Term 3 Ped's Exam 1 & 2

A nurse is reinforcing teaching about nonstress testing with a client who is pregnant. Which of the following pieces of information should the nurse include? A. "This test is an invasive procedure that presents minimal risk to the fetus." B. "If the test is reactive, that means your baby's heart rate is healthy." C. "When your baby moves, the test should record the baby's heart rate decreasing by about 15 beats per minute." D. "The results of the test will be recorded as positive if no fetal movement occurs during the 20-minute testing period."

✔ B. "If the test is reactive, that means your baby's heart rate is healthy."

A nurse is assisting with the care of a newborn who has a myelomeningocele. Which of the following actions should the nurse take? A. Place the newborn in an infant carrier B. Initiate a latex-free environment C. Cover the sac with a large piece of dry gauze D. Obtain a rectal temperature every 4 hours

✔ B. Initiate a latex-free environment

A nurse is reinforcing teaching about oxytocin with a client who is in the third trimester of pregnancy and has pre-eclampsia. Which of the following is a contraindication for use of this medication? A. Prolonged rupture of membranes at 38 weeks of gestation B. Intrauterine growth restriction C. Active genital herpes D. Post-term pregnancy

✔ C. Active genital herpes The use of oxytocin is contraindicated for clients who have an active genital herpes infection. The newborn can acquire the infection as they pass through the birth canal. Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection. Incorrect Answers: A. When the client is at or near term with prolonged rupture of membranes, oxytocin induction is indicated. B. Intrauterine growth restriction is an indication for the use of oxytocin to induce labor. D. Induction of labor with oxytocin is suggested in post-term pregnancies.

A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 seconds. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? A. Administer oxygen B. Place the newborn in an isolette C. Continue to monitor the newborn routinely D. Check the newborn's blood glucose

✔ C. Continue to monitor the newborn routinely This newborn is exhibiting a normal respiratory rate and rhythm. No additional measures are needed at this time. Incorrect Answers: A. This newborn is exhibiting a normal pattern, and no action is indicated at this time. B. This newborn is not exhibiting clinical findings of hypothermia or cold stress. D. This newborn does not show evidence of hypoglycemia such as jitters or poor sucking

A nurse is contributing to the plan of care for a client who is at 12 weeks of gestation and has a BMI of 45. Which of the following recommendations should the nurse make for the client regarding weight gain during her pregnancy? A. "You should plan to gain no more than 20 lb during your pregnancy." B. "You should plan to gain between 25 and 35 lb during your pregnancy." C. "You should not plan to gain any weight during your pregnancy because you are already well-nourished." D. "Since you have higher energy needs than an average-sized pregnant client, you should plan to gain 45 to 50 lb."

✔ A. "You should plan to gain no more than 20 lb during your pregnancy." Women who have a BMI greater than 30 should limit weight gain to 11 to 20 pounds during pregnancy. Excessive weight and weight gain increase the risk of complications during and after pregnancy. Incorrect Answers: B. This is the recommended weight gain for a pregnant client who has a BMI of 18.5 to 25. C. Pregnancy is not an appropriate time for the client to be dieting. Clients who are overweight or obese should be counseled to gain enough weight to compensate for the fetus, placenta, and amniotic fluid (11 to 20 pounds). D. Women with a BMI greater than 30 should limit weight gain to 11 to 20 pounds during pregnancy.

A nurse is reinforcing teaching with a client who has active genital herpes simplex virus, type 2. Which of the following statements by the nurse should be included in the teaching? A. "You will have a cesarean birth prior to the onset of labor." B. "Your baby will receive erythromycin eye ointment after birth to treat the infection." C. "You should take oral metronidazole for 7 days prior to 37 weeks of gestation." D. "You should schedule a cesarean birth after your water breaks."

✔ A. "You will have a cesarean birth prior to the onset of labor." Whenever possible, a cesarean birth should be scheduled prior to the onset of labor or rupture of membranes to reduce the risk of neonatal transmission of herpes. Incorrect Answers: B. Erythromycin provides prophylaxis against ophthalmia neonatorum. It is given to prevent gonorrhea and chlamydia infections in newborns. C. A client who has active herpes should receive a prescription for acyclovir. Metronidazole should be prescribed for bacterial vaginosis. D. The cesarean birth should be planned prior to the rupture of membranes. If rupture of membranes occurs, an emergency cesarean birth should be done as soon as possible, but every attempt should be made to prevent this situation.

A nurse is caring for a client in the third trimester of pregnancy who is scheduled to undergo a non-stress test. Which of the following actions should the nurse take prior to the test? A. Ask the client to drink a glass of orange juice B. Prepare the client for a vaginal examination C. Request a serum hemoglobin level D. Obtain a clean-catch urine specimen

✔ A. Ask the client to drink a glass of orange juice The nurse should give the client orange juice or a glucose preparation prior to this test. This should raise the client's blood glucose level and help promote fetal movement. Incorrect Answers: B. A non-stress test involves the application of a fetal heart monitor and a tocodynamometer to track uterine contractions and fetal movement. There is no vaginal examination with this procedure. C. A non-stress test evaluates the fetal heart rate's response to uterine contractions and fetal movement. It does not involve the client's hemoglobin level. D. A non-stress test evaluates the fetal heart rate's response to uterine contractions and fetal movement. It does not involve identifying indications of a urinary tract infection in the client.

A nurse is assisting with an amniotomy for a client who is in active labor. Which of the following actions should the nurse take? A. Assess the fetal heart rate before and after the procedure B. Monitor the client's temperature every 4 hours after the procedure C. Medicate the client for pain 30 minutes prior to the procedure D. Perform cervical assessments every 2 hours after the procedure

✔ A. Assess the fetal heart rate before and after the procedure The nurse should assess the fetal heart rate for the presence of variable decelerations or bradycardia, which can occur after rupture of the membranes if the umbilical cord has prolapsed. Incorrect Answers: B. The client's temperature should be assessed every 2 hours after rupture of the membranes due to the increased risk of infection. C. An amniotomy procedure is not painful because there are no nerve endings in the amniotic sac. D. The nurse should limit vaginal examinations for cervical assessment after rupture of the membranes, as microorganisms from the vagina can ascend to the uterus and cause an infection.

A nurse is assisting with the assessment of a 1-day-old newborn. Which of the following findings indicates that the newborn has acrocyanosis? A. Bluish-colored skin B. Pursed lips C. Clenched fists D. Rounded nose

✔ A. Bluish-colored skin Acrocyanosis is a bluish discoloration of the hands and feet. It is a normal finding in the first 24 hours after birth. Incorrect Answers: B. Pursed lips are not a sign of acrocyanosis. However, the nurse should examine the newborn's lips when checking for acrocyanosis. C. Clenched fists are not a sign of acrocyanosis. However, the nurse should examine the newborn's hands and feet when checking for acrocyanosis. D. A rounded nose is not indicative of acrocyanosis. However, the nurse should examine the newborn's nose for nostril flaring, which can be a sign of respiratory distress.

A provider is assisting with the care of a client who is postpartum following a vaginal delivery. The nurse should identify that which of the following circumstances is a risk factor for postpartum hemorrhage? A. Oxytocin-induced labor B. Oligohydramnios C. Small fetus D. Gravida 1

✔ A. Oxytocin-induced labor Oxytocin-induced labor can result in a prolonged labor and can be a risk factor for postpartum hemorrhage, Postpartum hemorrhage is the leading cause of maternal mortality and morbidity in the US and worldwide, involving a loss of 500 mL or more of blood after a vaginal delivery and 1000 mL or more after a cesarean birth. Incorrect Answers: B. Hydramnios, rather than oligohydramnios, is a risk factor for postpartum hemorrhage. C. A large fetus, rather than a small fetus, is a risk factor for a postpartum hemorrhage. D. High parity, rather than gravida 1, is a risk factor for postpartum hemorrhage.

A nurse is assisting with the care of a client in labor who is receiving IV oxytocin. The nurse notes contractions lasting 3 minutes each. What action should the nurse take? A. Stop the oxytocin infusion B. Apply oxygen at 2 L/min via nasal cannula C. Administer methylergonovine intramuscularly D. Prepare for an emergent cesarean birth

✔ A. Stop the oxytocin infusion A pattern of contractions lasting longer than 2 minutes or more than 5 contractions in a 10-minute period is considered tachysystole. This pattern can result in decreased placental perfusion of oxygen. The appropriate action is to discontinue the oxytocin infusion. Incorrect Answers: B. Tachysystole can lead to fetal hypoxia, which would be determined via an abnormal fetal heart rate pattern on the fetal monitor. If fetal hypoxia is suspected, oxygen should be applied at 10 L/min via face mask. C. Methylergonovine is a uterotonic medication that causes sustained uterine contractions. It can be used to treat postpartum hemorrhage and should never be administered during pregnancy. D. Unless there are indications that the fetus is in irreversible distress, a cesarean birth is not indicated for this client.

A nurse is assisting with the care of a client who is at 32 weeks of gestation and has preeclampsia. Which of the following provider prescriptions should the nurse expect? A. The client should take low-dose aspirin daily. B. The client should check fetal kick counts every other day. C. The client should have her blood pressure measured while standing. D. The client should maintain complete bed rest.

✔ A. The client should take low-dose aspirin daily Daily low-dose aspirin has been found to reduce adverse outcomes in preeclampsia. The current recommendation is for low-dose aspirin to be initiated late in the first trimester for clients who have a history of early onset preeclampsia. Incorrect Answers: B. The nurse should instruct the client to check the baby's activity daily. Decreased activity, defined as 4 or fewer movements per hour, can indicate fetal comprise and should be reported to the provider. C. The nurse should check the client's blood pressure while the client is sitting, not standing. D. This practice increases the risk of adverse outcomes related to immobility, including thrombophlebitis. There is no evidence that bed rest improves pregnancy outcomes for clients who have preeclampsia

A nurse is caring for a client who reports cramping while trying to breastfeed her newborn. Which of the following instructions should the nurse provide to the client? A. "You might need to walk around to decrease gas." B. "Breastfeeding can cause uterine contractions." C. "We will need to check you for hemorrhaging." D. "You should lie on your side during breastfeeding."

✔ B. "Breastfeeding can cause uterine contractions." The nurse should explain to the client that oxytocin is released during breastfeeding, which can cause uterine contractions. Incorrect Answers: A. A client who is experiencing gas will report cramping other times than with breastfeeding. Ambulation assists the client by moving gas through the gastrointestinal system. C. Cramping is an indication that the uterus is firm, which decreases the risk of hemorrhaging. D. The nurse should encourage the client to lie on her side during breastfeeding in order to promote rest. Lying on her side will not decrease cramping during breastfeeding.

A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and is scheduled for a nonstress test. Which of the following instructions should the nurse provide the client? A. "You should press a button when you feel contractions." B. "You will be positioned in a semi-Fowler's position." C. "You must sign consent prior to the procedure." D. "The test will take approximately 10 minutes."

✔ B. "You will be positioned in a semi-Fowler's position." The nurse should reinforce that the client will be placed in a semi-Fowler's position for the nonstress test. Incorrect Answers: A. The nurse should reinforce the need to press the handheld event marker when the client feels fetal movement. Uterine contractions are not an indication to press the button on the handheld event maker. C. The nurse should reinforce with the client that a nonstress test is a noninvasive procedure to assess fetal wellbeing; the client is not required to sign a consent form prior to the procedure. D. The nurse should reinforce with the client that a nonstress test takes approximately 20 to 30 minutes to complete.

A nurse is collecting data from a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? A. Overlapping suture lines B. Generalized petechiae C. Acrocyanosis D. Transient strabismus

✔ B. Generalized petechiae The nurse should report generalized petechiae to the provider. This manifestation can be associated with an infection or clotting factor deficiency. Incorrect Answers: A. Overlapping suture lines are an expected variation for a newborn. The newborn's head molds during the second phase of labor to ease delivery of the fetal head from the vagina. C. Acrocyanosis is an expected manifestation for newborns during the first 24 hours following birth. D. Transient strabismus is an expected manifestation until the newborn is 3 to 4 months old.

A nurse is assisting with monitoring the fetal heart rate tracings of a client who is in labor. Which of the following findings should the nurse report to the provider? A. Baseline fetal heart rate of 110 to 130/min B. Moderate baseline variability C. Accelerations in response to fetal stimulation D. Late decelerations with fetal bradycardia

✔ D. Late decelerations with fetal bradycardia

A nurse is caring for a client who is in the transition phase of labor. Which of the following actions should the nurse take? A. Monitor the client's contractions once every 30 minutes B. Encourage the client to use a rapid pant-blow breathing pattern C. Assist the client to void once every 3 to 4 hours D. Place the client in the lithotomy position

✔ B. Encourage the client to use a rapid pant-blow breathing pattern The nurse should encourage the client to use a rapid pant-blow breathing pattern. This breathing pattern distracts the client, which can reduce the perception of pain. Incorrect Answers: A. The nurse should monitor the client's contractions every 10 to 15 minutes during the transition phase of labor, every 30 to 60 minutes during the latent phase of labor, and every 15 to 30 minutes during the active phase of labor. C. A distended bladder can interfere with the descent of the newborn. Therefore, the nurse should assist the client to void at least once every 2 hours while in labor. D. During the first stage of labor, the nurse should encourage the client to change positions frequently. The nurse can place the client in a lithotomy position during the second stage of labor.

A nurse is collecting data on the respiratory status of a newborn who was born 2 hours ago. Which of the following findings should the nurse identify as a manifestation of respiratory distress? A. Acrocyanosis B. Expiratory grunting C. Respiratory rate 56/min D. Irregular respirations

✔ B. Expiratory grunting Expiratory grunting is an indication of respiratory distress that is caused by narrowing of the bronchi. The nurse should report this finding to the provider. Incorrect Answers: A. Acrocyanosis (a bluish discoloration of the hands and feet) is an expected finding in a newborn in the first 24 hours after birth. C. A respiratory rate of 56/min is within the expected reference range of 30 to 60/min for a newborn. D. Irregular shallow respirations are an expected finding in a newborn.

A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. Tinnitus B. Numbness in the hand C. Headache D. Nasal stuffiness interfering with sleep

✔ C. Headache This is a complication that requires further evaluation. Postpartum-onset preeclampsia can cause headaches. Also, if the client was given epidural or spinal anesthesia, cerebral spinal fluid leakage must be ruled out. The nurse should report this finding to the provider. Incorrect Answers: A. Tinnitus is a bothersome condition of pregnancy. The nurse should reassure the client that this should resolve within a couple of days. B. This finding is indicative of carpal tunnel syndrome caused by compression of the median nerve. It is a common discomfort of pregnancy. Therefore, notifying the provider is not required. D. Nasal stuffiness is a common discomfort of pregnancy. The nurse should reassure the client that the stuffiness should resolve within the next couple of days.

A nurse is collecting data from a pregnant client who is at 38 weeks of gestation. The client reports that her breathing has become easier but notes an increased frequency of urination. The nurse should document this occurrence as which of the following? A. Effacement B. Dilation C. Lightening D. Quickening

✔ C. Lightening Lightening is the term used to describe engagement of the fetal head into the pelvis. When this occurs, breathing becomes easier, but urination is more frequent. Incorrect Answers: A. Effacement is the thinning of the cervical tissue. B. Dilation is the widening of the cervix during labor. D. Quickening is the initial occurrence of fetal movement.

A nurse is assisting with the preparation of a laboring client who is scheduled to receive an intrauterine pressure catheter. The client asks why this type of monitoring is needed. Which of the following responses should the nurse make? A. "This type of monitoring is necessary for timing the frequency of your contractions." B. "This type of monitoring is noninvasive, so it is the best way to monitor your labor contractions." C. "This type of monitor allows us to evaluate your baby's heart rate while you are in labor." D. "This type of monitoring will allow us to measure the intensity of your contractions."

✔ D. "This type of monitoring will allow us to measure the intensity of your contractions." A tocotransducer can monitor the frequency and duration of contractions, but only an intrauterine pressure catheter can monitor the intensity of contractions. Incorrect Answers: A. Although the intrauterine pressure catheter will show the frequency of contractions, the external tocotransducer is also an adequate and noninvasive method of timing contractions. B. Intrauterine pressure catheters are invasive monitoring equipment and used only when deemed necessary for high-risk labors. C. An intrauterine pressure catheter monitors the frequency, intensity, and duration of contractions. The ultrasound transducer and spiral electrode will monitor fetal heart tones.

A nurse is collecting data from a client who is at 39 weeks of gestation and shows manifestations of labor. Which of the following findings should alert the nurse to notify the provider that the client is in true labor? A. Contractions felt in the upper abdomen B. Small amount of bloody discharge C. Contractions occurring every 2 to 10 min D. Changes in cervical dilation or effacement

✔ D. Changes in cervical dilation or effacement Cervical changes are signs of true labor. Incorrect Answers: A. True labor contractions are typically felt in the lower back and radiate to the lower abdomen. B. A small amount of bloody discharge can occur due to cervical trauma from intercourse or a vaginal exam. It does not indicate that the client is in true labor. C. Irregular contractions are known as Braxton-Hicks contractions and are not a sign of true labor.

A nurse is caring for a client who has preeclampsia and is postpartum. Which of the following actions should the nurse implement when measuring the client's blood pressure? A. Encourage the client to take a walk in the halls prior to measuring blood pressure B. Hold the client's arm above heart level during the measurement C. Choose a cuff that covers 50% of the client's upper arm D. Use the Korotkoff phase V to record the diastolic value

✔ D. Use the Korotkoff phase V to record the diastolic value The nurse should use the Korotkoff phase V (the disappearance of sound) to document the diastolic value. Incorrect Answers: A. The nurse should have the client sit quietly for 10 minutes prior to taking the blood pressure measurement. B. The nurse should hold the client's arm horizontal at the level of the heart for the most accurate measurement. C. The nurse should choose a cuff that covers 80% of the client's upper arm for the most accurate measurement.

