taken if an adolescent misses a dose of oral contraception. "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test.": - The adolescent should be evaluated for pregnancy if she does not menstruate within 21 days following administration of this medication. "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it.": - Levonorgestrel is an emergency contraceptive that prevents or delays ovulation. Therefore, the nurse should inform the client that she will not be protected from pregnancy if she has unprotected sexual intercourse in the days and weeks after receiving this medication.
Nurse reviews medical record at 1800 for patient at 34 weeks gestation. Based on chart findings and documentation, nursing POC should include what? Exhibit: Lecithin/sphingomyelin (L/S) ratio 1.4:1, Phosphatidylglycerol (PG) absent, ABO-Rh B-negative Terbutaline 0.25 mg SQ every hr PRN contractions, Rho(D) immune globulin 300 mcg IM once, Nalbuphine 10 mg IV every 3 hr PRN pain 1655 - Amniocentesis completed, tocotransducer and external fetal monitor applied 1700 - Fetal heart rate 130/min with moderate variability Uterine contractions q 5 to 8 min lasting 30 to 60 sec duration Uterine contractions palpated at 1+ intensity Client reports uterine contraction pain of 2 on a scale of 0 to 10 Administer terbutaline. Discuss possible genetic anomalies with the client. Administer nalbuphine. Discontinue external fetal monitoring.
ANS: Administer terbutaline: - The nurse should administer terbutaline to stop contractions because the laboratory results indicate that the fetus's lungs are not mature enough for birth. Discuss possible genetic anomalies with the client: - There is no indication of genetic anomalies based on the results of the amniocentesis. Administer nalbuphine: - Nalbuphine is an analgesic used for moderate to severe pain. A report of 2 on a scale of 0 to 10 is mild pain. Discontinue external fetal monitoring: - The nurse should not discontinue external fetal monitoring. Because the client is exhibiting manifestations of preterm labor, fetal well-being and contraction patterns should be continuously monitored to continue to assess for preterm labor and provide necessary interventions to stop contractions.
Nurse caring for client in labor and whose fetus is in right occiput posterior position. The client is dilated 8 cm and reports back pain. Which actions should the nurse take? Apply sacral counterpressure. Perform transcutaneous electrical nerve stimulation (TENS). Initiate slow-paced breathing. Assist with biofeedback.
ANS: Apply sacral counterpressure: - The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position. Perform transcutaneous electrical nerve stimulation (TENS): - The nurse should perform TENS during the first stage of labor. Initiate slow-paced breathing: - The nurse should transition a client to pattern-paced breathing during this stage of labor. Assist with biofeedback: - The nurse should teach the client about biofeedback during the prenatal period for it to be effective during labor.
Nurse is caring for a newborn undergoing phototherapy to treat hyperbilirubinemia. Which actions should the nurse take? Cover the newborn's eyes while under the phototherapy light. Keep the newborn in a shirt while under the phototherapy light. Apply a light moisturizing lotion to the newborn's skin. Turn and reposition the newborn every 4 hr while undergoing phototherapy.
ANS: Cover the newborn's eyes while under the phototherapy light.: - Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light. Keep the newborn in a shirt while under the phototherapy light: - It is acceptable for the nurse to keep a diaper or other covering over the newborn's genitals and buttocks, but the nurse should remove all other clothing and blankets to expose as much body surface area as possible to the phototherapy light. Apply a light moisturizing lotion to the newborn's skin: - The nurse should not apply any cream or moisture to the newborn's skin because it can absorb heat and cause burns. Turn and reposition the newborn every 4 hr while undergoing phototherapy: - The nurse should turn and reposition the newborn Q 2 to 3 hr to allow for maximum exposure of body surfaces to the phototherapy light.
Nurse assesses client in postpartum and has idiopathic thrombocytopenia purpura (ITP). Which findings should the nurse expect? Decreased platelet count Increased erythrocyte sedimentation rate (ESR) Decreased megakaryocytes Increased WBC
ANS: Decreased platelet count: - A client who has ITP has an autoimmune response that results in a decreased platelet count. Increased erythrocyte sedimentation rate (ESR): - an indication of chronic renal failure. Decreased megakaryocytes: - A client who has ITP will have megakaryocytes within the expected reference range. Increased WBC: - an indication of infection.
Nurse caring for client who becomes unresponsive upon delivery of placenta. Which actions should nurse take first? Determine respiratory function. Increase the IV fluid rate. Access emergency medications from cart. Collect a maternal blood sample for coagulopathy studies.
ANS: Determine respiratory function: - The priority action the nurse should take when using the ABC approach to client care is to determine respiratory function and the need for CPR. Increase IV fluid rate: - The nurse should increase the IV fluid rate to maintain circulation. However, this is not the first action the nurse should take. Access emergency medications from cart: - The nurse should access emergency medication to assist in resuscitative efforts. However, this is not the first action the nurse should take. Collect a maternal blood sample for coagulopathy studies: - The nurse should collect a maternal blood sample in preparation for a blood transfusion. However, this is not the first action the nurse should take.
