OB-GYN 1500 / Midterm Questions & Answers Graded A Plus, Exams of Nursing

Download OB-GYN 1500 / Midterm Questions & Answers Graded A Plus and more Exams Nursing in PDF only on Docsity! Week 1 1. A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? a. "It's a minor inconvenience, which you should ignore." i. This is a nontherapeutic response that disregards the client’s concern and offers unwarranted reassurance. b. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." i. The presence or absence of bladder tone has no bearing on urinary frequency during pregnancy. c. "There is no way to predict how long it will last in each individual client." i. This is a nontherapeutic response that does not provide appropriate information to the client. d. "It occurs during the first trimester and near the end of the pregnancy." i. Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the end of the pregnancy as the enlarging uterus places pressure on the bladder. 2. A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? a. The client is not experiencing a rubella infection at this time. i. A negative rubella titer indicates the client is susceptible to the rubella virus. It does not indicate the presence or absence of a rubella infection. b. The client is immune to the rubella virus. i. A negative rubella titer indicates the client is susceptible to the rubella virus. c. The client requires a rubella vaccination at this time. i. Rubella vaccination during pregnancy is contraindicated because of possible injury to the developing fetus. d. The client requires a rubella immunization following delivery. i. A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month. 3. A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching? a. Limit alcohol consumption. i. Alcohol consumption has no effect on the incidence of neural tube defects. It is related to the incidence of other congenital defects and fetal alcohol syndrome (FAS) in newborns of clients who consume alcohol during pregnancy. b. Increase intake of iron-rich foods. i. Iron intake has no effect on the incidence of neural tube defects. A diet low in iron places a client who is pregnant at risk for preterm labor and postpartum hemorrhage. c. Consume foods fortified with folic acid. i. Increased consumption of folic acid in the 3 months prior to conception, as well as throughout the pregnancy, reduces the incidence of neural tube defects in the developing fetus. d. Avoid foods containing aspartame. i. Aspartame in the diet has no effect on the incidence of neural tube defects in a fetus. Clients who have phenylketonuria should be advised to avoid aspartame since it contains phenylalanine. 4. A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate? a. "Exercising during pregnancy is not recommended." i. Physical activity during pregnancy improves circulation, rest, and relieves boredom. However, risky activities that require precise balance and coordination should be avoided. b. "Daily jogging for up to 30 minutes is fine throughout the pregnancy." i. While weight-bearing exercises might become uncomfortable in the last trimester, they are generally not contraindicated, providing the client stays hydrated and avoids becoming overheated for extended periods. c. "Activities that raise the body temperature, such as saunas and hot tubs, are safe until the third trimester." i. Prolonged or repeated elevations of maternal and fetal temperature can result in birth defects, especially during the first trimester of pregnancy. d. "It is recommended that pregnant clients limit their exercise routine to stretching activities on a mat several times a week." i. Daily moderate exercise throughout pregnancy is recommended. After the fourth month of pregnancy, clients should avoid exercising flat on their back due to the risk of vena cava syndrome. 5. A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make? a. "This will occur during the last trimester of pregnancy." i. A primigravida client should detect fetal movement earlier than the last weeks of pregnancy. b. "This will happen by the end of the first trimester of pregnancy." i. This is too early in the pregnancy for a primigravida client to detect fetal movement. c. "This will occur between the fourth and fifth months of pregnancy." i. Quickening is defined as the first time the client is able to feel her fetus move. In a primigravida client, this usually occurs at 18 weeks of gestation or later. In a multigravida client, this can occur as early as 14 to 16 weeks. d. "This will happen once the uterus begins to rise out of the pelvis." i. The uterus rises out of the pelvis at 12 to 14 weeks of gestation, which is too early for a primigravida client to notice fetal movement. 6. A nurse is caring for a client who is scheduled for a maternal serum-alpha-fetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client? a. This test assesses fetal lung maturity. b. It assesses various markers of fetal well-being. c. This test identifies an Rh incompatibility between the mother and fetus. d. It is a screening test for spinal defects in the fetus. i. The maternal serum alpha-fetoprotein (MSAFP) screening test is used to identify suspected neural tube defects (NTDs) and abdominal wall defects. These include spina bifida, microcephaly, and anencephaly. This tool is the basis for further testing, such as amniocentesis and specialized ultrasounds. 7. A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should instruct the client to call the clinic if she experiences which of the following manifestations? a. Leukorrhea b. Urinary frequency c. Nausea and vomiting d. Facial edema i. Facial edema is a warning sign of a hypertensive condition or preeclampsia and should be reported immediately to the provider. 8. A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on July 27. What is the client's EDB? (State the date in MMDD. For example, July 27 is 0727). a. 0504 i. Using Nägele's rule, the nurse subtracts three months from the date of the last menstrual period, then adds 7 days. July minus 3 months equals April. There are 30 days in April, so 27 + 7 = May 4. The client's EDB is May 4, which would be written as 0504 in the MMDD format. 9. A nurse is providing preconception counseling for a client who is planning a pregnancy. Which of the following supplements should the nurse recommend to help prevent neural tube defects in the fetus? a. Calcium 14. A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make? a. "It would be best if you gained about 11 to 20 pounds." i. Clients who are obese, having a BMI greater than 30, should be advised that the recommended weight gain is 5 to 9 kg (11 to 20 lb). This client is not obese. b. "The recommendation for you is about 15 to 25 pounds." i. Clients who are overweight, having a BMI of 25 to 29.9, should be advised that the recommended weight gain is 7 to 11.5 kg (15 to 25 lb). The pattern of weight gain is also important, with minimal gain in the first trimester. c. "A gain of about 25 to 35 pounds is recommended for you." i. Clients who have a single fetus and a BMI of 18 to 24.9, the normal range, should gain 11.5 to 16 kg (25 to 35 lb) during pregnancy. This client’s BMI indicates that she is overweight. d. "A gain of about 1 pound per week is the best pattern for you." i. Clients who are underweight, having a BMI less than 18.5, are advised that a weight gain of 0.5 kg (1.1 lb) per week during the second and third trimesters is appropriate. This client‘s BMI indicates that she is overweight. 15. A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus? a. 3 cm above the umbilicus i. This level indicates a pregnancy at more than 22 weeks of gestation. b. Slightly above the umbilicus i. At 22 weeks of gestation, the fundal height should be just above the level of the umbilicus. The distance in centimeters from the symphysis pubis to the top of the fundus is a gross estimate of the weeks of gestation. c. Slightly below the umbilicus i. This level indicates a pregnancy at less than 22 weeks of gestation. d. 3 cm below the umbilicus i. This level indicates a pregnancy at less than 22 weeks of gestation. 16. A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following? a. Ballottement i. Ballottement is the passive movement of the fetus when the examiner performs a vaginal examination and gently pushes on the fetus with a fingertip. b. Lightening i. Lightening is the beginning of fetal descent and engagement in the maternal pelvis during the final weeks of a term pregnancy. c. Quickening i. Clients describe quickening as a fluttering sensation, which can be felt as early as the 14th week of gestation. It reflects fetal movement. d. Chloasma i. Chloasma is the presence of a brown hyperpigmentation over the forehead, nose, and cheeks of a client who is pregnant. It is due to an increased level of melatonin, reflecting the hormonal changes of pregnancy. 17. A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make? a. Retained bile in the liver results in delayed digestion. i. Retention of bile can result in its thickening, which can lead to gallstones during pregnancy. b. Increased estrogen production causes increased secretion of hydrochloric acid. i. Increased estrogen production causes decreased secretion of hydrochloric acid. c. Pressure from the growing uterus displaces the stomach. i. At 12 weeks of gestation, the uterus is not large enough to place pressure on the stomach. d. Increased progesterone production causes decreased motility of smooth muscle. i. Increased progesterone production causes a relaxation of the cardiac sphincter of the stomach and delayed gastric emptying, which can result in heartburn. 18. A nurse is teaching about fetal development to a group of clients in the antenatal clinic. Which of the following statements should the nurse include in the teaching? a. "The baby’s heart beat is audible by a Doppler stethoscope at 12 weeks of pregnancy." i. The fetal heartbeat is audible by Doppler stethoscope between 8 to 17 weeks of gestation. b. "The sex of the baby is determined by week 8 of pregnancy." i. The sex of the fetus is determined at conception. c. “Very fine hairs, called lanugo, cover your baby’s entire body by week 36 of pregnancy." i. Lanugo covers the fetal body at week 20 of gestation and begins to disappear by week 36. d. "You will first feel your baby move in week 24 of pregnancy." i. Quickening, the feeling of fetal movement, begins between weeks 14 to 16 of gestation in multiparous women and at week 18 or later in nulliparous women. 19. A nurse in a prenatal clinic is caring for a patient who asks what her estimated date of delivery will be if her last menstrual period was May 4, 2015. Which of the following is the appropriate response by the nurse? a. April 27, 2016 b. February 27, 2016 c. February 11, 2016 i. Subtracting 3 calendar months and adding 7 days plus one year will result in this estimated date of delivery. d. April 11, 2016 20. A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify? a. Fetal attitude is in general flexion. i. Flexion permits the smallest part of the fetal head to present to the outlet. It is not a contributing cause of back labor. b. Fetal lie is longitudinal. i. A longitudinal fetal lie is the most common position for vaginal birth and is not a contributing cause of back labor. c. Maternal pelvis is gynecoid. i. A gynecoid maternal pelvis is the most common type (50%) for women and is not a contributing cause of back labor. d. Fetal position is persistent occiput posterior. i. The persistent occiput posterior position of the fetus is a common cause of prolonged, difficult labor with severe back pain as spinal nerves are being compressed. Counterpressure or a hands-and-knees position can offer pain relief. 21. A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate the provider will order a maternal serum alpha-fetoprotein (MSAFP) screening for which of the following clients? a. A client who has mitral valve prolapse b. A client who has been exposed to AIDS c. All of the clients i. MSAFP is a screening tool to detect open spinal and abdominal wall defects in the fetus. This maternal blood test is recommended for all pregnant woman d. A client who has a history of preterm labor. 