RN Maternal Newborn Online Practice 2019 B

A nurse is teaching a client who is at 24 weeks of gestation regarding a 1 hr glucose tolerance test. Which of the following statements should the nurse include in the teaching?

"A blood glucose of 130 to 140 is considered a positive screening result." "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. "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."MY ANSWERThe nurse should instruct the client that fasting is not required for a 1-hr glucose tolerance test.

A nurse is caring for a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? "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."MY ANSWERClients 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.

"I will eat foods that taste good instead of balancing my meals."

A nurse is planning discharge for a client who is 3 days postpartum. Which of the following nonpharmacological interventions should the nurse include in the plan of care for lactation suppression?

Apply cabbage leaves to the breasts. Place warm, moist packs on the breasts.MY ANSWERThe client can use cold compresses to decrease breast discomfort during lactation suppression. 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.

A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. the client is dilated 8cm and reports back pain. Which of the following actions should the nurse take?

Apply sacral counterpressure. Apply sacral counterpressure.MY ANSWERThe 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.

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? Decreased heart rate Chin quivering Pinpoint pupils Slowed respirations

Chin quivering Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow. The heart rate will increase when a newborn is experiencing pain. When experiencing pain, a newborn's pupils typically dilate. When experiencing pain, a newborn's respirations are typically rapid and shallow.

A nurse is reviewing the lab results for a client who is at 10 weeks of gestation. Which of the following lab findings should the nurse report to the provider?

Hemoglobin 10 g/dL Hemoglobin 10 g/dLA hemoglobin level of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this laboratory finding to the provider. WBC count 15,000/mm3This white blood cell count is within the expected reference range of 5,000 to 15,000/mm3 for a client who is pregnant. This finding is does not require reporting. RBC count 5.8 million/mm3MY ANSWERThis red blood cell count is 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%This hematocrit is within the expected reference range of greater than 33% for a client who is pregnant and does not require reporting.

A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following actions should the nurse take?

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 every 4 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.MY ANSWERBetamethasone 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. 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.

A. nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?

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. Instruct the client to press the provided button each time fetal movement is detected.MY ANSWERFetal 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.

A nurse is assessing a newborn for manifestations of hypoglycemia. Which of the following findings should the nurse expect?

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.

A nurse is caring for a client who is pregnant and at the end of her first trimester. the nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the fetal heart tones (FHT)?

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.

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?

Leakage of fluid from the vagina Increased fetal movementDecreased fetal movement is a potential complication that should be reported to the provider. Leakage of fluid from the vaginaLeakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider. Upper abdominal discomfortMY ANSWERUpper abdominal discomfort is not a potential complication associated with an amniocentesis. Urinary frequencyUrinary frequency is not a potential complication associated with an amniocentesis.

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

Temperature O2 saturationAssessing the client's O2 saturation is important during labor. However, another assessment is the nurse's priority. TemperatureMY ANSWERThe greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature. Blood pressureAssessing the client's blood pressure is important. However, another assessment is the nurse's priority. Urinary outputAssessing the client's urinary output is important during labor. However, another assessment is the nurse's priority.

A nurse is caring for a newborn who was transferred to the nursery 30 minutes after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

Verify the newborn's identification. 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. Verify the newborn's identification.MY ANSWERWhen 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.

A nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?

"I will have blood tests because my potassium might decrease." "I will get injections of the medication once daily until my labor stops."Terbutaline is administered subcutaneously every 4 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. "I will have blood tests because my potassium might decrease."MY ANSWERAn adverse effect of terbutaline is hypokalemia. "My blood pressure may increase while I'm on this medication."An adverse effect of terbutaline is hypotension.

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements should the nurse make about the indication for medication administration?

"This medication stimulates fetal lung maturity." "This medication will stop your labor."Betamethasone is not a tocolytic and does not stop labor. "This medication stimulates fetal lung maturity."MY ANSWERThe 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.

A nurse is speaking with a client who is trying to make a decision about tubal ligation. The client asks, "What effects will this procedure have on my sex life?". Which of the following responses should the nurse make?

"This procedure should have no effect on your sexual performance or adequacy." "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. "This procedure should have no effect on your sexual performance or adequacy."MY ANSWERThe 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.

A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statements should the nurse include in the teaching? "You should replace the diaphragm every 5 years."The client should replace the diaphragm every 2 years. "You should leave the diaphragm in place for at least 6 hours after intercourse."MY ANSWER 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.

"You should leave the diaphragm in place for at least 6 hours after intercourse."

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?

