Test 3 Adult 2
A nurse is reinforcing teaching with the guardian of a newborn who is scheduled to undergo a circumcision. Which of the following pieces of information should the nurse include in the teaching?
"Apply the diaper loosely over the penis." The nurse should instruct the guardian to apply the diaper loosely over the newborn's penis to avoid creating pressure at the circumcision site.
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?
"Breastfeeding can cause uterine contractions." The nurse should explain to the client that oxytocin is released during breastfeeding, which can cause uterine contractions.
A nurse is reinforcing discharge instructions with a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching?
"Do not become pregnant for at least 1 year." Hydatidiform moles are uncontrolled growths in the uterus arising from placental or fetal tissue in early pregnancy. There is an increased incidence of choriocarcinoma associated with molar pregnancies. Pregnancy must be avoided for 1 year so the client can be closely monitored for manifestations of this condition.
A nurse is reinforcing teaching with the guardian of a newborn about formula preparation and feeding. Which of the following statements by the guardian indicates an understanding of the teaching?
"I should discard any formula left in the bottle after a feeding." The nurse should instruct the guardian that any leftover formula should be discarded, not stored and reused. When sucking, an infant exchanges a small amount of saliva for milk, which can cause bacterial growth in the formula.
A nurse is reinforcing teaching with a postpartum client who is breastfeeding. Which of the following statements indicates an understanding of the teaching?
"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.
A nurse is reinforcing teaching with a client at 7 weeks of gestation who is experiencing nausea and vomiting. Which of the following client statements indicates to the nurse an understanding of the teaching?
"I should have a small snack before bedtime." A small snack at bedtime can relieve nausea and vomiting through the night and prevent the client from feeling too hungry on waking.
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?
"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.
A nurse is reinforcing teaching about newborn care with the parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
"I will place a hat on my baby's head prior to going outside." The parent should place a hat or bonnet on the newborn's head to protect the scalp, minimize heat loss, and protect against sunburn.
A nurse is reinforcing teaching about formula feeding with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
"I will warm the bottle of formula by placing it in a pan of hot water." The nurse should instruct the client to warm the bottle of formula by placing it in a pan of hot water and to test the temperature of the formula by dropping a couple drops on the wrist. A bottle of formula should never be placed in the microwave to warm.
A nurse is talking with a client at 20 weeks of gestation who is scheduled for a sonogram. The client states, "I am here to have my regular prenatal checkup, but I do not want any pictures taken of my baby." Which of the following responses should the nurse make?
"I would like to hear more about why you do not want the sonogram, including any cultural reasons." The nurse should be culturally sensitive to all clients and respect and recognize a client who is refusing care for cultural or religious reasons. Collecting more information about the reason the client does not want the sonogram is important so the nurse can better advocate for the client.
A nurse is reinforcing discharge teaching with a postpartum client regarding elimination. Which of the following statements should the nurse include in the teaching?
"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.
A nurse is caring for an adolescent who is in the second trimester of pregnancy. The client states, "I've gotten used to the idea of this pregnancy. It will be fun to have a little baby around the house." Which of the following is the appropriate response by the nurse?
"Tell me how you think your life will be after the baby is born." Open-ended questions allow the client to provide additional assessment data for the nurse about the client's reaction to pregnancy.
A client at a routine prenatal care visit asks the nurse if vaginal yeast infections are common during pregnancy. Which of the following responses should the nurse make?
"The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common." This is an information-seeking question; therefore, a therapeutic response will provide the client with the information she is requesting.
A nurse is reinforcing teaching with a client about squatting exercises during pregnancy. Which of the following statements should the nurse include?
"These exercises should be done for 15 minutes each day to strengthen the perineal muscles." Squatting exercises help stretch the perineum, allowing stretching during delivery and improving functional efficiency after delivery.
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?
"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.
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?
"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.
A nurse at a family-planning clinic is preparing to give a presentation to clients about using a diaphragm. Which of the following pieces of information should the nurse plan to include in the session?
"Use spermicidal jelly whenever you use your diaphragm." A diaphragm is a barrier device that helps prevent pregnancy. Use of a diaphragm alone is not 100% effective in preventing pregnancy, but use with spermicidal jelly increases the effectiveness of the device.
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?
"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.
A nurse is caring for a client at her first prenatal visit. The client is worried about the health of her fetus because she drank alcohol and smoked in the first week of pregnancy, before she knew she was pregnant. Which of the following responses should the nurse make?
"Your baby wasn't susceptible to substances during the first 2 weeks of your pregnancy." Implantation takes place between 6 and 10 days after conception. The blastocyst is not susceptible to teratogens in the first 2 weeks.
A nurse is reinforcing teaching with a client who has come to the family-planning clinic requesting an intrauterine device (IUD). Which of the following pieces of information should the nurse reinforce with the client?
"Your risk for ectopic pregnancy increases with an IUD." An IUD is a contraceptive device the provider inserts through the cervix into the uterus to prevent pregnancy. The IUD works by changing the lining of the uterus and fallopian tubes, making fertilization in the uterus more difficult. Consequently, an IUD increases the risk of ectopic pregnancy.