A nurse is assisting with performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks about the purpose of the test. Which of the following responses should the nurse provide? A. "This test will determine if you are likely to deliver within the next week." B. "This test will help determine if your baby is healthy." C. "This test can show how your baby responds when you have contractions." D. "This test will determine if your baby's lungs are mature."

✔ B. "This test will help determine if your baby is healthy." An NST is used for antenatal fetal assessment. It tracks fetal heart rate patterns expected with fetal movement and can help identify fetal distress. Incorrect Answers: A. An NST does not evaluate uterine relaxation. It measures certain expected patterns that occur with fetal movement. C. A contraction stress test is used to assess the fetal response to uterine contractions. D. Fetal lung maturity is assessed by performing an amniocentesis.

A nurse is reinforcing education with a client who is at 34 weeks of gestation about a non-stress test (NST). Which of the following pieces of information should the nurse include? A. "It will take about 10 minutes to complete the test." B. "You might have to drink orange juice during the test." C. "During the test, you will be asked to massage your nipples." D. "During the test, you will receive a medication to relax your uterus."

✔ B. "You might have to drink orange juice during the test." An NST monitors for accelerations of the fetal heart rate over a 20-minute period. During this time, the fetus can be asleep and experience hypoactivity. The parent might be asked to drink orange juice during testing to stimulate fetal movements. Incorrect Answers: A. An NST will take about 20 to 30 minutes to complete. C. During an NST, the nurse is monitoring fetal wellbeing. Nipple stimulation is used for a contraction stress test in order to achieve uterine contractions. D. An oxytocin infusion is used for a contraction stress test in order to achieve uterine contractions. This is not indicated for an NST.

A nurse is assisting with the care of a postpartum client who has preeclampsia and excessive uterine bleeding. The nurse should plan to administer which of the following medications? A. Terbutaline B. Magnesium sulfate C. Oxytocin D. Methylergonovine

✔ C. Oxytocin Oxytocin is a uterotonic medication that causes the uterus to contract and reduces excessive uterine bleeding. Incorrect Answers: A. Terbutaline is a tocolytic medication that causes uterine relaxation and is used to treat preterm labor. It is not an appropriate medication to treat uterine atony. B. Magnesium sulfate is a tocolytic medication used to treat preterm labor and decrease the risk of eclamptic seizures. It is not an appropriate medication to treat uterine atony. D. Methylergonovine is a uterotonic medication that has an adverse effect of hypertension. Therefore, this medication is contraindicated for a client who has preeclampsia.

A nurse is assisting with the care of a client who is in the early stage of labor and has preeclampsia with severe features. Which of the following interventions should the nurse perform? A. Assess the fetal heart rate and contractions hourly B. Encourage oral intake of clear, low-sodium fluids C. Instruct the client to ambulate during the early phase of labor D. Implement seizure precautions

✔ D. Implement seizure precautions The nurse should identify that clients who have preeclampsia with severe features are at risk for seizures. The nurse should keep the side rails of the client's bed up and ensure oxygen and suction are readily available. Incorrect Answers: A. The nurse should continually assess the fetal heart rate and contraction pattern during labor. There is an increased risk of uteroplacental insufficiency and placenta abruption when a client is preeclamptic. B. The nurse should restrict fluid intake to no more than 125 mL/hr. Clients with preeclampsia can have abnormal fluid shifts and develop pulmonary edema. C. The nurse should maintain the client on bed rest in a dimmed, quiet environment because clients who have preeclampsia with severe features are at risk for seizures.

A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. The client's temperature measures 101.9°F (38.8°C) 3 hours following delivery. B. Lochia is red with small clots and mucus 2 days after delivery. C. Client reports abdominal pain 48 hours after delivery when the newborn is breastfeeding. D. The fundus feels soft and is a fingerbreadth below the umbilicus 72 hours after delivery.

✔ D. The fundus feels soft and is a fingerbreadth below the umbilicus 72 hours after delivery. The fundus will rise to the height of the umbilicus about 1 hour after delivery and remains there for about 24 hours. It should decrease by 1 fingerbreadth per day and become more firm. A soft fundus on day 3 that has not dropped could indicate uterine atony and should be reported to the provider. Incorrect Answers: A. An increased temperature during the first 24 hours after delivery is an expected finding as the client's body adjusts and returns to its pre-pregnant state. A fever after 24 hours can indicate infection. B. For the first 3 days after birth, lochia discharge consists almost entirely of blood with only small particles of decidua and mucus. C. When the infant is breastfeeding, the sucking causes a release of oxytocin from the client's posterior pituitary. Oxytocin increases the strength of uterine contractions, which are benign and expected.

What can be detected using amniotic fluid?

-sex of the baby -down syndrome -spina bifida -cystic fibrosis -fragile X syndrome

A nurse is assisting with the care of a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make? A. This could indicate a UTI B. The bleeding is minimal until I discontinue your IV medication C. You might have retained some fragments of your placenta D. You will require additional medication to increase your bleeding

B. The bleeding is minimal until I discontinue your IV medication The flow of lochia is often scant while receiving oxytocin medication until the effects of medication wear off. This can be observed regardless of the administration route of oxytocin medication.

frank breech presentation

The fetal legs are flexed at the hips and extend toward the shoulders; this is the most common type of breech presentation. The buttocks present at the cervix.

A nurse is assisting with the care of a client who is attempting a trial of labor (TOL) after several cesarean births. The client reports a sudden onset of constant abdominal pain, and the nurse observes a prolonged deceleration on the fetal heart rate tracing. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Place the client in a knee-chest position C. Plan to administer calcium gluconate D. Prepare the client for an emergency cesarean delivery

✔ D. Prepare the client for an emergency cesarean delivery A sudden onset of abdominal pain in a laboring client who previously delivered by cesarean section, accompanied by a prolonged fetal deceleration, is a manifestation of a uterine rupture, which requires an emergency cesarean delivery. Incorrect Answers: A. It would not be appropriate to ambulate this client to the bathroom. B. A knee-chest position is a nursing intervention for variable decelerations or a prolapsed cord, not a uterine rupture. C. The administration of calcium gluconate is indicated for a client who has magnesium toxicity, not a uterine rupture.

A nurse is reinforcing teaching about manifestations of postpartum depression with a client. Which of the following findings should the nurse include? A. Episodes of irritability without justification B. Sleeping more than 15 hours per day C. Desire to take care of the newborn without help D. Ability to verbalize negative feelings about the newborn

A. Episodes of irritability without justification A client who has postpartum depression can experience episodes of irritability without justification that can escalate quickly and without warning. Incorrect Answers: B. A client who has postpartum depression might wake often from sleep and have difficulty falling asleep. C. A client who has postpartum depression often is disinterested in her newborn and is awkward in responding to the needs of the newborn. D. A client who has postpartum depression often is embarrassed about her feelings and attitudes toward the newborn and is afraid to express these feelings to others.

A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider? A. Fetal heart rate baseline of 90 bpm B. Maternal temperature of 37.8°C (100°F) C. Uterine relaxation of 1 min between contractions D. Uterine contractions increasing in intensity

A. Fetal heart rate baseline of 90 bpm A fetal heart rate baseline of 90 bpm is considered bradycardia and should be reported to the provider. Fetal bradycardia is associated with fetal cardiac defects, maternal hypoglycemia, and fetal viral infections. Incorrect Answers: B. The nurse should report a maternal temperature of 38°C (100.4°F) or greater to the provider. A maternal temperature greater than 38°C is associated with chorioamnionitis, an infection caused by bacteria ascending from the vagina into the uterus. C. There should be at least 1 minute of resting time between contractions to allow adequate placental perfusion. Less than 1 minute of resting time can lead to fetal hypoxia and should be reported to the provider. D. As labor progresses, uterine contractions are expected to increase in intensity and frequency.

A nurse is assisting with the care of a client who is 8 hours postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider? (Select all that apply.) A. Massage the fundus B. Give oxygen at 2 L/min via nasal cannula C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30°

A. Massage the fundus C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30° The nurse should massage the fundus to expel clots and assist the uterus to contract. Also, the nurse should add oxytocin to the intravenous drip and insert an indwelling urinary catheter to monitor urinary output and perfusion to the kidney. Finally, the nurse should place the client in a lateral position with her legs elevated 30°. Incorrect Answers: B. The nurse should administer oxygen 10 L/min via nonrebreather face mask.

A nurse collecting data from a full-term newborn who is demonstrating the Moro reflex. Which of the following movements are expected responses to this reflex? (Select all that apply.) A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward C. Arms and legs adducting D. Arms falling backward after startling E. Head turning to the right

A. Thumb and forefinger forming a "C" B. Legs extending before pulling upward These are expected components of the Moro reflex. This response is present at birth and absent by 6 months of age in neurologically intact infants. Incorrect Answers: C. Full-term newborns who have an intact Moro reflex abduct their arms and legs. D. The arms of full-term newborns who have an intact Moro reflex form a complete embrace after startling and then return to flexion and movement. Preterm infants lack the neurological maturity to complete the embrace, and their arms fall backward as a result of weakness. E. This is an expected component of the tonic neck reflex, not the Moro reflex.

A nurse is reinforcing postpartum teachings with a client who is non-lactating about breast discomfort. Which of the following interventions should the nurse discuss with the client? A. "Wear a loose-fitting bra to alleviate breast discomfort." B. "Place fresh cabbage leaves on your breasts." C. "Apply warm, moist compresses to your breasts." D. "Express small amounts of milk from the breasts frequently."

B. "Place fresh cabbage leaves on your breasts." After 3 days postpartum, the client's breasts can become swollen and distended because of congestion of the vascular structures of the breasts. Fresh cabbage leaves can be applied to engorged breasts to help relieve breast discomfort. The coolness of the leaves and the phytoestrogens exert a therapeutic effect on engorged breasts. Leaves should be replaced when they become wilted. Incorrect Answers: A. The client should be instructed to wear a tight-fitting bra or breast binders to alleviate engorgement and swelling. C. Application of warmth to the breasts should be avoided because heat can stimulate milk production. An ice pack should be used to relieve engorged breasts. D. Milk should not be expressed from the breasts. This intervention would increase milk production rather than decrease it.

A nurse on a postpartum unit is reinforcing teaching with a client about postpartum blues. Which of the following instructions should the nurse include? A. "Seek immediate assistance for feelings of fatigue." B. "Plan opportunities to get out of the house frequently." C. "You will experience intense fears and anxiety if you have postpartum blues." D. "Most parents feel angry when the baby cries."

B. "Plan opportunities to get out of the house frequently." The nurse should encourage the client to continue to do things for herself to reduce the risk of postpartum blues. Incorrect Answers: A. Fatigue is an expected finding following delivery. The nurse should reinforce that postpartum blues occur frequently and should subside by day 10 postpartum. C. Postpartum depression is more serious and longer-lasting than postpartum blues. It also includes manifestations of intense fears, anxiety, and despondency. D. Anger is a warning sign of postpartum depression. The client would need medical intervention for these symptoms and permission to place the baby somewhere safe and walk away when these feelings occur to prevent harm to the baby.

A nurse is caring for a client who is 48 hours postpartum. The client expresses distress about her older children's acceptance of the new baby. Which of the following statements should the nurse make? A. "It would be best if your children met the new baby at home in a familiar setting." B. "Present the older children with a small gift and say it is from the baby." C. "Make sure you are holding the baby when the older children come to visit." D. "Try not to split up the children so no one will feel left out."

B. "Present the older children with a small gift and say it is from the baby." The nurse should encourage the parents to give the older children a small gift each day they visit. In addition, the parents should state the gift is from the new baby. Incorrect Answers: A. The nurse should encourage the client to arrange for the older children to come to the hospital. In addition, the older children should be amongst the first people to see the new baby. C. The client should be instructed to have whoever is bringing the children call her prior to the children's arrival. This will allow the client to set down the baby and have open arms to greet the children when they arrive. D. The client is encouraged to spend individual time with each child to provide individual attention.

A nurse is caring for a client who is 12 hr postpartum. Which of the following interventions should the nurse implement? Lab values: Hgb: 10 g/dL Hct: 32% WBC 12,000/mm3 Platelets 150,000/mm3 Blood Type O+ A. Encourage the client to use a hot pack on the perineum B. Administer ferrous sulfate orally C. Help the client apply a breast binder D. Administer Rh immune globulin

B. Administer ferrous sulfate orally The nurse should administer ferrous sulfate orally for a client who has a hemoglobin level of <10.5 g/dL. Incorrect Answers: A. The nurse should encourage the client to use a cold pack on the perineum to decrease edema and promote comfort. C. The nurse can assist with applying a breast binder or a well-fitted support bra to relieve discomfort for a client who does not plan to breastfeed. D. The nurse should administer Rh immune globulin within 72 hours of birth to clients who are Rh-negative and have a newborn who is Rh-positive.

A nurse in a postpartum unit is caring for a client who plans to breastfeed her newborn exclusively. The client has a prescription for depot medroxyprogesterone acetate (DMPA). At which of the following times should the nurse schedule the client to receive the first dose of the medication? A. After 3 months postpartum B. At 6 weeks postpartum C. Within the first 5 days postpartum D. During the first week of the first postpartum menstrual cycle

B. At 6 weeks postpartum The nurse should tell the client that the first dose should be administered at 6 weeks postpartum if the client is exclusively breastfeeding and after ensuring the client is not pregnant. Incorrect Answers: A. The second dose is administered 3 months after the first dose. C. The first dose should be administered within the first 5 days postpartum only if the client is not breastfeeding and after ensuring the client is not pregnant. D. The first dose should be administered during the first 5 days of a normal menstrual period for a client who is not postpartum and after ensuring the client is not pregnant.

A nurse is caring for a client who is 1 day postpartum following a cesarean birth. Which of the following laboratory findings should the nurse report to the provider? A. Hematocrit 34% B. White blood cell count 12,000/mm^3 C. Blood glucose 50 mg/dL D. Erythrocyte sedimentation rate 33 mm/hr

C. Blood glucose 50 mg/dL The placental enzyme insulinase reverses the diabetogenic effects of pregnancy, which results in significantly lower blood glucose levels in the immediate postpartum period. Pregnant clients who have type 1 diabetes will likely require much less insulin for several days after birth. This blood glucose level is dangerously low and requires intervention. The normal level for blood glucose is about 70 to 110 mg/dL. Incorrect Answers: A. In clients with average blood loss during birth, the hematocrit level drops moderately for 3 to 4 days, begins to increase, and reaches non-pregnant levels by 8 weeks postpartum. Further intervention is usually not necessary. A normal hematocrit level for a female client is about 37 to 48%. B. Normal leukocytosis of pregnancy averages approximately 12,000/mm^3. During the first 4 to 7 days after birth, values between 20,000 and 25,000/mm^3 are common. A normal white blood cell count is about 5,000 to 10,000/mm^3. Immediately following the birth of a newborn, leukocytosis is not definitive of an infection. D. This test can be used to measure inflammation in the body. The normal level for a female client is about 0 to 29 mm/hr. This level is normally elevated following birth of infant newborn.

A nurse is reinforcing discharge teaching with a client who is postpartum and plans to breastfeed her infant. Which of the following pieces of information should the nurse reinforce with the client? (Select all that apply.) A. Schedule feedings every 4 hr. B. Offer supplemental formula every other feeding during the first week. C. Thaw frozen breast milk with warm water. D. Massage breast milk onto the nipples after breastfeeding. E. Frequent swallowing by the infant indicates adequate suckling.

C. Thaw frozen breast milk with warm water. D. Massage breast milk onto the nipples after breastfeeding. E. Frequent swallowing by the infant indicates adequate suckling. The nurse should reinforce how to thaw frozen breast milk with warm water or a bottle warmer. The nurse should instruct the client to avoid using a microwave to thaw breast milk because it can decrease the anti-infective properties and nutritional value of breast milk. To prevent and treat sore nipples, the nurse should recommend rubbing a small amount of breast milk onto the nipples after breastfeeding. Frequent swallowing by the infant is an indicator of successful suckling during feedings. Incorrect Answers: A. Infants should be breastfed on demand when the infant exhibits indications of hunger. Infants who are breastfed are expected to be hungry every 2 to 3 hours. B. The nurse should reinforce the importance of avoiding the use of supplemental formula to promote lactation and breastfeeding by the infant. Lactation is expected to be established after 3 weeks.

A nurse is caring for a client who is postpartum and is having difficulty voiding. Which of the following actions should the nurse take first? A. Place the client's hands in warm water B. Administer an analgesic to the client C. Pour water from a squeeze bottle over the client's perineum D. Assist the client to the bathroom

D. Assist the client to the bathroom The greatest risk to this client is an injury from a distended bladder; therefore, the first action the nurse should take is to assist the client to the bathroom to encourage spontaneous voiding. If this is unsuccessful, the nurse can try other techniques to promote voiding. Incorrect Answers: A. The nurse should place the client's hands in warm water to help stimulate voiding. A warm shower or sitz bath might also be helpful. However, there is another action the nurse should take first. B. Analgesics can facilitate voiding and will be helpful if the client anticipates pain. However, there is another action the nurse should take first. C. Pouring water from a squeeze bottle over the client's perineum can stimulate voiding. However, there is another action the nurse should take first.

A client who is experiencing postpartum depression following the birth of her first child is experiencing a _____________ crisis.

maturational A client who is experiencing postpartum depression following the birth of a child is experiencing a maturational crisis, which occurs during different stages across the lifespan.