22. A nurse in a prenatal clinic is teaching a group of clients about nutrition requirements during lactation. Which of the following statements should the nurse make? a. "Calcium intake should be at least 2,000 mg per day." i. The calcium requirement during lactation for women over age 19 is 1,000 mg, which is the same as during pregnancy and for nonpregnant female clients of the same age. b. "Zinc intake should be at least 12 mg per day." i. Zinc intake should be increased to 12 mg per day during lactation, which is above the recommended levels for pregnancy and nonpregnant female clients over age 19. c. "The recommended intake of folic acid remains the same as for pregnant women." i. Folic acid requirements are 500 mcg per day during lactation, as compared to a recommended intake of 600 mcg during pregnancy. d. "The recommended intake of iron increases." i. Iron requirements do not increase during lactation. They remain 9 mg per day for female clients over age 19. for further teaching? a. "I will reduce my stress level." i. Several risk factors have an effect on prenatal development, and stress is one of them. It is important for the client to reduce stress to promote fetal well-being. Maternal stress can increase blood pressure, which compromises the delivery of oxygenated blood to the developing fetus. b. "I will tell my doctor before using home remedies for nausea." i. Many clients are prone to self-diagnose and self-treat with home remedies when feeling unhealthy or any discomfort. The provider should review home remedies prior to client use to prevent injury to the developing fetus and the client. c. "I will monitor my weight gain during the remaining months." d. Weight gain during pregnancy promotes fetal development. i. Gaining weight at a steady rate within recommended boundaries also can lower chances of hemorrhoids, varicose veins, stretch marks, backache, fatigue, indigestion, and shortness of breath during pregnancy. A sensible meal plan that is rich in vitamins and minerals is essential for fetal development. Foods especially high in protein, calcium, and folic acid will promote fetal well-being. e. "I will use only nonprescription medications while pregnant." i. Both nonprescription and prescription medications can be harmful to the fetus. The client needs to understand the importance of disclosing all medications, supplements, and vitamins to the provider prior to use during pregnancy. 29. A charge nurse observes a nurse checking fetal heart tones (FHT) for a client who is at 12 weeks of gestation. Which of the following actions by the nurse indicates a need for intervention by the charge nurse? a. Places a pillow under the client’s head i. When examining the abdomen, the nurse should support the client’s head on a pillow, the client should have an empty bladder, and the client should be observed for signs of supine hypotension. b. Counts the fetal heart rate for a full minute i. Because FHT might be difficulty to locate early in pregnancy and fetal heart rate varies greatly, the nurse should count for a full minute to avoid error. c. Auscultates above the symphysis pubis i. To locate and listen for FHT in early pregnancy, the nurse auscultates at the client’s midline and just above the symphysis pubis. The uterus is not greatly enlarged at 12 weeks of gestation. d. Listens with a fetoscope i. A fetoscope is not able to detect FHT this early in the pregnancy. The nurse should use a Doppler or ultrasound stethoscope. Typically at 12 weeks, the heart tones will be heard midline just above the symphysis pubis with a Doppler or ultrasound device. A fetoscope can be used to assess FHT later in the pregnancy, around 16 to 20 weeks. 30. Week 2 1. A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor? a. Rupture of the membranes i. The membranes can rupture spontaneously long before the onset of labor. b. Changes in the cervix i. Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor. c. Station of the presenting part i. A client who is a primigravida will typically engage before labor and can enter labor at -1, 0, or even +1 station. d. Pattern of contractions i. A client can have regular contractions for a significant period of time prior to the onset of true labor. 2. A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first? a. Cover the cord with a sterile, moist saline dressing. i. While this is appropriate, it is not the first action the nurse should take. b. Prepare the client for an immediate birth. i. Although an emergency vaginal or cesarean birth might be necessary to deliver the fetus safely, this is not the first action the nurse should take. a. Fetal breathing b. Fetal motion c. Fetal neck translucency d. Amniotic fluid volume i. A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume. A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume. A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume e. Fetal gender 8. A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52mmHg. Which of the following nursing interventions should the nurse perform? a. Prepare for a cesarean birth. b. Assist the client to an upright position. c. Prepare for an immediate vaginal delivery. d. Assist the client to turn onto her side. i. Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena cava. Turning the client to her right side relieves this pressure and restores blood pressure to the expected reference range. 9. A nurse in a prenatal clinic is reviewing the health record of a client who is at 28 weeks of gestation. The history includes one pregnancy, terminated by elective abortion at 9 weeks; the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks. According to the GTPAL system, which of the following describes the client's current status? a. 4-0-1-2-2 i. This response correctly describes the client's current status: pregnant currently and had 3 prior pregnancies (G); no term births (T); one pregnancy resulted in the preterm birth (P) of twins; two pregnancies ended in abortion (A); and she has two living children (L). b. 3-0-2-0-2 c. 2-0-0-2-0 d. 4-2-0-2-2 10. A nurse in a prenatal clinic is caring for a client who believes that she might be pregnant because she feels the baby moving. Which of the following statements should the nurse make? a. "This is a presumptive sign of pregnancy." i. Presumptive signs of pregnancy include physical changes that are apparent to the client, such as quickening. b. "This is a probable sign of pregnancy." i. Probable signs of pregnancy include manifestations that can be seen upon examination, such as a positive serum or urine pregnancy test. c. "This is a possible sign of pregnancy." i. There is no classification of "possible signs of pregnancy." d. "This is a positive sign of pregnancy." i. Positive signs of pregnancy include findings related to the presence of a fetus, such as detecting fetal heart tones. 11. A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels light-headed, and her fingers are tingling. Which of the following actions should the nurse take? a. Administer oxygen via nasal cannula. b. Assist the client to breathe into a paper bag. i. This client is experiencing respiratory alkalosis due to hyperventilation. The client should be assisted to breathe into a paper bag or to cup her hands over her mouth to increase the carbon dioxide level, which replaces the bicarbonate ion. c. Have the client tuck her chin to her chest. d. Instruct the client to increase her respiratory rate to more than 42 breaths per min. 12. A nurse in the labor and delivery unit is caring for a client who is undergoing external fetal monitoring. The nurse observes that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. Which of the following actions should the nurse take first? a. Place the client in the lateral position i. This is a late deceleration and is associated with fetal hypoxemia due to insufficient placental perfusion. Placing the client in the lateral position is the first action the nurse should take. b. Increase the rate of maintenance IV infusion i. This is a late deceleration and is associated with insufficient placental perfusion. Increasing the rate of maintenance IV infusion is an appropriate action; however, there is another action the nurse should take first. c. Elevate the client’s legs i. This is a late deceleration and is associated with insufficient placental perfusion. Elevating the client’s legs is an appropriate action; however, there is another action the nurse should take first. d. Administer oxygen using a nonrebreather mask i. This is a late deceleration and is associated with insufficient placental perfusion. Administering oxygen at 8 to 10 L/min by a nonrebreather mask is an appropriate action; however, there is another action the nurse should take first. 13. A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain? a. Administer prescribed analgesic medication. i. The gate control theory of pain is based on the concept of preventing the transmission of pain signals to the brain by using distraction techniques. Administering pain medication does not address this theory. b. Encourage the client to rest between contractions. i. The gate control theory of pain is based on the concept of preventing the transmission of pain signals to the brain by using distraction techniques. Encouraging the client to rest between contractions does not address this theory. c. Massage the client's back. i. The gate control theory of pain is based on the concept of blocking or preventing the transmission of pain signals to the brain by using distraction techniques such as massage. Massaging the client’s back focuses on neuromuscular and cognitive changes. d. Turn the client onto her left side. i. The gate control theory of pain is based on the concept of preventing the transmission of pain signals to the brain by using distraction techniques. Turning the client to her left side does not address this theory. 14. A nurse on the labor and delivery unit is caring for a patient following a vaginal examination by the provider which is documented as: -1. Which of the following interpretations of this finding should the nurse make? a. The presenting part is 1 cm above the ischial spines. i. Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is minus 1, then the presenting part is 1cm above the ischial spines. b. The presenting part is 1 cm below the ischial spines. c. The cervix is 1 cm dilated. d. The cervix is effaced 1 cm 15. A nurse is caring for a client during a nonstress test (NST). At the end of a 30-min period of observation, the nurse notes the following findings: The fetal heart rate baseline is 120/min with minimal variability and no accelerations. There are two decelerations of 15 /min in the fetal heart rate during a period of fetal movement, each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make? a. A negative test i. A negative test is one of the findings for a client having a contraction stress test (CST). This result indicates that at least three uterine contractions occurred in a 10- min period with no late or significant variable decelerations. b. A nonreactive test i. An NST that does not produce two or more qualifying accelerations within a 20-min period is interpreted as nonreactive. Qualifying accelerations peak at least 15 /min above the FHR baseline and last at least 15 seconds. c. A positive test i. A positive test is one of the findings for a client having a contraction stress nonstress test. c. There is no evidence of uteroplacental insufficiency. i. A contraction stress test determines how well the fetus tolerates the stress of uterine contractions. A test is negative when there are at least 3 uterine contractions in a 10-min period with no late or significant variable decelerations during electronic fetal monitoring. Uteroplacental insufficiency produces late decelerations. d. There are less than 3 uterine contractions in a 10-min period. i. This finding is an interpretation of an unsatisfactory contraction stress test. 22. A nurse in a clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor? a. Decreased vaginal discharge b. A surge of energy i. Prior to the onset of labor, the pregnant client experiences a surge of energy. c. Urinary retention d. Weight gain of 0.5 to 1.5 kg 23. A nurse is caring for a client who experienced a vaginal birth 12 hr ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase? a. Expressions of excitement i. Expressing excitement and being talkative are characteristic of this phase. b. Lack of appetite i. A lack of appetite is not a characteristic of maternal postpartum adjustment. c. Focus on the family unit and its members i. A focus on the family unit and its members is a finding in the interdependent, letting go phase of maternal postpartum adjustment. d. Eagerness to learn newborn care skills i. A desire to learn newborn care is a finding in the dependent- independent, taking hold phase of maternal postpartum adjustment. 