A community health nurse is contributing to the plan of care for 4 high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse recommend to care for first?
A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy 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 the client's 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. An elevated bilirubin level can lead to kernicterus; therefore, the nurse must initiate phototherapy immediately to help prevent this dangerous outcome.
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?
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.
A nurse is preparing to administer erythromycin ophthalmic ointment 0.5% to a newborn. Which of the following actions should the nurse plan to take?
Apply the ointment in the lower conjunctival sac of each eye The nurse should administer the ointment into the lower conjunctival sac by gently squeezing the tube, starting at the inner canthus and moving toward the outer canthus.
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?
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.
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?
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.
A nurse is assisting with an amniotomy for a client who is in active labor. Which of the following actions should the nurse take?
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.
A nurse is assisting with the care of a client who is in labor. She received meperidine for pain 1 hour prior to entering the second stage of labor. Which of the following actions should the nurse take?
Assess the newborn for respiratory depression Meperidine should not be administered to laboring clients who are expected to deliver within 4 hours of the medication administration. This medication crosses the placenta and causes respiratory depression in the newborn, peaking 2 to 3 hours after administration. Narcan is ineffective at reversing the respiratory depression caused by this medication.
A nurse is assisting with the care of a client who is in active labor and receiving an oxytocin infusion. The nurse notes tachysystole with a Category 1 fetal heart-rate tracing. Which of the following actions should the nurse take?
Assist the client into a side-lying position and continue to monitor A Category 1 fetal heart rate tracing is an expected finding and does not represent fetal distress. The nurse should assist the client into a side-lying position to optimize uteroplacental perfusion and continue to monitor the tracing for another 10 minutes to determine whether tachysystole resolves.
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?
Assist the client to ambulate in the hallway Ambulation and rocking in a rocking chair stimulate the passage of flatus and stool.
A nurse is collecting data from a client who missed 2 menstrual cycles and states that she might be pregnant. Which of the following findings is a positive sign of pregnancy?
Auscultation of a fetal heart rate. The auscultation of a fetal heart rate is a conclusive sign of pregnancy.
A nurse is checking the vital signs of a newborn. Which of the following routes should the nurse use when checking the newborn's temperature?
Axillary The axillary route is considered safe and accurate and can provide a reading in under a minute.
A nurse is assisting with obtaining a New Ballard score for a newborn. Which of the following manifestations indicates prematurity?
Abundant lanugo Abundant lanugo is a physical manifestation of prematurity. The nurse should assign this finding a score of 1.
A nurse in a provider's office is caring for a client who is in the first trimester of pregnancy. Which of the following psychological tasks should the nurse expect the client to accomplish during this trimester?
Accepting the pregnancy Accepting the pregnancy is a psychological task that the client is expected to accomplish during the first trimester.
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?
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.
A nurse is preparing to administer routine medications to a newborn following birth. Which of the following actions should the nurse take?
Administer vitamin K in the newborn's thigh The nurse should administer vitamin K in the vastus lateralis muscle in the newborn's thigh.
A nurse is caring for a 12-hour-old newborn who is asymptomatic and has a blood glucose level of 32 mg/dL. Which of the following actions should the nurse take?
Advise the parent to feed the newborn The nurse should identify a blood glucose level of 32 mg/dL in a 12-hour-old newborn as borderline hypoglycemia. This level should be treated by offering the newborn carbohydrates such as breast milk or formula; therefore, the nurse should advise the parent to feed the newborn.
A nurse is reviewing the plan of care before assuming the care of a newborn who is prescribed a hepatitis B vaccine, vitamin K, and an antiretroviral regimen. The plan of care indicates the newborn's mother is HIV-positive and plans to breastfeed. Which of the following findings should the nurse address with the newborn's interdisciplinary team?
Breastfeeding In areas with access to nutritious infant formula and clean water, breastfeeding by mothers who are HIV-positive is not recommended because HIV can be transmitted through breast milk. HIV is a contraindication to breastfeeding and requires discussion with the newborn's interdisciplinary team.
A nurse is assisting with the care of a client who is in labor. The client speaks a different language than the nurse and is grimacing. Which of the following actions should the nurse take while waiting for an interpreter?
Change the client's position Offering position changes and comfort measures such as drinks or ice, heat packs, and other tangible items will aid in relieving pain and developing trust. A stoic persona might not mean the client is not in need of pain management.
A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse recommend?
Change the newborn's position every 2 to 3 hours
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?
Changes in cervical dilation or effacement Cervical changes are signs of true labor.
A nurse is reinforcing discharge teaching about bathing with the parent of a newborn. Which of the following instructions should the nurse include?
Clean the newborn's face first using water The parent should proceed from the cleanest parts of the newborn's body to the most soiled areas. The face should be washed first before the eyes, ears, and nose. The parent should clean the newborn's genital area last.
A nurse is reinforcing teaching about the selection of commercial formula with the guardian of a newborn. Which of the following pieces of information should the nurse include?
