The Point OB Part 2

Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is: taking-in, taking-hold, letting-go. taking-in, holding-on, letting-go. taking-in, taking-on, letting-go. taking, holding-on, letting-go.

taking-in, taking-hold, letting-go.

The nurse suspects that a newborn is experiencing a drop in its blood sugar. Which symptoms are early signs of hypoglycemia in this client? Select all that apply. irritability increased appetite diaphoresis jitteriness low body temperature

jitteriness irritability

The nurse is caring for a client in the transition phase of the labor process. Which client statement requires nursing action? "My lips and fingers are tingling." "I feel burning in my perineum." "My contractions are really intense now." "My mouth and lips are so dry."

"My lips and fingers are tingling."

The heart rate of the newborn in the first few minutes after birth will be in which range? 80 to 120 bpm 120 to 130 bpm 180 to 220 bpm 110 to 160 bpm

110 to 160 bpm

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 ml with each hourly void. How would the nurse interpret this finding? The urinary output is above expected levels. The urinary output is normal. The urinary output is inadequate suggestive of urinary retention. The urinary output is inadequate and the mother needs to drinks more fluids.

The urinary output is normal.

The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event? Cord compression Maternal fatigue Uteroplacental insufficiency Maternal hypotension

Uteroplacental insufficiency

Which method does the nurse use to determine fetal presentation, position, and attitude? Assess location of fetal kicks. View on an ultrasound. Utilize Leopold maneuvers. Complete a vaginal examination.

Utilize Leopold maneuvers.

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next? fetal scalp stimulation application of vibroacoustic stimulation administration of oxygen by mask tactile stimulation

administration of oxygen by mask

A nurse is providing care to a 3-hour-old neonate. The nurse ensures that her hands are warm prior to touching the neonate to prevent heat loss by which mechanism? radiation evaporation convection conduction

conduction

During the assessment of a woman in labor, the nurse explains that certain landmarks are used to determine the progress of the birth. The nurse identifies which area as one of these landmarks? cervical os ischial tuberosity pubic symphysis ischial spine

ischial spine

A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding? increased feelings of control increased cervical dilation (dilatation) less anxiety decreased sedation

less anxiety

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency? urinary tract infection postpartum diuresis trauma to pelvic muscles urinary overflow

postpartum diuresis

After completing a class for new parents, the nurse notes the session is successful when the class recognizes the newborn should be bathed how often? two or three times per week once a day every other day once a week

two or three times per week

A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern? "I'm sorry to hear that. There are some excellent formulas on the market now, so you will still be able to provide for your infant's nutritional needs." "You are experiencing lactational amenorrhea. It may be several weeks before your milk comes in." "You may have developed mastitis. I'll ask the primary care provider to examine you." "It takes about 3 days after birth for milk to begin forming."

"It takes about 3 days after birth for milk to begin forming."

The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response? Moro rooting fencing tonic neck

Moro

Which laboratory test results would the nurse consider as a normal finding in a newborn soon after birth? platelets: 600,000/uL red blood cells: 3,500,000/uL white blood cells: 5,000/mm3 hemoglobin: 17.5 g/dl

hemoglobin: 17.5 g/dl

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client? increase in the body temperature lethargy and hypotonia increased appetite hyperglycemia

lethargy and hypotonia

The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply. uterine resting tone change in temperature frequency of contractions intensity of contractions change in blood pressure

uterine resting tone frequency of contractions intensity of contractions

A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take? Call the primary care provider. Stimulate the neonate. Inform the charge nurse. Document the data.

Document the data.

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize? Watch for signs of eye irritation. Instill 0.5% ophthalmic erythromycin. Instill 0.5% ophthalmic silver nitrate. Instill 0.5% ophthalmic tetracycline.

Instill 0.5% ophthalmic erythromycin.

The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system? Fluid is removed from the alveoli and replaced with air. Pressure changes occur and result in closure of the ductus arteriosus. Oxygen is exchanged in the lungs. The oxygen in the blood decreases.

Pressure changes occur and result in closure of the ductus arteriosus.

The nurse cares for a newborn with a congenital cardiac anomaly. What component of nursing care is the priority for the newborn? Accompany the newborn to all radiologic examinations. Maintain oxygen saturation at 95% or above. Prevent pain as much as possible. Teach the parents to take pulse and blood pressure measurements.

Prevent pain as much as possible.

The nurse is preparing a nursing care plan for an immediate postpartum client. Which nursing diagnosis should the nurse prioritize? Acute pain related to afterpains or episiotomy discomfort Risk for infection related to multiple portals of entry for pathogens Risk for injury: postpartum hemorrhage related to uterine atony Risk for injury: falls related to postural hypotension and fainting

Risk for injury: postpartum hemorrhage related to uterine atony

A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience? postpartum reaction postpartum depression postpartum baby blues postpartum anxiety

postpartum baby blues

The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize? Report tachypnea. Document normal findings. Recheck blood pressure in 15 minutes. Put warming blanket over infant.

Document normal findings.

When collecting data to devise a labor plan for a multiparous woman, which question bestallows the nurse to develop individualized strategies? "Picking from these options, what options do you feel is best?" "Tell me how you handled labor pain in your past deliveries." "Who do you want to be with you when you are in labor?" "How do you want the health care team to plan your care?"

"Tell me how you handled labor pain in your past deliveries."

Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing? Bathe the baby under a radiant warmer. Postpone breastfeeding until after the initial bath. Limit the bathing time to 5 minutes. Bathe the baby in water between 90 and 93 degrees.

Bathe the baby under a radiant warmer.

A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority? fetal position signs of infection maternal comfort level FHR

FHR

Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated? Have the client lightly push to meet the need. Have the client pant and blow through the contraction. Have the client divert the energy to squeezing a hand. Assist the client to a Fowler position.

Have the client pant and blow through the contraction.

A nurse is aware that the newborn's neuromuscular maturity assessment is typically completed within 24 hours after birth. Which assessment would the nurse be least likely to complete to determine the newborn's degree of maturity? popliteal angle scarf sign square window Moro reflex

Moro reflex

The nurse is caring for a client who is sent to the obstetric unit for evaluation of fetal well-being. At which location is the nurse correct to place the tocodynamometer? Midline but low on the abdomen On the right side of the abdomen At the level of the umbilicus On the uterine fundus

On the uterine fundus

The nurse is teaching new parents the best way to prevent hypothermia. Which mechanism would the nurse include when explaining about the newborn's primary method of heat production? thermoconduction shivering thermogenesis nonshivering thermogenesis thermoregulation

nonshivering thermogenesis

When assessing a postpartum woman, the nurse would find which factor to be most significant in identifying possible postpartum hemorrhage? pulse rate hematocrit blood pressure cardiac output

pulse rate

A nursing mother calls the nurse and is upset. She states that her newborn son just bit her when he was nursing. Upon examining the newborn's mouth, two precocious teeth are noted on the lower central portion of the gums. What would be the nurse's best response? "This is most unusual! Let me get the lactation specialist to assist you in breastfeeding. It should not be a problem though." "The teeth will fall out within the first month, so don't worry about them." "The teeth will fall out when the newborn's baby teeth come in so this is a blessing." "Precocious teeth can occur at birth but we may need to remove them to prevent aspiration."

"Precocious teeth can occur at birth but we may need to remove them to prevent aspiration."

A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize? Ensure the baby empties the breasts at each feeding Restrict fluid intake to 2 L each day. Apply ice packs before a feeding. Wear a tight fitting bra at all times.

Ensure the baby empties the breasts at each feeding

Which type of anesthesia is anticipated when the delivery of the fetus must be done quickly due to an emergency situation? Local Short acting Regional General

General

What measures can a nurse take to reduce the risk of hypoglycemia in a newborn? Select all that apply. Feed the newborn formula every 4 hours, starting 8 hours after birth. Dry the newborn off immediately after birth to prevent chilling. Begin skin-to-skin (kangaroo) care for the newborn. Feed only glucose water for the first 24 hours following birth. Initiate early and frequent breastfeeding.

Initiate early and frequent breastfeeding. Dry the newborn off immediately after birth to prevent chilling. Begin skin-to-skin (kangaroo) care for the newborn.

The nurse is caring for a newborn, born at 39 weeks' gestation, with a weight of 4120 grams. What action is the priority for the nurse? Educate the mother about the vitamin K given after birth. Monitor the glucose level. Assess mother-newborn bonding. Provide teaching about breastfeeding versus bottle feeding.

Monitor the glucose level.