Nurse in antepartum clinic assesses client's adaptation to pregnancy. Client states, "happy one min and crying the next". Nurse should interpret statement as what? Emotional lability Focusing phase Cognitive restructuring Couvade syndrome
ANS: Emotional lability: - The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason. Focusing phase: - The focusing phase is the third phase of the father's emotional response to the pregnancy. It is characterized by his active involvement in the pregnancy and his relationship with the child. Cognitive restructuring: - accepting the idea of pregnancy and assimilating it into the woman's life. The degree of acceptance is shown in the mother's emotional responses. Couvade syndrome: - pregnancy-like manifestations experienced by the expectant father. Manifestations include nausea, weight gain, and other physical manifestations of pregnancy.
Nurse is preparing to admin. oxytocin to client who's postpartum. Which findings is an indication for admin. of meds? (SATA) Flaccid uterus Cervical laceration Excess vaginal bleeding Increased afterbirth cramping Increased maternal temperature
ANS: Flaccid uterus is correct: - Oxytocin increases the contractility of the uterus. ANS: Excess vaginal bleeding is correct: - Oxytocin enhances uterine contractility, decreasing vaginal bleeding. Cervical laceration is incorrect: - Bleeding resulting from a cervical laceration continues even when the uterus is contracted and firm. It will require repair by the provider. Increased afterbirth cramping is incorrect. - The use of oxytocin will increase, rather than decrease, afterbirth cramping. Increased maternal temperature is incorrect: - The use of oxytocin will have no effect on maternal temperature.
Nurse is reviewing lab results for client at 10 weeks gestation. Which lab findings should nurse report to HCP? Hemoglobin 10 g/dL WBC count 15,000/mm3 RBC count 5.8 million/mm3 Hematocrit 34%
ANS: Hemoglobin 10 g/dL: - below the expected reference range of > 11 g/dL for a client who is pregnant. The nurse should report this lab finding to the provider. WBC count 15,000/mm3: - within the expected reference range of 5,000 - 15,000/mm3 for a client who is pregnant. This finding is does not require reporting. RBC count 5.8 million/mm3: - within the expected reference range of 5 to 6.25 million/mm3 for a client who is pregnant and does not require reporting. This count increases by 20% to 30% during pregnancy. Hematocrit 34%: - within the expected reference range of >33% for a client who is pregnant and does not require reporting.
Nurse on postpartum unit is caring for patient experiencing hypovolemic shock. After notifying HCP, which actions should nurse take next? Massage the client's fundus. Insert an indwelling urinary catheter. Administer oxygen at 10 L/min. Elevate the client's right hip.
ANS: Massage the client's fundus: - The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions. Insert an indwelling urinary catheter: - to monitor perfusion of the kidneys. However, this is not the next action the nurse should take. Administer oxygen at 10 L/min: - The nurse should administer oxygen at 10 L/min via rebreather face mask to enhance perfusion. However, this is not the next action the nurse should take. Elevate the client's right hip: - The nurse should elevate the client's right hip to enhance perfusion. However, this is not the next action the nurse should take.
Nurse reviews medical record of newly admitted client who's 32 weeks gestation. Which conditions is an indication for fetal assessment using electronic fetal monitoring? Oligohydramnios Hyperemesis gravidarum Leukorrhea Periodic tingling of the fingers
ANS: Oligohydramnios: - The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis. Hyperemesis gravidarum: - not an indication for further fetal assessment using electronic fetal monitoring unless complications occur. Leukorrhea: - a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring unless complications occur. Periodic tingling of the fingers: - a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring.
Nurse is teaching client with new prescription for combined oral contraceptives about potential adverse effects of med. Which findings should nurse instruct the client to notify the HCP? Shortness of breath Breakthrough bleeding Vomiting Breast tenderness
ANS: Shortness of breath: - nurse should instruct the client to notify the HCP ASAP of any SOB. SOB and chest pain can indicate a pulm embolus or MI. Also, the nurse should instruct the client to notify HCP of other adverse effects that can indicate potential complications, including abd. pain, sudden/persistent headaches, blurred vision, & severe leg pain. Breakthrough bleeding: - Breakthrough bleeding outside the menstrual period is a common adverse effect of combined oral contraceptives. Vomiting: - N/V are common adverse effects of combined oral contraceptives. Breast tenderness: - a common adverse effect of combined oral contraceptives.