24. A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block? a. Vomiting i. Vomiting is not an adverse effect of epidural anesthesia. It is an adverse effect of opioids and opioid agonist analgesics, both of which can help minimize labor pain. b. Tachycardia i. Tachycardia is not an adverse effect of epidural anesthesia. It is an adverse effect of opioid agonist-antagonist analgesics, such as butorphanol. c. Respiratory depression i. Respiratory depression is not an adverse effect of epidural anesthesia. It is a risk for clients receiving magnesium sulfate for pre-eclampsia or premature labor. d. Hypotension i. Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of the epidural catheter to decrease the likelihood of this complication. 25. A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client's blood pressure is 80/40 mm Hg, and the fetal heart rate is 140/min. Which of the following is the priority nursing action? a. Elevate the client's legs. b. Monitor vital signs every 5 min. c. Notify the provider. d. Place the client in a lateral position. i. Based on Maslow's hierarchy of needs, the client should be moved to a lateral position, or a pillow placed under one of the client's hips to relieve pressure on the inferior vena cava and improve the blood pressure. 26. A nurse is teaching a client who is at 23 weeks of gestation and will return to the facility in 2 days for an amniocentesis. Which of the following instructions should the nurse give the client? a. Food and fluids should not be consumed the day of the procedure. i. The client does not have to fast for an amniocentesis. b. Complete a bowel prep protocol the day before the procedure. i. The client does not complete a bowel prep protocol the day before the procedure. c.Empty her bladder immediately prior to the procedure. i. Emptying the bladder before amniocentesis prevents possible puncture of the bladder and displacement of the uterus and fetus. i. Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix has dilated. Administration too close to the time of delivery could cause respiratory depression in the newborn. c. Monitor the fetal heart rate (FHR) every hour d. Insert an indwelling urinary catheter 33. A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record? a. Vertex b. Shoulde r c. Breech i. An RSA position indicates that the body part of the fetus that is closest to the cervix is the sacrum. Therefore, the buttocks or feet are the presenting part, which is classified as a breech presentation. d. Mentum 34. A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply.) a. "I am likely to have a fever during the first week I am home” b. "I will resume taking my prenatal vitamins." c. "I will call my provider if I have discharge from my incision." d. "I should not have unrelieved pain in my abdomen." e. "I will rest in a recliner until my incision is healed." 35. A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? a. Maintain the client in the lithotomy position b. Perform vaginal examinations frequently c. Remind the client to bear down with each contraction d. Encourage the client to empty her bladder every 2 hr 36. A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.) a. Blot the perineal area dry after cleansing. b. Clean the perineal area from front to back. c. Perform hand hygiene before and after voiding. d. Apply ice packs to the perineal area several times daily. e. Wash the perineal area using a squeeze bottle of warm water after each voiding. 37. A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse’s priority? a. The client reports weakness of the lower extremities. i. Weakness of the lower extremities can limit the client's ability to move and maintain control during labor; however, another finding is the nurse's priority. b. Blood pressure 80/56 mm Hg i. When using the airway, breathing, circulation approach to client care, the nurse's priority finding is a blood pressure of 80/56, which indicates hypotension. The client's blood pressure is not adequate to sustain uteroplacental perfusion and oxygen to the fetus, which can lead to respiratory distress and possibly death. c. Temperature 38.2 C (100.8 F) i. A temperature of 38.2°C (100.8°F) can indicate infection; however, another finding is the nurse's priority. d. The client reports perfuse itching. i. Perfuse itching may indicate an adverse reaction to the opioid analgesia; however, another finding is the priority. 38. A nurse is providing teaching to a client who is at 30 weeks of gestation and is to have a nonstress test (NST). Which of the following statements by the client indicates a need for further teaching? a. "I will have to lie on my back during the test." i. The client is placed in a Semi-Fowler’s position with one hip slightly elevated to promote uterine perfusion and prevent supine hypotension as a result of the uterus compressing the maternal vena cava. b. "My baby’s heart rate will be monitored during the test." i. The NST monitors fetal activity and accelerations in the fetal heart rate that accompany fetal movement. c. "I should schedule the test when the baby is usually active." i. The most common reason for the absence of fetal heart rate accelerations is the fetal sleep state. The client should be instructed to schedule the test when the baby is usually active. Vibroacoustic stimulation may be used to stimulate fetal activity. d. "It will take 20 to 30 minutes to complete the test." i. The client is instructed that it will take 20 to 30 min to complete the test if the fetus is active. More time might be needed if the fetus is in a sleep state. 39. A nurse is assessing a client who is 12 hr postpartum and received spinal anesthesia for a cesarean birth. Which of the following findings requires immediate intervention by the nurse? a. Blood pressure 100/70 mm Hg i. Although hypotension is a potential adverse effect of spinal anesthesia, the client's BP is still within the expected reference range. Therefore, another finding is the priority. b. Headache pain rated a 6 on a scale of 0 to 10 i. A headache is a potential adverse effect of spinal anesthesia. Therefore, another finding is the priority. c. Respiratory rate 10/min i. A client who has received spinal anesthesia is at risk for respiratory depression and hypotension. A respiratory rate of 10/min indicates bradypnea and requires immediate intervention. d. Urinary output 30 mL/hr i. Although difficulty urinating is a potential adverse effect of spinal anesthesia, the client's output is within the expected reference range. Therefore, another finding is the priority. 40. A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first? a. Apply a fetal scalp electrode b. Increase the rate of the IV infusion c. Administer oxygen at 10 L/min via a nonrebreather mask d. Change the client’s position i. The first action the nurse should take is to change the client's position in an attempt to increase blood flow to the fetus. 41. A nurse is teaching a client who is at 23 weeks of gestation about immunizations. Which of the following statements should the nurse include in the teaching? a. "You should not receive the rubella vaccine while breastfeeding." b. "You should receive a vaccine before you deliver." c. "You can receive an influenza vaccination during pregnancy." i. It is recommended that pregnant women receive annual influenza vaccinations. d. "You cannot receive the Tdap vaccine until after you deliver." 42. A nurse is caring for a client who presents to a labor and delivery unit experiencing rapidly progressing labor. Which of the following is the priority action for the nurse to take? a. Cut the umbilical cord. i. Cutting the umbilical cord is not a priority. The cord is clamped and cut after the placenta stops pulsating. It is not uncommon for the umbilical cord to encircle the neck. It is rare for the cord to be wrapped so tightly as to cause hypoxia. If the cord is wrapped around the neck, the cord should be gently slipped over the head. If the loop is too tight, the cord should be clamped twice, and the cord should be cut between the clamps. b. Apply perineal pressure to the emerging fetal head. i. Using Maslow’s hierarchy of needs, the priority intervention is to prevent injury to the fetus during the delivery by applying gentle perineal pressure to the emerging head. This avoids rapid expulsion of the fetal head. A change in pressure within the fetal skull due to a rapid delivery can cause neurologic damage (increased intracranial pressure and dural/subdural tearing). Rapid birth can also cause maternal injury, such as vaginal or perineal lacerations. c. Prevent the perineum from tearing. i. Maternal complications associated with rapid labor and an emergency birth can include uterine rupture, lacerations of the birth canal, and postpartum hemorrhage. Applying perineal pressure as the fetal head is crowning can decrease maternal tearing and injury. However, preventing the perineum from tearing is not the priority concern. d. Promote delivery of the placenta. 5. A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client’s right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones? a. Left lower b. Right lower c. Left upper d. Right upper i. Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be in the right upper quadrant. 1. A nurse in is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure? a. Observe color and consistency of fluid b. Assess the fetal heart rate pattern i. Variable fetal heart rate decelerations and bradycardia can occur with an amniotomy as a result of umbilical cord prolapse or compression. Cord prolapse necessitates an emergent delivery. c. Assess the client’s temperature d. Evaluate the client for presence of chills and increased uterine tenderness using palpation 2. A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn’s Apgar score. a. 6 points i. The Apgar score is 6 out of a possible 10. It is based on 5 signs evaluated at 1 and 5 min after delivery that indicate the physiologic state of the newborn as he transitions from intrauterine life to extrauterine life: heart rate over 100/min = 2; slow, weak cry = 1; some flexion of extremities = 1; grimace in response to suctioning of the nares = 1; body pink in color with blue extremities = 1. A score of 4 to 6 indicates moderate difficulty adjusting to life outside of the womb. 3. A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take? a. Decrease the rate of infusion of the maintenance IV solution i. Increasing the rate of infusion of the maintenance IV solution is an appropriate action to take when late decelerations occur. b. Discontinue the infusion of the IV oxytocin. i. Discontinue the oxytocin infusion immediately if a client is experiencing late decelerations due to uterine hyperstimulation. c. Increase the rate of infusion of the IV oxytocin. i. Increasing the rate of the oxytocin infusion can result in fetal distress due to uterine hyperstimulation. d. Slow the client’s rate of breathing i. Oxygen should be administered at a rate of 8 to 10 L/min when late decelerations occur due to uterine hyperstimulation. 4. A nurse is caring for a patient who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vaginal examination. Which of the following actions should the nurse take? a. Apply fundal pressure. b. Observe for the presence of a nuchal cord. c. Observe for crowning. i. In the descent phase of the second stage of labor, crowning occurs when the fetal head is at +2 to +4 station. Because this is the client's third childbirth experience, it is reasonable to assume that delivery is imminent. d. Prepare to administer oxytocin. 5. A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching? a. "The test will be performed if your baby's heartbeat is heard." b. "This test will determine if your baby's lungs are mature." c. "This test requires the presence of amniotic fluid." i. Amniocentesis requires adequate amniotic fluid for testing, which is not available until after 14 weeks of gestation. d. "After the test, you will be given Rh0 immune globulin since you are Rh positive." 