The nursery nurse notes that one of the newborn infants has white patches on his tongue that look like milk curds. What action would be appropriate for the nurse to take? Wipe the tongue off vigorously to remove the white patches. Report the finding to the pediatrician. Rinse the tongue off with sterile water and a cotton swab. Since it looks like a milk curd, no action is needed.

Report the finding to the pediatrician.

by the nurse when asked by the client what this means concerning the location of the baby? 1 cm below the symphysis pubis. 1 cm above the ischial spine. 1 cm above the symphysis pubis. 1 cm below the ischial spine.

1 cm below the ischial spine.

The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment? 1 cm above the umbilicus 1 cm below the umbilicus At the symphysis pubis At level of umbilicus

1 cm below the umbilicus

The nurse receives a report from labor and delivery on an infant and mother couplet. Which reported Apgar score will the nurse prioritize for close observation for the entire transition period? 8 at 1 minute; 9 at 5 minutes 5 at 1 minute; 6 at 5 minutes 7 at 1minute; 8 at 5 minutes 6 at 1 minute; 7 at 5 minutes

5 at 1 minute; 6 at 5 minutes

A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life? 20% of their birth weight 10% to 15% of their birth weight 5% to 10% of their birth weight 15% to 18% of their birth weight

5% to 10% of their birth weight

A nurse is explaining to new parents how a newborn adapts to extrauterine life. When discussing the physiologic changes that occur, the nurse would explain that this transition usually occurs within the first: 4 to 6 hours of life. 6 to 10 hours of life. 8 to 12 hours of life. 2 to 4 hours of life.

6 to 10 hours of life.

A woman in scrubs enters a mother's room while the nurse is completing an assessment. The woman states the doctor is in the nursery and has requested the infant be brought back for an examination. What will the nurse do? Ask how long the infant will be gone since her next feeding is in 30 minutes. Ask the woman to bring the infant back when the doctor finishes the examination. Call the nursery to confirm the doctor does indeed need this infant at this time. Ask to see the woman' hospital identification badge.

Ask to see the woman' hospital identification badge.

Prior to infusing medication into an epidural catheter inserted into a laboring mother, which vital sign is a priority? Respiratory rate Temperature Pain level Blood pressure

Blood pressure

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? Recommend that the mother pump her breast milk and measure it before feeding. Weigh the infant daily to ensure that she is gaining 1.5 to 2 ounces (42.5 to 57 grams) per day. Add cereal to the newborn's feedings twice a day. Breastfeed the infant every 2 to 4 hours on demand.

Breastfeed the infant every 2 to 4 hours on demand.

Patterned breathing techniques used in labor provide which benefits? Select all that apply. spirituality conscious relaxation distraction pain relief without special tools

conscious relaxation distraction pain relief without special tools

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition? hemorrhoids cervical laceration hemorrhage thromboembolism

hemorrhage

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize? maternal hypertension and fetal tachycardia maternal hypotension and fetal tachycardia maternal hypertension and fetal bradycardia maternal hypotension and fetal bradycardia

maternal hypotension and fetal bradycardia

A nurse is preparing to administer vitamin K to a newborn who was just birthed vaginally. Which site would be appropriate for the nurse to select? deltoid vastus lateralis ventrogluteal dorsogluteal

vastus lateralis

The nurse prepares to give the first bath to a newborn and notes a white cheese-like substance on the skin. The nurse should document this as which substance? vernix lanugo milia amniotic fluid

vernix

A nurse is reviewing the FHR and notes it to be in the range of 100 to 106 bpm over the past 10 minutes. Which conditions might the nurse suspect as the cause? Select all that apply. prematurity effect of maternal analgesia fetal hypoxia prolonged umbilical cord compression maternal fever

fetal hypoxia effect of maternal analgesia prolonged umbilical cord compression

The parents of a newborn male ask the nurse about circumcision. They are undecided as to what to do. Which response by the nurse is best? "I recommend you discuss the pros and cons of circumcision with the newborn's health care provider." "It is best not to circumcise your baby because the procedure is very painful for newborns." "Circumcision is best because it will prevent the baby from obtaining a sexually transmitted infection." "If you do not circumcise your baby, he will have difficulty maintaining adequate hygiene."

"I recommend you discuss the pros and cons of circumcision with the newborn's health care provider."

A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breastfeeding, the nurse would identify which hormone that is responsible for milk production? estrogen oxytocin prolactin progesterone

prolactin

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? "If your newborn is wetting three to four diapers and producing several stools a day, enough formula is likely being consumed." "Your newborn should finish a bottle in less than 15 minutes." "Your newborn should be taking about 2 oz of formula for every pound of body weight during each feeding." "A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."

"A sign of good nutrition is when your newborn seems satisfied and is gaining sufficient weight."

A client asks why she should learn breathing patterns for labor. After instruction is given, the nurse determines teaching has been effective when the client states: "Breathing patterns are distraction techniques taught to decrease pain in labor." "Breathing patterns cannot be taught while in labor." "Breathing patterns must be used with a coach." "Breathing patterns help a woman concentrate on pain."

"Breathing patterns are distraction techniques taught to decrease pain in labor."

A woman received morphine during labor to help with pain control. Which finding would the nurse need to monitor the newborn for after birth? low Apgar increased crying increased agitation decreased alertness

decreased alertness

The client pushes and the baby's head emerges. External rotation begins, but the baby's chin is drawn back just inside the vagina. The nurse recognizes that additional providers are needed in the delivery room. What emergency protocol does the nurse call? Fetal macrosomia Shoulder dystocia Cephalopelvic disproportion Nuchal cord

Shoulder dystocia

Which assessment finding is most important as labor progresses? The uterus relaxes completely between contractions. The pulse and respirations rise with the work of labor. The client is remaining in control of emotions. Labor is completed within 18 hours.

The uterus relaxes completely between contractions

Which assessment finding is most important as labor progresses? The client is remaining in control of emotions. The uterus relaxes completely between contractions. Labor is completed within 18 hours. The pulse and respirations rise with the work of labor.

The uterus relaxes completely between contractions.

Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize? Maternal heart rate Blood pressure Level of consciousness Respiratory status

Respiratory status

A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request? "As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" "That's a great idea! They can also take the baby out into the hall and walk with it for a while to give you a break." "Your baby is so vulnerable to infections right now that it would be better to wait until you are at home to introduce her to her siblings." "I recommend that you introduce the new baby to her siblings once you are back at home. Right now you need to rest and recover

"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?"

A client who gave birth 5 days ago reports profuse sweating during the night. What should the nurse recommend to the client in this regard? "Drink plenty of cold fluids before you go to bed." "I would suggest that you speak with your primary care provider about this." "Be sure to change your pajamas to prevent you from chilling." "I'm not sure why this is occurring since this usually doesn't occur until much later in the postpartum period."

"Be sure to change your pajamas to prevent you from chilling."

Which statement made by a new nurse indicates additional teaching is needed on the topic of hyperbilirubinemia (physiologic jaundice) in newborns? "The problem is a result of the shortened lifespan of the newborn's red blood cells (RBCs)." "Breastfed babies need supplements of glucose water to help lower bilirubin levels." "Placing the infant in direct sunlight for short periods helps in eliminating the bilirubin." "Physiologic jaundice usually begins in the first week after birth."

"Breastfed babies need supplements of glucose water to help lower bilirubin levels."

The nurse is assessing a male neonate in the presence of the parents and notes that the neonate has hypospadias. How should the nurse respond when questioned by the parents as to what this means? "He has normal male genitalia." "His testicles have not descended into the scrotal sac." "He has fluid in the scrotal sac." "The opening of his urethra in located on the under surface of the tip of the penis."

"The opening of his urethra in located on the under surface of the tip of the penis."

A nurse is making a home visit to a new mother with a 5-day-old newborn. The mother tells the nurse that the baby is fussy and she does not know how to calm her. Which suggestions would be most appropriate for the nurse to make? Select all that apply. "Try shushing her loudly." "Gently tap her shoulders and back." "Try swaddling her nice and snuggly." "Have her lie on your lap on her back." "Encourage her to suck."

"Try swaddling her nice and snuggly." "Try shushing her loudly." "Encourage her to suck."

A woman who has been in labor for a few hours is now complaining of being hungry. Which response by the nurse would be best if the client asks for some food to eat? "What would you like to eat?" "I can get you something soft and easy to digest, like pudding." "You can have a protein supplement." "You could have some hard candy to suck on."

"You could have some hard candy to suck on."

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring? rupture of membranes insertion by any staff cervical dilation of 1 cm the presenting fetal part not visible

"You have no trouble walking around and using the bathroom after you receive the epidural."