Cow's milk-based formula is recommended for healthy newborns. The nurse should identify that cow's milk-based formulas are similar to human breast milk and are recommended for newborns and infants unless prescribed otherwise by the provider. Certain conditions that might indicate a need to switch to an alternate formula include galactosemia, a congenital lactase deficiency, and immunoglobulin E allergies.
A nurse is reinforcing discharge instructions with the parent of a newborn. Which of the following statements should the nurse include?
Crib slats should be less than 2.25 inches apart.
A nurse is collecting data from a newborn who has hypoglycemia. Which of the following findings should the nurse expect?
Decreased temperature
A nurse is collecting data from a client who has placenta previa and is at 27 weeks of gestation. Which of the following manifestations should the nurse expect?
Decreased urinary output The nurse should identify that decreased urinary output is a manifestation of placenta previa.
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?
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.
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?
Document the findings and continue to monitor
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?
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.
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?
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.
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?
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).
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?
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.
A nurse is assisting with the care of a client who is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects?
Fetal asphyxia Oxytocin can cause tachysystole, which can lead to uteroplacental insufficiency. Inadequate oxygen transfer to the placenta will result in fetal asphyxia.
A nurse is caring for a client who states, "I think I am pregnant." Which of the following findings should the nurse identify as a positive sign of pregnancy?
Fetal heart tones auscultated by Doppler
A nurse is caring for a client who has a BMI of 22.6 and expresses concern about weight gain during pregnancy. Which of the following responses should the nurse make?
Gaining weight will promote a healthy pregnancy. A weight gain of 11.3 to 15.9 kg (25 to 35 lb) during pregnancy is essential for supporting the growth and development of the fetus. Limiting caloric intake can result in using fat stores for energy and developing ketonemia, which is a risk factor for preterm labor.
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?
Generalized petechiae The nurse should report generalized petechiae to the provider. This manifestation can be associated with an infection or clotting factor deficiency.
A nurse is reviewing risk factors for postpartum depression with a newly licensed nurse. Which of the following risk factors should the nurse include?
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.
A nurse is assisting with the care of a newborn. The nurse should obtain informed consent before taking which of the following actions?
Giving the hepatitis B vaccine The nurse must obtain informed consent from the newborn's guardian before administering the hepatitis B vaccine.
A nurse is reinforcing education with a client who is of childbearing age. The nurse should state that which of the following structures expels the mature ovum?
Graafian follicle The Graafian follicle expels the mature ovum.
A nurse is assisting with the plan of care for a client who is at 35 weeks of gestation. Which of the following laboratory tests should the nurse obtain?
Group B streptococcus ß-hemolytic culture The nurse should obtain a vaginal/anal group B streptococcus ß-hemolytic (GBS) culture at 35 to 37 weeks of gestation to screen for infection. Prophylactic antibiotics should be given during labor to the client who is positive for GBS.
A nurse is contributing to the plan of care for a client who plans to formula-feed her newborn. Which of the following actions should the nurse include in the plan?
Have the client place ice packs on her breasts 4 times per day
A nurse is caring for a client who is 24 years old and at 13 weeks of gestation. The client's history includes a BMI of 31 prior to pregnancy, a prior post-term delivery, and a newborn birth weight of 4,167.38 g (9 lb 3 oz). Which of the following laboratory values should the nurse expect to collect?
HbA1c HbA1c measures average plasma glucose concentration over the 12 weeks preceding the test. A female client whose BMI is >30 and who has a history of delivering a baby weighing over 4,082.33 grams (9 lb) is at risk for impaired glucose metabolism and should be screened at the end of the first trimester.
A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider?
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.
A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as a manifestation of a urinary tract infection?
Hematuria Manifestations of a urinary tract infection include dysuria, urinary retention, hematuria, frequency, and urgency.
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?
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.
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?
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 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?
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.
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?
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.
A nurse is caring for a client who is 3 days postpartum and has chosen to bottle feed the newborn. During examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take?
Instruct the client to apply cold compresses.
In nurse is reinforcing teaching with a group of clients who are pregnant about vitamin K for newborns. Vitamin K helps prevent which of the following conditions in a newborn?
Intracranial hemorrhage
A nurse is assisting with planning a sibling class for a group of expectant parents and their older children. Which of the following statements should the nurse include to facilitate sibling adaptation?
Involve the siblings in decorating your newborn's room.
A nurse is caring for a client who is pregnant and whose last menstrual period began on April 8. Using Naegele's rule which of the following dates would be the clients estimated date of birth?
January 15
A nurse is reinforcing teaching with the guardian of a newborn who has physiological jaundice. The guardian asks, "Why does my baby have this condition?" Which of the following responses should the nurse make?
Jaundice is related to increased levels of bilirubin.
A nurse in a clinic is collecting data from a client who is at 13 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse identify as the priority?
Ketones 2+ The greatest risk to this client is malnutrition that poses a serious risk to the developing fetus. Ketonuria indicates that the client's body is breaking down fat and protein stores for energy and cannot provide the fetus with essential nutrients. Therefore, this is the priority finding, and the nurse should report it to the provider immediately.
