What action should the nurse implement with the family when an infant is born with anencephaly? Show
Ensure that measures to facilitate the attachment process are offered. Prepare the family to explore ways to cope with the imminent death of the infant. Inform the family about multiple corrective surgical procedures that will be needed. Provide emotional support to facilitate the consideration of fetal organ donation. B Anencephaly, a neural tube congenital malformation, is the incomplete embryological formation of both cerebral hemispheres, which often results in death due to respiratory failure. While comfort measures are provided, there is no resuscitation effort or successful treatment available, so the family should be prepared for the infant's imminent death (B) and encouraged to explore ways to cope with the loss and express grief. Providing opportunities with the infant promote a realistic experience of connectedness and facilitates parental closure, not attachment (A). (C) is not warranted. Although (D) may be considered, it may not be the most therapeutic family-centered intervention when initially confronting the parents with the infant's prognosis. Which prescription should the nurse administer to a newborn to reduce complications related to birth trauma? Silver nitrate. Erythromycin (Ilotycin ointment). Ceftriaxone (Rocephin). Vitamin K (AquaMEPHYTON). D The normal neonate is vitamin K deficient, so to rapidly elevate prothrombin levels and reduce the risk of neonatal bleeding, newborns receive a single injection of vitamin K (AquaMEPHYTON) (D). (A and B) are prophylactic ophthalmic agents used to prevent neonatal ophthalmia. (C) is an antibiotic used to treat neonatal infections. Which behavior should the nurse anticipate for a new mother with an uncomplicated vaginal birth on the third postpartum day? Request help with ambulation and perineal care. Exhibit interest in learning more about infant care. Sleep most of the time when the baby is not present. Be very excited and talkative about the birth experience. B By the third postpartum day, the new mother should start to "take hold" of caring for her infant, by asking questions about infant care and initiating care of her infant (B). This client should be independent with self-care (A). Excessive sleeping (C) is more indicative of immediate post-delivery behavior when the new mother is tired from the process of labor. Being excited and talkative about the birth is more characteristic of "taking in" behavior, seen in the first 24 to 48 hours after delivery (D). A multiparous client is experiencing bleeding 2 hours after a vaginal delivery. What action should the nurse implement next? Determine the firmness of the fundus. Give oxytocin (Pitocin) intravenously. Inform the healthcare provider of the bleeding. Assess the vital signs for indicators of shock. A The first step in recognizing the potential cause of postpartum bleeding is to evaluate the contractility of the uterus (A). (B) should not be implemented until the cause of the bleeding is determined. The nurse should implement (C) after completing the assessment of the potential cause for bleeding. (D) is important, but (A) is a higher priority. On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) would be November 22. A A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH). The healthcare provide prescribed magnesium sulfate is to control the symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved? 4+ reflexes. C The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? Elicit a positive scarf sign on the affected side. B The nurse is planning preconception care for a new female client. Which information should the nurse provide the client? Discuss various contraceptive methods to use until pregnancy is desired. D A client who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client? Elevate lower legs while resting. D The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching? Cuddles the baby close to her. C The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding?