A nurse is caring for a client who is 32 hours postpartum. The client reports nipple soreness and breast engorgement. Which of the following recommendations should the nurse provide? A. "Call me so I can check your baby's latch the next time you breastfeed." B. "You should reduce the frequency of breastfeeding." C. "Apply expressed breast milk to sore nipples and cover them with nursing pads and a bra." D. "You should apply warm packs to the breasts between nursing sessions."

✔ A. "Call me so I can check your baby's latch the next time you breastfeed." Nipple soreness can be a result of a poor latch. The nurse should observe the next breastfeeding session to offer hands-on advice and assistance to ensure an ideal latch. Incorrect Answers: B. Clients who are experiencing engorgement should be encouraged to continue breastfeeding frequently and to use pumping or hand expression as needed. Reducing the frequency of breast "emptying" will increase engorgement in the short-term and reduce milk supply in the long-term. C. Expressed breast milk can soothe sore nipples, but the client should keep sore nipples exposed to air to promote healing. Covering sore and potentially damaged nipples in a dark, moist environment can increase skin breakdown. D. The application of cold packs and cabbage leaves to engorged breasts between breastfeeding sessions can reduce swelling and inflammation.

A nurse is reinforcing teaching about dietary changes with a client who is pregnant and has pregestational diabetes. Which of the following statements should the nurse include in the teaching? A. "Carbohydrates should make up 55% of your diet." B. "Protein should make up 70% of your diet." C. "Fats should make up 45% of your diet." D. "Fiber should make up 10% of your diet."

✔ A. "Carbohydrates should make up 55% of your diet." For clients who have pregestational diabetes, intake of simple carbohydrates should be limited. The ideal diet is composed of 55% carbohydrates, 20% protein, 25% fat, and less than 10% saturated fat. Incorrect Answers: B. Protein should only make up 20% of the diet for clients who have pregestational diabetes. C. The ideal diet for clients who have pregestational diabetes contains 25% fat. D. There is no limitation on the amount of fiber a client who has pregestational diabetes should consume. Fiber should be recommended to clients to decrease constipation, which can be an effect of pregnancy.

A nurse is reinforcing teaching with a postpartum client who is breastfeeding. Which of the following statements indicates an understanding of the teaching? A. "I should feed my baby 8 to 12 times a day, based on feeding cues." B. "My baby should have 6 or 7 wet diapers a day during the first week." C. "I should switch my baby to the other breast after 15 min." D. "My nipple pain should go away after a few weeks of breastfeeding."

✔ A. "I should feed my baby 8 to 12 times a day, based on feeding cues." For the first few days, parents might have to wake the newborn to feed every 2 to 3 hours. Once the infant is feeding well and gaining weight, feedings should be based on the infant displaying hunger cues such as sucking on the fist and rooting. Incorrect Answers: B. During the first week of life, newborns should have a minimum of 1 wet diaper for every day of their age. For example, a 2-day-old infant should have a minimum of 2 wet diapers. By the end of the first week, infants should have 6 to 8 heavy wet diapers each day. C. The mother should switch breasts based on cues from the infant, not based on the clock. She should feed on 1 breast until the infant takes a break and the breast has softened. She can then offer the other breast, in which the infant may or may not show interest. This method ensures an adequate intake of the fatty hind milk. D. Nipple pain is not an expected finding with breastfeeding. Mothers who experience nipple pain throughout the feeding should seek the assistance of a lactation consultant.

A nurse is providing education to a client who is 4 weeks postpartum and is breastfeeding. The client asks about expected weight loss. Which of the following responses should the nurse make? A. "Losing 2.2 pounds each month would be acceptable." B. "Losing 4.4 pounds each month would be acceptable." C. "Losing 5.5 pounds each month would be acceptable." D. "Losing 6.6 pounds each month would be acceptable."

✔ A. "Losing 2.2 pounds each month would be acceptable." An important postpartum goal is for the client to lose the weight gained during pregnancy. An acceptable amount of weight loss for a client who is lactating is 1 kg (2.2 lb) per month. Incorrect Answers: B. C. D.. Clients who are not lactating should lose approximately 0.5 to 0.9 kg (1.1 to 2 lb) per week.

A nurse is reinforcing teaching with a postpartum client about the proper technique for performing Kegel exercises. Which of the following statements should the nurse make? A. "Pretend you are urinating and stop your urine stream intermittently." B. "You should bear down as if you are passing gas during the exercises." C. "You should feel tightening in the buttocks during the exercises." D. "Each muscle contraction should be held for a minimum of 30 seconds."

✔ A. "Pretend you are urinating and stop your urine stream intermittently." Kegel exercises are a technique used to reinforce the bladder and urethra by strengthening the pelvic muscle floor. The goal of these exercises is to decrease accidental urine loss for the client. The nurse should instruct the client to tighten the muscle and hold it for 10 seconds, rest for 10 seconds, and then repeat the process several times each day as desired. Incorrect Answers: B. The client should avoid bearing down or straining during these exercises. The nurse should instruct the client to pretend she is trying to prevent the passing of gas. C. The client should be advised that this technique is used to strengthen the pelvic floor. Therefore, tightening in the buttocks is a possible indication that the client is performing the exercises incorrectly. D. The nurse should instruct the client to tighten or contract the pelvic muscle and hold it for 10 seconds, rest for 10 seconds, and then repeat the process several times each day as desired.

A nurse is assisting with discussing a nonstress test with a client who is at 39 weeks of gestation. Which of the following statements indicates an understanding of the information? A. "This test will assist in determining if my baby is okay by monitoring the heart rate." B. "This test will determine if chromosomal disorders are present." C. "This test will require me to take a medication that will prompt contractions." D. "This test will use sonar to determine how my baby is doing."

✔ A. "This test will assist in determining if my baby is okay by monitoring the heart rate." The nurse should instruct the client that a nonstress test will provide information that will evaluate fetal wellbeing by assessing the fetal heart rate and fetal movement. Incorrect Answers: B. An amniocentesis, not a nonstress test, will provide conclusive information about the presence of chromosomal disorders. C. An oxytocin-stimulated contraction test is used to stimulate uterine contractions to assess fetal wellbeing. It is initiated after a nonstress test is nonreactive or a nipple contraction test is unable to be obtained. D. A biophysical profile is a noninvasive sonar assessment of the fetus that assesses amniotic fluid index, fetal movements, fetal breathing, and fetal tone. It is used along with a nonstress test to assess fetal wellbeing.

A nurse is caring for a client who asks, "How will I know if I'm having true or false labor contractions?" Which of the following responses should the nurse make? A. "True contractions will begin irregularly and then become regular in timing." B. "True contractions will go away with ambulation." C. "False contractions increase in frequency and duration the closer you are to your due date." D. "False contractions are first felt in the pelvic area and then in the lower back and abdomen."

✔ A. "True contractions will begin irregularly and then become regular in timing." False contractions begin and remain irregular, but true contractions will begin irregularly and become regular and predictable. Incorrect Answers: B. False contractions will usually go away if the client ambulates or goes to sleep, whereas true contractions will continue regardless of the client's activity level. C. False contractions do not increase in duration, frequency, or intensity no matter how close the client is to her due date. If the frequency and duration are increasing, the contractions are considered true contractions. D. False contractions are felt in the client's abdomen and remain in the abdominal and groin area, whereas true contractions begin in the lower back and spread around to the abdomen.

A nurse is performing a routine prenatal examination of a client who is in the second trimester. The client reports backaches with no other symptoms and refuses medication. Which of the following responses should the nurse make? A. "Try pelvic tilt exercises." B. "Limit your physical activity." C. "Soak in a warm bubble bath." D. "Lie flat on your back for 1 hour."

✔ A. "Try pelvic tilt exercises." Backaches are common during the second trimester due to the relaxation of the joints that otherwise stabilize the pelvis and the shift in the client's center of gravity. Pelvic tilt exercises, resting, and sleeping on a firm mattress can help ease this pain. Incorrect Answers: B. Although the client should get adequate rest, physical activity is essential during pregnancy for promoting wellbeing and enhancing circulation. There are specific exercises the client can perform to help relieve back pain, including abdominal muscle contractions. C. To prevent urinary tract infections and irritation of the urethra, the client should avoid soaking in a bubble bath. D. The client should avoid lying on her back because of the risk of supine hypotension. The client should rest on her side instead.

An antepartum client asks the nurse about safety tips for riding in a motor vehicle. Which of the following responses should the nurse make? A. "Wear the lap belt snugly across your pelvic bones." B. "Disable the airbags in your vehicle as per manufacturer instructions." C. "Place your seat as close as possible to the steering wheel." D. "Place the shoulder harness underneath your arm when driving."

✔ A. "Wear the lap belt snugly across your pelvic bones." The lap belt should be worn low across the pelvic bones, and the shoulder harness should be worn above the pregnant uterus. A combination seatbelt is recommended for clients who are pregnant. Incorrect Answers: B. The airbags should remain active and engaged. If the client is driving, the steering wheel should be tilted up and away from the pregnant uterus. The client should be advised to move the driver's seat back from the steering wheel as far as possible. C. The nurse should advise the client to sit upright and back away from the steering wheel as far as possible when driving. The client should also choose a seat with a headrest to reduce the chance of whiplash in the event of an accident. D. The client should be instructed to use a combination seatbelt that has both a lap belt and a shoulder harness. The shoulder harness should be positioned above the pregnant uterus.

A nurse is reinforcing teaching with a client who is breastfeeding and has pregestational diabetes controlled with insulin. Which of the following instructions should the nurse include? A. "You have a higher risk for hypoglycemia due to breastfeeding." B. "Reduce your overall carbohydrate intake until you achieve your prepregnancy weight." C. "You will need to take twice the amount of insulin while you breastfeed." D. "You should tailor your mealtimes depending on the needs of your baby."

✔ A. "You have a higher risk for hypoglycemia due to breastfeeding." Clients who breastfeed have a greater risk of hypoglycemia due to the increase in carbohydrates used for milk production. Incorrect Answers: B. Blood glucose levels can fluctuate in the postpartum period, and insulin adjustments are expected. The client might be at risk for hypoglycemia as well. Eating consistent carbohydrates is emphasized. C. Clients who breastfeed might only need half of the prepregnancy dose due to the increase in carbohydrates used for production of human milk. D. Clients who have diabetes mellitus should eat on a regular schedule regardless of other demands to prevent hypoglycemia.

A nurse is reinforcing teaching to a client who is postpartum and has been prescribed warfarin therapy for a deep vein thrombosis. Which of the following instructions should the nurse include? A. "You will need to use a reliable form of contraception while on warfarin therapy." B. "You will need to take a baby aspirin every day while on warfarin therapy." C. "You will need to use formula instead of breast milk while on warfarin therapy." D. "You will need to massage your affected leg 3 times a day while on warfarin therapy."

✔ A. "You will need to use a reliable form of contraception while on warfarin therapy." Warfarin is teratogenic, and pregnancy should be avoided by using a reliable form of contraception. Incorrect Answers: B. Aspirin inhibits clotting and increases the risk of bleeding. Therefore, it should be avoided while undergoing warfarin therapy. C. Warfarin is not excreted through breast milk. A client can continue to breastfeed while undergoing warfarin therapy. D. Massaging the affected leg can cause the clot to become dislodged and should be avoided.

A nurse is caring for a client who is postpartum and reports abdominal pain due to flatus. Which of the following actions should the nurse take? A. Assist the client to ambulate in the hallway B. Encourage the client to increase fiber intake C. Administer a dose of laxative medication to the client D. Increase the client's fluid intake

✔ A. Assist the client to ambulate in the hallway Ambulation and rocking in a rocking chair stimulate the passage of flatus and stool. Incorrect Answers: B. Increasing fiber intake will assist the client in softening the stool. Many high-fiber foods are gas-forming and should be avoided to decrease flatus. C. Laxatives do not treat gas pain. Antiflatulent medications should be administered to treat flatus. D. Fluid intake does not directly affect gas production or the passage of flatus and the relief of pain. If the client is constipated, the nurse should ensure adequate and varied fluid intake.

A nurse is assisting with the care of a client who is experiencing preterm labor. Which of the following medications should the nurse anticipate administering to enhance fetal lung maturation? A. Betamethasone B. Nifedipine C. Indomethacin D. Verapamil

✔ A. Betamethasone Betamethasone is administered as antenatal glucocorticoid therapy and is given to clients who are experiencing preterm labor to stimulate fetal lung maturation. Incorrect Answers: B. Nifedipine is administered as tocolytic therapy for preterm labor. C. Indomethacin is administered as tocolytic therapy for preterm labor.

A nurse is providing care to a client who is in labor. A fetal heart tracing shows early decelerations. Which of the following actions should the nurse take? A. Continue to monitor the fetal heart tracings B. Elevate the client's legs C. Increase the rate of the maintenance IV fluid D. Administer oxygen via facemask

✔ A. Continue to monitor the fetal heart tracings Early decelerations reflect fetal head compression and are a benign and normal finding during labor. The nurse should reassure the client and should continue to monitor the fetal heart tracings. Incorrect Answers: B. Elevating the client's legs is an appropriate intervention for late decelerations. Elevating the client's legs helps resolve maternal hypotension. C. Increasing the rate of the client's maintenance IV fluids is an intervention to correct maternal hypotension and late decelerations. D. Oxygen via facemask is an appropriate intervention for late or variable decelerations.

A nurse is caring for a client who has preeclampsia with severe features and is receiving a continuous infusion of magnesium sulfate. The nurse notes that the client is difficult to arouse and has absent deep tendon reflexes. Which of the following action should the nurse take? A. Discontinue the magnesium sulfate B. Reposition the client to a left lateral recumbent position C. Administer hydralazine intravenously D. Darken the room and avoid making loud noises

✔ A. Discontinue the magnesium sulfate Changes in level of consciousness and diminished or absent deep tendon reflexes are manifestations of magnesium sulfate toxicity. Therefore, the nurse should discontinue the infusion immediately. Incorrect Answers: B. The left lateral recumbent position prevents supine hypotensive syndrome. It does not mitigate the effects of magnesium sulfate toxicity. C. Hydralazine is an antihypertensive medication and does not counteract the effects of magnesium sulfate toxicity. D. A darkened room and a calm environment reduce the risk of seizures for a client who has preeclampsia. They have no effect on magnesium sulfate toxicity.

A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. Which of the following actions should the nurse take? A. Encourage the client to frequently change positions. B. Instruct the client to take breaths and hold them for 10 seconds while pushing C. Assess maternal vital signs every 1 hour D. Assist the client to the restroom

✔ A. Encourage the client to frequently change positions. During the second stage, frequent position changes can promote the descent of the fetus through the birth canal. The nurse should assist the client in finding optimal positions of comfort which allow the client to rest between contractions but also enhances expulsive efforts. Incorrect Answers: B. Having the client hold her breath while pushing increases intrathoracic and cardiovascular pressure and decreases the amount of oxygen that reaches the fetus. C. The nurse should assess the client's vital signs every 5 to 30 minutes while the client is in the second stage of labor. D. The client should remain on bedrest during this stage of labor due to impending delivery.

A nurse in an antepartum clinic is assisting with the care of a client who is at 24 weeks of gestation. Which of the following findings should the nurse report to the provider? A. Frequent headaches B. Leukorrhea C. Epistaxis D. Periodic numbness of the fingers

✔ A. Frequent headaches The nurse should report frequent headaches to the provider. Frequent headaches, swelling of the face and fingers, visual disturbances, and epigastric pain are findings associated with preeclampsia. Incorrect Answers: B. Leukorrhea is a common discomfort of pregnancy. It is an abundant amount of vaginal mucus that may be seen throughout pregnancy. C. Epistaxis is a common discomfort of pregnancy related to the increase of estrogen. D. Periodic numbness of fingers is a common discomfort of pregnancy due to compression of the nerves and does not need to be reported to the provider.

A nurse working on a maternal-newborn unit is assisting with planning an in-service training session for staff about assisting new mothers with breastfeeding. Which of the following infant conditions should the nurse recommend including in the teaching as a contraindication for breastfeeding? A. Galactosemia B. Hyperbilirubinemia C. Glycogen storage disease D. Hypothyroidism

✔ A. Galactosemia An infant who has galactosemia cannot metabolize lactose. Breast milk contains lactose, which can cause failure to thrive, cirrhosis, developmental delays, and even death in affected infants. An infant who has galactosemia is fed with formula made with milk substitutes. Incorrect Answers: B. An infant who has hyperbilirubinemia can develop jaundice due to the accumulation of bilirubin in the system. Breastfeeding is encouraged in the early postpartum period for infants who develop hyperbilirubinemia because the colostrum in breast milk is a natural laxative that promotes the excretion of excess bilirubin. C. Glycogen storage disease is a congenital disorder in which glycogen, which is usually stored in the liver and metabolized into glucose when needed, cannot be metabolized into glucose due to a missing or deficient enzyme. As a result, the infant develops hypoglycemia and can experience neurological damage. Treatment involves continuous nasogastric or gastrostomy feedings during the night. However, breastfeeding is not contraindicated for infants who have glycogen storage disease. D. Infants who are born with congenital hypothyroidism will require lifelong treatment with a thyroid-replacement medication. However, breastfeeding is not contraindicated for infants who have hypothyroidism.