6. A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (SATA) a. Fetal breathing b. Fetal motion c. Fetal neck translucency d. Amniotic fluid volume i. A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume. A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume. A biophysical profile is an assessment of fetal well-being and includes ultrasound evaluation of fetal breathing movements, gross fetal movements, and amniotic fluid volume e. Fetal gender 7. A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Which of the following is the priority nursing action? a. Monitor vaginal bleeding. i. The quantity of vaginal bleeding and any associated pain should be monitored, but this is not the priority action by the nurse. b. Administer glucocorticoids. i. Glucocorticoids should be administered to the client who is at less than 34 weeks of gestation to promote fetal lung maturity, but this is not the priority action by the nurse. c. Insert an IV catheter. i. IV access should be established, but this is not the priority action by the nurse. d. Apply an external fetal monitor. i. Based on Maslow’s hierarchy of needs, the nurse should immediately apply the fetal monitor to determine if the fetus is in distress. 8. A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action? a. Elevate the client’s legs b. Position the client on her side i. Late decelerations stem from decreased blood perfusion to the placenta or compression of the placenta. A position change should increase perfusion or decrease compression, and it is the first intervention the nurse should try. The greatest risk to the client is fetal hypoxia, so the priority action is the one that has the best chance of improving fetal perfusion. c. Administer oxygen via face mask d. Increase the infusion rate of the IV fluid 9. A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following a vaginal birth. Which of the following actions should the nurse take? a. Apply an ice pack to the affected area i. During the first 24 hr, ice packs and cool water sitz baths are used. They reduce edema and promote comfort. The client may also apply witch hazel compresses to reduce edema. The nurse should instruct the client on the use of prescribed anesthetic creams, sprays, and ointments. b. Offer a warm sitz bath c. Provide a squeeze bottle of antiseptic solution d. Place a hot pack to the perineum 10. A nurse is caring for a client who is in active labor when the client’s membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first? a. palpate the client’s uterus b. administer oxygen to the client c. increase the client’s IV fluid infusion rate d. Turn the client onto her side i. When using the urgent vs non-urgent approach to client care, the nurse determines that the priority action is to turn the client onto her left side. Late decelerations indicate that the client might have uteroplacental insufficiency, maternal hypotension, uterine tachysystole form oxytocin is ~ In 1. A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? a. Administer vitamin K i. Administration of vitamin K is important, but it can be delayed until the newborn is held by the mother and is breastfed. There is another, more important nursing action. b. Dry the skin i. The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother’s abdomen, and a cap applied to the newborn’s head to prevent cold stress. The newborn responds to the cooler environment by increasing his respiratory rate, which can lead to respiratory distress. Based on Maslow’s hierarchy of needs, this is the most important nursing action after securing the airway. c. Administer eye prophylaxis i. Administration of eye prophylaxis should occur within the first hour after birth. There is another, more important nursing action. d. Place an identification bracelet i. Correct identification of the newborn is important, but it can be delayed, as long as it is completed prior to the mother and newborn leaving the delivery room. There is another, more important nursing action. 2. A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn? a. Clear the respiratory tract. i. Clearing the airway of the infant is the first action the nurse should take immediately following delivery. b. Dry the infant off and cover the head. i. Drying the infant and covering the head should be done shortly after the delivery, but it is not the first action the nurse should take. c. Stimulate the infant to cry. i. Stimulating the infant to cry should be done shortly after the delivery, but it is not the first action the nurse should take. d. Cut the umbilical cord. i. Cutting the umbilical cord should be done shortly after the delivery, but it is not the first action the nurse should take. 3. A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse? a. "I will call your primary care provider to report your concerns." b. "I will take your baby to the nursery for further examination." c. "This occurs because newborns lack muscle control to regulate eye movement." i. This addresses the client’s concerns because it provides information that addresses her concerns. The eyes of newborns are structurally incomplete and muscle control is not fully developed for 3 months. d. "This is a concern, but strabismus is easily treated with patching." 4. A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn’s plan of care? a. Observe for meconium in respiratory secretions. i. When a fetus is SGA, there is an increased risk for intrauterine hypoxia due to the presence of meconium in the amniotic fluid. The nurse should observe for meconium in respiratory secretions when suctioning the newborn at delivery. Newborns who are SGA are at risk for perinatal asphyxia due to the stress of labor and are often depressed. They require careful resuscitation and suctioning at delivery. b. Monitor for hyperglycemia. c. Identify manifestations of anemia. d. Monitor for hyperthermia. 5. A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.) a. Cracked, peeling skin b. Positive Moro reflex c. Short, soft fingernails d. Abundant lanugo e. Vernix in the folds and creases 6. A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, "How will I know if my baby gets enough breast milk?" Which of the following responses should the nurse make? a. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding." i. Babies will typically sleep after a feeding, making this an unreliable indicator that the newborn is getting enough breast milk. b. "Your baby should wet 6 to 8 diapers per day." i. Newborns should wet 6 to 8 diapers per day. This is an indication that the newborn is getting enough fluids. c. "Your baby should burp after each feeding." i. Burping the baby will not ensure the newborn is getting enough breast milk. d. "Your baby should sleep at least 6 hours between feedings." i. A newborn should eat at least every 4 hr at night; however, length of sleep between feedings is not an indicator that the infant is getting enough breast milk. 7. A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother’s room. Which of the following is an appropriate response by the nurse? a. "You may carry your grandchild to the room." i. This is not an appropriate response. Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting a newborn to leave the nursery. b. "You can push the baby to the room in a wheeled bassinet." i. This is not an appropriate response. Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting a newborn to leave the nursery. c. "Have the mother call and I will take the baby to the room." i. Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting an infant to remain in the mother’s room. d. "If you show me your photo identification, you can take the infant." i. This is not an appropriate response. Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting a newborn to leave the nursery. 8. A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect? a. Copious vernix i. A newborn who is postmature lacks vernix. b. Scant scalp hair i. A newborn who is postmature commonly has profuse scalp hair. c. Increased subcutaneous fat i. A newborn who is postmature lacks subcutaneous fat. d. Dry, cracked skin i. A newborn who is postmature has dry, cracked skin. 9. A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make? a. "Preterm newborns have a smaller body surface area than normal newborns." i. Preterm newborns have a large body surface area for their weight. b. "The added brown fat layer in a preterm newborn reduces his ability to generate heat." i. The lack of brown fat stores found in a preterm newborn limits the ability to generate body heat. c. "Preterm newborns lack adequate temperature control mechanisms." i. Preterm newborns have poor body control of temperature and need support to avoid losing heat. They require an external heat source, such as an incubator. d. "The heat in the incubator rapidly dries the sweat of preterm newborns." i. Preterm newborns do not sweat. 10. A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn? a. 22/min i. This action decreases the loss of heat from a warm body to a cooler solid surface in close proximity but not in direct contact. This process is called radiation. Air drafts increase the effect of radiation. c. Drying the newborn’s skin thoroughly i. Heat loss through evaporation occurs when moisture on the skin is converted to a vapor. This process is the most significant cause of heat loss in the first few days of life but is minimized by quickly and thoroughly drying the infant d. Maintaining ambient room temperature at 24° C (75° F) i. This action decreases the loss of body heat to the cooler ambient air. This process is called convection. 15. A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions? a. Perform a sharp hand clap near the infant. i. To elicit the Moro reflex, the nurse performs a sharp hand clap near the newborn and observes symmetric abduction and extension of the arms, fanning of the fingers with the thumb and forefinger to form a C, and then a return to a relaxed flexion position. b. Hold the newborn vertically allowing one foot to touch the table surface. i. This position is used to elicit the stepping reflex. The newborn should respond by alternating flexion and extension of his feet, as if he was walking. c. Place a finger at the base of the newborn's toes. i. This action elicits the plantar grasp reflex. The expected response is that the newborn’s toes will curl downward. d. Turn the newborn’s head quickly to one side. i. This action elicits the tonic neck reflex. The expected response is that the newborn will extend the arm and leg on the side where the head was turned, while the opposite arm and leg will flex. 16. A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse? a. "Mongolian spots can be found on the skin of many newborns." i. Mongolian spots are bluish-black areas of pigmentation more commonly noted on the back and buttocks. b. "A caput succedaneum occurs due to compression of blood vessels." i. A caput succedaneum is an area of edema on the newborn’s occiput, often seen where the cup of the vacuum was applied. It is present at birth and will disappear within 3 to 4 days. c. "This is a cephalhematoma, which can occur spontaneously." i. A cephalohematoma is a collection of blood between the skull and periosteum and does not cross the suture line. It appears after the birth and will take 3 to 6 weeks to resolve. d. "This is erythema toxicum, which is a transient condition." i. Erythema toxicum is a transient skin rash that can occur during the first 3 weeks of life. It is thought to be an inflammatory response and no treatment is required. 17. A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn? a. Cold stress i. When an infant is stressed by cold exposure, oxygen consumption increases and pulmonary and peripheral vasoconstriction occurs. Metabolic demands for glucose increase. If the cold stress continues, hypoglycemia and metabolic acidosis can result. b. Shivering i. The shivering mechanism in newborns is rarely operable. Newborns respond to cold by increasing muscle and metabolic activity and through metabolizing brown fat. c. Basal metabolic rate reduction i. : If the newborn becomes chilled, he will increase his basal metabolic rate in an attempt to generate heat. This results in an increased consumption of oxygen and blood glucose. d. Brown fat production i. Infants are born with stores of brown fat, which they utilize during the first few weeks of life to produce heat. Brown fat is unique to the newborn and can increase heat production by 100%. 