"You should take the medication within 72 hours following unprotected sexual intercourse." "You should take the medication within 72 hours following unprotected sexual intercourse."MY ANSWERLevonorgestrel 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.

A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a non-stress test. Which of the following statements should be included in the teaching?

"You will be offered orange juice to drink during the 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."MY ANSWERThe nurse should instruct the client that the procedure will take 20 to 40 min. "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.

A nurse is caring for a client who is in active labor and has had no cervical change in the last 4 hr. Which of the following statements should the nurse make?

"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."MY ANSWERA 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. "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.

A nurse is preparing to perform Leopold maneuvers for a client.

1. palpate the client's fundus to identify the fetal part 2. determine the location of the fetal back 3. palpate for the fetal part presenting at the inlet 4. identify the attitude of the head 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.

A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1 g orally now". Available is 250mg tablets. How many tablets should the nurse administer? (Round to nearest whole number)

4 tablets

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates her uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?

Assist the client to empty her bladder. Reassess the 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. Assist the client to empty her bladder.MY ANSWERThe 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.

A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?

Cover the newborn's eyes while under the phototherapy light. 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.MY ANSWERThe 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 every 2 to 3 hr to allow for maximum exposure of body surfaces to the phototherapy light.

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?

Determine respiratory function. Determine respiratory function.MY ANSWERThe priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation. Increase the 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.

A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. the nurse should instruct the client to increase her daily intake of which of the following nutrients?

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. Other options' rationale: Vitamin D The recommendation for vitamin D intake during pregnancy is 600 IU/day, the same as that for women who are not pregnant. Vitamin E The recommendation for vitamin E intake during pregnancy is 15 mg/day, the same as that for women who are not pregnant. 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.

A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?

Platelets 50,000/mm3 A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider. Hct 39%An Hct of 39% is within the expected reference range and does not indicate a postpartum complication. Serum albumin 4.5 g/dLMY ANSWERA serum albumin level of 4.5 g/dL is within the expected reference range. This finding is consistent with mild preeclampsia and does not indicate a worsening of the condition. WBC 9,000/mm3A WBC of 9,000/mm3 is within the expected reference range and does not indicate a postpartum complication.

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?

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 calvesVaricose veins are an expected finding in the second 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 edemaMY ANSWERNonpitting 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 cheeksHyperpigmentation 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.

A nurse is assisting with the care of a client who is in the first stage of labor, the nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take?

Apply internal upward pressure to the presenting part using two gloved fingers 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, evidence-based practice indicates that the nurse should take a different action first. Apply internal upward pressure to the presenting part using two gloved fingers.MY ANSWERUsing evidence-based practice, 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.

A nurse is reviewing the lab report of a newborn who is 24 hr old. Which of the following results should the nurse report to the provider?

Blood glucose 30 mg/dL Hgb 20 g/dLThis value is within the expected reference range of 14 to 24 g/dL for a newborn who is 24 hr old. Total bilirubin 5 mg/dLThis value is within the expected reference range of 2 to 6 mg/dL for a newborn who is 24 hr old. Blood glucose 30 mg/dLMY ANSWERNewborns less than 24 hr old should have a blood glucose of 40 to 60 mg/dL. Newborns who are greater than 24 hr old should have a blood glucose of 50 to 90 mg/dL. A blood glucose 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/mm3This value is within the expected reference range of 9,000 to 30,000/mm3 for a newborn who is 24 hr old.

A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?

Explain to the client this is an expected occurrence. 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. Explain to the client this is an expected occurrence.MY ANSWERChloasma, 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.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. 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.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. Changing skin care products will not affect the client's condition.

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electric fetal monitoring?

Oligohydramnios OligohydramniosMY ANSWERThe 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 gravidarumHyperemesis gravidarum is not an indication for further fetal assessment using electronic fetal monitoring unless complications occur. LeukorrheaLeukorrhea is 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 fingersPeriodic tingling of the fingers is a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring.

A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medications. For which of the following findings should the nurse instruct the client to notify the provider?

Shortness of breath Shortness of breathMY ANSWERThe nurse should instruct the client to notify the provider immediately of any shortness of breath. Shortness of breath and chest pain can indicate a pulmonary embolus or myocardial infarction. Also, the nurse should instruct the client to notify the provider of other adverse effects that can indicate potential complications, including abdominal pain, sudden or persistent headaches, blurred vision, and severe leg pain. Breakthrough bleedingBreakthrough bleeding outside the menstrual period is a common adverse effect of combined oral contraceptives. VomitingNausea and vomiting are common adverse effects of combined oral contraceptives. Breast tendernessBreast tenderness is a common adverse effect of combined oral contraceptives.