A nurse is reviewing risk factors for postpartum depression with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Gestational diabetes B. Planned pregnancy C. Being married D. Post-term birth

✔ A. Gestational diabetes Gestational diabetes increases the risk of postpartum depression. Other risk factors include infertility treatment, pregnancy complications, preterm birth, and a history of mood disorder. Incorrect Answers: B. An unplanned pregnancy increases the risk of postpartum depression. Significant life events such as job loss also increase the risk. C. Being married is a protective factor against postpartum depression. Being unmarried increases the risk of experiencing postpartum depression. D. Preterm birth increases the risk of postpartum depression. Having an ill newborn also increases this risk

A nurse is reviewing the laboratory report of a newborn who has a blood type of B-negative. The mother's blood type is O-positive. The laboratory results indicate the direct antiglobulin test is positive. Which of the following complications should the nurse anticipate? A. Hyperbilirubinemia B. Central cyanosis C. Intracranial hemorrhage D. Cardiomyopathy

✔ A. Hyperbilirubinemia The nurse should identify that some infants of mothers with type O blood are at an increased risk for developing hyperbilirubinemia because these mothers possess naturally occurring A and B antibodies, which are transferred across the placenta to the fetus. Incorrect Answers: B. Central cyanosis in newborns occurs due to certain congenital cardiac defects rather than blood type. C. Risk factors for intracranial hemorrhage include forceps- or vacuum-assisted birth, precipitous or prolonged second stage labor, and increased fetal size. D. Cardiomyopathy in newborns generally occurs due to poorly controlled maternal diabetes.

A nurse is assisting with the care of a client who is scheduled to receive a spinal anesthetic. Which of the following actions should the nurse plan to perform? A. Infuse a 500-mL bolus of 0.9% sodium chloride immediately prior to the procedure B. Assess the fetal heart rate pattern for 10 minutes prior to the procedure C. Position the client upright and erect on the edge of the bed prior to the procedure D. Monitor vital signs every 15 minutes after the anesthetic is placed

✔ A. Infuse a 500-mL bolus of 0.9% sodium chloride immediately prior to the procedure The nurse should infuse a fluid bolus of 500 to 1,000 mL of 0.9% sodium chloride or lactated Ringer's 15 to 30 minutes before the procedure to offset the potential complication of hypotension. Incorrect Answers: B. The nurse should assess the fetal heart rate pattern for a minimum of 20 to 30 minutes prior to the procedure. C. The nurse should position the client with her spine flexed to open the intervertebral spaces and allow the placement of the spinal needle. D. The nurse should monitor the client's blood pressure, pulse, respirations, and fetal heart rate every 5 to 10 minutes after the introduction of the anesthetic agent.

A nurse is assisting with the plan of care for a newborn who was born at 30 weeks of gestation. The nurse should plan to collect data for which of the following potential complications associated with prematurity? A. Intraventricular hemorrhage B. Hyperglycemia C. Hyperthermia D. Meconium aspiration syndrome

✔ A. Intraventricular hemorrhage When an infant is born before 34 weeks of gestation, the blood vessels in the brain are fragile. Additionally, premature infants have an impaired coagulation process and fluctuating blood pressure. When combined, these factors increase the risk of bleeding into the ventricles of the brain, causing neurological damage. Incorrect Answers: B. Premature infants have an increased risk of hypoglycemia due to decreased glycogen stores and increased metabolic needs. They are typically unable to meet nutritional needs with oral intake. C. Due to limited subcutaneous and brown fat stores, as well as an inability to maintain a flexed position, a premature infant has a greatly increased risk of hypothermia. D. Meconium aspiration syndrome is typically a complication of post-term infants. Insufficient gas exchange from an aging placenta can lead to hypoxic episodes during which the fetus releases meconium into the amniotic sac.

A nurse is caring for a client following a forceps-assisted birth. The nurse should identify which of the following findings as a complication of this procedure? A. Pelvic hematoma B. Retained placenta C. Infertility D. Uterine inversion

✔ A. Pelvic hematoma Pelvic hematoma is a collection of blood in the connective tissue. Clients experience pain and pressure in the vaginal area. Hematoma is associated with forceps-assisted births, episiotomy, and primigravidity. Incorrect Answers: B. Retained placenta is when the placenta has not been delivered within 30 minutes following the birth of the newborn. Fragments of the placenta can remain if the placenta fails to separate completely. C. Infertility can be caused by fibroids, ectopic pregnancy, pelvic inflammatory disease, or scar tissue. D. Uterine inversion can be caused by vigorous fundal pressure, uterine atony, prolonged labor, or a short umbilical cord

A nurse enters a postpartum client's room and notices many visitors in the room, conversing loudly and taking turns holding the newborn. The newborn intermittently cries and attempts to suck on her hand. After a few minutes, the newborn quiets, stares, and turns her head away when someone talks to her. What teaching should the nurse provide for this family? A. The newborn would benefit from skin-to-skin contact in a quiet environment. B. The newborn's blanket should be removed so her movements will not be restricted. C. The newborn's hat should be removed to avoid overheating. D. The newborn should be discouraged from sucking on her hand since this habit can interfere with feeding.

✔ A. The newborn would benefit from skin-to-skin contact in a quiet environment. Staring and gaze aversion indicate the newborn is overstimulated and is "switching off" in an attempt to cope with excess stimuli. When these phenomena are observed, stimulation should be decreased, and supportive measures such as skin-to-skin contact should be increased. Incorrect Answers: B. Swaddling with a blanket has a calming effect on the newborn and is beneficial in a stimulating environment. C. The baby is not exhibiting indications of hyperthermia. Newborns can lose body heat from their heads through convection. Placing a hat on the newborn helps maintain body temperature. D. Nonnutritive sucking can calm the newborn and is an effective self-soothing behavior.

A nurse is reinforcing teaching with a client who is postpartum and breastfeeding. Which of the following nutrients should the client increase her intake of while breastfeeding? A. Vitamin C B. Iron C. Folate D. Calcium

✔ A. Vitamin C Vitamin C is important for tissue formation and integrity. The nurse should instruct the client to consume 115 to 120 mg of vitamin C per day, which is an increase from the recommended value when the client was pregnant. Incorrect Answers: B. Iron is important for fetal iron storage and maternal hemoglobin. The nurse should instruct the client to consume 9 to 10 mg of iron per day, which less than the recommended value when the client was pregnant. C. Folate is important for prevention of fetal neural tube defects. The nurse should instruct the client to consume 500 mg of folate per day, which is less than the recommended value when the client was pregnant. D. Calcium is important for fetal growth and maternal bone mineralization. The nurse should instruct the client to consume 1000 to 1300 mg of calcium per day, which is the same recommended value when the client was pregnant.

A nurse is caring for a client who is postpartum and non-lactating. The client reports breast pain. Which of the following statements should the nurse make? A. "Try taking a warm shower." B. "Be sure to wear a well-fitted supportive bra." C. "Expel breast milk using your hand." D. "Avoid laying your newborn on your chest until the pain subsides."

✔ B. "Be sure to wear a well-fitted supportive bra." The nurse should instruct the client to wear a breast binder and to apply ice packs or cold cabbage leaves to the breasts to suppress milk production. This intervention helps relieve pain in non-lactating mothers. Incorrect Answers: A. The nurse should instruct the client to use this technique prior to breastfeeding because it stimulates milk flow and relieves stasis. C. Although this will reduce the swelling, it will also increase milk production. The nurse should not encourage this non-lactating mother to expel milk using her hand. D. This is not an intervention to assist with pain caused by engorgement of the breast. Skin-to-skin contact between the parent and newborn is recommended when possible to assist with attachment and bonding.

A nurse is reinforcing education with a client who is pregnant about symptoms that should immediately be reported to the provider. Which of the following client responses indicates an understanding of the teaching? A. "I should call my provider if I develop melasma." B. "If I notice that my eyes are puffy, I should call my provider." C. "I should call my provider if I notice that my feet and ankles are swollen." D. "If I notice periodic numbness and tingling in my fingers, I should call my provider."

✔ B. "If I notice that my eyes are puffy, I should call my provider." Puffy eyes are associated with facial edema, which is a sign of pregnancy-induced hypertension. This should be reported immediately. Incorrect Answers: A. Melasma, a blotchy pigmentation of the skin on the face, is an expected finding during pregnancy. C. Dependent edema (physiological edema) during pregnancy requires no treatment. If the client also has swelling of the face or hands, reporting is warranted. D. These symptoms are caused by drooping of the shoulders during pregnancy, which creates traction on the brachial plexus nerves. This is a common occurrence during pregnancy. Maintaining good posture will help diminish the sensation.

A nurse is reinforcing discharge teaching with a postpartum client regarding elimination. Which of the following statements should the nurse include in the teaching? A. "You should urinate at least twice daily." B. "Increase fluids to help prevent constipation." C. "Put your hand under running cold water if you experience hesitancy when trying to urinate." D. "You should use laxatives daily to keep your bowel movements regular."

✔ B. "Increase fluids to help prevent constipation." The nurse should encourage the client to increase fluids and fiber intake to help prevent constipation. Ambulation will also help with prevention of constipation. Incorrect Answers: A. The nurse should encourage the client to void at least every 6 to 8 hours after giving birth (i.e. 3 to 4 times daily). C. The nurse should reinforce several techniques that can be employed to assist with urination such as having the client listen to running water, placing her hands in warm water, or pouring water from a squeeze bottle over her perineum. D. The nurse should reinforce that laxatives are not recommended for daily use. Furthermore, they should not be used unless prescribed by the provider.

A nurse is reinforcing teaching with a client about postpartum fatigue. Which of the following statements should the nurse include? A. "Strenuous exercise can help improve your sleep." B. "Try to take naps when your infant is napping." C. "Avoid consuming dairy products such as milk before bedtime." D. "You might want to ask family not to visit until you are more rested."

✔ B. "Try to take naps when your infant is napping." The client should be encouraged to sleep while her infant is sleeping. This helps the client replenish energy and decrease fatigue. Incorrect Answers: A. The client should be encouraged to avoid routines that can interfere with sleep such as strenuous mental or physical activity. C. The client should avoid dairy products in order to improve sleep. The client can be encouraged to drink warm milk, play soothing music, or get a back rub to promote optimal sleep conditions. D. The nurse might ask the client about family members that can visit to help with household tasks and infant care. This will help the client rest during the day.

A nurse is caring for a client who in the first trimester of a low-risk pregnancy. The client tells the nurse that she and her partner would like to continue their sexual relationship, but she is afraid it will cause a miscarriage. Which of the following responses should the nurse make? A. "I will talk to your provider about a referral to a sex therapist." B. "You can safely have intercourse as long as you don't feel discomfort." C. "You should try alternative positions for sexual intercourse." D. "You should abstain from intercourse until 6 weeks postpartum."

✔ B. "You can safely have intercourse as long as you don't feel discomfort." The nurse should inform the client that sexual intercourse will not cause a miscarriage. However, the client should report any discomfort experienced during intercourse to the provider so the cause can be identified. Incorrect Answers: A. Couples who have long-standing sexual problems that are intensified by pregnancy are candidates for sex therapy. The nurse should be prepared to answer a client's questions about sexual activity during pregnancy. C. The client is concerned about safety and has not reported discomfort. Alternative positions are helpful for preventing maternal discomfort but have no effect on the fetus or the pregnancy. D. Intercourse is safe as long as it is not uncomfortable and the client has no history of premature cervical dilation, problems with the placenta, or ruptured membranes in the current pregnancy.

A nurse is collecting data from a pregnant client who is at 26 weeks of gestation. The client states, "I felt dizzy yesterday when I was lying on my back." Which of the following responses should the nurse make? A. "You will need a laboratory test to rule out preeclampsia." B. "You should lie on your side when resting." C. "You will need an ultrasound to ensure your baby is alright." D. "You should decrease your potassium intake."

✔ B. "You should lie on your side when resting." The nurse should advise the client to lie on her side rather than her back when resting to prevent supine hypotension. This condition causes dizziness and faintness when the client is lying on her back. Incorrect Answers: A. Manifestations of preeclampsia include a headache, visual disturbances, swelling, and epigastric pain. Dizziness on arising from a supine position is not a manifestation of preeclampsia. C. Ultrasonography is a diagnostic tool used to determine fetal wellbeing. Dizziness is not an indication of a problem with the fetus. Therefore, an ultrasound is not required. D. Adequate amounts of potassium are important for pregnant clients to decrease the risk of developing hypertension. Therefore, decreased amounts of potassium are not recommended.

A nurse is reinforcing teaching with a client about using the Lamaze method to manage pain during labor. Which of the following pieces of information should the nurse include? A. "Learning about childbirth will reduce any fear you might have, which will help you focus more on abdominal breathing during contractions." B. "You will learn how to prevent pain during labor by focusing your mind to control your breathing." C. "During labor, you will be encouraged to disassociate by using an internal focal point." D. "During labor, you will use conscious relaxation and levels of progressive breathing."

✔ B. "You will learn how to prevent pain during labor by focusing your mind to control your breathing." The Lamaze philosophy is based on prophylaxis by using the mind. The method is based on the theory that through stimulus-response conditioning, clients can learn to use controlled breathing to reduce pain during labor. Incorrect Answers: A. This response is representative of the Dick-Read method of managing pain during childbirth because it focuses on reducing fear. Fear is reduced through education prior to labor. C. This response is representative of the Bradley or partner-coached method. This method is based on the premise that pregnancy and childbirth are joyful, natural processes and that a woman's partner should play an active role during pregnancy, labor, and the early newborn period. D. The psychosexual method includes a program of conscious relaxation and levels of progressive breathing that encourage a woman to flow with rather than struggle against contractions.

A nurse in a clinic is reinforcing teaching with a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. Which of the following statements should the nurse make? A. "Your provider will insert a hand into your uterus and turn your baby around." B. "You will receive a medication to relax your uterus prior to the procedure." C. "This procedure will be performed in the clinic at your next visit." D. "Your baby's heartbeat will be monitored occasionally throughout the procedure."

✔ B. "You will receive a medication to relax your uterus prior to the procedure." A client who is scheduled to undergo an external cephalic version often receives a tocolytic prior to the procedure to allow the uterus to relax. A relaxed uterus allows an easier version by the provider. Incorrect Answers: A. This action is appropriate for internal version. With external version, the provider attempts to turn the fetus around externally and not internally. C. External version is a high-risk procedure that is performed in a hospital setting in the event of an emergency. D. During the external version, the fetal heart-rate pattern is monitored continuously because the fetus is at risk of bradycardia and variable decelerations. The nurse also monitors the fetal heart rate for at least 60 minutes following the procedure.

A nurse is caring for a client who had a vaginal delivery 24 hours ago. Which of the following findings should the nurse report to the provider? A. 2,000 mL urine since delivery B. 3+ deep tendon reflexes C. Fundus at umbilicus D. Soft breasts

✔ B. 3+ deep tendon reflexes Deep tendon reflexes of 3+ or greater can indicate preeclampsia and should be reported to the provider. Incorrect Answers: A. Estrogen changes experienced by clients who are postpartum will cause diuresis of the extracellular fluid. The client can void up to 3,000 mL per day. C. The fundus will involute approximately 1 cm per day. At 24 hours, the fundus is expected to be at the umbilicus. D. The client's breasts will be soft for the first 2 days following birth. They will start to fill by day 3, becoming full by day 5.

A nurse is contributing to the plan of care for a client who is at 34 weeks of gestation and has preeclampsia with severe features. Which of the following interventions should the nurse include as the priority action following a seizure? A. Provide a peaceful, relaxing environment for the client B. Administer oxygen to the client at 10 L/min via face mask C. Place blankets on the raised side rails of the client's bed D. Insert an indwelling urinary catheter for the client

✔ B. Administer oxygen to the client at 10 L/min via face mask The priority intervention the nurse should include when using the airway, breathing, and circulation (ABC) approach to client care is to administer oxygen to the client at 10 L/min via face mask. Incorrect Answers: A. The nurse should provide a peaceful, relaxing environment to help calm the client following a seizure. However, another intervention is the priority. C. The nurse should raise the side rails of the client's bed and pad the rails with blankets or pillows to ensure the client's safety. However, another intervention is the priority. D. The nurse should insert an indwelling urinary catheter to monitor the client's output. However, another intervention is the priority.

A nurse is caring for a client who is postpartum. After bringing the newborn back to the parent following an assessment, the parent immediately gives the infant to the grandparent. Which of the following actions should the nurse take? A. Make a referral to child protective services B. Ask the client about the family's cultural beliefs C. Take the newborn back to the nursery until the mother is ready to offer care D. Explain to the client the importance of caring for the newborn personally

✔ B. Ask the client about the family's cultural beliefs In some cultures, extended family members show respect to the client by caring for the newborn. The nurse should explore the client's actions by asking about their cultural beliefs. Incorrect Answers: A. C. D. In some cultures, extended family members show respect to the client by caring for the newborn.

A nurse is assisting with the care of a recently delivered newborn whose mother had gestational diabetes. Which of the following actions should the nurse take within the first hour after birth? A. Administer the hepatitis B vaccine B. Assess the newborn's blood glucose level C. Bathe the newborn D. Perform a screening for congenital heart disease

✔ B. Assess the newborn's blood glucose level Newborns whose mothers have diabetes have a greater risk of developing hypoglycemia due to the cessation of the fetal blood glucose supply and fetal hyperinsulinemia. Blood glucose levels should be assessed within 1 hour after birth, followed closely, and treated promptly. Incorrect Answers: A. The nurse should administer this vaccine prior to discharge. There is no indication to administer the vaccine within 1 hour of birth. C. The nurse should not bathe the newborn until the newborn's temperature has stabilized in the extra-uterine environment. Ideally, the nurse should place the infant in skin-to-skin contact with the mother for at least the first 1 to 2 hours after birth. Alternately, the nurse can place the newborn under a radiant heat source and assess the newborn's temperature every hour until stabilized. D. The nurse should use a pulse oximeter to screen for congenital heart disease 24 to 48 hours after birth. If the nurse performs the screening prior to 12 hours after birth, acrocyanosis might alter the results.