A nurse on the antepartum unit is caring for a client who is at 28 weeks of gestation and reports dizziness when lying on her back. Into which of the following positions should the nurse assist the client?
Lateral A lateral or side-lying position promotes uteroplacental blood flow and helps relieve the symptoms of supine hypotension, including faintness, dizziness, and breathlessness.
A nurse is reinforcing teaching about nutrition with a client who is at 6 weeks of gestation. The nurse should identify that which of the following foods contains the highest folate content per serving?
Liver The nurse should identify that liver is the best food source to recommend because it contains 200 to 500 mcg of folate per serving.
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?
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.
A nurse is reinforcing teaching about formula feeding with the guardian of a newborn. Which of the following pieces of information should the nurse include?
Mix 1 scoop of powdered formula with 2 oz of water The guardian should use sterile water or water that has been boiled for 2 minutes when mixing powdered formula. The guardian should mix 1 scoop in 2 oz of water.
A nurse is assisting with the plan of care for a client who is postpartum and has a history of a pulmonary embolus. The provider has prescribed heparin therapy prophylactically. Which of the following interventions should the nurse recommend to include in the plan?
Monitor aPTT and platelet count
A nurse is contributing to the plan of care for a client who is pregnant and has a deep-vein thrombosis (DVT). Which of the following actions should the nurse include?
Monitor the client for bleeding from intravenous insertion sites
A nurse is collecting data from a newborn. Which of the following findings suggests the newborn is post-mature?
Nails extending over the fingers This is an expected finding for a post-term infant.
A nurse is collecting data from a newborn. Which of the following findings should the nurse immediately report to the provider?
Nasal flaring
A nurse is collecting data from a 7-month-old infant during a well-child visit and notes the presence of a full Moro reflex. For which of the following should the nurse screen the infant?
Neurological disorder The Moro reflex, also known as the startle reflex, is elicited by striking the surface next to the newborn to startle him/her. A classic pattern of abduction and extension of the arms that follows is expected. This reflex should be gone by 4 months of age; its presence after 4 months of age is associated with the presence of a neurological disorder.
A nurse is assisting with caring for a client who is at 36 weeks of gestation and has preeclampsia. Which of the following findings should the nurse identify as the priority?
Non reactive non stress test
A nurse at a prenatal clinic is collecting data from an adolescent who is pregnant and is visiting the clinic for the first time. Which of the following evaluations is the nurse's priority?
Nutritional status
A nurse is collecting data for a newborn who is 12 hours old and notes mild jaundice of the face and trunk. Which of the following actions should the nurse take?
Obtain a stat prescription for a bilirubin level Jaundice in the first 24 hours after birth is pathologic. The nurse should notify the provider and obtain a stat prescription for a bilirubin level.
A nurse is calculating a client's estimated date of delivery using Naegele's rule. The client's last menstrual period started on January 20. Which of the following is the client's expected date of delivery?
October 27
A nurse 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?
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.
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?
Pelvic and uterine pain is present while at rest.
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?
Pelvic hematoma
A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy?
Pelvic inflammatory disease An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus, and the placenta and fetus begin to develop there. The most common site is within a fallopian tube, but ectopic pregnancies can occasionally occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, pelvic inflammatory disease (PID) places the client at risk for an ectopic pregnancy.
A nurse is caring for a newly admitted newborn who is large for gestational age. After 30 minutes, the newborn becomes jittery and lethargic with hypotonic muscles and a cry that is different from the time of admission. Which of the following actions should the nurse take?
Perform a heel stick to check the newborn's glucose level
A nurse is assisting with the care of a newborn who has hyperbilirubinemia and is scheduled to receive phototherapy. Which of the following actions should the nurse take?
Place an opaque mask over the newborn's eyes The nurse should cover the newborn's eyes with an opaque mask to prevent retinal damage from the ultraviolet light used in phototherapy.
A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take?
Place the unwrapped newborn on the mother's bare chest
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?
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.
A nurse is collecting data from a client who has hyperemesis gravidarum. Which of the following findings should the nurse expect?
Presence of ketones in the urine The nurse should expect a client who has hyperemesis gravidarum to have ketonuria due to an inadequate dietary intake, resulting in the breakdown of protein and stored fat.
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?
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.
A nurse is collecting data from a client who is in labor and has received epidural anesthesia for pain control. Which of the following manifestations should the nurse identify as an adverse effect of epidural anesthesia?
Pruritus Pruritus (severe itching of the skin) is an adverse effect of epidural anesthesia often associated with an opioid. Pruritus can be controlled by the use of antipruritic medications.
A nurse is caring for a client who is in the first trimester of pregnancy and asks how to manage heartburn. Which of the following responses should the nurse make?
Reduce the amount of food you eat during meals. The nurse should recommend that the client avoid eating large meals and avoid eating foods that are gas-producing or have a high fat content.
A nurse is collecting data from a client who is postpartum. Which of the following findings should the nurse report to the provider?
