Test 4 Maternal Pediatric
The mother of a formula-fed newborn asks how she will know if her newborn is receiving enough formula during feedings. Which response by the nurse is correct?
"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."
The nurse is conducting a teaching session for breastfeeding mothers. Which statement by a mother requires further clarification by the nurse?
"I am glad I can have my two cups of coffee in the morning again."
A nurse has been assigned to assess a pregnant client for abruptio placenta. For which classic manifestation of this condition should the nurse assess?
"knife-like" abdominal pain with vaginal bleeding
A low-risk client is in the active phase of labor. The nurse evaluates the fetal monitor strip at 10:00 a.m. and notes the following: moderate variability, FHR in the 130s, occasional accelerations, and no decelerations. At what time should the nurse reevaluate the FHR?
10:30 a.m.
The nurse is reviewing client data following a regular monthly appointment at 6 months' gestation. Which fundal height requires no further intervention?
24 cm
A client in labor has requested the administration of narcotics to reduce pain. At 2 cm cervical dilatation, she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do?
Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor.
What is the most effective way for a nurse to assess a woman's usual food intake during her pregnancy?
Ask her to describe her intake for the last 24 hours.
The practical nurse is evaluating the tracings on the fetal heart monitor. The nurse is concerned that there is a change in the tracings. What should the practical nurse do first?
Assess and reposition the woman.
A breastfeeding mother wants to know how to help her 2-week-old newborn gain the weight lost after birth. Which action should the nurse suggest as the best method to accomplish this goal?
Breastfeed the infant every 2 to 4 hours on demand.
A nurse is teaching a group of pregnant women about the signs that labor is approaching. When describing these signs, which sign would the nurse explain as being essential for effacement and dilation to occur?
Cervical ripening and softening
A woman has come to the clinic for her first prenatal visit. Which method would be the most effective way for the nurse to initiate data gathering for a health history?
Conduct an interview in a private room to obtain her health history.
The nurse is assessing a client at 12 weeks' gestation who reports enjoying her usual slow, long daily walk. The nurse should point out which recommendation to this client?
Continue this as long as she enjoys it.
Which disease process would the nurse screen for under potential genetic disorders?
Cystic fibrosis
A woman in early labor is using a variety of techniques to cope with her pain. When the nurse enters the room she notes that the woman is making light, circling movements with her fingertips across her abdomen. What technique is she using?
Effleurage
A multigravida client is pregnant for the third time. Her previous two pregnancies ended in an abortion in the first and third month of pregnancy. How will the nurse classify her pregnancy history?
G3 P0020
Why is a Papanicolaou test done at the first prenatal visit?
It identifies abnormal cervical cells.
A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest. The rash has tiny red lesions all across the nipple line. What does this rash indicate?
It is a normal skin finding in a newborn.
A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation?
Newborns have the ability to focus only on objects in close proximity.
A client at 37 weeks' gestation presents to the emergency department with a BP 150/108 mm Hg, 1+ pedal edema, 1+ proteinuria, and normal deep tendon reflexes. Which assessment should the nurse prioritize as the client is administered magnesium sulfate IV?
Respiratory rate
A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response?
Support the client's decision and call the obstetrician.
Which client outcome during active and transitional labor is best?
The client will practice breathing techniques during contractions.
What assessment finding would suggest to the care team that the pregnant client has completed the first stage of labor?
The client's cervix is fully dilated.
The nurse is planning a class for nurses learning to teach early prenatal classes. Which statement indicates that teaching has been effective?
The goal of early prenatal care is to optimize the health of the woman and the fetus.
A nurse determines that a newborn has a 1-minute Apgar score of 5 points. What conclusion would the nurse make from this finding?
The infant is experiencing moderate difficulty in adjusting to extrauterine life.
A nurse at the health care facility assesses a client at 20 weeks' gestation. The client is healthy and progressing well, without any sign of complications. Where should the nurse expect to measure the fundal height in this client?
at the level of the umbilicus
A woman is being closely monitored and treated for severe preeclampsia with magnesium sulfate. Which finding would alert the nurse to the development of magnesium toxicity in this client?
diminished reflexes
The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding?
duration
Which finding from a woman's initial prenatal assessment would be considered a possible complication of pregnancy that requires reporting to a primary care provider for management?
episodes of double vision
The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use?
external electronic fetal monitoring
During the initial clinic visit for a primapara woman, the nurse reviews the topic of constipation during pregnancy when the woman interjects that she has been "straining forcefully" almost on a daily basis. The nurse offers some measures that may help to prevent the occurrence of which complication?
hemorrhoid development that may eventually need surgical repair
A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will:
instruct the client or her partner to perform light fingertip repetitive abdominal massage.
A full-term neonate delivered an hour after the mother received IV meperidine is showing signs of respiratory depression. The nurse should be prepared to administer which medication?
naloxone
A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?
respiratory rate
A nurse working in the neonatal nursery anticipates the primary care provider to prescribe which medication for a premature newborn having difficulty breathing?
surfactant
The American Academy of Pediatrics and the American Dietetic Association recommend breastfeeding exclusively for how long?
the first 6 months
The nurse is assessing the abdomen of the neonate. When inspecting the umbilical cord area of a newborn, the nurse would expect which finding?
two arteries and one vein
A nurse is performing a vaginal examination of a woman in the early stages of labor. The woman has been at 2 cm dilated for the past 2 hours, but effacement has progressed steadily. Which statement by the nurse would best encourage the client regarding her progress?
"You are still 2 cm dilated, but the cervix is thinning out nicely."
A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize?
Ask the woman to describe why she believes that she is in labor.
At 32 weeks' gestation a client with a BMI of 23 has gained 24 lb (11 kg). What is the nurse's recommendation for weight gain for the remainder of this pregnancy?