A nurse is reinforcing teaching with a client at 10 weeks of gestation about self-care management for common discomforts in pregnancy. Which of the following instructions should the nurse include? A. Douche every other day to minimize leukorrhea B. Consume frequent snacks to decrease episodes of nausea C. Refrain from scheduling dental procedures until the third trimester D. Decrease fluid intake to reduce urinary frequency

✔ B. Consume frequent snacks to decrease episodes of nausea Clients who have nausea during pregnancy should be instructed to ingest small snacks frequently. An empty or overloaded stomach can increase feelings of nausea. Incorrect Answers: A. Douching disrupts normal vaginal flora and can lead to vaginal infections. Leukorrhea is normal and has a protective function during pregnancy. C. Pregnant clients should maintain good dental hygiene and see a dentist as needed throughout pregnancy. Dental procedures, including X-rays and the use of local anesthetics, are considered safe during pregnancy. Research links periodontal disease to an increased risk of preterm births and preeclampsia. D. Pregnant clients should consume at least 2 L of water each day to help prevent constipation caused by slowed gastrointestinal motility and oral iron supplementation.

A nurse is collecting data from a newborn who has hypoglycemia. Which of the following findings should the nurse expect? A. Abdominal distention B. Decreased temperature C. Increased muscle tone D. Transient nystagmus

✔ B. Decreased temperature The nurse should identify that decreased temperature is a manifestation of hypoglycemia. Other manifestations include decreased muscle tone, abnormal crying, and jitteriness. Incorrect Answers: A. The nurse should identify that abdominal distention is a manifestation of hypocalcemia. C. The nurse should identify that decreased muscle tone is a manifestation of hypoglycemia. D. The nurse should identify that transient nystagmus is an expected finding in a newborn and is not related to blood glucose level.

A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings is a sign of a potential complication? A. Dark red lochia with small clots B. Deep tendon reflexes 4+ C. Urine output since birth of 3,000 mL D. Soft pink hemorrhoids

✔ B. Deep tendon reflexes 4+ 2+ is an expected finding for deep tendon reflexes. 4+ can be an indication of preeclampsia. Incorrect Answers: A. A client will have dark red lochia for approximately 3 days following delivery. Large clots are an indication of a complication. C. Diuresis begins approximately 12 hours following delivery. It is expected for a client to have a urine output of 3,000 mL in a 24-hour period. D. Discolored hemorrhoid tissue can be an indication of a complication.

While assisting with the care of a client in labor, a nurse observes a pattern of early decelerations on the fetal monitor. Which of the following actions should the nurse take? A. Notify the provider B. Document the findings and continue to monitor C. Administer oxygen to the client via face mask D. Assist with sterile speculum examination

✔ B. Document the findings and continue to monitor Early decelerations are a normal and benign finding caused by compression of the fetal head during uterine contractions. Incorrect Answers: A. The presence of this type of deceleration does not warrant provider notification. C. Administration of oxygen is not necessary. D. There is no indication that a sterile speculum exam is necessary.

A nurse is collecting data from a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider? A. Varicose veins B. Double vision C. Leukorrhea D. Flatulence

✔ B. Double vision Double vision, blurred vision, or visual disturbances are signs of potential complications associated with preeclampsia. The nurse should report this finding to the provider. Incorrect Answers: A. Varicose veins are a common manifestation associated with pregnancy. They are caused by the relaxation of the smooth muscle walls of the veins and pelvic vasocongestion. C. Leukorrhea is a hormonal production of an abundant amount of mucus. It is a common manifestation associated with pregnancy. D. Flatulence is a common manifestation associated with pregnancy. Progesterone causes reduced gastrointestinal motility.

A nurse is collecting data from a client who is 3 days postpartum. When examining the client's uterus, which of the following techniques should the nurse use? A. Press down and forward with the hand that is placed on the base of the uterus B. Measure the height of the fundus in fingerbreadths in relation to the umbilicus C. Place the client in a semi-Fowler's position prior to checking the uterus D. Massage the fundus with gentle palpation until it becomes soft to touch.

✔ B. Measure the height of the fundus in fingerbreadths in relation to the umbilicus The nurse should measure the height of the fundus in fingerbreadths and should expect the height to decrease 1 fingerbreadth in height daily after birth. The fundus should be about 3 fingerbreadths below the umbilicus by the third day postpartum. Incorrect Answers: A. The nurse should place a hand at the base of the uterus to provide support. The other hand should be placed at the umbilicus and should be pushed downward and inward against the uterine fundus. C. The nurse should place the client in a supine position prior to checking the uterus. D. The nurse should perform a gentle massage of the uterus until it becomes firm.

A nurse is collecting data from a client who is 48 hours postpartum. Which of the following findings should the nurse report to the provider? A. The fundus is firm after palpation with moderate lochia noted. B. Pelvic and uterine pain is present while at rest. C. Urination is documented every 2 to 4 hours. D. The client reports difficulty sleeping the previous night.

✔ B. Pelvic and uterine pain is present while at rest. Pelvic and uterine pain can be an indication of endometritis and should be reported to the provider. Incorrect Answers: A. Following delivery, the fundus should be midline and firm. Moderate lochia is an expected finding. C. Diuresis postpartum is due to hormonal and vascular changes and is an expected finding. The nurse should encourage the client to void every few hours. D. Altered sleep patterns due to excitement, discomfort, and hospitalization are an expected finding. The nurse should provide the client with a sleep-promoting environment.

A nurse in a prenatal clinic is reviewing the laboratory results of a client who is at 33 weeks of gestation. For which of the following results should the nurse notify the provider? A. Hgb 11.3 g/dL B. Platelet count 135,000/mm^3 C. WBC count 10,500/mm^3 D. Hct 38%

✔ B. Platelet count 135,000/mm^3 The nurse should notify the provider of this result because it is an indication of thrombocytopenia. A low platelet count is a manifestation of preeclampsia or HELLP syndrome and requires further evaluation. Incorrect Answers: A. The nurse should notify the provider if the client's Hgb is below 11 g/dL because this is an indication of anemia. C. The nurse should notify the provider if the client's WBC count is greater than 15,000/mm^3 because this is an indication of infection. D. The nurse should notify the provider if the client's Hct is under 33% because this is an indication of anemia.

A nurse is assisting with the care of a client who is in labor and has received epidural analgesia. The nurse observes that the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Position the client on her side C. Assist with an examination for cord prolapse D. Provide glucose via oral hydration or IV

✔ B. Position the client on her side Maternal hypotension is a common cause of late decelerations. Maternal position influences both maternal hypotension and the fetal response to low blood pressure. Positioning the client on her side relieves the pressure of the uterus on the inferior vena cava and improves maternal circulation. Incorrect Answers: A. A client who has received epidural analgesia should not be assisted out of bed to the toilet or a bedside commode due to inhibited muscle control and the increased risk of a fall. C. Umbilical cord prolapse is a common cause of variable decelerations, not late decelerations. D. Hypotension is a function of low blood pressure rather than low blood glucose. The nurse should address low blood pressure through positioning and bolus IV fluids.

A nurse is assisting with the care of a client who is in labor and has received epidural analgesia. The nurse observes that the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take? A. Assist the client to the bathroom to empty her bladder B. Position the client on her side C. Assist with an examination for cord prolapse D. Provide glucose via oral hydration or IV

✔ B. Position the client on her side Maternal hypotension is a common cause of late decelerations. Maternal position influences both maternal hypotension and the fetal response to low blood pressure. Positioning the client on her side relieves the pressure of the uterus on the inferior vena cava and improves maternal circulation. Incorrect Answers: A. A client who has received epidural analgesia should not be assisted out of bed to the toilet or a bedside commode due to inhibited muscle control and the increased risk of a fall. C. Umbilical cord prolapse is a common cause of variable decelerations, not late decelerations. D. Hypotension is a function of low blood pressure rather than low blood glucose. The nurse should address low blood pressure through positioning and bolus IV fluids.

A nurse is assisting with the care of a client in active labor whose fetus is in an occipital brow presentation. Which of the following complications should the nurse anticipate as a result of this fetal presentation? A. Precipitous labor B. Prolonged labor C. Hypertonic uterine dysfunction D. Umbilical cord prolapse

✔ B. Prolonged labor An occipital brow presentation increases the diameter of the presenting part, which may prevent the fetal head from descending into the pelvis. This can result in prolonged labor, forceps- or vacuum-assisted birth, or a cesarean delivery. Incorrect Answers: A. Precipitous labor proceeds abnormally fast, progressing from the onset of labor to delivery in less than 3 hours. An occipital brow presentation is not a contributing factor in precipitous labor. C. Hypertonic uterine dysfunction commonly occurs in the latent, not the active, phase of the first stage of labor. An occipital brow presentation is not a contributing factor to this labor pattern. D. A cord prolapse occurs when the umbilical cord precedes the fetal presenting part. Risk factors for cord prolapse include an abnormally long cord, breech or shoulder presentation, polyhydramnios, a small fetus, or an unengaged presenting part. An occipital brow presentation is not a contributing factor.

A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take? A. Encourage the client to ambulate B. Provide a sitz bath with warm water C. Instruct the client to perform Kegel exercises D. Apply anesthetic cream topically each hour while the client is awake

✔ B. Provide a sitz bath with warm water The nurse should provide a client who is postpartum with a sitz bath to decrease episiotomy discomfort. A sitz bath provides warm, moist direct heat to the incision area, which helps relieve the pulling and stinging associated with the healing incision. The warm water increases blood flow to the area through vasodilatation, which promotes healing and comfort. Incorrect Answers: A. The nurse should help the client lie on her side to decrease episiotomy discomfort. C. The nurse should instruct the client to perform Kegel exercises to strengthen perineal muscles following a vaginal delivery. However, these exercises do not decrease episiotomy discomfort. D. The nurse should administer prescribed analgesics, including topical anesthetic cream. However, the cream should be applied no more than 3 or 4 times per day.

A nurse is reinforcing teaching about breastfeeding with a client. Which of the following client statements indicates an understanding of the teaching? A. "I should consume about 700 extra calories a day while breastfeeding." B. "I will introduce bottle feeding of pumped breast milk when my baby is 2 weeks old." C. "I may notice increased cramping when I am feeding my baby." D. "I will place my baby on a strict feeding schedule to help establish a good feeding pattern."

✔ C. "I may notice increased cramping when I am feeding my baby." The client may notice an increase in uterine cramping while breastfeeding due to the release of oxytocin, which causes uterine muscle contraction. Incorrect Answers: A. A client who is breastfeeding requires an additional 500 calories per day to support lactogenesis. B. The client should not introduce an artificial nipple to the newborn until breastfeeding is well established (in approximately 3 or 4 weeks). D. The client should breastfeed on demand, not place the newborn on a strict feeding schedule. Forcing a newborn to wait for a feeding can lead to weight loss and failure to thrive.

A nurse is reinforcing teaching about the rubella immunization with a client who is 24 hours postpartum. Which of the following client statements indicates an understanding of the teaching A. "I should not breastfeed for at least 3 days after receiving this immunization." B. "I will need a second rubella booster when I see my midwife at 6 weeks postpartum." C. "I should be careful to avoid becoming pregnant within the next month." D. "This vaccine will be given into my arm muscle."

✔ C. "I should be careful to avoid becoming pregnant within the next month." While the chances of fertility in the first 4 weeks postpartum are low, clients who receive a rubella immunization must be additionally careful to avoid pregnancy either through maintaining abstinence or through using an effective contraceptive. The rubella vaccine is a live virus vaccine and can cause birth defects. Incorrect Answers: A. The rubella vaccine is a live virus vaccine, but the live attenuated rubella virus is not passed via breastmilk. However, it can be spread via other bodily fluids such as urine. If there are other family members who are immunocompromised, the vaccine should not be administered to the client. B. A single rubella vaccine postpartum is adequate for most non-immune clients. If a client also receives RhoGAM postpartum, the client should be tested 3 months postpartum to verify immunity. D. The rubella vaccine is administered as the MMR (measles, mumps, and rubella) vaccine subcutaneously.

A nurse is reinforcing teaching with a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching? A. "I know not to eat anything after midnight." B. "I will have medication given to me to cause contractions." C. "I should press the button on the handheld marker when my baby moves." D. "I will have to stimulate my breast to cause contractions."

✔ C. "I should press the button on the handheld marker when my baby moves." The purpose of a nonstress test is to assess fetal wellbeing. The client should press the button on the handheld marker when she feels fetal movement. Incorrect Answers: A. There is no reason for the client to be NPO for this test. The client is encouraged to eat prior to the test in order to prompt fetal activity. When the fetus is asleep, the nurse will often offer the client orange juice to stimulate the fetus. B. The client does not need medication to induce contractions. Oxytocin is used to induce contractions for an oxytocin challenge test. D. The client does not need to perform nipple stimulation to induce contractions. Nipple stimulation is necessary for a contraction stress test.

A nurse is caring for a client who is 6 hours postpartum following a dysfunctional labor. Which of the following statements by the client indicates a possible complication? A. "Suddenly, I seem to be urinating all the time." B. "I am really thirsty and hungry this morning." C. "I think I have changed my pad every 15 minutes." D. "Honestly, I'm so tired I don't want to hold the baby."

✔ C. "I think I have changed my pad every 15 minutes." A saturated pad every 15 minutes is an indication of excessive blood loss. The nurse should immediately perform a focused assessment and interventions such as massaging the fundus, checking for urinary distention, and collecting data on vaginal output characteristics.

A nurse is providing postpartum discharge teaching about proper storage of breast milk for a client who is breastfeeding. Which of the following client statements indicates an understanding of the teaching? A. "I can store my pumped milk in the door of the refrigerator." B. "I can use the microwave to thaw my frozen breast milk." C. "I will discard any unused breastmilk that is left in the bottle." D. "I can refreeze any breastmilk after it has been thawed."

✔ C. "I will discard any unused breastmilk that is left in the bottle." Unused milk left in the bottle after a feeding should be discarded because bacteria can grow in the breastmilk, resulting in contamination. Incorrect Answers: A. Pumped milk should be stored in the middle or the back of the refrigerator to keep it cold. Milk stored in the door of the refrigerator does not stay as cold. B. Breastmilk should be defrosted in the refrigerator or under warm running water. Microwaving or boiling breastmilk can cause uneven heating and increase the risk of burning the baby's mouth. D. Once breast milk has been thawed, it cannot be refrozen due to the possibility of bacteria getting in the milk if it is left at room temperature.

A nurse is reinforcing teaching about the use of nitrous oxide analgesia for pain control with a client who is in labor. Which of the following statements by the client indicates an understanding of the teaching? A. "Nitrous oxide could make my baby sleepy when he is born." B. "I should inhale the nitrous oxide between contractions." C. "I will feel the effects of the nitrous oxide almost immediately." D. "Nitrous oxide can make me feel disoriented."

✔ C. "I will feel the effects of the nitrous oxide almost immediately." The effects of nitrous oxide are felt within 1 minute of inhalation. Incorrect Answers: A. Nitrous oxide does not appear to cause neonatal sedation or a difference in Apgar scores. B. The client should inhale nitrous oxide through a face mask as the contraction begins and use it during the contraction. D. Nitrous oxide induces a feeling of relaxation and decreases the client's perception of pain. It does not cause feelings of disorientation.

A nurse is assisting with the care of a client who has been experiencing mild contractions for a few days. The nurse places an external fetal monitor on the client. The client asks, "What will the monitor show you?" Which of the following responses should the nurse make? A. "It will indicate if you are in active labor." B. "It will measure your heart rate." C. "It indicates if your baby is receiving an adequate amount of oxygen." D. "It indicates the intensity of the contractions you are currently having."

✔ C. "It indicates if your baby is receiving an adequate amount of oxygen." A fetal monitor is a reliable tool that indicates the amount of oxygen the fetus is receiving and measures changes in the fetal heart rate during any kind of stress, including contractions, spontaneous fetal movement, or cord compression. It gives the nurse and provider a snapshot of whether the fetal heart rate is increasing or decreasing, which shows if the fetus is in distress. Incorrect Answers: A. A fetal monitor does not determine if the client is in active labor. It measures the condition of the fetus related to oxygenation and heart rate. B. A fetal monitor does not measure the client's heart rate. It measures oxygenation, the fetal heart rate, and how the rate reacts to spontaneous movement and contractions. D. A fetal monitor does not measure the intensity of the client's contractions. It is a reliable tool for measuring oxygenation, fetal heart rate, and the fetal response to stresses.

A nurse is reinforcing teaching with a client who is at 38 weeks of gestation. The client asks, "When will I know I am in the first stages of labor?" Which of the following responses should the nurse make? A. "Labor starts when you feel pelvic pressure." B. "This stage begins with the expulsion of the placenta." C. "Labor begins with consistent regular contractions." D. "Labor starts when the fetal head is delivered."

✔ C. "Labor begins with consistent regular contractions." The first stage of labor begins with regular, effective contractions until the cervix completely dilates. Incorrect Answers: A. Pressure can be noted as the fetus gets into position for delivery and is not considered the first stage or start of actual labor. B. Expulsion of the placenta occurs at the end of the third stage of labor. D. The head of the fetus is delivered during the second stage of labor, which begins when the cervix is fully dilated and ends when the fetus is delivered.

A nurse is reinforcing education about continuous heparin therapy with a client who is 18 hr postpartum and has developed a deep vein thrombosis (DVT). Which of the following statements should the nurse include in the teaching? A. "An adverse effect of this medication is drowsiness." B. "This medication will require frequent monitoring of WBC levels." C. "Use a soft toothbrush to gently brush your teeth." D. "Avoid taking acetaminophen while receiving this medication."