18. A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention? a. A newborn who is 24 hr post-delivery and has not voided i. First voiding usually occurs within 24 to 48 hr following delivery. b. A newborn who is 18 hr post-delivery and has acrocyanosis i. Acrocyanosis, a bluish discoloration of the hands and feet, can persist for 24 hr following delivery. c. A newborn who is 24-hr post-delivery and has not passed meconium i. Passage of meconium usually occurs within 12 to 48 hr post-delivery. d. A newborn who is 12 hr post-delivery and has a temperature of 37.5° C (99.5° F) i. Hyperthermia in the newborn requires immediately intervention. Hyperthermia is typically caused by increased heat production related to sepsis or decreased heat loss. 19. A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care? a. Position the newborn to promote extension of muscles. i. Preterm newborns lack motor development that allows for muscle flexion. A prone position or the use of a sling promotes flexion. b. Use fingertips when calming the newborn. i. The use of both hands is the most effective calming technique, especially when repositioning the newborn’s extremities close to his body. c. Cluster the newborn's care activities. i. By clustering activities and organizing care, the nurse prevents excessive interruptions and allows the newborn extended periods of rest and energy conservation that promote development. d. Keep the newborn in a well-lit nursery. i. To promote sleep-wake cycles, newborns should be protected from light at night by dimming nursery illumination, placing a cover over the incubator, or positioning a mask over the eyes. 20. A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.) a. "I’ll expect the plastic ring to fall of f by itself within a week." b. "I’ll apply petroleum jelly to his penis with diaper changes." c. "I’ll wash his penis with warm water and mild soap each day." d. "I’ll call the doctor if I see any bleeding." e. "I’ll make sure his diaper is loose in the front." 21. A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take? a. Ask another nurse to verify the heart rate. i. Unless the nurse has doubts about measuring the newborn’s apical heart rate, there is no need to ask another nurse to verify this finding. b. Document this as an expected finding. i. The expected reference range for an apical pulse in a newborn who is awake is 120 to 160/min. The nurse should document this as an expected finding. c. Call the provider to further assess the newborn. i. Based on this finding, there is no need to call the provider to assess the newborn. d. Prepare the newborn for transport to the NICU. i. Based on this finding, there is no need to prepare the newborn for transport to the NICU. 22. A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what to do when her newborn cries persistently. Which of the following strategies should the nurse suggest? (Select all that apply.) a. Take the newborn for a ride in the car. b. Keep the newborn in the center of a large crib. c. Carry the newborn in a front or back pack. d. Swaddle the newborn in a receiving blanket. e. Allow the newborn to continue crying. 23. A nurse is completing a newborn gestational age assessment. Which of the following findings should be recorded as part of this assessment on the newborn? a. Acrocyanosis of hands and feet i. Acrocyanosis is monitored as part of the Apgar and newborn physical assessment but is not a component of gestational age assessment. b. Anterior fontanel soft and level i. The anterior fontanel is palpated as part of newborn physical assessment but is not a component of gestational age assessment. c. Plantar creases cover 2/3 of sole i. Observing the presence of creases on the plantar surface is one of the components of a gestational age assessment. d. Vernix caseosa in inguinal creases i. Vernix caseosa in inguinal creases is a normal newborn finding but not a component of gestational age assessment. 24. A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles? a. Vastus lateralis i. The nurse should administer vitamin K, or phytonadione, into the vastus lateralis muscle in the thigh. This medication prevents and treats hemorrhagic disease of the newborn, as newborns are born with vitamin K deficiency. b. Ventrogluteal i. The ventrogluteal muscle is used for some IM injections, but it is not the preferred site for injecting vitamin K into a newborn. c. Dorsogluteal i. The dorsogluteal muscle in newborns is too small to receive an IM medication, and it is near the sciatic nerve. It is not recommended as an injection site in small children. d. Deltoid i. The deltoid muscle in newborns is too small to receive an IM medication. It is not recommended as an injection site in small children. 25. A nurse is caring for a newborn who has macrosomia and whose mother has diabetes mellitus. The nurse should recognize which of the following newborn complications as the priority focus of care? a. Hypoglycemia i. Newborns of mothers who have diabetes are at high risk for hypoglycemia due to the loss of high levels of glucose after the umbilical cord is cut. This results in fetal hyperinsulinemia. It can take several days for the newborn to adjust to secreting appropriate amounts of insulin for the lower level of blood glucose. Because severe hypoglycemia can lead to cyanosis and seizures, prevention of hypoglycemia becomes the nurse’s priority focus of care. b. Hypomagnesemia i. Newborns of mothers who have diabetes are at risk for hypomagnesemia, but this is not the nurse’s priority focus of care. c. Hyperbilirubinemia i. Newborns of mothers who have diabetes are at risk for hyperbilirubinemia, but this is not the nurse’s priority focus of care. d. Hypocalcemia i. Newborns of mothers who have diabetes are at risk for hypocalcemia, but this is not the nurse’s priority focus of care. 26. A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive? a. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months i. This is not the appropriate vaccine and immune globulin schedule for a newborn whose mother is positive for the hepatitis B surface antigen. b. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen i. This is not the appropriate vaccine and immune globulin schedule for a newborn whose mother is positive for the hepatitis B surface antigen. c. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth i. A newborn whose mother is positive for the hepatitis B surface antigen should receive both the hepatitis B vaccine and the hepatitis B immune globulin within 12 hr of birth. sleeping is no longer recognized as an acceptable alternative to the fully supine position. b. "I should remove extra blankets from my baby’s crib." i. Loose bedding such as sheets and blankets could cover the baby’s head and lead to suffocation. c. "I should pad the mattress in my baby’s crib so that he will be more comfortable when he sleeps." i. Infants should sleep on firm crib mattresses to decrease the risk of suffocation. d. "I should place my baby’s crib next to the heater to keep him warm during the winter." i. Linens in the crib could catch fire if they come in contact with a heat source. 35. A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene? a. The mother cleans the newborn's eyes from the inner canthus outwards. i. The mother should clean the newborn's eyes from the inner canthus outwards to prevent introducing micro-organisms into the eyes. b. The mother cleans the umbilical cord with tap water. i. The mother should use tap water to clean around the base of the cord. c. The mother leaves the yellow exudate on the circumcision site. i. The mother should not remove the yellow exudate from the circumcision site because it is part of the healing process. d. The mother plans to use a cotton-tipped swab to clean the nares. i. To prevent injury, the mother should use the corner of a washcloth to clean the newborns ears and nares. 36. A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? (Select all that apply.) a. Vitamin K injection b. Hepatitis B immunization c. Antibiotic ointment to both eyes d. Lidocaine gel to the umbilical stump e. Haemophilus influenza type b immunization (Hib) 37. A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching? a. "I will use mild soap." i. Mild soap should be used. The newborn is completely bathed two to three times a week using mild soap without hexachlorophene. This compound is an antibacterial detergent found in some soap products that can disrupt the pH of newborn skin. The nurse should instruct the client to first cleanse from the cleanest to dirtiest part of the newborn’s body, beginning with eyes, face, and head, proceed to the chest, arms, and legs, and wash the groin area last. The client should cleanse the eyes from the inner canthus outward and then wash the area around the cord, taking care not to get it wet. The nurse should recommend bathing the newborn before feeding to prevent spitting or vomiting. The nurse should remind the client that soap should not be used on the face. b. “I will use a basin during bathing." i. A basin will be used to bathe the newborn. Most infants and children can be bathed in a portable basin or tub at the bedside, on the bed, or in a standard bathtub or shower. The client should not immerse the newborn in a tub of water until the newborn’s umbilical cord has fallen off and the circumcision site has healed. Providing head support is important until the newborn has head and neck control, which occurs around 3 months. c. "Baby powder will help prevent a diaper rash." i. Lotions, creams, oils, or powders can alter a newborn’s skin and provide a medium for bacterial growth or cause an allergic response. Powders can be inhaled, leading to respiratory distress. This statement requires the nurse to clarify instruction on newborn care. d. "I will test the water on my wrist for temperature before bathing." i. Bath water should be 38 to 40&deg C (100.4 to 104° F); or lower to avoid a burn injury. Environmental control is essential to avoid newborn hypothermia by closing windows, avoiding drafts, and controlling room temperature with a reliable heat source. Prior to bathing, the water should be tested for comfort on the inner wrist to avoid injury to newborn skin. The home’s hot water heater should be set at 49° C (120° F). 38. A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice? a. Begin phototherapy. i. Phototherapy is a treatment for hyperbilirubinemia. It does not prevent jaundice in the newborn. b. Initiate early feeding. i. Prevention of jaundice can be facilitated best by early and frequent feeding, which stimulates intestinal activity and passage of meconium. Jaundice occurs due to elevated serum bilirubin, which is excreted primarily in the newborn’s stool. Physiologic jaundice manifests after 24 hr and is considered benign. However, bilirubin may accumulate to hazardous levels and lead to a pathologic condition. c. Suction excess mucus with a bulb syringe. i. A bulb syringe is used to remove excess or tenacious mucus from the newborn’s nose and mouth and to maintain a patent airway. This action does not prevent jaundice in the newborn. d. Prepare for an exchange blood transfusion. i. Exchange blood transfusions are rarely done but can be used to lower serum bilirubin levels when phototherapy is unsuccessful in the treatment of hyperbilirubinemia. They do not prevent jaundice in the newborn. 39. A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority? a. Platelets 200,000/mm3 i. Platelets 200,000/mm is within the expected reference range for a newborn; therefore, another finding is the nurse’s priority. A newborn can have a low platelet count (thrombocytopenia) hemolytic anemia, hemorrhage, and infections or a high platelet count (thrombocytosis) from polycythemia. b. Bilirubin 19 mg/dL i. Bilirubin 19 mg/dL is above the expected reference range for a newborn at 4 hr of age. A bilirubin level greater than 15 mg/dL or an increase by more than 6 mg/dL in 24 hr is pathologic or nonphysiologic jaundice. Pathologic jaundice is a result of an underlying disease and occurs before 24 hr of age; therefore, this is the nurse's priority finding. c. Blood glucose 45 mg/dL i. A blood glucose level of 45 mg/dL is within the expected reference range for a newborn; therefore, another finding is the nurse’s priority. The nurse should follow facility protocols to check the blood glucose levels of any newborns that are at risk for hypoglycemia, such as those whose mothers have diabetes and those who are small for gestational age. d. Hemoglobin 22 g/dL i. Hemoglobin 22 g/dL is within the expected reference range for a newborn; therefore, another finding is the nurse's priority. Causes of a low hemoglobin level in a newborn include hemorrhage and hemolytic anemia. Causes of an elevated hemoglobin level in a newborn include congenital heart disease, polycythemia and severe dehydration. 