A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate? "You might try using a water-soluble lubricant to ease the discomfort." "This is entirely normal, and many women go through it. It just takes time." "It takes a while to get your body back to its normal function after having a baby." "Try doing Kegel exercises to get your pelvic muscles back in shape."

"You might try using a water-soluble lubricant to ease the discomfort."

A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize? 100.1ºF (37.8ºC) at 24 hours postbirth and decreases the second postpartum day 99.1ºF (37.3ºC) at 12 hours postbirth and decreases after 18 hours 100.3ºF (37.9ºC) at 24 hours postbirth and remains the same for the second postpartum day 100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum

100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum

How long is the neonatal period for a newborn? 45 days 90 days 14 days 28 days

28 days

A nurse does an initial assessment on a newborn and notes a pulsation over the anterior fontanel (fontanelle) that corresponds with the newborn's heart rate. How would the nurse interpret this finding? This finding is normal if the pulsation can also be palpated in the posterior fontanel (fontanelle). This is an abnormal finding and needs to be reported immediately. If the fontanel (fontanelle) feels full, then this is normal. It is normal to feel pulsations that correlate with the newborn's heart rate over the anterior fontanel (fontanelle).

A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn.

The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner? Remain in bed for at least 30 minutes. Ambulate only with assistance from the nurse or caregiver. Sit on the edge of the bed with her feet dangling before ambulating. Ambulate within 15 minutes to prevent spinal headache.

Ambulate only with assistance from the nurse or caregiver.

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents? Reduced risk of penile cancer Lower rate of urinary tract infections Anesthetic may not be effective during the procedure Fewer complications than if done later in life

Anesthetic may not be effective during the procedure

After the birth of the newborn, the mother is ready to be discharged home. The client's mother is present and will remain with her for 1 month. The client's mother tells the nurse that her daughter will not be allowed to leave the house for the first month after the birth, based on the family's cultural customs. How should the nurse respond to this statement? Ask the client's mother why she is putting such restrictions on her daughter. Explain to the client's mother that her daughter may have to go places in caring for the newborn. Remind the client's mother that the woman needs to get out and get fresh air over the next month. Accept the mother's statement and perform discharge teaching accordingly.

Accept the mother's statement and perform discharge teaching accordingly.

The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize? Blood sugar 42 mg/dl heart rate 158 bpm respiratory rate 42 breaths/min temperature of 97.8°F (36.5°C)

Blood sugar 42 mg/dl

A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate? Assist the woman into the shower, and have her run cold water over her breasts. Explain to the woman that she should breastfeed because she is producing so much milk. Ask the woman if she wants a breast pump to empty her breasts. Assist the woman in placing ice packs on her breasts.

Assist the woman in placing ice packs on her breasts.

The nurse is caring for a newborn who has a large surface area to body mass ratio. What action will the nurse take to help this newborn regulate temperature? Assure the newborn has a cap on the head and is kept covered. Educate the parents to rinse the newborn skin well after using soap. Maintain accurate intake and output and monitor for dehydration. Monitor the newborn's skin for changes related to fluid loss, such as turgor.

Assure the newborn has a cap on the head and is kept covered.

A client who is 3 days' postpartum calls the office and reports excessive night sweats. Which explanation should the nurse provide for the client? The body is trying to get rid of the extra blood made during pregnancy. The patient may be drinking too much fluid. Change in pregnancy hormone Body secreting the excess fluids from pregnancy

Body secreting the excess fluids from pregnancy

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? Evaporation Convection Radiation Conduction

Convection

The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth? Creases covering one fourth of the foot Heel but no anterior creases Creases on two-thirds of the foot Longitudinal but no horizontal creases

Creases on two-thirds of the foot

A nurse is conducting the initial assessment for a 3-hour-old neonate and notes the following: RR 30 breaths/min, BP 60/40 mm Hg, HR 155 beats/min, axillary temperature 98.2°F (36.8°C), and the neonate is in a state of quiet alert. What action should the nurse take? Call the primary care provider. Inform the charge nurse. Stimulate the neonate. Document the data.

Document the data.

Which action would be priority for the nurse to complete immediately after the delivery of a 40-week gestation newborn? Assess the newborn's glucose level. Dry the newborn and place it skin-to-skin on mother. Complete a full head-to-toe assessment. Swaddle the infant and place in the bassinet.

Dry the newborn and place it skin-to-skin on mother.

A multigravida client is still focusing on her difficult labor and discusses it with the nurse at each opportunity, several hours after the birth. Which action should the nurse prioritize after noting the client's partner is spending more time with the infant than the client? Redirect her attention to the baby by reminding her of the details of newborn care. Ask her to describe how she plans to integrate the newcomer into her existing family, including any actions she has taken to prepare the siblings. Point out positive features of her baby, and encourage her to hold and cuddle the baby. Encourage her to discuss her experience of the birth and answer any questions or concerns she may have.

Encourage her to discuss her experience of the birth and answer any questions or concerns she may have.

A new mother calls her pediatrician's office concerned about her 2-week-old infant "crying all the time." When the nurse explores further, the mother reports that the infant cries at least 2 hours each day, usually in the afternoons. What recommendation would the nurse not make to this mother? Swaddling the infant before returning to the crib Feeding the infant more formula whenever she begins to fuss Gently patting or stroking the infant's back Rocking and talking to the infant

Feeding the infant more formula whenever she begins to fuss

The nurse is explaining to new parents the various vaccinations their newborn will receive before being discharged home. Which immunization should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life? HiB Hep B HBV immunoglobin Vitamin K

Hep B

A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestion should the nurse give to the client's husband to resolve the issue? Read up on parental care. Speak to his friends who have children. Have the client speak to the primary care provider on her husband's behalf Hold the baby frequently.

Hold the baby frequently.

New parents report to the nurse that their newborn has "crying jags" in the afternoon each day. They are worried that if they hold the newborn every time she cries, she will become spoiled. What advice would the nurse give these parents? Try walking with the newborn around the house then place her back in the crib to let her cry for a while. Rocking the newborn may soothe her but the time needs to be limited to 30 minutes per session. Holding and comforting the newborn will not cause the infant to become spoiled. Crying indicates that the newborn has a need, so changing the diaper and feeding the infant should help.

Holding and comforting the newborn will not cause the infant to become spoiled.

What is the best rationale for trying to decrease the incidence of cold stress in the neonate? Evaporative heat loss happens when the neonate is not bundled and does not have a hat on. If the neonate becomes cold stressed, he or she will eventually develop respiratory distress. It takes energy to keep warm, so the neonate has to remain in an extended position. The neonate will stabilize his or her temperature by 8 hours after birth if kept warm and dry.

If the neonate becomes cold stressed, he or she will eventually develop respiratory distress.

The nurse is evaluating the morning blood glucose results from the laboratory of several 1-day-old infants. Which result should the nurse prioritize for further action? Infant C - 48 mg/dl Infant D - 60 mg/dl Infant A - 52 mg/dl Infant B - 56 mg/dl

Infant C - 48 mg/dl

The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention? Hesitates to hold newborn, expressing disappointment with baby's appearance. Neglects to engage or provide care or show interest in infant. Tearful for several days, difficulty eating and sleeping. Express doubt in ability to care for newborn.

Neglects to engage or provide care or show interest in infant.

On a newborn's initial assessment, it is noted that the newborn's head is misshapen and elongated with swelling of the soft tissue of the skull. What nursing intervention is needed? Have the mother massage the scalp twice daily to reduce the swelling. Place a snug cap on the newborn's head to compress the swelling. An ice pack should be placed on the edematous scalp. No interventions are needed. This will resolve on its own over the next several days.

No interventions are needed. This will resolve on its own over the next several days.

The nurse is monitoring a client who is 3 hours postpartum. On assessment, the nurse notes a temperature of 102.4°F (39.1°C). Which action should the LPN prioritize? Continue to monitor for another hour. Notify the RN who will then notify the health care provider. Assist the client in ambulation. Administer an antipyretic.

Notify the RN who will then notify the health care provider.

A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. As long as there is a prescription, what intervention would the nurse perform next? Insert a 20 gauge IV. Perform urinary catheterization. Administer oxytocin IV. Notify the health care provider.

Perform urinary catheterization.

Within three days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest, is lethargic, and has to be awoken to feed. Which condition does the nurse suspect this infant is manifesting? Physiologic jaundice. Bile duct blockage. Pathologic jaundice. Breastfeeding jaundice.

Physiologic jaundice.