Report of blurred vision Visual disturbances such as blurred vision and diplopia are manifestations of preeclampsia and should be reported to the provider.
A nurse is preparing to perform a heel stick on a newborn. Which of the following actions should the nurse take?
Restrain the newborn's foot The nurse should restrain the newborn's foot with a free hand. This is done to prevent the newborn from moving around so that the nurse can quickly get an accurate heel stick.
A nurse is reinforcing teaching with new parents about newborn reflexes. Which of the following reflexes facilitates infant feeding? Show Explanation
Rooting The rooting reflex is elicited when the cheek is stroked, causing the newborn to turn his/her head while making sucking motions with the mouth. This reflex supports effective sucking.
The nurse is reviewing the laboratory results of a term newborn. For which of the following findings should the nurse notify the provider?
Serum glucose 120 mg/dL The expected reference range for serum glucose for a term newborn under 1 day old is 30 to 60 mg/dL. A laboratory result of 120 mg/dL is greater than the expected reference range and should be reported to the provider.
A nurse is reinforcing teaching with a client who is postpartum and has a hearing impairment. Which of the following techniques should the nurse use?
Sit at the client's eye level When speaking, the nurse should face the client directly and should be at the same level.
A nurse is reinforcing teaching about newborn skin care with a group of new parents. Which of the following instructions should the nurse include?
Sponge-bathe the newborn every other day Daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The parents should sponge-bathe the infant until the cord stump has detached and the area has healed.
A nurse is instructing a client about how to use a diaphragm. In what order should the client complete the insertion process? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Step 1. The nurse should instruct the client to inspect the diaphragm using a light source or by filling the diaphragm with water to detect any small holes. Step 2. The nurse should place 2 tsp of contraceptive jelly on the side of the diaphragm that will go against the cervix. Step 3. The nurse should assume a squatting position. Step 4. The nurse should hold the diaphragm between the thumb and fingers. Step 5. The nurse should insert the diaphragm into the vagina.
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?
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.
A nurse is teaching a client who is in the third trimester of pregnancy and has herpes genitalis. Which of the following instructions should the nurse include?
Talk with your doctor about a prescription for acyclovir to treat your symptoms
A nurse is reinforcing teaching with the parent of a premature infant on interventions to promote optimal development. Which of the following actions should the nurse instruct the parent to take?
Teach the parent to provide kangaroo care for the infant Studies show that premature infants who are held skin-to-skin (i.e. given kangaroo care) demonstrate improved thermostability, oxygen saturation, interest in feeding, and maintenance of an organized, relaxed state.
A nurse is collecting data from a newborn who was circumcised 24 hours ago. Which of the following findings should the nurse report to the provider?
The newborn has urinated once since the circumcision. A newborn should void 2 to 6 times a day the first 24 to 48 hours after birth and then 6 to 8 times per day starting on the third day. Therefore, the nurse should report 1 void in 24 hours following circumcision to the provider.
A nurse is reinforcing discharge teaching with a client about breastfeeding her newborn. Which of the following pieces of information should the nurse include?
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.
A nurse is preparing to provide care for a newborn with a light skin tone who was recently assigned an Apgar score of 2 for color. Which of the following findings should the nurse expect to observe in the newborn?
The newborn's skin will appear completely pink all over. A newborn who has skin that is completely pink would receive an Apgar score of 2.
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?
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.
A nurse enters the hospital room of client who has preeclampsia. The client is out of bed, falls, and begins having tonic-clonic convulsions. Which of the following actions should the nurse take?
Turn the client's head to the side This action helps keep the client's airway clear and is a priority for client safety during convulsions.
A nurse is preparing to elicit the fencing reflex from a newborn. Which of the following actions should the nurse take?
Turn the newborn's head quickly to 1 side
A nurse is collecting data from a client with suspected hyperemesis gravidarum. Which of the following laboratory tests should the nurse check first?
Urine ketones When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority laboratory test to check is urine ketones. Excessive ketones in the urine indicate the body is not using carbohydrates from food as fuel and is inadequately trying to break down fat. The presence of ketones in the urine supports the diagnosis of hyperemesis gravidarum.
A nurse is caring for a client who is at 16 weeks of gestation and has severe iron-deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication?
Use a 20-gauge needle and administer the medication using the Z-track method The nurse should administer iron using the Z-track method to prevent tissue staining. A 20-gauge needle is the correct size.
A nurse is reinforcing teaching with a client in the third trimester of pregnancy who reports difficulty sleeping. Which of the following instructions should the nurse provide?
Use additional pillows to support extremities and abdomen Finding a comfortable position for sleeping can be challenging during the last 3 months of pregnancy due to fetal growth. Using additional pillows promotes a more comfortable sleeping position.
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?
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.
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?
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.
A nurse is collecting data from a newborn who is 18 hours old. Which of the following findings should be reported to the provider?
Yellow tinge to the skin Jaundice in the first 24 hours is not an expected finding and should be reported to the provider. It can indicate the presence of a neonatal hemolytic disorder.
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?
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.