✔ C. "Use a soft toothbrush to gently brush your teeth." An adverse effect of heparin therapy is increased risk for bleeding. The client should use a soft toothbrush to prevent trauma and bleeding. Incorrect Answers: A. Drowsiness is not an adverse effect of heparin. Common adverse effects of this medication include anemia, bleeding, rashes, and thrombocytopenia. B. Heparin is an anticoagulant use to treat DVT. During continuous administration, the client will need frequent monitoring of activated partial thromboplastin time (aPTT) levels to assess for the effectiveness of therapy. D. A DVT can be uncomfortable and the client needs accurate information to improve comfort. She can use prescribed oral analgesics, warm moist heat, and elevation of the affected extremity to enhance comfort. The client should avoid aspirin while receiving heparin therapy.

A nurse is reinforcing teaching with a client who is pregnant and has type 1 diabetes mellitus. Which of the following statements should the nurse include in the teaching? A. "You should expect to increase your insulin dosage during the first trimester of pregnancy." B. "You should expect to decrease your insulin dosage during the second and third trimesters of pregnancy." C. "You should expect to decrease your insulin dosage immediately after you deliver your baby." D. "You will need to increase your insulin dosage if you are breastfeeding."

✔ C. "You should expect to decrease your insulin dosage immediately after you deliver your baby." The client will immediately lose insulin resistance upon the delivery of the placenta. Clients who have type 1 diabetes mellitus should need only 50% to 60% of the predelivery dosage of insulin. Incorrect Answers: A. Clients who are pregnant and have diabetes mellitus typically need lower insulin dosages during the first trimester of pregnancy due to hormonal changes causing an improved response to the insulin. B. Clients who are pregnant and have diabetes mellitus should expect to have increased insulin needs during the second and third trimesters of pregnancy due to placental hormones causing insulin resistance. D. Clients who breastfeed typically require half of their pregnancy insulin dosages due to the carbohydrates used in the process of producing breast milk.

A nurse is reinforcing discharge teaching with a client who is postpartum. Which of the following statements should the nurse make? A. "You should notify the provider if your breasts feel full 5 days following delivery." B. "You should contact the provider if you do not have a bowel movement within 2 days." C. "You should notify the provider immediately if either of your legs becomes swollen." D. "You should contact the provider if you experience vaginal discharge lasting longer than a week." Check Answer

✔ C. "You should notify the provider immediately if either of your legs becomes swollen." Unilateral swelling of the legs can indicate thrombophlebitis and should be reported to the provider immediately. Incorrect Answers: A. The client's breasts will begin to feel more full 3 to 5 days following delivery as milk is being produced. B. The client should notify the provider if she does not have a bowel movement within 4 days following delivery. A postpartum client is at risk for constipation related to pain, dehydration, and immobility. D. Lochia is uterine discharge and is an expected finding for the client during the postpartum period. Lochia rubra, which is dark red in color, lasts for 1 to 3 days. Lochia serosa, which is reddish brown or pink in color, lasts for 3 to 10 days. Lochia alba, which is yellow to white in color, lasts from 4 to 8 weeks. However, uterine discharge varies with each client.

A nurse is reinforcing teaching with a postpartum client who is breastfeeding. Which of the following pieces of information should the nurse include in the teaching? A. "You should supplement your baby with formula until you notice that your breasts become firm and full." B. "You should adhere to a schedule when feeding your baby to ensure she is getting enough to eat." C. "Your milk supply will noticeably increase in volume around the third or fourth day after delivery." D. "It is typical for your nipples to hurt for the first few weeks while you are breastfeeding."

✔ C. "Your milk supply will noticeably increase in volume around the third or fourth day after delivery." As the colostrum transitions to mature breast milk, the volume of milk produced will also increase. Typically, the postpartum client will notice that 72 to 96 hours after delivery her breasts feel fuller and firmer and that milk is leaking from her nipples. Incorrect Answers: A. Colostrum is present in a mother's breasts before the newborn is delivered. Unless there is a medical indication, there is no need for formula supplementation. B. Newborns and infants should be breastfed on demand. Adhering to a strict timing for feedings can lead to a failure to meet the nutritional needs of the newborn/infant. D. Painful nipples during breastfeeding are an indication that the newborn is not correctly latched onto the breast. The baby should be removed from the breast and relatched. Breastfeeding clients should report only a tugging sensation on their nipples.

A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take? A. Prepare to initiate a warm water sitz bath for the client's perineum B. Encourage the client to sit on a soft pillow C. Apply cold ice packs to the client's perineum D. Administer an acetaminophen suppository rectally

✔ C. Apply cold ice packs to the client's perineum A third-degree laceration extends from the perineum to the external sphincter of the rectum. This can cause severe discomfort. Cold ice packs are used on the perineal area during the first 24 hours to decrease edema, pain, and discomfort. Incorrect Answers: A. Warm sitz baths are appropriate after the first 24 hours postpartum. A cool sitz bath is recommended within the first 24 hours to reduce edema and promote comfort. B. The nurse should encourage the client to sit on firm surfaces. The client should avoid soft pillows and donut pillows because they separate the buttocks and decrease venous blood flow, resulting in more pain and discomfort to the perineal area. D. The use of suppositories or enemas is contraindicated for a client who has a third-degree perineal laceration due to the severity of the laceration.

A nurse is collecting data from a client on the first postpartum day. Findings include a fundus that is firm and 1 fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following actions should the nurse take? A. Report the vital signs to the provider B. Massage the fundus C. Ask the client when she last voided D. Obtain a prescription for an oxytocic agent

✔ C. Ask the client when she last voided Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be found firm at midline. A deviated, firm fundus usually indicates a full bladder. The nurse should assist the client to void. Incorrect Answers: A. A slight maternal temperature increase is commonly seen in the first 6 to 10 days postpartum. A pulse of 52/min is within the expected reference range. B. The nurse should massage the fundus when it is boggy. D. The client's fundus is firm with moderate lochia rubra. Administering an oxytocic agent is not an appropriate intervention. Oxytocic agents are given for clients who have increased lochia rubra or a boggy fundus to promote uterine contractions.

A nurse administers betamethasone to a client who is at 33 weeks of gestation to stimulate fetal lung maturity. When assisting with the plan of care for the newborn, the nurse should identify which of the following conditions as an adverse effect of this medication? A. Hyperthermia B. Irritability C. Decreased blood glucose D. Rapid pulse rate

✔ C. Decreased blood glucose Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery. It is important to check the newborn's blood glucose level within the first hour following birth and frequently thereafter until blood glucose levels are stable. Incorrect Answers: A. Betamethasone does not affect the newborn's ability to maintain body temperature. Hyperthermia is not an adverse effect of betamethasone. B. Irritability is not an adverse effect of betamethasone. D. Betamethasone administered to the antepartum client does not affect the newborn's vital signs. If the newborn has a rapid apical pulse, it is related to another cause such as prematurity or respiratory insufficiency.

A nurse is assisting with the care of a client who is 2 hours postpartum and is exhibiting signs of hypovolemic shock. Which of the following actions should the nurse take? A. Saline lock the IV catheter B. Provide oxygen via nasal cannula C. Elevate the client's legs to a 30° angle D. Place the client in a semi-Fowler's position

✔ C. Elevate the client's legs to a 30° angle The nurse should position the client on her side with her right hip elevated by a pillow or in a supine position with her legs elevated to at least a 30° angle. This improves blood flow and reduces manifestations of hypotension. Incorrect Answers: A. A client who is experiencing postpartum hypovolemic shock requires IV fluid replacement and potentially blood transfusion. The nurse should maintain running IV access and possibly increase the IV fluid rate. B. Oxygen supplementation is important for a client who is experiencing postpartum hypovolemic shock. Oxygen should be administered at 10 L/min via facemask to increase oxygenation and perfusion to the tissues. D. The nurse should position the client on her side with her right hip elevated by a pillow or in a supine position with her legs elevated to at least a 30° angle.

A nurse is reinforcing teaching about breastfeeding with a client who is 4 hours postpartum. Which of the following pieces of information should the nurse include? A. Feed the newborn for 5 minutes on each breast B. Newborns are expected to lose up to 15% of their birth weight C. Ensure the newborn's mouth covers the nipple and areola D. Provide a pacifier to the newborn between feedings starting 3 days after birth

✔ C. Ensure the newborn's mouth covers the nipple and areola The newborn's mouth should open wide prior to latching on to the breast. The client should ensure the newborn's mouth covers the nipple and areola to allow an adequate seal and prevent tissue damage. Incorrect Answers: A. The nurse should instruct the client to feed the newborn for approximately 15 to 20 minutes per breast, or until the newborn shows signs of satiety. B. Newborns might lose 7% to 10% of their birth weight. The nurse should notify the provider if a breastfed newborn loses more than 7% of the birth weight or if a formula-fed newborn loses more than 10% of the birth weight. D. The client should not offer a pacifier to the newborn until breastfeeding is well established, which is generally 3 to 4 weeks after birth.

A nurse is assisting with the care of a client who is in labor and experienced a spontaneous rupture of membranes. Which of the following findings requires intervention by the charge nurse? A. Intense contractions lasting less than 30 seconds B. Rest periods between contractions lasting longer than 90 seconds C. Fetal heart rate decreased by 15/min D. Maternal temperature of 37.8°C (100°F) after ruptured membranes

✔ C. Fetal heart rate decreased by 15/min A fetal heart rate decrease of 15/min is known as VARIABLE DECELERATIONS and requires intervention by the nurse due to cord compression. The cord can prolapse after the rupture of membranes, compromising the fetus. The fetal heart rate and pattern should be monitored for several minutes after the rupture of membranes to assess the wellbeing of the fetus. Incorrect Answers: A. Contractions lasting less than 30 seconds are an expected finding. Contractions lasting longer than 90 seconds can be a risk with or without membrane rupture. B. Rest periods lasting longer than 90 seconds allow the fetus to recover. Rest periods lasting less than 30 seconds can be a risk for the fetus because of the shortened recovery period. D. A temperature of less than 37.8°C (100°F) would be an expected finding and not an indication of a potential problem. However, a maternal temperature over 37.8°C (100°F) after membranes are ruptured could indicate the potential for infection.

A nurse is collecting data from a newborn. Which of the following findings should the nurse report to the provider? A. Pink-tinged urine B. Scant amount of nipple discharge C. Grunting with expiration D. Bluish discoloration of feet and hands

✔ C. Grunting with expiration Grunting, nasal flaring, and substernal or intercostal retractions are signs of respiratory distress in a newborn. The nurse should report this finding to the provider. Incorrect Answers: A. Pink-tinged urine is an expected finding in a newborn and is caused by uric acid crystals. B. Nipple discharge is an expected finding in a newborn due to the effects of maternal estrogen during pregnancy. D. Bluish discoloration of the hands and feet is known as acrocyanosis. This is an expected finding in a newborn.

A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should the charge nurse include in the teaching? A. Newborn respiratory depression at birth B. Impaired ability of the neonate to maintain body temperature C. Impaired placental perfusion D. Decreased fetal heart rate (FHR) variability

✔ C. Impaired placental perfusion Maternal hypotension can occur in 10% to 30% of women who receive epidural or spinal anesthesia. This can result in decreased blood flow to the placenta and impair the delivery of oxygen to the fetus. Incorrect Answers: A. Respiratory depression in the newborn may occur if narcotic agonist-antagonist analgesics are administered to the mother within 1 to 4 hours of birth. B. The use of diazepam in labor can disrupt newborn thermoregulation and result in hypothermia. D. Minimal or absent FHR variability is a side effect of administering opioids to a laboring client.

A nurse is assisting with the care of a client in the latent stage of labor who is reporting a pain level of 4 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Encourage the client to use hydrotherapy B. Teach the client biofeedback to control labor pain C. Instruct the client about relaxation breathing techniques D. Administer a benzodiazepine medication

✔ C. Instruct the client about relaxation breathing techniques Relaxation breathing techniques in the first stage of labor promote relaxation of the abdominal muscles. This decreases discomfort and allows fetal descent. Incorrect Answers: A. Hydrotherapy should not be implemented for pain relief until the client has entered the active stage of labor. Early introduction of hydrotherapy is associated with a prolonged labor. B. While biofeedback can be an effective method of relaxation, the technique must be introduced and practiced during the prenatal period to be effective during labor. D. Benzodiazepines are not recommended for laboring clients. They have a significant maternal amnesic effect and can disrupt thermoregulation in the newborn.

A nurse is assisting with planning care for a client who is scheduled to have prostaglandin E2 gel inserted for cervical ripening. Which of the following actions should the nurse take? A. Assess fetal heart rate and contraction pattern every 15 minutes after insertion B. Warm the frozen gel in a warm-water bath prior to insertion C. Maintain the client in a side-lying position for 30 minutes after insertion D. Initiate an oxytocin infusion for induction 1 hour after gel insertion

✔ C. Maintain the client in a side-lying position for 30 minutes after insertion The client should maintain a side-lying or supine position with lateral tilt for 30 to 40 minutes after insertion of the medication to keep the gel in contact with the cervix. Incorrect Answers: A. Fetal heart rate and contractions should be assessed continuously because prostaglandin E2 gel can cause tachysystole and fetal distress. B. Using a warm water bath or microwave to accelerate the warming of the gel can inactivate the ingredients. The gel should be allowed to thaw at room temperature. D. The initiation of an oxytocin infusion should be delayed for 6 to 12 hours after the last instillation of prostaglandin E2 gel.

A nurse is collecting data from a newborn. For which of the following findings should the nurse notify the provider? A. Heart rate 136/min B. Acrocyanosis C. Mottling D. Respiratory rate 60/min

✔ C. Mottling The nurse should report mottling to the provider as an indication of hypothermia or respiratory distress. Incorrect Answers: A. A heart rate of 136/min is within the expected reference range for a newborn. The nurse should notify the provider if the newborn's heart rate is below 80/min while asleep or above 180/min while crying. B. Acrocyanosis (a bluish discoloration of the hands and feet) is an expected finding in a newborn. The nurse should notify the provider if the newborn has central cyanosis. D. A respiratory rate of 60/min is within the expected reference range for a newborn. The nurse should notify the provider if the newborn's respiratory rate is under 25/min or above 60/min.

A nurse is assisting with caring for a client who is at 36 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse identify as the priority? A. 1+ proteinuria B. Blood pressure 140/98 mmHg C. Nonreactive nonstress test D. Fundal height 33 cm

✔ C. Nonreactive nonstress test The nurse should apply the urgent versus non-urgent priority-setting framework. Using this framework, the nurse should consider urgent needs to be the priority because they pose more of a threat to the client. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which finding is the most urgent. Using the urgent vs nonurgent approach to client care, the nurse determines that the priority finding is a nonreactive nonstress test. A nonstress test measures fetal heart rate (FHR) accelerations with normal movement. A fetal acceleration is a positive sign and is present when the FHR increases by 15/min and lasts for 15 seconds. In a nonreactive nonstress test, there are no accelerations. The absence of FHR accelerations suggests that the fetus may be going into distress. Incorrect Answers: A. Pre-eclampsia is the development of edema, elevated blood pressure, and proteinuria during pregnancy. 1+ proteinuria should be closely monitored in a client who has pre-eclampsia. However, this is not the priority finding. B. Pre-eclampsia is the development of edema, elevated blood pressure, and proteinuria during pregnancy. Pre-eclampsia is defined as a blood pressure reading of 140/90 mmHg, an increase of 30 mmHg or more in systolic pressure, or 15 mmHg in diastolic over baseline on 2 occasions taken at least 6 hours apart. A blood pressure reading of 140/98 mmHg is elevated and consistent with pre-eclampsia. However, this is not the priority finding. D. A fundal height of 33 cm is slightly below the expected reference range for a client who is at 36 weeks of gestation. The fundal height should be approximately the same as the number of weeks of gestation, plus or minus 2 cm. The nurse should report this finding to the provider. However, this is not the priority finding. Peer Comparison A 11% B 23% C 58% D 7% Difficulty level: Moderate Grade Pause Previous

A nurse is collecting data from a postpartum client and observes a steady trickle of bright red blood from the client's vagina. The uterus is palpated as firm, midline, and located 1 cm below the umbilicus. Which of the following actions should the nurse take? A. Massage the fundus B. Instruct the client to empty her bladder C. Notify the provider D. Teach the client how to perform a sitz bath

✔ C. Notify the provider Excessive vaginal bleeding in the presence of a contracted uterus is a sign of a vaginal or cervical laceration. The provider must be notified so the laceration can be repaired. Incorrect Answers: A. Massaging the uterus would be appropriate if the fundus were not contracted. The fundus is firm and contracted; therefore, the excessive bleeding is not coming from the uterus. B. Emptying the bladder will have no effect on vaginal bleeding. D. A sitz bath is used to promote comfort. This intervention will not address the issue of excessive vaginal bleeding.

A nurse is caring for a client who is postpartum. The client suddenly appears restless and reports an inability to catch her breath. Which of the following actions should the nurse take? A. Evaluate vital sign trends, focusing on blood pressure history B. Review admission laboratory values, specifically hematocrit C. Notify the unit charge nurse and the rapid response team D. Ask the client about pain, urination, and lochia characteristics

✔ C. Notify the unit charge nurse and the rapid response team This client requires an emergency response. A sudden onset of air hunger can be related to hemorrhage or pulmonary embolism, which are medical emergencies that can lead to cardiopulmonary arrest if they are not managed aggressively. Incorrect Answers: A. The client is demonstrating acute signs of hemodynamic compromise, which is managed based on the client's status. Vital sign trends will not offer the nurse information about the client's current situation. B. An emergent complete blood count should be drawn at this time. Admission laboratory results will not offer the nurse information about the client's current change in hemodynamic status. D. The nurse should recognize that this client is experiencing a medical emergency. Asking the client about pain, urination, and lochia characteristics will not offer the nurse information about the client's current situation.