The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize? Put on a witch hazel pad. Apply a warm washcloth. Notify a health care provider. Place an ice pack.

Place an ice pack.

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. Stools should be yellow-green and loose. Stools should be greenish and formed in consistency. Stools should be brown and loose.

Stools should be yellow-gold, loose, and stringy to pasty.

A woman has just given birth vaginally to a newborn. Which action will the nurse do first? Determine the rectal temperature. Suction the mouth and nose. Assess an apical heart rate. Apply identification bracelets.

Suction the mouth and nose.

Which statement is false regarding bathing the newborn? The bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth. While bathing the newborn, the nurse should wear gloves. Bathing should not be done until the newborn is thermally stable. Mild soap should be used on the body and hair but not on the face.

The bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.

A 1-day-old newborn is being examined by the nurse practitioner, who makes the following notation: face and sclera appear mildly jaundiced. What causes this finding? Feedings are not adequate to eliminate the build-up of bilirubin. The GI tract is immature, so the bilirubin remains in the intestines. The breakdown of RBCs release bilirubin, which the liver cannot excrete. The newborn's vitamin K levels are low.

The breakdown of RBCs release bilirubin, which the liver cannot excrete.

A client who has given birth a week ago reports discomfort when defecating and ambulating. The birth involved an episiotomy. Which suggestions should the nurse provide to the client to provide local comfort? Select all that apply. Use of anesthetic sprays. Use good body mechanics. Use of witch hazel pads. Use of warm sitz baths. Maintain correct posture.

Use of warm sitz baths. Use of anesthetic sprays. Use of witch hazel pads.

A first-time mother informs the nurse that she is unable to breastfeed her newborn through the day as she is usually away at work. She adds that she wants to express her breast milk and store it for her newborn to have later. What instruction would be correct to offer the mother to ensure the safety of the stored expressed breast milk? Use microwave ovens to warm the chilled milk. Refreeze any unused milk for later use if it has not been out more that 2 hours. Use the sealed and chilled milk within 24 hours. Use any frozen milk within 6 months of obtaining it.

Use the sealed and chilled milk within 24 hours.

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply. Ophthalmoscope Identification bands Warmer bed Suction equipment Glucose water

Warmer bed Suction equipment Identification bands

The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching? Wear a tight, supportive bra. Express small amounts of milk when they are too full. Run warm water over the breast in the shower. Massage the breasts when they are painful.

Wear a tight, supportive bra.

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature? Bathe the infant immediately after birth. Wrap the infant in a warm, dry blanket. Turn the temperature up in the birth room. Place the infant on the mother's abdomen after birth.

Wrap the infant in a warm, dry blanket.

A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct? Only clean half of the house per day to allow yourself more rest. You should not lift anything heavier than your infant in its carrier. You need to hire a maid for the first month after delivery to help out around the house. You should be able to resume normal activities after 2 weeks.

You should not lift anything heavier than your infant in its carrier.

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? applying warm compresses administering bromocriptine applying ice restricting fluids

applying ice

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress? acrocyanosis asymmetrical chest movement short periods of apnea (less than 15 seconds) respiratory rate of 50 breaths/minute

asymmetrical chest movement

The nurse is admitting a 10-pound (4.5-kg) newborn to the nursery. What is important for the nurse to monitor during the transition period? temperature heart rate blood sugar Apgar score

blood sugar

A nurse is reviewing the history of a postpartum woman. The nurse determines that the woman is at low risk for uterine subinvolution based on which findings? Select all that apply. breastfeeding early ambulation hydramnios prolonged labor uterine infection

breastfeeding early ambulation

A newborn's primary method of heat production is through nonshivering thermogenesis. This process oxidizes which substance in response to cold exposure? muscles nerves brown fat white fat

brown fat

A primiparous mother gave birth to an 8 lb 12 oz (3970 g) infant daughter yesterday. She is being bottle fed, is Rh positive, has a cephalohematoma, and received her hepatitis A vaccine last evening. Which factor places the newborn at risk for the development of jaundice? hepatitis A vaccine cephalohematoma formula feeding Rh positive blood type female gender

cephalohematoma

Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism? convection conduction radiation evaporation

convection

The nurse is aware that the newborn's circulatory dynamics during transition can be positively affected by which action? clamping the cord at 1 minute giving the infant oxygen as needed clamping the cord immediately delayed umbilical cord clamping

delayed umbilical cord clamping

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue? easy to separate clots foul-smelling lochia difficult to separate clots yellowish-white lochia

difficult to separate clots

A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client? hypotension decreased level of consciousness fluid overload tachycardia

fluid overload

While assessing a newborn, the nurse notes that half the body appears red while the other half appears pale. The nurse interprets this finding as: erythema toxic. congenital dermal melanocytosis (slate gray nevi). harlequin sign. stork bites.

harlequin sign.

The Apgar score is based on which 5 parameters? heart rate, breaths per minute, irritability, tone, and color heart rate, respiratory effort, temperature, tone, and color heart rate, muscle tone, reflex irritability, respiratory effort, and color heart rate, breaths per minute, irritability, reflexes, and color

heart rate, muscle tone, reflex irritability, respiratory effort, and color

The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication? respiratory distress syndrome transient tachypnea of the newborn hyperbilirubinemia polycythemia

hyperbilirubinemia

During the newborn assessment, which finding alerts the nurse to obtain a glucose level? vigorous crying respiratory rate of 48 breaths/min temperature of 98.1°F (36.7°C) hypotonia

hypotonia

The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning? increased hematocrit level increased cardiac output increased blood pressure increased heart rate

increased heart rate

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea of the newborn. The nurse explains that this is due to which occurrence? lack of thoracic compressions during birth loss of blood volume due to hemorrhage prolonged unsuccessful vaginal birth inadequate suctioning of the mouth and nose of the newborn

lack of thoracic compressions during birth

A nurse is assisting with the gestational age assessment of a newborn. When assessing the newborn's physical maturity, which areas would the nurse likely address? Select all that apply. posture arm recoil lanugo square window breast tissue

lanugo breast tissue

During the early postpartum period, a new parent is displaying dependent behaviors typical of the taking-in phase. What behavior(s) will the nurse recognize as normal for this period? Select all that apply. changing her newborn's diaper with guidance from the nurse needing assistance with changing the peripad asking the nurse to take the newborn away so the client can rest telling the nurse about the delivery experience desiring to hold the newborn

needing assistance with changing the peripad telling the nurse about the delivery experience asking the nurse to take the newborn away so the client can rest

A nurse needs to monitor the blood glucose levels of a newborn under observation at a health care facility. When should the nurse check the newborn's initial glucose level? on admission to the nursery 24 hours after admission to the nursery after the newborn has received the initial feeding 4 hours after admission to the nursery

on admission to the nursery

During the birth, the primary care provider performed an episiotomy. The client is now reporting discomfort. To reduce this discomfort and increase hygiene to the perineum, the nurse would encourage the client to use which intervention? alcohol wipes moist cloths baby wipes peribottle and warm water

peribottle and warm water

The nurse notes the listed assessment findings in a newborn. Which finding correlates with a glucose level for a newborn is 39 mg/dl (2.16 mmol/l). strong cry elevated temperature heart rate of 142 beats/min poor feeding

poor feeding

According to Brazelton's Neonatal Behavioral Assessment Scale, a newborn would be in what state if the eyes are open and looking at people nearby, and he/she has minimal activity or body movement? quiet alert drowsy active alert active attentive

quiet alert

A nurse is assessing a newborn with the parents present. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function? reflex crying response orientation to surroundings voluntary movements

reflex

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment? taking-hold acquaintance/attachment letting-go taking-in

taking-in

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment? taking-hold taking-in acquaintance/attachment letting-go

taking-in

A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the postpartum restorative period is this client in? taking-hold phase taking-in phase rooming-in phase letting-go phase

taking-in phase

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states: "Effleurage is the effect of a full bladder on fetal descent." "Effleurage is the pattern for cleaning the perineum before birth." "Effleurage is massaging the perineum as the fetus enlarges the vaginal opening." "Effleurage is light abdominal massage used to displace pain."

"Effleurage is light abdominal massage used to displace pain."

A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement? "If I develop chills or my fever goes above 100.4℉ (38℃), I need to let someone know." "My episiotomy should begin to heal and feel better over the next few weeks" "I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." "I need to let the doctor know if my lochia begins to have a foul smell."

"I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged."

A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states: "I may end up with a severe headache from the spinal anesthesia." "The anesthesia will numb both of my legs to a level above my breasts." "I will need to lie on my right side to reduce vena cava compression." "I can continue sitting up after the spinal is given."