A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80-90 seconds, and a vaginal exam reveals that her cervix is dilated to 9cm. The nurse should identify that the client is in which of the following phases of labor?

Transition ActiveMY ANSWERThe 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. TransitionThe 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. LatentThe 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. DescentThe descent phase of labor is characterized by active pushing with contractions every 1 to 2 min, each lasting for 90 seconds.

A nurse is teaching a client who has pregestational type 1 DM about management during pregnancy. Which of the following statements by the client indicates the understanding of the teaching?

"I will continue taking my insulin if I experience nausea and vomiting." "I should have a goal of maintaining my fasting blood glucose between 100 and 120."The nurse should teach the client to maintain her fasting blood glucose level between 60 and 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. "I will continue taking my insulin if I experience nausea and vomiting."MY ANSWERThe 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.

A nurse is teaching a client who is Rh- about immune globulin. Which of the following statements by the client indicates an understanding of the teaching?

"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. "I will need this medication if I have an amniocentesis."MY ANSWERRho(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.

A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?

"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. "Staff members who take care of your baby will be wearing a photo identification badge."MY ANSWERThe 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.

A nurse in a prenatal clinic is caring for a client who reports that her menstrual period is 2 weeks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?

"You can miss your period for several other reasons. Describe your typical menstrual cycle." "You can miss your period for several other reasons. Describe your typical menstrual cycle."MY ANSWERAmenorrhea 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.

A nurse is teaching a new parent about newborn safety. Which of the following instructions should the nurse include in the teaching?

"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, the nurse should instruct the parent to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome. Other options' rationale: "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 sudden infant death syndrome. "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 temperature 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 sudden infant death syndrome.

A nurse on the antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?

A client who is at 34 weeks of gestation and reports epigastric pain A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dLA fasting blood glucose of 120 mg/dL is above the expected reference range for a client who has gestational diabetes, which is a nonurgent finding. Therefore, another client is the nurse's priority. A client who is at 34 weeks of gestation and reports epigastric painWhen 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/dLThis 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 dysuriaMY ANSWERDysuria 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. Thereofre, another client is the nurse's priority.

A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions? Diagnostic Results​Lecithin/sphingomyelin (L/S) ratio 1.4:1Phosphatidylglycerol (PG) absentABO-Rh B-negative Medication Administration Record​Terbutaline 0.25 mg SQ every hr PRN contractionsRho(D) immune globulin 300 mcg IM onceNalbuphine 10 mg IV every 3 hr PRN pain A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.) Progress Report1655 - Amniocentesis completed, tocotransducer and external fetal monitor applied1700 - Fetal heart rate 130/min with moderate variabilityUterine contractions q 5 to 8 min lasting 30 to 60 sec durationUterine contractions palpated at 1+ intensityClient reports uterine contraction pain of 2 on a scale of 0 to 10 A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions? (Click on the exhibit button for additional information about the client. There are three tabs that contain separate categories of data.) Administer terbutaline. Discuss possible genetic anomalies with the client. Administer nalbuphine. Discontinue external fetal monitoring.

Administer terbutaline. 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.MY ANSWERThere 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.

A nurse is reviewing laboratory results of a newborn who is 4 hr old. Which of the following findings should the nurse report to the provider?

Bilirubin 9 mg/dL A bilirubin level of 9 mg/dL is 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/dLThis hemoglobin level is within the expected reference range of 14 to 24 g/dL for a newborn and does not require reporting. Platelets 175,0000/mm3This platelet count is within the expected reference range of 150,000 to 300,000/mm3 for a newborn and does not require reporting. Hematocrit 45%This hematocrit level is within the expected reference range of 44% to 64% for a newborn and does not require reporting.

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?

Biophysical profile (BPP) Percutaneous umbilical blood samplingPercutaneous umbilical blood sampling, commonly called cordocentesis, is the most common method used for fetal blood sampling and transfusion. This is not a diagnostic test used for clients who have a positive contraction stress test. AmnioinfusionMY ANSWERAn amnioinfusion of normal saline or lactated Ringer's 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. 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.

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (SATA)

Cholecystitis Hypertension Migraine headaches MY ANSWER Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension 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. Migraine headaches is correct. A history of migraine headaches is 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.

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect? Decreased platelet count Increased erythrocyte sedimentation rate (ESR) Decreased megakaryocytes Increased WBC

Decreased platelet count A client who has ITP has an autoimmune response that results in a decreased platelet count. Rationale for other options An increased ESR is an indication of chronic renal failure. A client who has ITP will have megakaryocytes within the expected reference range. An increased WBC is an indication of infection.