Two vessels: one artery and one vein. C A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? The length of labor and method of delivery. B A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? Cervical dilation of 5 cm with 90%
effacement. D A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? Encourage the mother to provide total care for her infant. C A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? Encourage
the mother to provide total care for her infant. D A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pad are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next? Cleanse the perineum. C Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. Which answer accurately reflects the nurse's understanding of the the variation of an accumulation of blood between the periosteum and skull that does not cross the suture line? a cephalhematoma, caused by forceps trauma and may last up to 8 weeks. A A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement? Discontinue the oxytocin (Pitocin) infusion. D A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug? Maternal blood pressure and respirations. B The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? Insert an internal fetal monitor. C A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which response is best for the nurse provide? "Weigh the baby daily, and if she is gaining weight, she is eating enough." B A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which complaint would indicate to the nurse that the woman's fallopian tubes are patent? Back pain. C The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.) Select all that apply AC A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? Wear support stockings. C In evaluating the respiratory effort of a one-hour-old infant using the Silverman-Anderson Index, the nurse determines the infant has synchronized chest and abdominal movement, just visible lower chest retractions, just visible xiphoid retractions, minimal and transient nasal flaring, and an expiratory grunt heard only on auscultation. What Silverman-Anderson score should the nurse assign to this infant? (Enter numeral value only.) 4 A Silverman-Anderson Index has five categories with scores of 0, 1, or 2. The total score ranges from 0 to 10. Four of the these assessment findings should receive a score of 1, and the 5th finding (synchronized chest and abdominal movement) receives a score of 0. Therefore, the total score is 4. A total score of 0 means the infant has no dyspnea, a total score of 10 indicates maximum respiratory distress. A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous . Which assessment is the highest priority for the nurse to monitor during the administration of this drug? B A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? Raise the foot of the bed. A A multigravida client arrives at the labor and delivery unit and tell the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next? Complete a sterile vaginal exam. A Which cardiovascular findings should the nurse assess further in a client who is at 20-weeks gestation? Decrease in pulse rate. Decrease in blood pressure. Increase in heart sounds (S1, S2). Increase in red blood cell production. A Between 14 and 20 weeks gestation, the pulse increases about 10 to 15 beats/minute, which persists to term, so a decrease (A) should be assessed further. During the second trimester, both systolic and diastolic pressures decrease by about 5 to 10 mm Hg (B), a more audible splitting of S1 and S2 occurs (C), and there is an accelerated production of red blood cells (D). A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage? Vaginal bleeding. Complaints of abdominal pain. Changes in fetal heart rate patterns. Alteration in maternal blood pressure. C Hypoperfusion of the fetus may be present before the onset of clinical signs of maternal compromise or shock in a pregnant woman, so the external fetal monitor tracings should be assessed first to determine signs of fetal hypoxia due to internal bleeding in the mother. (A, B, and D) are not the first findings of internal hemorrhage in the pregnant client. What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta? Maternal bradycardia. Hard, board-like abdomen. Decrease in fundal height. Decrease in abdominal pain. B Abruptio placenta causes concealed intrauterine hemorrhage when the placenta separates and its edges do not. The formation of a hematoma behind the placenta and subsequent infiltration of the blood manifests as a firm, board-like abdomen (B), which should be reported immediately to the healthcare provider. As bleeding occurs, fetal oxygenation and maternal stability are compromised leading to fetal and maternal tachycardia, not (A). With abruptio placenta, fundal height and abdominal pain increase, not (C and D).
A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to 70 mm Hg at the peak of a contraction and the resting tone is 6 to 10 mm Hg. Based on this information, what action should the nurse implement? Notify the client's healthcare provider. Bring the delivery table to the room. Prepare to administer an oxytocic. Document the findings in the client record. D This labor pattern indicates that the client is in the active phase of the first stage of labor and has a normal labor pattern, so the findings should be documented in the client's medical record (D). There is no indication to notify the healthcare provider (A) or bring the delivery table into the room (B) at this time. Oxytocin augmentation (C) is not needed for this labor pattern. A client at 28-weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client? Contraction stress test. Internal fetal monitoring. Abdominal ultrasound. Lecithin-sphingomyelin ratio. C Bright red, painless vaginal bleeding occuring after 20-weeks gestation can be an indicator of placenta previa, which is confirmed by abdominal ultrasound (C). (A, B and D) are invasive procedures that increase the risk for premature onset of labor, and are not indicated at this client's gestation. The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at 32-weeks gestation who has severe preeclampsia with pulmonary edema. As the PAC enters the right ventricle, what is the priority nursing assessment? Assess fetal response to the procedure. Note any complaint of sudden chest pain. Monitor for premature ventricular contractions. Observe for maternal blood pressure changes. C During and following the insertion of a pulmonary artery catheter (PAC), ECG activity should be monitored for the occurrence of any ventricular ectopy (C). Although fetal well-being (A) is important, the primary nursing assessment at this time is monitoring for immediate cardiac changes in the mother. Adverse cardiac responses to PAC insertion should first identify changes in the client's heart rhythm before the client complains of chest pain (B). Manual blood pressures (D) evaluate systemic perfusion, but the primary purpose in monitoring pulmonary artery pressures is to detect early cardiac changes due to left ventricular failure A client at 28-weeks gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client? It is not necessary to keep such a close watch on weight gain. Try to exercise more because too much weight has been gained. Increase the calories in your diet to gain more weight per week. The weight gain is acceptable for the number of weeks pregnant. D The normal pattern of weight gain is 2 to 4 pounds in the first trimester (by 13-weeks) and 1 pound per week after that. At 28-weeks gestation, a weight gain between 17 and 20 pounds is acceptable (D). (A, B and C) do not provide accurate information. When discussing birth in a home setting with a group of pregnant women, which situation should the nurse include about the safety of a home birth? Only the woman and her midwife should be present during the delivery. The woman should live no more than 15 minutes from the hospital. The woman's extended family should be allowed to attend the home birth. Medical backup should be available quickly in case of complications. D A client who is stable has family members present when the nurse enters the birthing suite to assess the mother and newborn. What action should the nurse implement at this time? Ask to meet with the client and infant without family members present. Do a brief assessment for only the infant while family members are present. Observe interactions of family members with the newborn and each other. Reschedule the visit so that the mother and infant can be assessed privately. C An opportunity to assess the emotional adjustment of individual family members to birth and lifestyle changes is presented, so the nurse should first observe the interaction of the family members (C). Although family members can remain during the assessment of the newborn (B), the mother should be assessed also. Privacy to assess the mother should be assured (A and D), but evaluation of the family dynamics provides essential data about mother-child bonding and should be determined at this time. Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor? Brighten the lighting so the mother can view the infant. Complete the newborn assessment as quickly as possible. Provide positive reinforcement for maternal care of infant. Encourage early initiation of breast or formula feeding. ... The nurse is discussing the stages of labor with a group of women in the last month of pregnancy and provides examples of different positional techniques used during the second stage of labor. Which position should the nurse address that provides the best advantage of gravity during delivery? Walking. B Squatting (B) helps to align the fetus with the pelvic outlet and allows gravity to assist in fetal descent and gives the client an adventitious position for birth. Although walking (A) and kneeling (C) also help to align the fetus with the pelvic outlet and allow for gravity to assist in fetal descent, these do not accomodate birth easily. The predominant position in the United States for physician-attended births is the lithotomy position which requires a woman to be in a reclined position with her legs in stirrups in which gravity has little effect in this position (D). A client at 39-weeks gestation is admitted to the labor and delivery unit. Her obstetrical history includes 3 live births at 39-weeks, 34-weeks, and 35-weeks gestation. Using the GTPAL system, which designation is the most accurate summary of this client's obstetrical history? 3-1-1-1-3. B What nursing action should be implemented when intermittently gavage-feeding a preterm infant? Allow formula to flow by gravity. A The nurse observes a male newborn who is displaying a rigid posture with his eyes tightly closed and grimacing as he is crying after an invasive procedure. The baby's blood pressure is elevated on the Dinamap display. What action should the nurse implement? Obtain a serum glucose level. B A client states, "During the three months I've been pregnant, it seems like I have had to go to the bathroom every five minutes." Which explanation should the nurse provide to this client? The client may have a bladder or kidney infection. D An infant who weighs 3.8 kg is delivered vaginally at 39-weeks gestation with a nuchal cord after a 30-minute second stage. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide the parents about this finding? Further assessment is indicated. ... Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routine standing order for methylergonovine maleate (Methergine)? Pregnancy induced hypertension. A Methergine is used for post-partum bleeding. A client's history of pregnancy-induced hypertension (A) is a contraindication for Methergine which causes vasoconstriction and increases blood pressure, so the routine standing order should be withheld and reported to the healthcare provider. (B, C, and D) are not contraindications for the use of Methergine. Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate? Tactile