"I may end up with a severe headache from the spinal anesthesia."

A client administered combined spinal-epidural analgesia is showing signs of hypotension and associated fetal heart rate (FHR) changes. What intervention should the nurse perform to manage the changes? Assist the client to a supine position. Turn the client to her right side. Discontinue intravenous (IV) fluid. Provide supplemental oxygen.

Provide supplemental oxygen

The client is experiencing increased labor pain due to a fetal occiput posterior position. What nonpharmacologic intervention will be most helpful for the nurse to offer? hot pack to the lower back effleurage abdominal massage warm compress to the perineum spaced breathing exercises

hot pack to the lower back

A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions? "Let me show you how to calm him down. I've been doing this for many years." "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." "Maybe you your husband will have better luck calming him down. Why don't you let him hold him?" "You would probably be more successful if you wrapped him in on a warm blanket."

"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."

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 facing the hip." "Our baby will come out with the buttocks first." "Our baby will come out face first." "Our baby will come out with the back of the head first."

"Our baby will come out face first."

A woman refuses to have an epidural block because she does not want to have a postdural puncture (spinal) headache after birth. What would be the nurse's best response? "Spinal headache is not a usual complication of epidural blocks." "The anesthesiologist will do her best to avoid this." "The pain relief offered will compensate for the discomfort afterward." "Your health care provider knows what is best for you."

"Spinal headache is not a usual complication of epidural blocks."

When a client is counseled about the advantages of epidural anesthesia, which statement made by the counselor would indicate the need for further teaching? "You have no trouble walking around and using the bathroom after you receive the epidural." "Epidural anesthesia is more effective than opioid analgesia in providing pain relief." "If you end up having a cesarean, the epidural can be used for anesthesia during surgery." "You can continuously receive epidural anesthesia until you have the baby, and even afterward if you need it."

"Spinal headache is not a usual complication of epidural blocks."

The health care provider is evaluating a high-risk woman for a continuous internal monitoring. Which criterion would need to be met for this type of monitoring? rupture of membranes the presenting fetal part not visible insertion by any staff cervical dilation of 1 cm

"Tell me how you handled labor pain in your past deliveries."

The nurse is notifying the health care provider that a client at 32 weeks' gestation reports bleeding. How best would the nurse report the data? "When ambulating the client to the bathroom, a gush of red blood was noted." "The client has saturated three sanitary napkins in the past 4 hours." "The client states that she is having heavy bleeding." "The client has lost 100cc of blood from what I approximate on her clothing."

"The client has saturated three sanitary napkins in the past 4 hours."

The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign? The urge to push occurs. Frequency of contractions are 5 to 6 minutes. Fetus is at -1 station. Emotions are calm and happy.

in the woman's lower abdominal quadrant

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? improper positioning of infant inadequate secretion of prolactin inability of infant to empty breasts cracking of the nipple

inability of infant to empty breasts

The nurse is caring for a client who received a dose of IV sedation, given by the charge nurse, 30 minutes prior. What action is appropriate? Remind the client that medication will assist in relieving pain from contractions. Assure the fetal heart tones are assessed every 2 to 3 hours via monitoring. Restrict the client's fluid to further prevent constipation from the medication. Remind the client to call for assistance before getting out of bed.

Remind the client to call for assistance before getting out of bed.

The laboring client who is at 3 cm dilation (dilatation) and 25% effaced is asking for a narcotic for pain relief. The nurse explains this usually is not administered prior to the establishment of the active phase. What is the appropriate rationale for this practice? The effects would wear off before birth. This would cause fetal depression in utero. This can lead to maternal hypertension. This may prolong labor and increase complications.

This may prolong labor and increase complications.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? Ask her to pant with the next contraction. Help the woman to sit up in a semi-Fowler's position. Turn her or ask her to turn to her side. Administer oxygen at 3 to 4 L by nasal cannula.

Turn her or ask her to turn to her side.

The nurse tests the pH of fluid found on the vaginal exam and determines that the woman's membranes have ruptured based on which result? 6.0 5.5 6.5 5.0

6.5

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is: 7.20. 7.15 or less. 7.25 or more. 7.21.

7.15 or less.

The licensed 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 LPN do first? Wait 2 minutes to review another tracing. Assess and reposition the woman. Notify the health care provider. Notify the registered nurse.

Assess and reposition the woman.

The licensed 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 LPN do first? Wait 2 minutes to review another tracing. Notify the registered nurse. Assess and reposition the woman. Notify the health care provider.

Assess and reposition the woman.

A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform? Assist the client to Trendelenburg position, assess the fetal heart rate, and administer oxygen via face mask. Assist the client to a sitting position, assess the fetal heart rate, give naloxone, and administer oxygen via face mask. Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask. Assist the client to the supine position, recheck the blood pressure, and administer an IV bolus of 1000

Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask.

The nurse is assisting a health care provider in inserting an epidural into a laboring mother. Completion of which nursing task helps prevent maternal hypotension? Elevating the client's legs while in bed Administering a vasopressor Priming tubing for initiating a fluid bolus Working with the mother on patterned breathing

Priming tubing for initiating a fluid bolus

A primigravida client admitted with signs of labor is evaluated with external electronic fetal monitoring that shows baseline FHR of 136 to 150 and two instances of FHR at 165 for 15 to 20 seconds. Which response should the nurse prioritize? Immediately report to the RN that the FHR shows tachycardia. Before reporting to the RN, determine the uterine contraction pattern. Before reporting to the RN, determine the short term variability (STV). Immediately report to the RN that the FHR shows no variability.

Before reporting to the RN, determine the uterine contraction pattern.

A nurse is providing care to several clients in labor. The nurse would anticipate preparing for an epidural block with an opioid analgesic for which client? Client A: dilated 2 cm and in the first stage of labor Client C: dilated 9 cm and in the late transition phase of labor Client D: dilated 10 cm and in the second stage of labor Client B: dilated 4 cm and in the late first stage of labor

Client B: dilated 4 cm and in the late first stage of labor

The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize? Call the primary care provider, and obtain a reduced dose of meperidine. Encourage her through the contractions, explaining why she cannot receive any pain medication. Give the meperidine because she needs pain relief now. Call the anesthetist from the nurse's station to retry the epidural.

Encourage her through the contractions, explaining why she cannot receive any pain medication.

How does a woman who feels in control of the situation during labor influence her pain? Decreased feeling of control helps during the third stage. Feeling in control shortens the overall length of labor. Feelings of control are inversely related to the client's report of pain. There is no association between the two factors.

Feelings of control are inversely related to the client's report of pain.

When stimulating the fetus via an acoustic vibrator, which action indicates fetal well-being? Fetal heart rate acceleration occurs. There is an increase in fetal movements. The fetus descends further into the birth canal. Fetal heart rate deceleration occurs.

Fetal heart rate acceleration occurs.

The nurse is monitoring a woman in labor, who reports severe pain. What action will the nurse take? Explain the risk of the pain control measures already implemented. Further assess the woman for complications or a medical emergency. Assess the woman for cultural pain expectations during labor. Reassure the woman that the pain is short-term and a sign of progressing labor.

Further assess the woman for complications or a medical emergency.

The postpartum nurse is providing care for a client who has just given birth and had epidural anesthesia. Her vital signs are stable, her pain is a 3 on a scale of 0 to 10, and she states that she is tired. The feeling in the client's legs has returned, but she cannot lift her knees, and she has not been out of the bed. What is the most appropriate nursing diagnosis to include in the plan of care at this time? Risk for Injury Activity Intolerance Disturbed Sleep Pattern Acute Pain

Risk for Injury

The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process? Use a birthing ball and find a position of comfort. Use the Valsalva maneuver for effective pushing. Stay low on her back to ease the back pain. Ask for privacy, and have just the partner present.

Take blood pressure and determine if clonus or edema is present

The nurse is admitting a client who appears to be in advanced labor with imminent birth. Which action should the nurse prioritize? Obtain a comprehensive obstetric history. Determine plans for labor and the newborn. Assess use of drugs, alcohol, and tobacco during pregnancy. Take blood pressure and determine if clonus or edema is present.

Take blood pressure and determine if clonus or edema is present.

A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement? Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. Dismiss the mother's concerns by telling her that you are sure she doesn't really mean it. Recommend rooming-in to foster attachment and confidence by the mother. Recommend that she talk to the unit social worker to get the mother some counseling prior to discharge.

Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby

Which psychosocial state is anticipated when the client enters the active phase of labor? The client will become more talkative and excited about the birth. The client will become tired and want the process over. The client will become angry and begin to scream. The client will become more quiet and introverted.

The client will become more quiet and introverted.

Which assessment finding is most important as labor progresses? The client is remaining in control of emotions. The uterus relaxes completely between contractions. The pulse and respirations rise with the work of labor. Labor is completed within 18 hours.

The uterus relaxes completely between contractions.

A nurse is preparing to auscultate the fetal heart rate of a pregnant woman at term admitted to the labor and birth suite. Assessment reveals that the fetus is in a cephalic presentation. At which area on the woman's body would the nurse best hear the sounds? at the upper outer quadrant of the woman's abdomen in the area above the woman's umbilicus at the level of the woman's umbilicus in the woman's lower abdominal quadrant

The urge to push occurs.

The nurse is discussing the various positions for birth with a client and her partner. The client mentions she would like a position that speeds up the process, decreases stress to her baby, and reduces the possibility of needing an episiotomy. Which position should the nurse point out will best meet the client's desires? lithotomy hands and knees side-lying modified dorsal recumbent

hands and knees

The nurse is caring for a client is who 24-hours post-delivery of an infant. Which assessment does the nurse predict the health care provider will prioritize for the mother at this time? hemoglobin and hematocrit blood type folic acid level iron level

hemoglobin and hematocrit

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal? a moderate amount of lochia alba a moderate amount of lochia rubra a scant amount of lochia serosa a scant amount of lochia alba

a moderate amount of lochia rubra

A 19-year-old woman presents to the emergency department in the late stages of active labor. Assessment reveals she received no prenatal care. As part of her examination, a rapid HIV screen indicates she is HIV positive. To reduce the perinatal transmission to her infant, which intravenous medication would the nurse anticipate administering? benzodiazepine ataractic antibiotic antiretroviral

antiretroviral

The nurse is caring for a client who had been administered an anesthetic block during labor. For which risks should the nurse watch in the client? Select all that apply. ambulation difficulty urinary retention perineal laceration incomplete emptying of bladder bladder distention

incomplete emptying of bladder bladder distention urinary retention

The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness? increased white blood cell count stirrup injury during birth decreased red blood cell count increased coagulation factors

increased coagulation factors

Which medication is administered to reverse the depressant effects of opioids? butorphanol nalbuphine naloxone meperidine

naloxone

The nurse is teaching a new mother about the changes in her newborn's gastrointestinal tract. The nurse determines that additional teaching is needed when the mother makes which statement? "The muscle opening that leads into the stomach is not mature." "His stomach can hold approximately 10 ounces." "The newborn's gut is sterile at birth." "He needs to get food orally to make vitamin K."

"His stomach can hold approximately 10 ounces."

A newly delivered mother asks the nurse "What can I do to help my womb to get back to a normal size more quickly?" The nurse's best response would be: "I would recommend that you rest for a few days to allow your body to heal and get back to normal." "If you are breastfeeding, that will help make your uterus contract and get smaller." "There is really nothing you can do to speed along the progress, so just be patient." "Eating a large amount of protein and carbohydrates will help make the uterus contract."

"If you are breastfeeding, that will help make your uterus contract and get smaller."

A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the bestresponse from the nurse when explaining this to the woman? "It is a sign of a group B streptococcus skin infection. " "It is a normal skin finding in a newborn." "It is an indication that the woman has mistreated her newborn." "It is a self-limiting virus that does not require treatment."

"It is a normal skin finding in a newborn."

Upon entering the room of the newborn, the nurse notes the newborn is laying on the bed wearing only a diaper while the parents decide on an outfit for the newborn. What response by the nurse is of most importance? "Let me show you how to swaddle the baby while you select the outfit." "What questions do you have about fabrics that are close to the baby's skin?" "I can see you are eager to find the perfect outfit for your baby." "Have you decided on which outfit you will put on the baby to go home?"

"Let me show you how to swaddle the baby while you select the outfit."

Parents tell the nurse they have been told to keep their newborn away from windows. They do not understand why this is necessary. Which rationale will the nurse provide to the parents? "Windows can be drafty and placing the newborn by one can result in evaporative heat loss." "Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss." "Newborns weighing below 8 lb (3630 g) lack enough brown fat to produce heat." "Covering the newborn with heavy blankets is the best way to keep your newborn warm."

"Newborns cannot shiver to produce heat and need to be kept away from sources of heat loss."

The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge education to address this issue? "Ovulation may return as soon as 3 weeks after birth." "You will not ovulate until your menstrual cycle returns." "Ovulation does not return for 6 months after birth." "You may have intercourse until next month with no fear of pregnancy."

"Ovulation may return as soon as 3 weeks after birth."

The student nurse is attending her first cesarean delivery and is asked by the mentor what should be carefully assessed in this infant. After responding "Respiratory status" the student is asked "Why?" What would be the best response? "Surfactant may be missing from the lungs depending on the newborn's gestational age." "The respiratory centers in the brain have not been stimulated when a newborn is delivered by a cesarean delivery." "A newborn delivered by cesarean has less sensory stimulation to breathe." "There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery."

"There is more fluid present in the lungs at birth after a cesarean delivery than after a vaginal delivery."

A nurse is teaching a newborn's caregivers how to change a diaper correctly. Which statement by the caregiver best indicates the nurse's teaching was effective? "We should clean the skin with soap and water after each bowel movement." "We will fold down the front of her diaper under the umbilical cord until it falls off." "We will apply a moisture barrier cream with every diaper change to prevent diaper rash." "It is best practice to change the diaper every 2 to 4 hours, even during the night."

"We will fold down the front of her diaper under the umbilical cord until it falls off."

New parents are getting ready to go home from the hospital and have received information to help them learn how best to care for their new infant. Which statement indicates that they need additional teaching about how to soothe their newborn if he becomes upset? "We'll hold off on feeding him for a while because he might be too full." "We'll swaddle him snuggly to make him feel secure." "We'll turn on the mobile that's hanging above his head in his crib." "We'll lightly rub his back as we talk to him softly."

"We'll hold off on feeding him for a while because he might be too full."

A client who had a vaginal birth 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is accurate? "You should notice a change in your respiratory status within the next 24 hours." "Everyone is different, so it is difficult to say when your respirations will be back to normal." "It usually takes about 3 months before all of your abdominal organs return to normal, allowing you to breathe normally." "Within 1 to 3 weeks, your diaphragm should return to normal, and your breathing will feel like it did before your pregnancy."

"Within 1 to 3 weeks, your diaphragm should return to normal, and your breathing will feel like it did before your pregnancy."

A parent asks the nurse how to swaddle the newborn because the parent heard that it helps newborns calm down. Which statement will the nurse include in the teaching? "The newborn needs to be held after being swaddled." "Newborns swaddled frequently may not respond to this comfort measure." "Wrapping the newborn too tightly can impair breathing." "It is best if you use the same blanket each time for swaddling."

"Wrapping the newborn too tightly can impair breathing."

The nurse is teaching a couple about the pros and cons of circumcision for their infant son. The nurse knows teaching has been effective when the couple can identify which contraindications to circumcision? Select all that apply. Preterm infant Difficult intravenous access Bleeding disorder Active infection Congenital genitourinary disorder

Preterm infant Bleeding disorder Congenital genitourinary disorder Active infection

A nurse is making a home visit to a new mother who gave birth vaginally 5 days ago. The woman tells the nurse that she has lost some weight but still feels as if she has a long way to go to return to her prepregnancy weight. The woman asks the nurse about the average weight loss for 5 days postpartum. Which information would the nurse incorporate into the response? 9 lb 24 lb 14 lb 19 lb

19 lb

A nurse is assessing a postpartum woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period? She is eager to talk about her birth experience. She has not asked for anything for pain all day. She did her perineal care independently. She sits and rocks her infant for long intervals.

She did her perineal care independently.

When assessing the effectiveness of the obstetrical regional analgesia received by a client, the nurse recognizes it is successful by the complete loss of pain sensation at which level of the spinal cord? below T8 level below T5 level below T7 level below T6 level

below T8 level

A nurse is explaining to new parents how a newborn adapts to extrauterine life. When discussing the physiologic changes that occur, the nurse would explain that this transition usually occurs within the first: 2 to 4 hours of life. 4 to 6 hours of life. 8 to 12 hours of life. 6 to 10 hours of life.

6 to 10 hours of life.