A nurse is assisting with the care of a client who had a precipitous delivery. Which of the following items of data is the nurse's priority during the fourth stage of labor? A. Obtaining the client's temperature B. Inspecting the client's perineum C. Palpating the client's fundus D. Checking the client for hemorrhoids

✔ C. Palpating the client's fundus The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. A precipitous delivery follows labor of less than 3 hours. Regardless of the cause of the rapid delivery, uterine atony can result, causing postpartum hemorrhage. The nurse should palpate the fundus and massage as needed to monitor for and reduce the risk of hemorrhage. Incorrect Answers: A. The nurse should monitor the client's temperature during the fourth stage of labor; however, another assessment is the priority. B. The nurse should assess the client's perineum, especially if an episiotomy or laceration is present; however, another assessment is the priority. D. The nurse should check the client for hemorrhoids during the fourth stage of labor; however, another assessment is the priority.

A nurse is assisting with the care of a client in active labor who is experiencing hypotension following epidural placement. Which of the following actions should the nurse take? A. Decrease IV fluids B. Give oxygen at 2 L/min via nasal cannula C. Place the client in a lateral position D. Administer indomethacin

✔ C. Place the client in a lateral position The nurse should place the client in a lateral position to increase uterine perfusion to the fetus. Incorrect Answers: A. The nurse should increase IV fluids for a client who is experiencing hypotension following an epidural placement. B. The nurse should administer oxygen at 10 to 12 L/min via nonrebreather face mask. D. The nurse should discuss with the Certified Registered Nurse Anesthetist (CRNA) about administering a vasopressor to increase maternal blood pressure. Indomethacin is used as a tocolytic for preterm labor.

A nurse is reinforcing teaching with a client about hormonal changes during pregnancy. The nurse should identify that which of the following hormones plays a key role in preventing miscarriage? A. Oxytocin B. Prolactin C. Progesterone D. Estrogen

✔ C. Progesterone Progesterone maintains the endometrium and has a relaxant effect on the uterus so that the pregnancy is not expelled. Incorrect Answers: A. Oxytocin stimulates uterine contractions and is responsible for the excretion of milk during lactation. B. Prolactin prepares the breasts to synthesize and secrete milk. D. Estrogen stimulates uterine contractility and the growth of the uterus and breast glandular tissue. Estrogen levels rise near the end of pregnancy to prepare for the onset of labor.

A nurse on an antepartum unit is assisting the charge nurse with an in-service session for newly licensed nurses. Which of the following descriptions should the nurse identify as referring to a pudendal block? A. Using low-voltage electric currents to decrease pain B. Eliminating sensation from the umbilicus to the thighs C. Providing local anesthesia to the perineum during delivery D. Removing sensation from the breasts to the feet

✔ C. Providing local anesthesia to the perineum during delivery The nurse should identify that a pudendal block is administered transvaginally into the space just anterior of the pudendal nerve. The local anesthetic block contains lidocaine or bupivacaine and has no serious maternal or fetal adverse effects. Incorrect Answers: A. A transcutaneous electrical nerve stimulation (TENS) is used to treat a variety of conditions. TENS is helpful for some antepartum clients as a component of nonpharmacological pain management and cutaneous stimulation strategies. B. An epidural block eliminates sensation from the level of the umbilicus to the thighs. It also relieves the pain of contractions, pressure, fetal descent, and perineal stretching. This analgesic block consists of morphine or fentanyl and is injected into the space at the fourth or fifth lumbar vertebrae. D. A spinal block eliminates all sensation from the level of the breasts to the feet. It is commonly used for cesarean births. A local anesthetic is injected directly into the spinal fluid at the third, fourth, or fifth lumbar interspace.

A nurse is monitoring a client who is receiving IV oxytocin for the induction of labor. The nurse identifies repetitive early decelerations on the fetal heart monitor. Which of the following actions should the nurse take? A. Increase the rate of the intravenous fluid infusion B. Discontinue the infusion of oxytocin C. Re-evaluate the FHR tracing in 15 minutes D. Request a prescription for an amnioinfusion

✔ C. Re-evaluate the FHR tracing in 15 minutes Early decelerations are a result of compression of the fetal head during contractions. They are benign and require no specific intervention. The nurse should reassess the fetal heart rate and contraction pattern in 15 minutes due to the infusion of oxytocin. Incorrect Answers: A. Oxytocin is given by starting a primary IV infusion and administering the medication through a secondary line. Therefore, the rate of IV fluids should be increased to improve uteroplacental perfusion if the client is experiencing late decelerations or uterine tachysystole. B. The nurse should discontinue the oxytocin infusion in the presence of tachysystole, late decelerations, or variable decelerations. This action is not appropriate for the presence of early decelerations. D. An amnioinfusion is used to relieve intermittent umbilical cord compression that results in variable decelerations.

A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider? A. Blood pressure 139/89 mmHg B. Deep tendon reflexes 2+ C. Report of blurred vision D. Bilateral, dull headache

✔ C. Report of blurred vision Visual disturbances such as blurred vision and diplopia are manifestations of preeclampsia and should be reported to the provider. Incorrect Answers: A. Vital signs fluctuate for the first 1 to 2 days following delivery. Blood pressure readings trending upward or 2 readings above 140/90 mmHg taken at least 4 to 6 hours apart can indicate preeclampsia. B. Deep tendon reflexes of 2+ is an expected finding. D. A bilateral, dull headache is an expected finding postpartum. More severe headaches can indicate preeclampsia, stress, or a complication of an epidural.

A nurse is discussing risk factors for necrotizing enterocolitis (NEC) in newborns with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Post-term birth B. Macrosomia C. Respiratory distress syndrome D. Maternal gestational diabetes

✔ C. Respiratory distress syndrome Respiratory distress syndrome is a risk factor for NEC. Respiratory distress causes intestinal ischemia secondary to hypoxia. Incorrect Answers: A. Preterm birth is a risk factor for NEC. Approximately 90% of cases of NEC occur in preterm newborns. B. Low birth weight and intrauterine growth restriction are risk factors for NEC. D. Maternal gestational diabetes is not a risk factor for NEC. Risk factors include asphyxia, gastrointestinal infection, and polycythemia.

A nurse is reinforcing teaching about parental attachment with a client who is postpartum. Which of the following client behaviors indicates an understanding of the teaching? A. The client primarily touches the newborn with her fingertips. B. The client does not critique the newborn's features and body parts. C. The client has given the newborn a name. D. The client is quiet with a blank facial expression.

✔ C. The client has given the newborn a name. A parent who names the newborn and incorporates the newborn into the family helps facilitate parental attachment. Incorrect Answers: A. This behavior inhibits parental attachment. A parent who uses palmar contact and holds the newborn facilitates parental attachment. B. Exploring the newborn is a part of becoming acquainted with the newborn. Discovering things that are alike, different, and unique facilitate parental attachment.

A nurse is reinforcing discharge teaching with a client about breastfeeding her newborn. Which of the following pieces of information should the nurse include? A. Milk should replace the colostrum in 12 to 14 days. B. The newborn should have 3 to 4 wet diapers each day. C. The newborn should appear satisfied after each feeding. D. The client's breasts should feel firm after each feeding.

✔ C. The newborn should appear satisfied after each feeding. The nurse should inform the client that the newborn should appear satisfied and content after feedings. A newborn who continues to show hunger indications (e.g. rooting, sucking on the hands, or crying) might not be effectively emptying the breasts during feedings. Incorrect Answers: A. The nurse should inform the client that milk production begins 3 or 4 days postpartum. B. The nurse should inform the client that the newborn should have 6 to 8 wet diapers and at least 3 bowel movements each day. D. The nurse should inform the client that her breasts should feel soft after each feeding. This is an indication that the newborn has emptied the breasts.

A nurse is preparing to apply an external uterine activity monitor for a client who is at 36 weeks of gestation. Which of the following actions should the nurse plan to take? A. Place the client in a supine position with her knees bent for the test B. Place the tocotransducer just below the level of the client's umbilicus C. Validate the monitor tracing by palpating for contraction frequency D. Ask the client to press the sensor each time she feels a contraction

✔ C. Validate the monitor tracing by palpating for contraction frequency The client should notify the nurse when she feels a contraction. The nurse can then determine the contraction frequency by using palpation to validate the monitor tracing. Incorrect Answers: A. The client should be placed in semi-Fowler's or a lateral position for fetal monitoring. If the client is in a supine position, the uterus can compress the vena cava. Therefore, the results of the test would be altered. B. The tocotransducer should be placed at the level of the fundus, which is above the level of the umbilicus. D. The monitors will be held in place by elastic straps. If the client depresses the sensor button when she feels a contraction, the results of the test would be altered.

A nurse is assisting with the care of a client who has developed hemorrhagic shock. Which of the following manifestations should the nurse expect? A. Urinary output of 40 mL/hr B. Deep abdominal breathing C. Weak and irregular pulse D. Warm, dry hands with prompt capillary refill

✔ C. Weak and irregular pulse A weak, irregular, and rapid pulse can indicate postpartum hemorrhagic shock due to decreased oxygenation and perfusion to the heart. The client will need fluid replacement and medical attention. Incorrect Answers: A. Decreased urinary output is a manifestation of hemorrhagic shock due to decreased renal perfusion. B. Rapid and shallow respirations are a sign of hemorrhagic shock due to the lungs lacking adequate oxygenation and perfusion. D. Cool and clammy skin is an indication of hemorrhagic shock due to poor circulation.

A nurse in an antepartum clinic is collecting data from a client who is 2 weeks postpartum and reports vaginal discharge. Which of the following discharge characteristics should the nurse expect? A. Dark red uterine discharge B. Pinkish-brown vaginal discharge C. Yellowish-white uterine discharge D. Bright red vaginal discharge

✔ C. Yellowish-white uterine discharge Lochia alba is yellow to white uterine discharge. This is present about 10 to 14 days following birth and can persist up to 8 weeks. Lochia alba consists of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria. Incorrect Answers: A. Lochia rubra is dark red uterine discharge with small blood clots. This consists mainly of blood and decidual and trophoblastic debris. It is expected uterine discharge during the first 2 days following birth. B. Lochia serosa is pink or brown uterine discharge and does not originate from the vagina. It is present after 3 to 4 days and can persist for up to 2 weeks following birth. Lochia serosa consists of old blood, serum, leukocytes, and tissue debris. D. This is a type of bleeding that spurts from the vagina and often originates from a cervical or vaginal tear.

A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses should the nurse make? A. "You will not get pregnant while you are breastfeeding, so you will not need any birth control." B. "A birth control pill that contains only estrogen is available for use while you are breastfeeding." C. "Condoms are the only method of contraception that is appropriate while you are breastfeeding." D. "A progestin-only pill or injection is available for use while you are breastfeeding."

✔ D. "A progestin-only pill or injection is available for use while you are breastfeeding." Progestin-only injections, implants, and birth control pills are acceptable options for clients who are breastfeeding, although some experts recommend waiting until 6 weeks postpartum to initiate the medication. Incorrect Answers: A. Breastfeeding can inhibit ovulation or prolong menstruation; however, it is not a reliable and effective means of birth control. The client may experience an unplanned pregnancy if she waits until her periods resume before considering birth control options. B. Estrogen-containing birth control pills, implants, patches, and vaginal rings are not recommended for clients who are breastfeeding due to the risk of inhibiting breast milk production and supply. C. Condoms and other non-hormonal birth control methods are appropriate for clients who are breastfeeding; however, there are other methods that are also appropriate.

A nurse is reinforcing teaching with a client who is postpartum and breastfeeding. Which of the following statements should the nurse include? A. "You will need to wait 3 months before resuming sexual intercourse." B. "You don't need to use contraception until you are 4 months postpartum." C. "As long as you breastfeed, you will experience an overproduction of vaginal lubrication." D. "A reduction in sexual interest could indicate postpartum depression."

✔ D. "A reduction in sexual interest could indicate postpartum depression." Manifestations of postpartum depression include decreased libido, feelings of sadness or anxiety, difficulty sleeping, or loss of appetite.

A nurse is reinforcing discharge teaching with the parents of a newborn about home safety. Which of the following parent responses indicates an understanding of the instructions? A. "I should attach a soft bumper pad to the rails on the inside of my baby's crib." B. "I should place my baby in an infant carrier on the sofa for daytime napping." C. "I should change the smoke detector batteries in my baby's room once a year." D. "I should use my elbow to check the temperature of my baby's bath water."

✔ D. "I should use my elbow to check the temperature of my baby's bath water." The nurse should instruct the parents to test the temperature of the water using their own elbow before placing the newborn in the bath. This prevents chilling or scalding of the newborn's skin. Incorrect Answers: A. Attaching a soft bumper pad to the rails on the inside of the crib increases the newborn's risk of suffocation. The parents should also avoid placing other soft items in the newborn's crib such as blankets, stuffed animals, and pillows. B. Placing the newborn in an infant carrier on the sofa increases the risk of injury. The parents should place the infant carrier on the floor in a safe area where the newborn can be seen. C. Changing the smoke detector batteries in the newborn's room once each year increases the risk of injury. The parents should test the smoke detector in the newborn's room once a month to ensure it is working properly and replace the batteries every 6 months.

A nurse is reinforcing teaching about lactation suppression with a client whose newborn will be bottle-fed. Which of the following client statements indicates understanding of the teaching? A. "I should lightly massage my breasts when I feel discomfort." B. "I should express a small amount of milk if my breasts feel tight." C. "I should take a warm shower twice a day." D. "I should wear a support bra for a few days."

✔ D. "I should wear a support bra for a few days." The nurse should instruct the client to wear a support bra that fits securely. Wearing this bra continuously for the first 3 postpartum days promotes suppression of lactation. Incorrect Answers: A. The nurse should instruct the client to avoid stimulation of the breasts, which promotes rather than suppresses lactation. B. The nurse should instruct the client to avoid the expression of breast milk, which promotes rather than suppresses lactation. C. The nurse should instruct the client to avoid running warm water on the breasts, which promotes rather than suppresses lactation.

A nurse is reinforcing teaching about mastitis with a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I will limit breastfeeding to 5 minutes per breast." B. "I will not breastfeed if I start to have flu-like symptoms." C. "I will shop for an underwire nursing bra today." D. "I will avoid any of my family members who are ill."

✔ D. "I will avoid any of my family members who are ill." The client should avoid ill family members to decrease the risk of mastitis. While the causative organisms of mastitis tend to be bacterial, exposure to viral illnesses can compromise the immune system and leave the client vulnerable to mastitis. Incorrect Answers: A. Adequate emptying of the breasts reduces the risk of developing mastitis. B. Flu-like symptoms could indicate maternal illness or early mastitis. However, the client should continue to breastfeed in order to promote adequate breast emptying. C. Underwire nursing bras can prevent adequate breast emptying and can predispose the client to mastitis.

A nurse is reinforcing teaching with a group of clients about pregnancy prevention during the postpartum period. Which of the following statements should the nurse include? A. "Non-lactating clients can ovulate immediately after giving birth." B. "Non-lactating clients ovulate in their third month postpartum on average." C. "Lactating clients can ovulate as early as their first month postpartum." D. "Lactating clients ovulate in their sixth month postpartum on average."

✔ D. "Lactating clients ovulate in their sixth month postpartum on average." Clients who breastfeed exclusively ovulate on average around the sixth month postpartum. If a client decides to breastfeed and supplement formula, she should be warned that a form of contraception should be used because ovulation may occur sooner. Incorrect Answers: A. Following delivery, a client's prolactin levels are high, which inhibits ovulation. A non-lactating client can ovulate as early as 27 days postpartum. B. C. A non-lactating client can ovulate as early as 27 days postpartum; however, lactation can delay ovulation.

A nurse is reinforcing teaching with a client who asks about using essential oils for her labor and delivery expected to occur next month. Which of the following responses should the nurse make? A. "Studies show that jasmine has an antidepressant effect during labor." B. "Studies show that the use of lavender is effective for strengthening contractions." C. "Studies do not promote diffusing essential oils during labor due to the possibility of respiratory compromise." D. "Studies show no evidence that essential oils improve labor outcomes."

✔ D. "Studies show no evidence that essential oils improve labor outcomes." Although evidence-based practice does not show any evidence that essential oil use improves labor outcomes, it is not associated with harm unless an allergic reaction is noted from topical application. Any effectiveness is due to an individual perception regarding nonpharmacological pain management. Incorrect Answers: A. Jasmine oil can reduce pain and promote relaxation in some clients. Rose oil can provide an antidepressant effect for some clients during labor. B. Lavender, rose, and jasmine oils can reduce pain and promote relaxation in some clients. C. Essential oils have been noted to promote relaxation, relieve tension, and diminish fear and anxiety while being diffused in an appropriate diffuser. There is no evidence to support negative effects on the respiratory status of the client.

A nurse is collecting data from a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements? A. "Prolactin is increasing the blood supply to your uterus, and you are feeling the blood vessel engorgement." B. "You probably have a small blood clot in your uterus, which is causing the uterus to contract in order to expel it." C. "Your breasts are secreting a hormone that enters the bloodstream and causes your abdominal muscles to contract." D. "The same hormone that is released in response to the baby's sucking, causing the milk to flow, also makes the uterus contract."