stimulation. D Which action is most important for the nurse to implement for a client at 36-weeks gestation who is admitted with vaginal bleeding? Monitor uterine contractions. C The priority nursing action is assessment of the fetal heart rate and maternal vital signs (C) to evaluate the impact of blood loss in the mother and fetus. Although monitoring uterine activity (A), applying pads to assess bleeding amount (B), and obtaining samples for hemoglobin and hematocrit levels (D) should be implemented, these are not as important as assessing maternal and fetal well-being. During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide? Discontinue all forms of contraception. B While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document? Molding. B A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective? Slowly increasing
urinary output over the last week. C Epogen, given to prevent or treat anemia, stimulates erythropoietin production, resulting in an increase in RBCs. Since the body has not had to compensate for anemia with an increased heart rate, changes in heart rate from high to normal is one indicator that Epogen is effective. A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous . Which assessment is the highest priority for the nurse to monitor during the administration of this drug? B Monitoring maternal and fetal heart rates is most important when terbutaline is being administered becauseTerbutaline acts as a sympathomimetic agent that stimulates both beta 1 receptors (causing tachycardia, a side effect of the drug) and beta 2 receptors (causing uterine relaxation, a desired effect of the drug). The nurse is planning preconception care for a new female client. Which information should the nurse provide the client? Discuss various contraceptive methods to use until pregnancy is desired. D Preconception care has an overall goal to prepare the client for a healthy pregnancy. It begins with encouraging healthy lifestyle choises in the family and should focus on measures to assist the client in reducing lifestyle variables that may increase the risk for problems in pregnancy. A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH). The healthcare provide prescribed magnesium sulfate is to control the symptoms. Which assessment finding would indicate that therapeutic drug level has been achieved? 4+
reflexes. C Magnesium sulfate is a CNS depressant that helps prevent seizures. A decreased respiratory rate indicates that the drug is effective. (Respiratory rate below 12 indicates toxic effects.) The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl. A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should the nurse prepare the client for additional information about fetal status? Biophysical profile (BPP). A A BPP (biophysical profile) provides data regarding fetal risk surveillance by examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate. The client's gestation has progressed past the estimated date of confinement, so the major concern is fetal well-being related to an aging placenta, not screening for fetal anomalies. A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit? Choking, coughing, and cyanosis. A The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class? Begin as soon as your baby is born to establish a four-hour feeding schedule. C The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching? Cuddles the baby close to her. C A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? Supplementary iron is more efficiently utilized during pregnancy. B The nurse is counseling a client who wants to become pregnant. The client tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. Which date accurately reflects the calculation of the client's next fertile period? January 14-15. C This client can expect her next period to begin 36 days from the first day of her last menstrual period. A menstrual cycle begins at the first day of the cycle and continues to the first day of the next cycle, therefore if January 8 was the first day on her last menstrual cycle, her next period would begin on February 13. Ovulation occurs 14 days before the first day of the menstrual period so this client would be ovulating on January 30- 31. The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement? Provide phototherapy for 30 minutes q8h. C The normal total bilirubin level is 6 to 12 mg/dl after Day 1 of life. This infant's bilirubin is beginning to climb and the infant should be monitored to prevent further complications. Breast milk provides calories and enhances GI motility, which will assist the bowel in eliminating bilirubin. A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first? Bathe the infant with an antimicrobial soap. A To reduce direct contact with the human immuno-virus in blood and body fluids on the newborn's skin, a bath with an antimicrobial soap should be administered first. The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) Select all that apply CD A client who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client? Elevate lower legs while resting. D A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain? Gravidity and parity. C A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? Cervical dilation of 5 cm with 90% effacement. C A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement? Discontinue the oxytocin (Pitocin) infusion. D A multigravida client arrives at the labor and delivery unit and tell the nurse that her "bag of water" has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next? Complete a sterile vaginal exam. A A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. When preparing to document the client's delivery history, it is important for the nurse to document in the client's record which GTPAL history? 