The nursing instructor is preparing a presentation which will explore the various sources of pain during the labor process. Which source should the instructor emphasize as the mainsource of pain during the first stage? birth canal cervix perineum back

cervix

The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be effective at this point? conscious relaxation/guided imagery in low Fowler position counterpressure against the sacrum effleurage of the abdomen during the contraction pant-blow (breaths and puffs breathing techniques)

counterpressure against the sacrum

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase? showing increased confidence when caring for the newborn having feelings of grief or guilt talking about her labor experience to others around her pointing out specific features in the newborn

showing increased confidence when caring for the newborn

What is a nursing intervention that helps prevent the most frequent side effect from epidural anesthesia in a pregnant client? administrating IV naloxone maintaining the client in a supine position starting an IV and hanging IV fluids administrating IV ephedrine

starting an IV and hanging IV fluids

The nurse notices that there is no vitamin K administration recorded on a newborn's medical record upon arrival to the newborn nursery. What would be the nurse's first action? Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented. Assume that the parents refused this medication for their infant. Administer an oral dose of vitamin K to the newborn. Give the IM dose of vitamin K to prevent the possibility of hemorrhage in the newborn.

Call the Labor and Delivery nurse who cared for the newborn to inquire about why the medication was not documented.

Which factor might result in a decreased supply of breast milk in a postpartum client? maternal diet high in vitamin C frequent feedings an alcoholic drink supplemental feedings with formula

supplemental feedings with formula

A nurse working in the neonatal nursery anticipates the primary care provider to prescribe which medication for a premature newborn having difficulty breathing? surfactant epinephrine albuterol norepinephrine

surfactant

A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase? taking-in phase attachment phase taking-hold phase letting-go phase

taking-in phase

A nurse is called into the room of one of the clients where the grandparents are visiting. The grandmother is visibly upset, and says "Just look at my grandson! His head is all soft and swollen here and it shouldn't be. The doctor injured him when he was born." The nurse assesses the newborn and finds an area of swelling about the size of a half-dollar at the center of the upper scalp. The nurse determines this finding is most likely which condition? Caput succedaneum Harlequin sign Increased intracranial pressure Molding

Caput succedaneum

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed? Assess for pain source. Place child in a radiant warmer. Check blood glucose. Assess the baby's temperature.

Check blood glucose.

The nurse notes the following on a newborn's assessment: poor muscle tone, jitteriness, and temperature 97.0oF (36.1oC), HR 120 bpm, RR 26 breathes per minute, and blood pressure 60/40 mm Hg. Which nursing action should the nurse prioritize? Check the infant's temperature again. Complete an entire set of vital signs. Assess the infant's blood sugar. Check oxygen saturation of the blood.

Assess the infant's blood sugar.

What are small unopened or plugged sebaceous glands that occur in a newborn's mouth and gums? milia congenital dermal melanocytosis Epstein pearls stork bites

Epstein pearls

Upon entering the room of the newborn and parents, the nurse notes the diapered newborn is undressed and laying on the foot of the bed while the parents plan which outfit to place on the baby. What is the priority for the nurse? Suggest the parents select an outfit that is not scratchy on the newborn's skin. Provide education on how to safely hold the newborn in the parents' arms. Discuss the various types of fabric and materials used in newborn outfits and clothing. Explain the need to keep the newborn wrapped or dressed to prevent cold stress.

Explain the need to keep the newborn wrapped or dressed to prevent cold stress.

The nurse is caring for a client who is gravida 3 para 2. The obstetric history reveals that all labors were uncomplicated with two vaginal deliveries. The client is 6 cm dilated and effaced. Which is the minimal acceptable amount of monitoring? No monitoring needed Intermittent fetal heart rate auscultation Fetal scalp sampling Continuous external fetal monitor

Intermittent fetal heart rate auscultation

There are advantages and disadvantages to any kind of method used to control pain during labor and birth. What is an advantage of opioid administration? It is generally given PO It can be administered by the nurse. It can be given frequently without risk to the fetus. Fetal monitoring can be safely discontinued.

It can be administered by the nurse.

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment? letting-go taking-hold acquaintance/attachment taking-in

taking-in phase

All of the following are ways the nurse can encourage bonding between the parents and the newborn except: asking the parents' permission to pick up the newborn. encouraging parents to provide care while the nurse is there to observe them. talking to the newborn in front of the parents. telling the mother that the best way to bond with her baby is to breastfeed.

telling the mother that the best way to bond with her baby is to breastfeed.

A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner? A length between 48 and 50 cm plots out at the 95th percentile for length. A birth weight between 2200 and 3000 g is considered small for gestational age. Normal birth length is usually 52 cm or above for a full-term newborn. A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn.

It keeps alveoli from collapsing with breaths.

The nursing instructor is teaching a class on the physiologic prosperities 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. It expands the lungs with breaths. It allows oxygen to move in the lungs. It removes fluid from the lungs.

It keeps alveoli from collapsing with breaths.

The mother of a newborn observes a diaper rash on her newborn's skin. Which intervention should the nurse instruct the parent to implement to treat the diaper rash? Use products such as talcum powder with each diaper change. Use only baby wipes to cleanse the perianal area. Place the newborn's buttocks in warm water after each void or stool. Expose the newborn's bottom to air several times a day.

Expose the newborn's bottom to air several times a day.

The client, G5P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting an assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago? Administer oxytocics to prevent uterine atony. Put on the call button to summon help. Gently massage the fundus until it tones up. Teach the woman to perform periodic self-fundal massage.

Gently massage the fundus until it tones up.

A new mother delivered 1 week ago and is tearful, anxious, sad, and has no appetite. She is diagnosed with postpartum blues. What factors contribute to this problem? Select all that apply. Fatigue Lack of activity Discomfort Disrupted sleep patterns Hormonal changes

Hormonal changes Fatigue Discomfort Disrupted sleep patterns

After the abdominal dressing is removed 24 hours following a cesarean delivery, the nurse inspects the incision and observes drainage from the incision, redness along the suture line and moderate edema. Staples are intact. What action would the nurse take? Since everything appears normal, continue to monitor the incision every 4 hours. Call the client's family. Let the health care provider know the condition of the incision. Re-apply a dressing over the incision line.

Let the health care provider know the condition of the incision.

What two elements play the biggest role in becoming a mother after delivery of her newborn? Interactions with the child and support systems Confidence and happiness with the pregnancy Planned and desired pregnancy and previous experience with infants Love and attachment to the child and engagement with the child

Love and attachment to the child and engagement with the child

Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain? Give the prescribed medication. Change the woman's position. Massage the woman's back. Encourage the woman to rest between contractions.

Massage the woman's back

The pregnant client is planning to hire a doula for support during labor. What statement by the client requires follow-up by the nurse? My doula will be able to support both me and my partner during the labor and birth. My doula will help me with contractions so I will not need any pain relief in labor. My doula will provide me with massage and encouragement in labor. My doula will come to my home in early labor and stay with me once I am admitted to the hospital.

My doula will help me with contractions so I will not need any pain relief in labor.

A pregnant woman with a fetus in the cephalic presentation is in the latent phase of the first stage of labor. Her membranes rupture spontaneously. The fluid is green in color. Which action by the nurse would be appropriate? Notify the health care provider about possible meconium. Check the maternal heart rate. Check the pH to ensure the fluid is amniotic fluid. Prepare to administer an antibiotic.

Notify the health care provider about possible meconium.

The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern? Look for nasal flaring to indicate that the newborn is breathing out of both sides of the nostrils. Pass an NG tube down both sides of the nostrils to assess patency. Use a swab to explore the nares bilaterally for occlusions. Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably.

Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably.

The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern? Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably. Look for nasal flaring to indicate that the newborn is breathing out of both sides of the nostrils. Pass an NG tube down both sides of the nostrils to assess patency. Use a swab to explore the nares bilaterally for occlusions.

Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably.

The nurse is looking at the latest lab work for her postpartum client. The client's predelivery hemoglobin and hematocrit (H & H) was 12.8 and 39, respectively. This morning, the client's values are 8.9 and 30. How would the nurse interpret these lab values? The client will be tired, so encourage her to sleep whenever the baby sleeps. The health care provider needs to be notified of the latest lab values. The client will need a transfusion, so the RN needs to be notified. These values are expected for a 1-day postpartum mother.

The health care provider needs to be notified of the latest lab values.

The nurse has administered erythromycin ointment to a newborn. What outcome indicates this nursing intervention has been effective? The newborn does not contract ophthalmia neonatorum. The newborn is about to produce sufficient tears. The newborn's active eye infection resolves. The newborn's sclerae do not appear yellow.

The newborn does not contract ophthalmia neonatorum.