A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?

Have calcium gluconate readily available. 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 urine output should be 30 mL/hr or greater. Have calcium gluconate readily available.MY ANSWERThe nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity. Assess deep tendon reflexes every 6 hr.The nurse should assess deep tendon reflexes every 1 to 4 hr during continuous infusion of magnesium sulfate. Monitor intake and output every 4 hr.The nurse should monitor intake and output hourly for clients who are receiving a continuous infusion of magnesium sulfate.

A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?

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. Demonstrate to the client how to perform a newborn bath.MY ANSWERDemonstrating 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.

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that she is "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following?

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 Cognitive restructuring is 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 Couvade syndrome is pregnancy-like manifestations experienced by the expectant father. Manifestations include nausea, weight gain, and other physical manifestations of pregnancy.

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication?

Flaccid uterus Excess vaginal bleeding Flaccid uterus is correct. Oxytocin increases the contractility of the uterus.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.Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding.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.

A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which manifestations should the nurse include?

Headache that is unrelieved by analgesia Shortness of breath when climbing stairsShortness of breath 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 daySwelling of feet and ankles is due to the enlarging uterus interfering with blood return to the heart and is an expected manifestation at 35 weeks of gestation. Headache that is unrelieved by analgesiaMY ANSWERA headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider. Braxton Hicks contractionsBraxton Hicks contractions are an indication that the uterus is preparing for labor and is an expected manifestation at 35 weeks of gestation.

A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer to assess the point of maximum intensity of the fetal heart?

Left lower quadrant Left upper quadrantThe fetal heart tones of a fetus in the left sacrum anterior position are best heard in the left upper quadrant. Right upper quadrantThe fetal heart tones of a fetus in the right sacrum anterior position are best heard in the right upper quadrant. Left lower quadrantMY ANSWERThe fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant. Right lower quadrantThe fetal heart tones of a fetus in the right occipital anterior position are best heard in the right lower quadrant.

A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, which of the following actions should the 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.

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. OR: nsert an indwelling urinary catheter.The nurse should 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.

A nurse is planning care for a client who is in labor and requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure 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. The nurse should not plan to restrict the client's intake prior to the epidural placement and the first dose of anesthetic solution because NPO status is not indicated for this procedure. Administer 1,000 mL of dextrose 5% in water prior to the first 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. 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.

A nurse is providing discharge teaching to the parents of the newborn about car seat safety. Which if the following instructions should the nurse include?

Place the retainer clip at the level of the newborn's armpits. 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. Place the retainer clip at the level of the newborn's armpits.MY ANSWERThe 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.

A nurse is calculating a client's expected DOB using Nagele's rule. The client tells the nurse that her LMP started on November 27th. Which is the client's expected DOB?

September 3rd September 3rdWhen 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 20thWhen 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 3rdWhen 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 20thMY ANSWERWhen 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.

A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include?

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. Stop suctioning when the newborn's cry sounds clear.MY ANSWERThe 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.

A nurse is assessing a newborn who is 12 hours old. Which of the following manifestations requires intervention by the nurse?

Substernal chest retractions while sleeping Acrocyanosis of the extremitiesAcrocyanosis of the extremities is an expected manifestation in newborns. Acrocyanosis is a bluish discoloration of the newborn's hands and feet. Murmur at the left sternal borderAn audible murmur heard at the left sternal border is an expected manifestation in newborns. Substernal chest retractions while sleepingMY ANSWERSubsternal chest retractions can indicate respiratory distress syndrome in the newborn. This manifestation requires further assessment and intervention by the nurse. Positive Babinski reflexA positive Babinski reflex is 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.

A nurse is providing discharge teaching to a client who is postpartum. For which of the following manifestations should the nurse instruct the client to monitor and report to the provider?

Unilateral breast pain Persistent abdominal striaePersistent abdominal striae are caused by the separation of the underlying connective tissue and are an expected postpartum finding. Temperature 37.8° C (100° F)MY ANSWERThe 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. Unilateral breast painSudden 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 5Brownish-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.

A nurse is assessing the newborn of a client who took a SSRI during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI? Large for gestational age Hyperglycemia Bradypnea Vomiting

Vomiting Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days. Tachypnea is an expected manifestation of fetal exposure to SSRIs. Hypoglycemia is an expected manifestation of fetal exposure to SSRIs. Low birth weight is an expected manifestation of fetal exposure to SSRIs.