A nurse is reinforcing teaching with the parent of a breastfed newborn about bowel elimination. Which of the following statements should the nurse make?
You can expect the stools to be yellow and seedy. The nurse should inform the parents to expect the newborn's stools to be yellow in color and seedy in texture.
A nurse is reinforcing education with a client who is at 34 weeks of gestation about a non stress test period which of the following pieces of information should the nurse include?
You might have to drink orange juice during the test
The nurse is reinforcing teaching with a client who is postpartum about the rubella vaccine. Which of the followings statements should the nurse include?
You must not become pregnant for 28 days after receiving this immunization. Clients must not become pregnant for 28 days following rubella immunization. They should be educated about the possible side effects and risk of teratogenic effects on the developing fetus.
A nurse is reinforcing teaching with a client who has hemorrhoids following a vaginal birth. Which of the following statements should the nurse include in the teaching?
You should apply witch hazel after voiding or defecating
A nurse is reinforcing teaching about toxoplasmosis with a client who is pregnant. Which of the following instructions should the nurse include?
You should avoid gardening during your pregnancy to decrease your risk of contracting toxoplasmosis. Toxoplasmosis infection is potentially teratogenic to the fetus. It can be transmitted through contact with cat feces, which can be found in garden areas. It can also be transmitted through contact with uncooked meat.
A nurse is reinforcing teaching with a client who is pregnant and has type one diabetes mellitus. Which of the following statements should the nurse include in teaching?
You should expect to decrease your insulin dosage immediately after you deliver your baby
A nurse is reinforcing teaching about weight gain during pregnancy for a client who is a primigravida of normal pre-pregnancy weight. Which of the following statements should the nurse include?
You should plan to gain 25 to 35 pounds during your pregnancy A client of normal prepregnancy weight should plan to gain 11.3 to 15.9 kg (25 to 35 lb) during pregnancy. Weight gain is primarily for maternal tissue growth during the first and second trimesters and fetal tissue growth during the third trimester.
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?
You should plan to gain no more than 20 lb during your pregnancy.
A nurse is reinforcing teaching with a client who is pregnant. Which of the following instructions should the nurse include?
You should use fluoride-based toothpaste to prevent dental caries
A nurse is reinforcing teaching with the guardian of a newborn about car seat safety. Which of the following pieces of information should the nurse include?
Place the shoulder harness in the slots that are level with the newborn's shoulders The guardian should place the shoulder harness in the slots that are level or slightly below the newborn's shoulders to ensure the child is restrained in the event of an accident.
A nurse is reinforcing teaching with a client who is at 32 weeks of gestation and reports regular alcohol use during her pregnancy. The nurse should inform the client that her child is at risk for which of the following characteristics?
Poor coordination
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.)
Massage the fundus Administer oxytocin with IV fluids Insert an indwelling urinary catheter Place the client in a lateral position with her legs elevated 30°
A nurse is reinforcing discharge teaching with the parent of a newborn regarding the immunization schedule. Which of the following parent statements indicates an understanding of the teaching?
My baby will receive the next immunization at 2 months old Newborns should receive the next scheduled immunization 2 months after birth.
A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the nurse's priority?
My heart feels as if it is racing.
A nurse is using Naegele's rule to determine the estimated date of birth (EDB) for a client whose first day of her last menstrual period was February 2, 2018. The nurse should identify which of the following as the client's EDB?
November 9, 2018
A nurse is measuring the body length of a newborn. Which of the following actions should the nurse take?
Place the newborn on a flat surface
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 progestin-only pill or injection is available for use while you are breastfeeding
In nurses caring for a client who is postpartum and non lactating. The client reports breast pain. Which of the following statements should the nurse make?
Be sure to wear a well fitted supportive bra
A nurse is collecting data from a newborn who has a congenital diaphragmatic hernia. Which of the following findings should the nurse expect?
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.
A nurse is reinforcing teaching about calcium intake with a client who is breastfeeding. Which of the following amounts of calcium is the daily recommended amount for a woman who is breastfeeding?
1,000 mg The nurse should instruct the client that 1,000 mg of calcium is recommended for women ages 19 and older, as well as those who are lactating. This amount of calcium is sufficient to meet the needs of the client and the infant because additional calcium is absorbed from the intestines.
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?
3+ deep tendon reflexes Deep tendon reflexes of 3+ or greater can indicate preeclampsia and should be reported to the provider.
A nurse is collecting data on a newborn who was born at 43 weeks of gestation. Which of the following findings should the nurse expect?
Absent vernix
A nurse is reviewing recent laboratory values during a prenatal visit for a client who is pregnant. The nurse notes a hemoglobin level of 10 g/dL. Which of the following actions should the nurse take?
Advise the client to start iron and vitamin C supplementation
A nurse is collecting data from a client 24 hr after delivery and notes the fundus is 2 cm above the umbilicus. Which of the following actions should the nurse take?
Ambulate the client to the bathroom
A nurse is assisting with the care of a client who is scheduled to have an amniocentesis to assess fetal lung maturity. The client is G2P1 at 36 weeks of gestation and has an O-positive blood type. Which of the following interventions should the nurse perform?