During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing? the binding-in phase the taking-in phase the taking-hold phase the letting-go phase

the taking-hold phase

What is the primary goal of nursing care immediately after birth? to give the mother a chance to breastfeed to obtain weight and length to ascertain whether the neonate needs lab tests to maintain the safety of the neonate from intrauterine to extrauterine life

to maintain the safety of the neonate from intrauterine to extrauterine life

A pregnant client in labor receives a pudendal block for pain relief. Which action by the nurse would be appropriate after the block is given? assess maternal blood pressure give a bolus of IV fluid administer supplemental oxygen turn the client on her left side

assess maternal blood pressure

What is the best way for the nurse to assess the newborn's heartbeat? palpating the brachial pulse for 60 seconds auscultating the apical pulse for 60 seconds auscultating the apical pulse for 30 seconds and multiplying by 2 palpating the femoral pulse for 30 seconds and multiplying by 2

auscultating the apical pulse for 60 seconds

The nurse is examining a newborn and notes that there is bruising and swelling on the newborn's head, limited to the right side of the scalp and does not cross the suture lines. How will the nurse interpret this finding? The newborn has caput succedaneum that will go away within the first week of life. This is a cephalohematoma that typically spontaneously resolves without interventions. This is concerning because the swelling does not cross the newborn's suture lines. This newborn has a subarachnoid hemorrhage requiring surgical intervention.

This is a cephalohematoma that typically spontaneously resolves without interventions.

The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize? Encourage her through the contractions, explaining why she cannot receive any pain medication. Call the anesthetist from the nurse's station to retry the epidural. Call the primary care provider, and obtain a reduced dose of meperidine. Give the meperidine because she needs pain relief now.

counterpressure against the sacrum

The nurse explains Leopold maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply. determining the lie of the fetus determining the weight of the fetus determining the position of the fetus determining the size of the fetus determining the presentation of the fetus

determining the presentation of the fetus determining the position of the fetus determining the lie of the fetus

The nurse is reviewing the nursing care plan with a woman during a prenatal visit. What action(s) in the plan is to decrease the woman's pain level during labor? Select all that apply. continuous labor support by a doula or trained nurse maintaining the same intervention throughout the laboring process using a nonpharmacologic method along with needed pharmacologic methods explaining the process and procedures to decrease anxiety and apprehension discussion about pain relief measures prenatally

discussion about pain relief measures prenatally using a nonpharmacologic method along with needed pharmacologic methods continuous labor support by a doula or trained nurse explaining the process and procedures to decrease anxiety and apprehension

A nurse notes a pregnant client has just entered the second stage of labor. Which interaction should the nurse prioritize at this time to assist the client? palpating the client's fundus for position and firmness alleviating perineal discomfort with the application of ice packs encouraging the client to push when they have a strong desire to do so completing the identification process of the newborn with the pregnant parent

encouraging the client to push when they have a strong desire to do so

A client in the first stage of labor is admitted to a health care center. The nurse caring for the client instructs her to rock on a birth ball. The nurse informs her that this causes the release of certain natural substances, which reduces the pain. To which substance is the nurse referring? relaxin endorphins progesterone prostaglandins

endorphins

A client receives an epidural anesthetic. Which medication would the nurse anticipate the primary care provider will prescribe if the client develops moderate hypotension? methylergonovine atropine ephedrine betamethasone

ephedrine

The nursing instructor is preparing a group of nursing students for their clinical phase and is questioning them on the various assessment skills they will need. The instructor determines the session is successful when the students correctly choose which time interval to assess the fetal heart rate of clients who are in the active phase of labor? every 45 to 60 minutes every 15 to 30 minutes every 2 to 4 hours every 10 to 15 minutes SUBMIT ANSWER

every 15 to 30 minutes

A pregnant client with a history of spinal injury is being prepared for a cesarean birth. Which method of anesthesia is to be administered to the client? local infiltration epidural block regional anesthesia general anesthesia

general anesthesia

The nurse is performing an assessment for a client in the immediate postpartum period. Which assessment finding should the nurse prioritize? hemorrhage infection bladder distention dehydration

hemorrhage

The nurse is caring for a woman in labor who is using mouth breathing to cope with the pain of labor. What intervention will the nurse implement? keeping the mouth moist with ice chips if permitted encouraging the woman to breathe quickly and rapidly encouraging the woman to breathe into her cupped hands massaging the back/shoulders with contractions

keeping the mouth moist with ice chips if permitted

Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide? blocking of nerve transmission via mechanical irritation of nerve fibers release of endorphins in response to the uterine contractions lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels distraction of the brain cortex by other stimuli occuring in the body

lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels

A woman dilated to 10 cm and feeling the urge to "have a bowel movement" is refusing to push and is screaming, "It hurts down there too much to push." What option should the nurse suggest at this point for pain management to facilitate pushing? pudendal block epidural anesthesia parenteral medication paracervical block

pudendal block

The parent of a newborn tells the nurse, "My baby seems to have periods where the eyes are open and my baby appears to be paying attention to me." The nurse identifies this description as which stage of the sleep-wake cycle? active alert drowsy alert quiet alert interactive alert

quiet alert

When the client in the transition phase of labor experiences dizziness and tingling in the fingers and around the mouth from hyperventilation, the client is anticipated to be in: respiratory alkalosis. metabolic acidosis. respiratory acidosis. metabolic alkalosis.

respiratory alkalosis.

A nurse is preparing a class for a group of new parents on the psychological adaptations that occur after the birth. The nurse should include which signs and symptoms that might suggest postpartum depression? Select all that apply. sleeping well hunger feelings of worthlessness feeling overwhelmed restlessness

restlessness feelings of worthlessness feeling overwhelmed

The nurse is assessing a client at a postpartum visit. Which hemodynamic change will the nurse expect the client to exhibit? increase in circulatory blood volume rise in hematocrit increase in cardiac output transient tachycardia

rise in hematocrit

A nursing student correctly chooses which stage of behavioral adaptation in the infant to reinforce teaching about feeding, positioning for feeding, and diaper-changing techniques? first period of reactivity period of decreased responsiveness second period of reactivity There is no preferred time.

second period of reactivity

A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider? writing pictures recognizing the meaning of words touching

touching

The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse would monitor the client for which condition? increased urine output stress incontinence urinary tract infection loss of pelvic muscle tone

urinary tract infection

During an assessment, the nurse notes that the client has been unable to urinate properly since giving birth and is bleeding more than expected. The nurse suspects which condition? postpartum diaphoresis uterine atony pain when voiding urinary tract infection

uterine atony

During an assessment, the nurse notes that the client has been unable to urinate properly since giving birth and is bleeding more than expected. The nurse suspects which condition? uterine atony pain when voiding urinary tract infection postpartum diaphoresis

uterine atony

The nurse is monitoring a client's uterine contractions. Which factors should the nurse assess to monitor uterine contraction? Select all that apply. frequency of contractions change in temperature uterine resting tone change in blood pressure intensity of contractions

uterine resting tone frequency of contractions intensity of contractions

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? diaphoresis edematous vagina uterus 1 cm below umbilicus lochia serosa

uterus 1 cm below umbilicus

The nurse is assisting with the assessment of a newborn. What assessment finding indicates that the nurse needs to monitor the newborn's respiratory status further? psychological jaundice weak cry heart rate 142 beats/min flexed position

weak cry

A woman comes to the clinic for her first postpartum visit. She gave birth to a healthy term neonate 2 weeks ago. As part of this visit, the woman has a complete blood count drawn. Which result would the nurse identify as a potential problem? white blood cell count 14,000/mm3 (14 ×109/L) hematocrit 42% (0.42) platelets 350,000/µL (350 ×109/L) hemoglobin 12.5 g/dL (125 g/L)

white blood cell count 14,000/mm3 (14 ×109/L)

A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? sweating and peripheral vasoconstriction nonshivering thermogenesis lack of brown adipose tissue radiation, convection, and conduction

xradiation, convection, and conduction

A nurse is assigned to care for a newborn with an elevated bilirubin level. Which symptom would the nurse expect to find during the infant's physical assessment? yellow sclera respiratory rate of 24 breaths/minute heart rate of 130 bpm abdominal distention

yellow sclera

The nurse reviews the newborn's morning laboratory levels and notes a bilirubin level of 5.8 mg/dl (99.20 µmol/l). What will the nurse expect to assess in the newborn? stools that are seedy and yellow enlarged liver, palpable on examination yellowing of the soles of the feet yellow-tinted skin on the head and face

yellow-tinted skin on the head and face