40. A nurse is providing teaching about phenylketonuria (PKU) testing to the parent of a newborn. Which of the following statements by the parent indicates a need for additional teaching? a. "My baby will be placed under special lights if the test result is positive." i. Phototherapy is used to reduce circulating unconjugated bilirubin in infants who have hyperbilirubinemia. Phototherapy for hyperbilirubinemia uses light energy to lower the bilirubin level in the newborn’s blood. This would not be appropriate therapy for PKU. b. "My baby needs to be on formula or breast milk before the test can be done." i. The test for PKU is not reliable until the newborn has ingested adequate amounts of protein from breast milk or formula. The screening is most reliable if the newborn has taken formula or breast milk for at least 24 hr. Newborn screening tests are mandatory in all 50 states. c. "This test checks for a genetic disorder that can be managed by diet." i. Phenylketonuria (PKU) is a genetic disorder that can lead to impaired cognitive functioning if not identified and treated with a special diet. It is diagnosed with a heel stick blood test soon after birth. Treatment includes a diet low in protein, a phenylalanine-restricted diet, and the addition of a special amino acid-containing formula or milk that does not contain phenylalanine. d. "Sometimes the test is repeated in the doctor’s office at the baby’s 2-week check- up." i. For PKU results to be most accurate, newborns should receive formula or breast milk at least 24 hr before the test is performed. Because newborns are sometimes discharged before 24 hr, the test should be repeated when the newborn is 1 to 2 weeks of age. Blood is obtained through a heel stick. 41. A nurse is providing teaching about newborn care to a client who is 2 hr postpartum. Which of the following statements by the client indicates a need for further teaching? a. "I should keep my baby’s head covered." i. Newborns have less adipose tissue and subcutaneous fat, placing them at risk for heat loss. Cold stress increases the need for oxygen and can deplete glucose stores. Newborns can react by increasing their respiratory rate and becoming cyanotic. A newborn’s temperature can be stabilized by keeping the head covered, drying and wrapping the newborn in warmed blankets after birth, and placing the newborn directly on the mother’s abdomen and covering with a warm blanket. b. "My baby’s temperature will be checked rectally every hour." i. The newborn’s axillary temperature should be checked every hour until the newborn’s temperature stabilizes. Frequent rectal temperature checks are not recommended and can lead to rectal mucosal injury. c. "I should place my baby on my stomach and cover her with a warm blanket." i. The newborn’s temperature can be stabilized by keeping the head covered, drying and wrapping the newborn in warmed blankets after birth, and placing the newborn directly on the mother’s abdomen and covering with a warm blanket. d. "My baby’s bassinet should be kept away from fans and air conditioning." i. The bassinet should be kept away from fans and air conditioning to prevent heat loss. Newborns have less adipose tissue and subcutaneous fat, placing them at risk for heat loss. 42. A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider? a. Poor sucking i. Vacuum-assisted birth involves attaching a vacuum cup to the fetal head and using negative pressure to assist in the birth of the head, placing the newborn at risk for a subdural hematoma. The nurse should report manifestations of cerebral irritation, such as listlessness and poor sucking to the provider. b. Blue coloring of the hands and feet i. Acrocyanosis, or blue coloring in the hands and feet, is an expected finding in newborns and does not need to be reported to the provider. c. Soft, edematous area on the scalp i. Caput succedaneum, or a soft-tissue hematoma, is an expected finding with vacuum extraction. The pressure from the suction forms an accumulation of fluid in the soft tissue. This is considered benign and generally disappears in 3 to 5 days. This finding does not need to be reported to the provider. d. Facial edema i. Facial edema is an expected finding in newborns and can persist up to 24 hr. It does not need to be reported to the provider 43. A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse? a. A pink rash appears on the newborn's trunk. i. A fine maculopapular rash can appear during phototherapy. b. The newborn's eyes are covered with a mask. i. The infant's eyes must be protected by an opaque mask. Prior to applying the mask, the eyes should be completely closed so as to avoid injury to the corneas. The mask should be removed during feedings to promote bonding. c. The mother applies lotion to the newborn's skin. i. Lotions and ointments should not be applied as they can absorb heat and cause burns. d. The newborn's stools increase in number. i. An increase in the number of stools is an expected outcome. Additionally, the color of the stools might change from dark green to yellow. The nurse 48. nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding? a. Caput succedaneum i. Caput succedaneum is edema of the presenting part of the newborn’s head due to pressure during labor. The edema extends across the suture lines of the skull. b. Cephalhematoma i. A cephalhematoma is a swelling, indicating bleeding under the subcutaneous tissues of the newborn’s scalp. The collection of blood is beneath the periosteum of the cranial bone and therefore does not cross the suture line. c. Molding i. Molding is a temporary misshaping of the fetal head due to overlapping cranial bones at the suture lines to accommodate the passage of the fetal head through the birth canal. d. Pilonidal dimple i. Pilonidal dimple can be observed when assessing the vertebral column and can be associated with spina bifida. 49. A nurse is planning care for a newborn who has a new diagnosis of phenylketonuria (PKU). Which of the following actions should be included in the plan of care? a. Initiate a controlled low-protein diet. i. PKU is managed by eliminating phenylalanine from the diet. It is found in most natural food proteins, such as milk and infant formulas. A special low- protein, amino-acid formula that is low in phenylalanine is initiated and included in the plan of care. b. Educate parents on blood glucose monitoring. i. Blood glucose monitoring is needed for the client who has a new diagnosis of diabetes. Therefore, educating parents on blood glucose monitoring is not an appropriate action to include in the plan of care. c. Administer thyroid hormone replacement. i. Thyroid hormone replacement is necessary for the client who has a new diagnosis of hypothyroidism. Therefore, administering thyroid hormone replacement is not an appropriate action to include in the plan of care. d. Obtain a blood sample for blood type. i. Obtaining a blood sample for blood type is not indicated for newborns who have PKU. Therefore, it is not an appropriate action to include in the plan of care. 50. A nurse in a clinic is teaching the mother of a 4-month-old infant who has been breastfed. The mother plans to switch her infant to an iron-fortified formula. Which of the following should be included in the teaching? a. Iron facilitates development of vision in infants. i. Vitamin A is important for development of vision. b. Iron facilitates growth of bones in infants. i. Calcium facilitates bone mineralization and growth. c. Iron stores in infants begin to deplete. i. Iron stores in infants are adequate until about 6 months of age. Infants who are weaned before 6 months of age should be given iron-fortified formula until 12 months of age. Iron stores will also be supplemented with the addition of iron- fortified cereals and iron-rich foods to the infant’s diet at 6 months of age. d. Iron is poorly absorbed in infants. i. The whey proteins in human milk and infant formulas have iron-binding capacities that allow for adequate absorption and storage of iron. 51. A nurse is teaching about nutrition guidelines to a parent of a newborn. Which of the following statements by the parent indicates understanding of the teaching? a. "I should start solid foods when my baby is 3 months old." i. The American Academy of Pediatrics recommends that the introduction of solid foods should not begin until after 4 months of age, and preferably not until 6 months of age. b. "I should introduce cow’s milk when my baby is 9 months old." i. Cow’s milk lacks adequate nutrients an infant needs to grow. Therefore, it is recommended that cow’s milk should not be introduced until the infant is 12 months old. c. "I should wait to give fruit juice until my baby is 6 months of age." i. Fruit juice provides minimal nutritional value to the infant’s diet. Therefore, fruit juices should be limited and not offered until the infant is 6 months of age. d. "I should wait to begin fluoride supplements until my baby is 4 months of age." i. Commercial iron-fortified formula has all the fluoride an infant needs for the first 6 months of life. Fluoride supplements should not begin until 6 months of age and only for infants if the local water supply is not fluoridated. 52. A nurse is completing an assessment of a 1-month-old newborn. Which of the following developmental skills is an expected finding? a. Displays a social smile i. An infant that is 2 months old is able to display a social smile. b. Follows movements of objects with eyes i. A 1-month-old infant is able to follow movements with their eyes. c. Reacts to sounds by turning head i. An infant that is 3 months old is able to turn their head to locate sounds. d. Makes babbling sounds i. An infant that is 3 months old is able to make a babbling sound. 53. A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make? a. "It sounds like you are feeling sad that things didn’t go as planned." b. ”At least you know you have a healthy baby." c. "Maybe next time you can have a vaginal delivery." d. "You can resume sexual relations sooner than if you had delivered vaginally." 54. A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find? a. Over-riding suture lines i. Newborns who have hydrocephalus will have widened suture lines and full or bulging fontanels due to pressure from the increased amount of cerebral spinal fluid. b. Dilated scalp veins i. Manifestations of hydrocephalus in newborns include dilated scalp veins, separated sutures, and, in late infancy, frontal enlargement. c. Hypertension i. Hydrocephalus increases pressure within the central nervous system, not within the cardiovascular system. Signs of increased pressure in the CNS include irritability, lethargy, and vomiting. d. A backward sloping appearance of the forehead. i. This finding is associated with microcephaly, in which the newborn’s head is smaller due to inadequate brain growth. 55. A nurse is teaching the parent of a newborn about car seat use. Which of the following information should the nurse include? a. "Position the newborn at a 45-degree angle in the car seat." i. The nurse should instruct the parent to place the newborn at a 45° angle to prevent the newborn's head from falling forward and obstructing the airway. b. "Place the retainer clip across the newborn's abdomen." i. The nurse should instruct the parent to place the retainer clip at the level of the newborn's armpits. The clip should not be placed over the abdomen or neck to prevent injury. c. "Keep the car seat rear-facing until the newborn can sit unsupported." i. The nurse should instruct the parent to keep the car seat rear-facing until the child is 2 years of age, or reaches the height and weight recommendation from the seat manufacturer. d. "Place the shoulder harness straps below the level of the newborn's armpits." i. The nurse should instruct the parent to place the shoulder harness straps at the level of the newborn's armpits. The straps should fit snugly over the newborns shoulders. 