Apply an external fetal monitor to the client The nurse should assess fetal heart tones and uterine tone prior to and throughout the procedure to establish a baseline and assess for changes.
A nurse is assisting with the care of a client in active labor and notes late decelerations on the fetal monitor. Which of the following actions should the nurse take?
Apply oxygen at 10 liters per minute via non breather facemask
In nurse is reinforcing teaching about circumcision care with a parent of a newborn. Which of the following instructions should the nurse include?
Avoid using diaper wipes on the site during diaper changes
A nurse at a prenatal clinic is reinforcing teaching with a client about how to perform a kick count. Which of the following statements should the nurse include in the teaching?
Before bedtime is a good time to start counting the kicks Clients should be instructed to perform a kick count, which is the daily fetal movement count (DFMC), before bedtime or after meals for 2 hours, or until 10 movements are counted. Alternatively, the client can count all fetal movements in a 12-hour period each day until at least 10 movements are counted.
Hey nurse is assisting with the care of a client who is experiencing pre term labor. Which of the following medications should the nurse anticipate administering to enhance fetal lung muturation?
Betamethasone
A nurse is collecting data from a newborn following a vaginal birth with the assistance of a vacuum extractor device. The newborn has head swelling that crosses the suture line. The nurse should document this finding as which of the following conditions?
Caput succedaneum
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?
Carbohydrates should make up 55% of your diet.
The nurse is assisting the respiratory therapist with obtaining an arterial blood gas specimen for me newborn. Which of the following actions should the nurse take?
Carefully restrain the newborn during the procedure
A nurse is caring for a client during her first prenatal visit and notes that she is lactose intolerant. Which of the following foods should the nurse recommend as a calcium source for this client?
Collard greens
A nurse is reinforcing teaching with the parent of a newborn about preventing cold stress. Which of the following statements should the nurse include?
Skin-to-skin contact with the parent helps provide warmth
A nurse is collecting data from a client who is at 20 weeks of gestation and reports frequent episodes of indigestion and heartburn. Which of the following instructions should the nurse reinforce with the client?
Decrease your intake of spicy food
A nurse is preparing to perform a blood draw on a client during her first prenatal visit. The client reports an extreme fear of needles causing anxiety during blood draws or injections. Which of the following actions should the nurse take?
Encourage the client to practice deep breathing exercises
A nurse is reinforcing teaching about manifestations of postpartum depression with a client. Which of the following findings should the nurse include?
Episodes of irritability without justification
A nurse is reinforcing teaching with a client who is pregnant and reports increased nasal stuffiness. The nurse should inform the client that which of the following hormones is responsible for this discomfort?
Estrogen
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect?
Exaggerated reflexes A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the central nervous system (CNS). Exaggerated reflexes are indicative of CNS irritability.
A nurse is collecting data from a newborn at birth who was delivered at 32 weeks of gestation. Which of the following findings should the nurse anticipate?
Extended extremities
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?
Fetal scalp electrode
A nurse is providing teaching to a client who is 1 hour postpartum about using the perineal squeeze bottle. Which of the following instructions should the nurse include?
Fill the perineal bottle with warm water prior to use The client should fill the squeeze bottle and use the entire contents each time she voids or has a bowel movement to cleanse her perineum. Warm water will promote healing and increase comfort to the perineal area. Cold water will be uncomfortable, and hot water could cause tissue trauma.
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?
Frequent stimulation
A nurse is reviewing laboratory findings for a newborn. Which of the following findings should the nurse report to the provider?
Glucose 29 mg/dL
A nurse in an antepartum clinic is collecting data from a client who is at 38 weeks of gestation. Which of the following findings should the nurse report to the provider?
Glycosuria
A nurse in a prenatal clinic is reinforcing teaching with a client who has a new diagnosis of heartburn. Which of the following statements should the nurse include?
Go for a walk after eating
A nurse is reinforcing teaching with a parent about how to care for his newborns circumcision site. which of the following clients statements indicates an understanding of the teaching?
I should apply what type are loosely until the circumcision site is healed
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
I should be careful to avoid becoming pregnant within the next month
The nurse is reinforcing discharge teaching with the guardians of a newborn about how to use a bulb syringe. Which of the following statements by a guardian indicates an understanding of the teaching?
I should insert the bulb syringe at the corners of the baby's mouth to suction the cheek pockets. The tip of the bulb syringe should be inserted into the corner of the mouth, and secretions should be suctioned from the pockets of the cheeks. The guardians should avoid inserting the bulb syringe tip into the middle of the mouth because it can cause the child to gag.
A nurse in an antepartum clinic is reinforcing teaching about recommended weight gain with a client who is at 12 weeks of gestation. The client has a documented prepregnancy BMI of 32. Which of the following client statements indicates an understanding of the teaching?
I should limit my weight gain to 20 pounds during pregnancy. Clients who have a prepregnancy BMI over 30 are considered to be obese and should plan to limit their weight gain to 5 to 9.1 kg (11 to 20 lb) during pregnancy.