3-1-2-0-3. D A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the nurse to monitor during the administration of this drug? Maternal blood pressure and respirations. B The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) Select all that apply CDF A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? Patellar reflex 4+. A A 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia, which is an indication of an impending seizure. A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? Encourage the mother to provide total care for her infant. D The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? Between the time the temperature falls and rises. A A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit with suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? (Select all that apply.) Select all that apply ADF A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? Supplementary iron is more efficiently utilized during pregnancy. B The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? Administer oxygen by face mask. C A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the nurse take first? Notify the pediatrician immediately. C A client in active labor complains of cramps in her leg. What intervention should the nurse implement? Ask if she takes a daily calcium tablet. B The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? Between the time the temperature falls and rises. A In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours after ovulation, when the corpus luteum of the ruptured ovary produces progesterone making between the time of the temperature fall and rise is the best time to try to conceive. A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pad are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next? Cleanse the
perineum. C The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? Herpes. C The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? Insert an internal fetal monitor. C The nurse is planning preconception care for a new female client. Which information should the nurse provide the client? Discuss various contraceptive methods to use until pregnancy is desired. D One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM X 1. What action should the nurse take immediately? Give the medication as
prescribed and monitor for efficacy. D A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin? Dehydration. B A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? Come to the clinic today for an ultrasound. A A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous . Which assessment is the highest priority for the nurse to monitor during the administration of this drug? Maternal blood pressure and respirations. B Monitoring maternal and fetal heart rates is most important when terbutaline is being administered becauseTerbutaline acts as a sympathomimetic agent that stimulates both beta 1 receptors (causing tachycardia, a side effect of the drug) and beta 2 receptors (causing uterine relaxation, a desired effect of the drug). A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately? Heart rate of 100 beats/minute. C Total (complete) placenta previa involves the placenta covering the entire cervical os (opening). The onset of uterine contractions places the client at risk for dilation and placental separation, which causes painless hemorrhaging. The risk of hemorrhage is the priority. A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? 3+ deep tendon reflexes and hyperclonus. A A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement? Notify the healthcare provider. C Erythema toxicum (or erythema neonatorum) is a newborn rash that is commonly referred to as "flea bites," but is a normal finding that is documented in the infant's record, and requires no further action. The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? Elicit a positive scarf sign on the affected side. B Rationale The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fractured clavicle should be suspected if an infant has limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex, crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved. The nurse is calculating the estimated date of confinement (EDC) using Ngele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? August 1. D Rationale Calculation of a client's EDC provides baseline data to monitor fetal gestation. N gele's rule uses the formula: subtract 3 months and add 7 days to the first day of the last normal menstrual period, so December 1 minus 3 months + 7 days is September 8. What assessment findings should the nurse report to the healthcare provider that is consistent with concealed hemorrhage and abrupt of placenta?What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta? Maternal bradycardia.
Which would the nurse expect to find when assessing a client suspected of having Abruptio Placentae?In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompany placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability.
Which finding is associated with Abruptio Placentae?The most common symptom of a placental abruption is vaginal bleeding, although you will not always bleed. You may also have sudden, ongoing pain in your abdomen or back.
Which of the following factors would the nurse suspect as predisposing a client to placenta previa?Which of the following factors would the nurse suspect as predisposing a client to placenta previa? Multiple gestation is one of the predisposing factors that may cause placenta previa. Uterine anomalies abdominal trauma, and renal or vascular disease may predispose a client to abruptio placentae.
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What assessment findings should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an Abruptio placenta?
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