56. A nurse is caring for a client who is in preterm labor with a current L/S ratio of 1:1. Which of the following actions should the nurse take? a. Infuse a bolus of IV fluid. i. The current L/S ratio is obtained via amniocentesis. IV fluid boluses are often given prior to an amniocentesis. An IV fluid bolus is not indicated after the amniocentesis. b. Administer hydralazine 25 mg IV. i. Hydralazine is a potent arteriolar vasodilator that is usually administered for severe chronic hypertension or severe preeclampsia, with a systolic greater than 160 mm Hg or a diastolic greater than 110 mm Hg. The usual initial IV dose of hydralazine is 5 mg. c. Prepare the client for immediate delivery. i. The L/S ratio is not reflective of fetal lung maturity. The L/S ratio should be greater than 2:1 to indicate fetal lung maturity. d. Administer betamethasone 12 mg IM. i. Betamethasone is classified as a corticosteroid medication. Corticosteroids are often administered to the mother to assist in fetal lung maturity. These are usually administered by IM injection of 12 mg for the first two doses. The subsequent dosing should be 6 mg by IM every 12 hr x 4 doses. 57. A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care? a. Obtain rectal temperatures. i. Obtaining rectal temperatures can cause rectal irritation and prolapse and should be avoided. b. Place the newborn in the prone position. i. Placing the newborn in the prone position prevents trauma to the lesion. The newborn’s knees should be assessed for evidence of skin breakdown. c. Cover the lesion with a dry dressing. i. The lesion should be covered with a sterile, moist, nonadherent dressing to prevent drying and to reduce the risk of infection. d. Apply snug, clean diapers. i. Diapering should be avoided to prevent urine and stool contamination of the lesion. Absorbent pads should be placed under the diaper area and changed frequently to keep the area dry and free of skin irritation. 58. A nurse is assessing a newborn who has Trisomy 21 (Down’s Syndrome). Which of the following are common characteristics? (Select all that apply.) a. Transverse palmar creases b. Large ears c. Muscular hypertonicity d. Protruding tongue e. Low birth weight 59. A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations a. "It is used to stop preterm labor contractions." i. Magnesium sulfate, not betamethasone, is an example of a tocolytic medication that helps stop preterm labor b. "It halts cervical dilation." i. A tocolytic medication relaxes the smooth muscles of the uterus to stop preterm labor, and if effective, will also halt cervical dilation. c. "It promotes fetal lung maturity." i. Betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of certain enzymes that help produce surfactant. d. "It increases the fetal heart rate." i. Betamethasone does not affect the fetal heart rate. Terbutaline is an example of a tocolytic medication that can cause fetal tachycardia. Week 6 1. A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? a. Document the findings and continue to monitor the client. i. These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. i. Tocolytic medications, such as terbutaline, indomethacin, and nifedipine are used to relax the uterus in preterm labor. A client who is in preterm labor at 26 weeks of gestation is a candidate for tocolytic therapy. c. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation i. The use of a tocolytic medication is contraindicated in a client at a gestational age of 36 weeks or more. d. A client who has a post-term pregnancy at 42 weeks of gestation i. Tocolytic medications are not administered to stimulate labor. 6. A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make? e. “You need to take pain medications so you are more comfortable." i. This answer does not address the client's concern about taking pain medication while breastfeeding. f. "We can time your pain medication so that you have an hour or two before the next feeding." i. This answer provides the client an option that allows for administration of pain medication but minimizes the effect it will have on the newborn while breastfeeding. g. "All medications are found in breast milk to some extent." i. This answer does not provide an option for the client that addresses the impact of pain medication on the newborn during breastfeeding. h. "You have the option of not taking pain medication if you are concerned." i. This answer does not provide an option for the client to enhance her comfort while breastfeeding her newborn. 7. A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make? a. The client is exhibiting early indications of mastitis. i. Clinical manifestations of mastitis include chills, fever, malaise, and a localized area of breast tenderness. b. Additional interventions are not indicated at this time. i. For this postpartum day, the client’s fundal location and lochia characteristics are within the expected reference range. Breast engorgement is typical, as this is the time when the breasts begin producing milk. Frequent breastfeeding and routine care can help relieve engorgement. c. Application of a heating pad to the breasts is indicated. i. Heat increases blood flow and can, therefore, increase congestion in breasts that are already engorged. A heating pad should not be offered. However, a warm shower before breastfeeding can help relieve engorgement. d. The client should be advised to remove her nursing bra. i. Wearing a nursing bra helps reduce discomfort due to engorgement. 8. A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions? a. Postpartum infection i. Methylergonovine has no anti-infective properties. b. Hypertension i. An adverse effect of methylergonovine is hypertension. This medication is contraindicated for the client who has hypertension or cardiac disease. c. Postpartum hemorrhage i. Methylergonovine is an oxytocic medication. It causes uterine contractions, which control postpartum bleeding. d. Thromboembolic events i. Methylergonovine has no anticoagulant properties. 9. A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client’s abdomen, at which of the following positions should the nurse expect to find the uterine fundus? a. At the level of the umbilicus i. Within 12 hr, the fundus should be palpable at the level of the umbilicus and then recede 1 to 2 cm each day. b. 2 cm above the umbilicus i. The position of the fundus 2 cm above the umbilicus is an indication of subinvolution. c. One fingerbreadth above the symphysis pubis i. The uterus would be palpated at a position between the umbilicus and symphysis pubis in a client who is approximately 1 week postpartum. d. To the right of the umbilicus i. A uterine fundus that is deviated to the right or left of the umbilicus indicates the client has a full bladder. 10. A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client’s need to urinate? a. Moderate lochia rubra i. Moderate lochia rubra is an expected finding 8 hr following delivery and does not correlate with a full bladder. b. Fundus three fingerbreadths above the umbilicus i. A full bladder can raise the level of uterine fundus and possibly deviate it to the side. c. Moderate swelling of the labia i. Swelling in the perineal area is an expected finding following a vaginal delivery and does not correlate with a full bladder. d. Blood pressure 130/84 mm Hg i. The client's blood pressure after delivery does not correlate with a full bladder. 11. A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect? a. Fundus soft, 1 cm to the right of the umbilicus i. A soft or boggy fundus indicates that the uterine muscle is not contracted. A fundal location that is not midline often indicates the client has a full bladder. b. Fundus firm, at the level of the umbilicus i. Within 12 hours after birth, the fundal tone is expected to be firm and the location is typically palpated midline and at the level of the umbilicus. c. Fundus present, to the left of the umbilicus i. The fundal tone, location, and placement all need to be assessed and monitored to prevent the occurrence of hemorrhage. d. Fundus soft, 2 cm above the umbilicus i. The fundus should be palpated as firm, indicating that it is contracted. Additionally, the expected location is at or below the level of the umbilicus. 12. A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take? a. Encourage the client to perform Kegel exercises. i. Kegel exercises help to restore pelvic muscle tone that is often lost during pregnancy and birth. b. Encourage the client to move to the left lateral position. i. Encouraging the client to lie on her side can decrease discomfort from an episiotomy or perineal laceration. c. Ask the client to rate her pain. i. Many women experience discomfort during the postpartum period. However, the fundal assessment is not an expected finding and needs further investigation. d. Assist the client to the bathroom to void. i. A full bladder causes the uterus to be displaced above the umbilicus and off to one side. This prevents the uterus from contracting normally and increases the risk of hemorrhage. 13. A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications? a. Puerperal infection i. Endometritis is the most common cause of postpartum infections. b. Retained placental fragments i. Placental retention due to poor separation is common in very preterm births. c. Thrombophlebitis i. The major causes of thromboembolic disease in the pregnant client are venous stasis and hypercoagulation. i. Although the expectation is moderate bleeding in the first 2 hr after delivery, saturating a perineal pad in 15 min or less indicates excessive blood loss. The priority nursing intervention is to palpate the client’s fundus to determine the presence of uterine atony, followed by fundal massage to stimulate uterine muscle tone. b. Assist the client on a bedpan to urinate. i. Assisting the client to urinate reduces bladder distention, which displaces the uterus. A midline position allows the uterus to contract normally and reduces bleeding; however, this is not the priority nursing intervention. c. Prepare to administer oxytocic medication. i. Oxytocic medication might be necessary if excessive bleeding persists; however, this is not the priority nursing intervention. d. Increase the client’s fluid intake. i. Increasing fluids, IV and PO, is essential for restoring fluid volume, but it is not the priority nursing intervention. 18. A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time? a. Massage the fundus. i. The client’s fundus is firm, so there is no indication for massage. b. Insert a urinary catheter. i. Catheterization might be necessary if the client is unable to void after implementing additional measures to promote urination. c. Have the client urinate. i. A full bladder displaces the uterine fundus and elevates it above the level of the umbilicus. This can lead to uterine atony and excessive bleeding. Having the client urinate allows the uterus to return to midline and remain below the umbilicus. d. Administer an analgesic. i. Unless the client reports pain, there is no indication to administer an analgesic. 19. A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse? a. Assist the family to identify prior use of positive coping skills in family crises. i. Assisting the family to identify the use of coping mechanisms at a time of family crisis is important, but it is not the first action the nurse should consider. b. Ask the client if she has considered harming her newborn. i. When using the nursing process in caring for a client, the first action should focus on assessment of the client’s mood, ability to concentrate, thought processes, and if the client has had thoughts of self-harm or of injuring her newborn. c. Anticipate a prescription by the provider for an antidepressant. i. Although it is likely that the client will need medication therapy, there are other actions that the nurse should consider first in using the nursing process. d. Reinforce postpartum and newborn care discharge teaching. i. It is appropriate to reinforce discharge teaching that focuses on the postpartum period and care of a newborn, but this is not the priority action by the nurse at this time. 20. A nurse is caring for a client who is postpartum and has a prescription for Rho (D) immunoglobulin. The nurse should verify which of the following prior to administration? a. Client is Rh positive and the newborn is Rh positive. i. Rho (D) immunoglobulin is unnecessary in this situation. b. Client is Rh negative and the newborn is Rh negative. i. Rho (D) immunoglobulin is not necessary if the newborn is Rh negative. c. Client is Rh negative and the newborn is Rh positive. i. Rho (D) immunoglobulin contains antibodies to Rho (D). Administering it prevents antibody formation in women who are Rh negative following exposure to Rh positive blood, such as from a fetus who is Rh positive. d. Client is Rh positive and the newborn is Rh negative. i. Rho (D) immunoglobulin is unnecessary in this situation. 