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?
I should press the button on the handheld marker when my baby moves.
A nurse is reinforcing teaching about home care with the parent of a newborn. Which of the following statements indicates an understanding of the teaching?
I should remove the bumper pad and stuffed toys from my baby's crib
A nurse is reinforcing discharge teaching about circumcision care for the parent of a newborn who has undergone a Gomco clamp procedure. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
I will apply petroleum jelly to my baby's penis for the first few days he client should apply petrolatum to the penis with each diaper change to protect the incision from contact with urine and feces.
In 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?
I will feel the effects of the nitrous oxide almost immediately
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?
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.
A nurse is talking with a client during her initial prenatal visit. The client reports a history of trisomy 13 syndrome in her family and is concerned her fetus might be at risk. Which of the following statements should the nurse provide?
If you sign an informed consent form, we can perform genetic screening to see if your baby has this disorder.
A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal findings is a potential risk factor for pathological hyperbilirubinemia?
Infection
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?
Instruct the client about relaxation breathing techniques
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?
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.
A nurse is assisting with the care of a pregnant client at 37 weeks of gestation who has a biophysical profile score of 4. Which of the following actions should the nurse anticipate taking?
Prepare the client for delivery
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?
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.
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?
Promote active movement in and out of bed
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?
Provide a sitz bath with warm water
A client who is pregnant tells the nurse that she is financially unable to buy the food and vitamins recommended during pregnancy. Which of the following actions should the nurse suggest when contributing to the plan of care for the client?
Refer the client to a community resource that could assist with providing nutrition
A nurse is obtaining the blood pressure of a client who is pregnant. The client's blood pressure is 142/90 mmHg. Which of the following actions should the nurse take?
Repeat the measurement after allowing the client to sit for 5 to 10 minutes
A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following interventions should the nurse include in the plan?
Reposition the newborn every 3 hours The nurse should reposition the newborn every 2 to 3 hours during phototherapy to maximize skin exposure to the light.
A nurse in a clinic is caring for a client who is pregnant and reports a last menstrual period (LMP) that began on December 7. Which of the following dates would be the client's estimated date of birth (EDB)?
September 14
A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. Which of the following actions should the nurse plan to take when performing a fundal massage? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Step 1. The nurse should gently massage the fundus to restore the muscle tone of the client's uterus. First, the nurse should place the client on her back with her knees flexed. Step 2. The nurse should place a hand just above the symphysis pubis Step 3. The nurse should position the other hand around the top of the client's fundus. Step 4. The nurse should rotate the upper hand to massage the client's uterus. Step 5. The nurse should use slight downward pressure to compress the client's fundus.
A nurse is reinforcing teaching with a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include?
Stress incontinence
A nurse in a provider's office is reviewing the medical record of a client who is at 28 weeks of gestation. The nurse should identify that prophylactic administration of Rh immune globulin is contraindicated for which of the following findings?
The client has Rh-positive blood.
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?
The client has given the newborn a name.
A nurse is collecting data from a client who is postpartum which of the following findings should the nurse report to the provider?
The fundus feels soft and is a fingerbreadth below the umbilicus 72 hours after delivery.
A nurse is caring for a newborn who has a prescription for phototherapy. The mother asks why the newborn needs to lay under a special light. Which of the following responses should the nurse make?
The light will help lower your baby's bilirubin level Jaundice is caused by the breakdown of red blood cells, which release bilirubin. A newborn's immature liver is unable to filter and excrete the bilirubin efficiently, leading to accumulation of bilirubin in the tissues. The ultraviolet light in phototherapy assists in breaking down the bilirubin so that it can be excreted in the urine and feces.
A nurse is caring for a client who had pelvic measurements recorded by the provider. The client asks, "Since my pelvis is gynecoid, will I be able to deliver vaginally?" Which of the following responses should the nurse make?
The shape of your pelvis is ideal for vaginal childbirth
A nurse is caring for a client who is at 8 weeks of gestation with Twins and is primigravida. The client states that even though she and her husband planned this pregnancy, she is experiencing many ambivalent feelings about. Which of the following responses should the nurse provide?
These feelings are normal at the beginning of pregnant
A nurse is reinforcing teaching about nutritional requirements during lactation for a client who is planning to breastfeed her newborn. Which of the following nutrients should nurse recommend the client increase during lactation?
Vitamin C Explanation: The nurse should recommend the client increase her vitamin C intake during lactation to 115 to 120 mg per day.
A nurse is reinforcing discharge teaching with a client who is postpartum. Which of the following statements should the nurse make?
You should notify the provider immediately if either of your legs becomes swollen.
A nurse is reviewing the medical record of a client who is at 20 weeks of gestation. Which of the following findings of the nurse identify as a presumptive indication of pregnancy?
reports of fetal movement by the client
a nurse is reinforcing teaching to a client who is postpartum and has been prescribed warfarin therapy for deep vein thrombosis. which of the following instructions should the nurse include?
you will need to use a reliable form of contraception while on warfarin therapy