✔ D. "The same hormone that is released in response to the baby's sucking, causing the milk to flow, also makes the uterus contract." Oxytocin is released in response to breastfeeding. This hormone also causes the uterus to contract, which decreases the risk of postpartal hemorrhage and increases involution. Incorrect Answers: A. Prolactin is responsible for milk production, not uterine contractions. B. Uterine contractions with breastfeeding do not indicate that the uterus is trying to expel clotted blood. Small clots are typically expressed in the lochia rubra. C. Breast tissue does not secrete hormones. The hormones that affect breast functions such as milk production are produced by the anterior pituitary gland and the posterior pituitary gland.

A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make? A. "This is an attempt by your body to retain the fluid gained during pregnancy." B. "This is caused by an increase in your estrogen hormonal levels." C. "This is caused by the increased pressure on your veins in your lower legs." D. "This is a source of your fluid loss after delivery."

✔ D. "This is a source of your fluid loss after delivery." Postpartum diuresis is the loss of the remaining pregnancy-induced increase in blood volume. The loss of excess tissue fluid begins within 12 hours after birth. Fluid loss by urination and perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum period. Incorrect Answers: A. Postpartum diuresis is attributed to decreased estrogen levels, the removal of increased venous pressure in the lower extremities, and the loss of the remaining pregnancy-induced increase in blood volume. B. Postpartum diuresis is caused by decreased estrogen levels. Fluid loss by urination and perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum period. C. Postpartum diuresis is caused, in part, by the removal of increased venous pressure in the lower extremities. Urine output can exceed 3000 mL/day during the first 2 to 3 days postpartum.

A nurse is assisting with the care of a client who is in labor. The client asks the nurse, "Why is the other nurse pressing on my abdomen?" Which of the following responses should the nurse make? A. "To determine your baby's heart rate" B. "To determine if you have sufficient fluid around your baby" C. "To make sure your baby moves with stimulation" D. "To determine the position of your baby"

✔ D. "To determine the position of your baby" Palpation of the abdomen can determine which fetal part is in the uterine fundus and where the back of the fetus is. Palpating the lower abdomen will help determine whether the fetus's head is down or if another extremity is the presenting part. Incorrect Answers: A. A fetal heart rate cannot be palpated. It can be obtained by auscultation and with a fetal monitor. B. An ultrasound is used to determine the presence and the amount of amniotic fluid. C. Pressing on the client's abdomen is unlikely to elicit fetal movement. Methods of eliciting fetal movement typically include vibroacoustic stimulation and fetal scalp stimulation.

A nurse is reinforcing teaching with a client who is pregnant. Which of the following instructions should the nurse include? A. "Take 600 milligrams of ibuprofen as needed for discomfort." B. "You should eat soft cheeses to increase your calcium intake." C. "You should roll your nipples daily to ensure they are everted." D. "You should use fluoride-based toothpaste to prevent dental caries."

✔ D. "You should use fluoride-based toothpaste to prevent dental caries." Nausea during pregnancy can lead to poor oral hygiene and inflammation of the gingival tissue, which can lead to dental caries. The nurse should instruct the client to use a fluoride-based toothpaste during pregnancy. Incorrect Answers: A. Ibuprofen usage during pregnancy is associated with fetal anomalies such as cleft lip, ductus arteriosus, and renal dysfunction. Therefore, the nurse should instruct the client to avoid taking ibuprofen during pregnancy. B. Soft cheeses such as brie, camembert, and soft Mexican cheeses are made with unpasteurized milk, which can cause the client to contract listeriosis. The nurse should instruct the client to avoid soft cheeses, unpasteurized milk, luncheon meats, and prepared deli salads. C. Performing exercises on the nipples during pregnancy does not correct the nipple and can cause uterine contractions. The nurse should instruct the client to use a breast shield to assist in pushing the nipple outward.

A nurse is reinforcing teaching about breastfeeding with a client who is at 32 weeks of gestation. Which of the following responses should the nurse make? A. "You should place plastic-lined breast pads into your bra." B. "You should start pumping your breasts now." C. "You should apply lanolin ointment to your areolas." D. "You should use warm water to wash your nipples."

✔ D. "You should use warm water to wash your nipples." Colostrum can dry on the nipples and create blockages. Warm water can be used to remove the dried colostrum gently. Incorrect Answers: A. Plastic-lined breast pads are uncomfortable and can irritate the client's areolas. B. Prenatal breast stimulation and pumping can cause preterm contractions and should be avoided. C. The client should avoid using scented soap or alcohol-based solutions on the nipples and areolas because they can strip the client's own protective oils.

A nurse is contributing to the plan of care for client who is in the active stage of labor and expresses a desire to use nonpharmacological methods of pain relief. Which of the following interventions should the nurse include? A. Encourage the client to listen to music B. Instruct the client how to use informational biofeedback C. Ask the client to reconsider using a regional anesthetic D. Assist the client into a warm shower

✔ D. Assist the client into a warm shower Assisting the client into a warm shower is a nonpharmacological method used to decrease labor pain. This method stimulates the release of endorphins and increases circulation. Research supports the use of hydrotherapy as an effective method of labor pain management. Incorrect Answers: A. Music can provide distraction and relaxation while a client is in early labor, but evidence does not support the effectiveness of music as a method of pain relief during active labor. B. Informational biofeedback can be an effective method of increasing relaxation; however, this method must be taught and practiced during the prenatal period to be effective during labor. C. Asking the client to reconsider using regional anesthetics such as epidural or spinal anesthetics does not support the client's wishes to utilize nonpharmacological methods of pain control.

A nurse is assisting with the plan of care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) immune globulin? A. While the client is in labor B. Following an episode of influenza during pregnancy C. Prior to a blood transfusion D. At 28 weeks of gestation

✔ D. At 28 weeks of gestation The nurse should administer Rh(D) immune globulin to a client who is pregnant and has Rh-negative blood at 28 weeks of gestation. Rh(D) immune globulin consists of passive antibodies against the Rh factor, which destroys any fetal RBCs in maternal circulation and blocks maternal antibody production. Incorrect Answers: A. The nurse should administer Rh(D) immune globulin to a client who is pregnant and has Rh-negative blood to prevent maternal antibody production. The nurse should administer Rh(D) immune globulin postpartum to a client who is Rh-negative and has an Rh-positive newborn. B. Receiving the influenza immunization during pregnancy is not an indication to administer Rh(D) immune globulin. C. The nurse should administer Rh(D) immune globulin following a mismatched blood transfusion.

A nurse is collecting data from a newborn who has a congenital diaphragmatic hernia. Which of the following findings should the nurse expect? A. Distended abdomen B. Increased blood pressure C. Generalized petechiae D. Barrel-shaped chest

✔ D. Barrel-shaped chest The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit a barrel-shaped chest as the abdominal organs have shifted into the chest cavity. Incorrect Answers: A. The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit a scaphoid abdomen as abdominal contents have shifted into the chest cavity. B. The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit decreased blood pressure and cyanosis. C. The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit cyanosis and respiratory distress, not petechiae.

A nurse is preparing to provide umbilical cord care for a newborn 12 hours after delivery. Upon inspection, the nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take? A. Check the newborn's heart rate B. Place a pressure dressing on the cord stump C. Administer vitamin K D. Check the integrity of the cord clamp

✔ D. Check the integrity of the cord clamp The nurse should apply the clamp to the umbilical cord while detaching it from the placenta to stop blood flow from the cord to the placenta. When the placenta is no longer attached, the blood vessels in the cord will atrophy as the cord stump dries and shrivels. If blood is coming from a vessel prior to the cord stump necrotizing, the nurse should ensure the cord clamp has not loosened or opened. If it has, the nurse should apply a new clamp immediately. Incorrect Answers: A. The nurse should measure vital signs routinely according to the facility's policies. Unless the newborn has already lost a large quantity of blood, it is unlikely that the newborn's heart rate would be unstable. B. A pressure dressing will not stop bleeding that is coming from a blood vessel. A pressure dressing is used to stop bleeding from a laceration or an incision such as after a circumcision. C. Nurses should administer vitamin K to the newborn immediately after delivery to prevent hemorrhagic disease of the newborn. An additional dose of vitamin K will not stop bleeding from the umbilical vessel.

A nurse is assisting with the care of a client in the third stage of labor who is receiving IV oxytocin. Which of the following actions should the nurse take? A. Discontinue the client's infusion of IV oxytocin B. Check the client's vital signs once every 30 minutes C. Massage the client's fundus once every 90 minutes D. Clean the client's perineum with warm sterile water

✔ D. Clean the client's perineum with warm sterile water The nurse should clean the client's perineum with warm sterile water or 0.9% sodium chloride irrigation. An ice pack can also be applied following cleansing to decrease swelling and pain. Incorrect Answers: A. The nurse should maintain the infusion of IV oxytocin to increase uterine tone and decrease the risk of hemorrhage. B. The nurse should check the client's vital signs every 15 minutes during the third and fourth stages of labor to monitor for hemorrhage. C. The nurse should massage the client's fundus every 15 minutes to ensure it remains firm following the delivery of the placenta and throughout the fourth stage of labor.

A nurse is assisting with the care of a client who is postpartum and reports abdominal cramping. Which of the following actions should the nurse take? A. Advise the client to lie on her side B. Request a prescription for an opioid analgesic C. Offer a sitz bath to the client D. Encourage the client to interact with the newborn

✔ D. Encourage the client to interact with the newborn Interacting with the baby can help provide a distraction and decrease the discomfort of uterine contractions. While it is important to let the parent know that afterpains are more intense during and after breastfeeding, it is also necessary to encourage the planning of methods that provide the most effective and timely relief. Other nonpharmacological interventions can include distraction, therapeutic touch, imagery, hydrotherapy, acupressure, aromatherapy, music therapy, massage therapy, and transcutaneous electrical nerve stimulation (TENS). Incorrect Answers: A. The nurse should recommend a prone position to help reduce the discomfort of uterine contractions. Side-lying is helpful in decreasing the discomfort of perineal lacerations and an episiotomy. B. For relieving the pain of the client's uterine contractions, the nurse should request a prescription for ibuprofen or acetaminophen, not an opioid. C. A sitz bath is recommended to decrease perineal discomfort. Relaxation techniques can be used to help reduce postpartum discomfort caused by uterine contractions.

A nurse is assisting with care for a client who is in labor. Which of the following methods will determine the frequency of the client's contractions? A. Palpating the firmness of the uterus during a contraction B. Calculating the time from the end of a contraction to the beginning of the next C. Measuring the time from the beginning of a contraction to the end of that same contraction D. Evaluating the amount of time from the beginning of a contraction to the beginning of the next contraction

✔ D. Evaluating the amount of time from the beginning of a contraction to the beginning of the next contraction The method for timing contractions is to measure the time from the beginning of a contraction to the beginning of the next. That time interval is the frequency of contractions at any given point in time. Incorrect Answers: A. This action will measure the intensity or strength of the contraction. B. Measuring the time from the end of a contraction to the beginning of the next will determine the resting period between contractions, not their frequency. C. Measuring the length of a contraction from beginning to end determines the duration of the contraction, not the frequency.

A nurse is assisting with the care of a client who is in active labor and notes early decelerations on the fetal monitor. The nurse should identify that which of the following circumstances can cause early decelerations? A. Cord compression B. Fetal hypoxemia C. Uteroplacental insufficiency D. Fetal head compression

✔ D. Fetal head compression The nurse should identify that early decelerations can indicate fetal head compression. These decelerations are a slowing of the FHR that occurs at the beginning of a contraction and returns to baseline at the end of the contraction. Incorrect Answers: A. Variable decelerations on the fetal monitor can indicate cord compression, a short cord, a prolapsed cord, or a nuchal cord. These decelerations indicate a slowing of the FHR that occurs in relation to uterine contractions. B. Late decelerations on the fetal monitor can indicate fetal hypoxemia associated with uteroplacental insufficiency. These decelerations are a slowing of the FHR after a contraction has started that return to baseline well after the contraction has ended. C. Late decelerations indicate uteroplacental insufficiency. These decelerations are a slowing of the FHR after a contraction has started that return to baseline well after the contraction has ended.

A nurse is collecting data from a client who is at 37 weeks of gestation and is HIV positive. Which of the following orders should the nurse clarify with the provider? A. Intermittent auscultation B. Biophysical profile C. Non-stress test (NST) D. Fetal scalp electrode

✔ D. Fetal scalp electrode The placement of a fetal scalp electrode is an invasive procedure that requires ruptured membranes. The electrode is inserted into the fetal scalp, which will increase the fetus's exposure to HIV and is contraindicated. Incorrect Answers: A. Intermittent auscultation with a Doppler is a noninvasive and safe method of fetal monitoring for a client who is HIV positive and poses no risk of transmitting HIV to the fetus. B. A biophysical profile includes an ultrasound and external fetal monitoring. It is a noninvasive method of evaluating fetal wellbeing and poses no risk for transmitting HIV to the fetus. C. An NST includes the application of external fetal and uterine monitors. It is a noninvasive and safe method of fetal monitoring for a client who is HIV positive and poses no risk of transmitting HIV to the fetus.

A nurse is caring for a newborn who was born to a client with narcotic use disorder. Which of the following nursing actions is contraindicated for the care of the newborn? A. Promoting maternal-newborn bonding B. Tight swaddling of the newborn C. Small, frequent feedings D. Frequent stimulation

✔ D. Frequent stimulation This newborn needs a quiet, calm environment with minimal stimulation in order to promote rest and reduce stress. A stimulating environment can trigger irritability and hyperactive behaviors. Incorrect Answers: A. Maternal-newborn bonding is an important part of the newborn's care. The client's drug use, as well as the newborn's hyperactive behavior, often interferes with the establishment of the maternal-newborn relationship. B. Tight swaddling of the newborn discourages hyperactivity and provides comfort. Additionally, it reduces self-stimulation behaviors and protects the newborn's skin from abrasions. C. A newborn who is exposed to narcotics often has an uncoordinated suck and swallow, predisposing the newborn to aspiration. Small, frequent feedings provide adequate caloric intake and reduce the risk of aspiration.

A nurse is caring for a client who is postpartum and has endometritis. Which of the following findings should the nurse report to the provider? A. Foul-smelling lochia B. Uterine pain with palpation C. Temperature 38.1°C (100.6°F) D. Oxygen saturation 93%

✔ D. Oxygen saturation 93% A decreased oxygen saturation can indicate sepsis, embolism, fluid overload, an adverse response to an antibiotic, or hemorrhage. The nurse should report oxygen saturations below 95% to the provider.

A nurse is reinforcing teaching about the process of involution with a client who is postpartum. Which of the following pieces of information should the nurse provide? A. The fundus is approximately 2 cm (0.79 in) above the level of the umbilicus at the end of the third stage of labor. B. The fundus is approximately 3 cm (1.18 in) above the umbilicus within 12 hours after delivery. C. The fundus is located halfway between the umbilicus and mons pubis on the sixth day postpartum. D. The fundus is not palpable abdominally at 2 weeks postpartum.

✔ D. The fundus is not palpable abdominally at 2 weeks postpartum. Involution is the return of the uterus to its normal prepregnancy state; this occurs after the delivery of the placenta. By the end of the third stage of labor, the fundus is 2 cm below the umbilicus. Within 12 hours after delivery, the fundus rises 1 cm above the umbilicus. The fundus descends 1 to 2 cm (0.39 in 0.79 in) every 24 hours. The fundus is not palpable after the sixth postpartum day. Incorrect Answers: A. The fundus is approximately 2 cm (0.79 in) below the level of the umbilicus at the end of the third stage of labor. B and C. Within 12 hours after delivery, the fundus rises 1 cm (0.39 in) above the umbilicus. The fundus descends 1 to 2 cm (0.39 in 0.79 in) every 24 hours.

A nurse is collecting data from a male newborn. Which of the following findings should the nurse report to the provider? A. Superficial cracking and peeling are evident on the skin of the hands and feet. B. The palmar grasp occurs spontaneously when the newborn is sucking. C. The bulge of the testes is palpable in the inguinal canal. D. There is decreased abdominal movement with breathing.

✔ D. There is decreased abdominal movement with breathing. The nurse should report this finding to the provider. Decreased abdominal movement with breathing is a deviation from an expected finding and could indicate phrenic nerve palsy or a congenital diaphragmatic hernia. The nurse should expect the newborn to have diaphragmatic breathing with synchronous abdominal and chest movements. Incorrect Answers: A. Slightly thickened skin on the hands and feet with superficial cracking and peeling is an expected finding in a newborn. B. A palmar grasp that occurs spontaneously when sucking or when the palm is stroked is an expected finding in a newborn. C. The testes should be palpable on each side and can present as a palpable bulge in the inguinal canal. This is an expected finding in a newborn.

A nurse is assisting with the care of a client in labor. Her cervix is dilated to 9 cm, and she has strong contractions every 2 min that last 75 sec. The nurse should recognize that this client is in which of the following phases or stages of labor? A. Latent phase of first stage B. Active phase of first stage C. Second stage D. Transition phase of first stage

✔ D. Transition phase of first stage These findings indicate the transition phase of the first stage of labor. The first stage ends with the transition phase, with the cervix dilating to 8 to 10 cm. Uterine contractions are strong, occurring every 2 to 3 minutes and lasting 45 to 90 seconds. Incorrect Answers: A. The latent phase is characterized by some cervical effacement and dilation from 0 to 3 cm and with little progress in the descent of the presenting part. B. The active phase is characterized by cervical dilation from 4 to 7 cm and significant descent of the presenting part. In this phase, the client has moderate to strong uterine contractions every 3 to 5 minutes that last 40 to 70 seconds. C. The second stage begins with complete cervical dilation and ends with the birth of the newborn.