21. A nurse is admitting a client who experienced a vaginal birth 2 hr ago. The client is receiving an IV of lactated Ringer’s with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification? a. Methylergonovine 0.2 mg IM now. i. Methylergonovine is contraindicated in the client with a blood pressure greater than 140/90 mm Hg. This prescription requires clarification. b. Insert an indwelling urinary catheter. i. Insertion of an indwelling urinary catheter is an appropriate prescription for the client who has a hypotonic uterus. c. Administer oxygen by nonrebreather mask at 5 L/min. i. Administration of oxygen by a nonrebreather mask at 5 L/min is an appropriate prescription for the client who has a hypotonic uterus. d. Obtain laboratory study of prothrombin and partial thromboplastin time. i. Laboratory studies include prothrombin time, partial thromboplastin time, complete blood count with platelet count, fibrinogen, fibrin split products, blood type, and antibody screen for the client who has a hypotonic uterus. 22. A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care? a. Apply warm, moist heat to the client’s lower extremities i. Warm, moist heat helps relieve the discomfort of thrombophlebitis, but it does not prevent it. b. Massage the client’s posterior lower legs. i. Massage of the legs does not prevent blood clot formation, and can dislodge a clot that is present and undetected. c. Place pillows under the client’s knees when resting in bed. i. Flexing the client’s knees by placing pillows under them causes blood to pool in the lower extremities and increases the risk of thrombophlebitis. d. Have the client ambulate. i. Venous stasis is a major cause of thrombophlebitis. To prevent clot formation, have the client ambulate as soon as she can after delivery and as often as possible. 23. A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis? a. Moderate amount of dark red lochia with a bloody odor i. Foul-smelling, profuse lochia indicates endometritis. b. A localized area of breast tenderness i. Localized breast tenderness along with fever and malaise are symptoms of mastitis. c. Pelvic pain i. Indications of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain. d. Hematuria i. Hematuria is an indication of a urinary tract infection. 24. A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action? a. Examination to determine cervical status i. Vaginal exams are contraindicated in the presence of a placenta previa. b. A magnesium sulfate infusion i. Magnesium sulfate infusions are indicated for the treatment of preterm labor or the prevention of seizures in the preeclamptic client. The therapeutic action is smooth muscle relaxation. c. Initiation of pushing i. All clients with a confirmed placenta previa must deliver via cesarean section. d. Preparation for cesarean birth i. A cesarean birth is indicated for all clients who have a confirmed placenta previa. 25. A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest? a. Flex her knee while resting. pain, this client is likely to have engorgement. The nurse should assist the client to breastfeed frequently and apply ice packs or cold compresses after breastfeeding. b. Cracked and bleeding nipples i. Tenderness of the nipples is expected in the first few days of breastfeeding. Cracking and bleeding nipples, however, is an indication that the infant's position and/or feeding method is incorrect. The nurse should instruct the mother to clean the nipples with water and apply a thin layer of a topical antibiotic cream or ointment after breastfeeding. c. Red and painful area in one breast i. Mastitis often appears as a red, hard, and painful area on the breast, commonly in the upper outer quadrant. Although mastitis can occur in both breasts, it is usually unilateral. A client who has mastitis can also influenza-like manifestations, such as fever, chills, headache, and myalgia. After delivery, the nurse should instruct the client to observe the breasts for indications of mastitis and to notify her provider if they occur. d. A white patch on a nipple i. A small white area, or pearl, on the nipple is an indication of a blocked milk duct. Plugged milk ducts occur most frequently as a result of inadequate emptying of milk from the breast. The nurse should apply warm compresses to the breast and nipple prior to feeding to help promote the emptying of the breast and clearing of the blocked milk duct. 33. A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse? a. Assist the family to identify prior use of positive coping skills in family crises. i. Assisting the family to identify the use of coping mechanisms at a time of family crisis is important, but it is not the first action the nurse should consider. b. Ask the client if she has considered harming her newborn. i. When using the nursing process in caring for a client, the first action should focus on assessment of the client’s mood, ability to concentrate, thought processes, and if the client has had thoughts of self-harm or of injuring her newborn. c. Anticipate a prescription by the provider for an antidepressant. i. Although it is likely that the client will need medication therapy, there are other actions that the nurse should consider first in using the nursing process. d. Reinforce postpartum and newborn care discharge teaching. i. It is appropriate to reinforce discharge teaching that focuses on the postpartum period and care of a newborn, but this is not the priority action by the nurse at this time. 34. A nurse is teaching a client who is breastfeeding about dietary recommendations. Which of the following statements by the client indicates understanding of the teaching? a. "I will decrease my daily fiber intake." i. During lactation, clients should consume about 4 g more of fiber per day than nonpregnant, nonlactating women. b. "I’ll make sure I reduce salt in my diet." i. Unless the client has an underlying disorder that requires sodium restriction, this is not necessary during lactation. Recommended sodium intake for nonpregnant, pregnant, and lactating female clients during the childbearing years is 1.5 to 2.3 g/day. c. “I'll eat more protein at each meal." i. During lactation, clients should consume about 25 g of additional protein per day, which is more than what is required by nonpregnant and nonlactating female clients. d. "I will consume more vitamin D-rich foods." i. The recommended intake of vitamin D is 5 mcg/day, which is the same for nonpregnant, pregnant, and lactating female clients. 35. A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make? a. Within 2 days i. In this time frame, most clients who are breastfeeding are still producing colostrum. b. In 3 to 5 days i. By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milk c. In 6 to 8 days i. Day 6 to 8 is not the usual time frame for the onset of breast milk production. l. "You have the option of not taking pain medication if you are concerned." i. This answer does not provide an option for the client to enhance her comfort while breastfeeding her newborn. 44. A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching? m. "I'll let my baby drain one breast at each feeding." i. The client should have her newborn drain both breasts at each feeding to soften them. If the newborn can only drain one breast, the client should pump the other breast to soften it. n. "I’ll try drinking an herbal tea to reduce the engorgement." i. Herbal remedies should be reviewed with the provider to determine those that are safe to use when breastfeeding. o. "I’ll apply cold compresses 20 minutes before each feeding." i. There is no evidence to support the use of cold compresses to relieve breast engorgement. If a client prefers the application of cold compresses to manage the discomfort of engorgement, it should be applied after each feeding. p. "I’ll feed my baby every 2 hours." i. Breast engorgement is relieved by emptying both breasts. The client might be able to accomplish this with more frequent feedings. Otherwise, she can pump her breasts after breastfeeding to ensure optimal emptying. 45. A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn’s mouth, which of the following responses should the nurse make? q. "You should place your nipple and some of the areola into her mouth." i. Placing the nipple and 2 to 3 cm of areolar tissue around the nipple into the baby’s mouth aids in adequately compressing the milk ducts. This placement decreases stress on the nipple and prevents cracking and soreness. r. "Babies know instinctively how much of the nipple to take into their mouth." i. The client should not rely on the newborn to perfect the breastfeeding technique. The client’s knowledge and guidance of the newborn are needed for successful breastfeeding. s. "Your baby’s mouth is rather small so she will only take part of the nipple." i. The size of the newborn’s mouth has some effect on the ability of the newborn to latch, as do the size of the nipple and the areola. There are general guidelines the client should use to promote successful breastfeeding. If the newborn sucks on only a portion of the nipple, nipple soreness is likely to develop. t. "Try to place the nipple, the areola, and some breast tissue beyond the areola into her mouth." i. Placing this much of the breast into the newborn’s mouth might not be possible, and the client will feel discouraged and unsuccessful in attempting to latch the newborn. 46. A nurse is caring for a client who is 6 hours postpartum and asks the nurse to feed her newborn. Which of the following responses should the nurse provide? u. "I’ll feed him today. Maybe tomorrow you can try it." i. This is a close-ended nontherapeutic response that might eliminate the client’s anxiety momentarily, but it does not provide an opportunity for the client to express her anxiety or to learn an essential skill. v. "Oh, this isn’t difficult. You’ll be fine doing this." i. This is an example of a nontherapeutic response that offers false reassurance. The nurse cannot assume the client has the knowledge to feed the newborn correctly. w. "You can learn to feed him; I wasn’t comfortable the first time I fed a baby either." i. This nontherapeutic response illustrates the technique of changing the topic to one that reflects a personal issue of the nurse, rather than focusing on the client’s issues. x. "Feeding an infant can feel a little intimidating at first, but I’ll stay and help you." i. The nurse, while recognizing and acknowledging the client’s apprehension, offers assistance and a sense of presence, with the intention of boosting client confidence. 47. A nurse is caring for a client who is 16 -hr postpartum and states “My baby has been breathing funny, fast and slow, off and on.” Which of the following responses should the nurse provide? y. "Most new mothers feel somewhat anxious about things like this." i. With this response, the nurse is using the nontherapeutic communication technique of passing judgment about the client’s feelings. It discourages the client from making further comments. z. "There’s nothing for you to worry about. Newborns often breathe this way." i. With this response, the nurse is using the nontherapeutic communication technique of offering false reassurance. It does not encourage the client to express her concerns. aa. "Why do you think there is something wrong with that?" i. With this response, the nurse is using the nontherapeutic communication technique of challenging the client for an explanation. It ends further statements of client concern. bb. "Let’s sit here together and observe your baby while you feed him." i. With this response, the nurse is using the therapeutic communication techniques of focusing and physical attending.