Continue to gain approximately 1 lb (.45 kg) per week during this pregnancy.
A client at 27 weeks' gestation still walks daily but reports "terrible" heartburn at night. Which action should the nurse point out will best address this situation?
Elevate the head of the bed.
The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as:
Epstein pearls.
Which consideration is a priority when caring for a mother with strong contractions 1 minute apart?
Fetal heart rate in relation to contractions
What term is used to describe the position of the fetal long axis in relation to the long axis of the mother?
Fetal lie
A 32-year-old woman presents to the labor and birth suite in active labor. She is multigravida, relaxed, and talking with her husband. When examined by the nurse, the fetus is found to be in a cephalic presentation. His occiput is facing toward the front and slightly to the right of the mother's pelvis, and he is exhibiting a flexed attitude. How does the nurse document the position of the fetus
ROA
The nurse is reinforcing health care provider education on the technique for an amniocentesis. Which piece of equipment will the nurse have ready?
Ultrasound equipment
The nurse is assessing a neonate as he transitions to extrauterine life. The nurse integrates understanding that which structure closes as a result of the neonate's first breath?
foramen ovale
A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply.
Assess client for underlying causes. Administer oxygen by mask. Turn the client on her left side.
A nurse is conducting a presentation for a group of pregnant women about labor and the importance of being well prepared and having good labor support. The nurse determines that additional discussion is needed when the group identifies which possible outcome as the result of being prepared?
need for someone to control the situation
A pregnant woman at her first prenatal visit asks the nurse if it is safe to have sex during her pregnancy. Which client statement alerts the nurse to the need for further teaching?
"I should substitute intercourse with nonsexual touch to avoid harming the fetus."
A pregnant woman enjoys exercising at a local health spa once a week. Which comment would lead the nurse to believe she needs additional health teaching?
"Nothing feels nicer than a hot sauna after exercise."
The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth?
"The baby is coming. I'll explain what's happening and guide you."
The community health nurse is conducting a presentation on labor and delivery. When illustrating the birth process, the nurse should point out zero station refers to which sign?
"The presenting part is at the true pelvis and is engaged."
A labor nurse is caring for a client who is 7 cm dilated, 100% effaced, at a +1 station, and has a face presentation on examination. The nurse knows that teaching was understood when the birth partner makes which statement?
"Our baby will come out face first."
A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize?
A dipstick value of 2+ for protein
A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax?
Anxiety can slow down labor and decrease oxygen to the fetus.
A nurse in the maternity triage unit is caring for a client with a suspected ectopic pregnancy. Which nursing intervention should the nurse perform first?
Assess the client's vital signs.
During which time is the nurse correct to document the end of the third stage of labor?
At the time of placental delivery
The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client?
Continuous labor support
The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism?
Convection
Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia?
Difficulty breathing
What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums?
Epstein pearls
The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?
Fetal position
A 41-year-old pregnant woman and her husband are anxiously awaiting the results of various blood tests to evaluate the fetus for potential Down syndrome, neural tube defects, and spina bifida. Client education should include which information?
Further testing will be required to confirm any diagnosis.
Which protective equipment is most appropriate when assisting the health care provider in the delivery of the fetus? Select all that apply.
Goggles Gloves Gown
The nursing instructor is teaching a class on the physiologic properities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function?
It keeps alveoli from collapsing with breaths.
When caring for a client in the third stage of labor, the nurse notices that the expulsion of the placenta has not occurred within 5 minutes after birth of the infant. What should the nurse do?
Nothing. Normal time for stage three is 5 to 30 minutes.
A 31-year-old client at 28 weeks' gestation reports frequent low back pain and ankle edema by the end of the day. Which suggestion should the nurse prioritize for this client?
Rest when possible with feet elevated at or above the heart.
A nurse is teaching a new mother about what to expect for bowel elimination in her newborn. Because the mother is breastfeeding, what should the nurse tell her about the newborn's stools?
Stools should be yellow-gold, loose, and stringy to pasty.
The client is 32 weeks pregnant and has been referred for biophysical profile (BPP) after a nonreassuring nonstress test (NST). Which statement made by the client indicates that the nurse's explanation of the procedure was effective?
The BPP is an ultrasound that measures breathing, body movement, tone, and amniotic fluid volume.
A pregnant client wants to know why the labor of a first-time-pregnant woman usually lasts longer than that of a woman who has already given birth once and is pregnant a second time. What explanation should the nurse offer the client?
The cervix takes around 12 to 16 hours to dilate during first pregnancy.
There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain?
Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience.
On examination, the hands and feet of a 12-hour-old infant are cyanotic without other signs of distress. The nurse should document this as:
acrocyanosis.
A nurse is conducting an in-service program for staff nurses working in the labor and birth unit. The nurse is discussing ways to promote a positive birth outcome for the woman in labor. The nurse determines that additional teaching is necessary when the group identifies which measure?
allowing the woman time to be alone
As a part of the newborn assessment, the nurse examines the infant's skin. Which nursing observation would warrant further investigation?
bright red, raised bumpy area noted above the right eye
The nurse measures a newborn's temperature immediately after birth and finds it to be 99°F (37.2°C). An hour later, it has dropped several degrees. The nurse understands that this heat loss can be explained in part by which factor in the newborn?
lack of subcutaneous fat
The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding?
lie
A client is in the first stage of labor and asks the nurse what type of pain she should expect at this stage. What is the nurse's most appropriate response?
pain from the dilation or stretching of the cervix
A pregnant woman has arrived to the office reporting vaginal bleeding. Which finding during the assessment would lead the nurse to suspect an inevitable abortion?
strong abdominal cramping