Nurse is assessing client at 30 weeks gestation during routine prenatal visit. Which findings should nurse report to HCP? Swelling of the face Varicose veins in the calves Nonpitting 1+ ankle edema Hyperpigmentation of the cheeks
ANS: Swelling of the face: - Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema. Varicose veins in the calves: - an expected finding in the 2d trimester. The increase in hormones during pregnancy causes the relaxation of the smooth muscle of the vascular system, leading to vessel dilation and vasocongestion. Additionally, the weight of the enlarging uterus on the pelvic veins decreases the return of blood from the lower extremities. Nonpitting 1+ ankle edema: - Nonpitting edema of the lower extremities is an expected finding in the third trimester. Warm weather, sitting or standing for prolonged periods of time, and tight clothing can increase edema. Hyperpigmentation of the cheeks: - Hyperpigmentation of the cheeks, areola, vulva, and linea nigra are expected findings in the second trimester. The anterior pituitary increases the production of melanocyte-stimulating hormone, which leads to hyperpigmentation of the skin.
Nurse is caring for patient who is in labor and reports increasing rectal pressure. Experiencing contractions 2-3 min apart, each lasting 80-90 secs, and a vag exam reveals that her cervix is dilated 9 cm. Nurse should ID that patient is in which phases of labor? Active Transition Latent Descent
Active: - The active phase of labor is characterized by a cervical dilatation of 4 to 7 cm and contractions every 3 to 5 min, each lasting 40 to 70 seconds. ANS: Transition: - The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds. Latent: - The latent phase of labor is characterized by cervical dilation of 0 to 3 cm and contractions every 5 to 30 min, each lasting 30 to 45 seconds. Descent: - The descent phase of labor is characterized by active pushing with contractions every 1 to 2 min, each lasting for 90 seconds.
Nurse is caring for patient who's 35 weeks gestation and has placenta previa. Which actions should nurse take? Perform a vaginal exam to determine cervical dilation every 2 hr. Instruct the client to ambulate in the hallway once every 4 hr. Administer betamethasone to the client via IM injection. Initiate continuous external fetal monitoring.
Perform a vaginal exam to determine cervical dilation every 2 hr: - A client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should place the client on pelvic rest and should not perform vaginal or rectal examinations. Instruct the client to ambulate in the hallway once Q4 hr: - A client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. Ambulating frequently could potentially stimulate labor and increase vaginal bleeding. Therefore, the nurse should place the client on bed rest with bathroom privileges. Administer betamethasone to the client via IM injection: - Betamethasone is given to enhance fetal lung maturity for clients who are experiencing preterm labor. It is given to clients between 24 and 34 weeks of gestation. ANS: Initiate continuous external fetal monitoring: - The nurse should identify that a client who has a placenta previa and is actively bleeding is at an increased risk for preterm labor and hemorrhage. The nurse should initiate interventions such as bed rest, pelvic rest, and continuous fetal heart monitoring, which assesses fetal well-being and the presence of contractions. The nurse should obtain IV access and monitor laboratory values. Also, the nurse should implement interventions to prepare for an emergency birth.
Nurse planning care for client in labor and requesting epidural anesthesia for pain control. Which actions should nurse include in POC? Place the client in a supine position for 30 min following the first dose of anesthetic solution. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution.
Place the client in a supine position for 30 min following the first dose of anesthetic solution: - The nurse should plan to position the client upright to allow the anesthetic solution to flow downward. If additional pain management is needed for a cesarean birth, the nurse can place the client supine with her head and shoulders elevated and at a lateral tilt to increase perfusion to the fetus. Administer 1,000 mL of dextrose 5% in water prior to 1st dose of anesthetic solution: - The nurse should plan to administer 500 to 1,000 mL of lactated Ringer's or 0.9% sodium chloride 15 to 30 min prior to the administration of the first dose of anesthetic solution to decrease the maternal risk for hypotension. The nurse should not administer dextrose because it can cause maternal hyperglycemia and neonatal hypoglycemia. ANS: Monitor the client's BP Q 5 min following the 1st dose of anesthetic solution: - The nurse should plan to obtain a baseline BP prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's BP every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution: - NPO status is not indicated for this procedure.
Nurse gives discharge teaching to parents of newborn about car seat safety. Which instructions should nurse include? Place the shoulder harness in the slots above the newborn's shoulders. Place the retainer clip at the level of the newborn's armpits. Place the newborn at a 60° angle in the car seat. Place the newborn in a blanket before securing them in the car seat.
Place the shoulder harness in the slots above the newborn's shoulders.: - The nurse should instruct the parents to place the shoulder harness in the slots that are at or just below the newborn's shoulders. ANS: Place the retainer clip at the level of the newborn's armpits.: - The nurse should instruct the parents to place the newborn in a federally approved car seat with the retainer clip snugly at the level of the newborn's armpits. Place the newborn at a 60° angle in the car seat: - The nurse should instruct the parents to position the newborn at a 45° angle to minimize the risk of airway obstruction from slumping forward. Place the newborn in a blanket before securing them in the car seat: - The nurse should instruct the parents to refrain from placing extra padding, including blankets, between the newborn and the straps of the car seat. Extra padding creates air pockets that decrease the effectiveness of the restraint and can lead to injuries.