ATI RN MAT NEWBORN ONLINE PRACTICE 2023 A

A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?

Deep tendon reflexes 4+

Fundal height 14 cm

Blood pressure 142/92 mm Hg

FHR 152/min

Answer: FHR 152/min

Rationale: The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse.

Incorrect rationales:

DTR rationale: Deep tendon reflexes (DTRs) are an indication of the balance between the cerebral cortex and spinal cord. The nurse should expect the client's DTR to be 2+. Therefore, a DTR of 4+ indicates hyperreflexia.

Fundal rationale: From gestational weeks 18 to 32, the height of the fundus is approximately equal to the number of weeks of gestation plus or minus 2 cm. Therefore, the nurse should expect the fundal height for this client to be 16 to 20 cm.

BP rationale: An elevated blood pressure may be an indication of preeclampsia. Therefore, the nurse should investigate this finding further and the client's blood pressure should be evaluated more frequently.

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?

Maintain the client NPO throughout the procedure

Place the client in a supine position

Instruct the client to massage the abdomen to stimulate fetal movement

Instruct the client to press the provided button each time fetal movement is detected

Answer: Instruct the client to press the provided button each time fetal movement is detected

Rationale: Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when they detect fetal movement will ensure that the fetal movement is noted.

Incorrect:

Maintain the client NPO throughout the procedure:

There is no indication for the client to be NPO. Sometimes clients are encouraged to drink liquids to promote adequate hydration.

Place the client in a supine position: The client should be placed in a semi-Fowler's or sitting position and tilted to the right or left to promote uterine perfusion and prevent supine hypotension.

Instruct the client to massage the abdomen to stimulate fetal movement: Massaging the abdomen does not stimulate fetal movement.

A nurse is caring for a newborn. For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis. Each finding may support more than one disease process.

Decreased temperature is associated with hypoglycemia and sepsis.

Yellow sclera and oral mucosa are associated with hyperbilirubinemia and sepsis.

Poor feeding is associated with hypoglycemia, hyperbilirubinemia and sepsis.

Ecchymotic caput succedaneum is associated hyperbilirubinemia.

Respiratory distress is associated with hypoglycemia and sepsis.

Lethargy is associated with hypoglycemia and sepsis.

When analyzing cues, the nurse should recognize that the newborn is experiencing hypoglycemia. Decreased temperature, poor feeding, respiratory distress, and lethargy are consistent with hypoglycemia.

When analyzing cues, the nurse should recognize that the newborn is experiencing hyperbilirubinemia. Yellow sclera and oral mucosa, and poor feeding are consistent with hyperbilirubinemia. A newborn with an ecchymotic caput succedaneum is at higher risk for hyperbilirubinemia.

When analyzing cues, the nurse should recognize that the newborn is experiencing sepsis. Decreased temperature, yellow sclera and oral mucosa, poor feeding, respiratory distress, and lethargy are consistent with sepsis.

A nurse is caring for a newborn who is 70 hr old. Which of the following findings should the nurse report to the provider?

Select all that apply.

Medical History:

Newborn delivered by repeat cesarean birth at 40 weeks of gestation.

Birth weight 7 lb 12 oz (3,515 g)

Apgar scores 8 at 1 min and 9 at 5 min

Maternal history of methadone use during pregnancy.

Vital Signs 0700: Heart rate 156/min

Respiratory rate 58/min

Temperature 37.2° C (98.9° F)

Oxygen saturation 98% on room air

Vital Signs 1100: Heart rate 160/min

Respiratory rate 60/min

Temperature 37.3° C (99.2° F)

Oxygen saturation 96% on room air

Correct:

Central nervous system findings

The newborn is displaying inconsolability, high-pitched cry, increased muscle tone, tremors, hyperactive Moro reflex, and excessive sucking. These findings are manifestations of NAS and should be reported to the provider.

Gastrointestinal findings.

The newborn is displaying poor feeding and loose stools. These findings are manifestations of NAS and should be reported to the provider.

Incorrect:

Respiratory findings is incorrect. The newborn's respiratory rate is within the expected reference range of 30 to 60/min. There is no indication the newborn has an alteration in respiratory status; therefore, this finding does not need to be reported to the provider.

Temperature is incorrect. The newborn's temperature is within the expected reference range of 36.5° to 37.5° C (97.7° to 99.5° F). Therefore, this finding does not need to be reported to the provider.

Oxygen saturation is incorrect. The newborn's oxygen saturation is within the expected reference range of greater than 94%; therefore, this finding does not need to be reported to the provider.

A nurse is caring for a newborn.

Medical History

1600: Apgar score 9 at 1 min and 9 at 5 min

Birth weight 4,706 g (10 lb 6 oz)

Gestational age 40 weeks

Difficult vaginal birth with shoulder dystocia.

Nurses' Notes

1700: Newborn is active and moves all extremities except for right arm.

No spontaneous movement of the right arm noted.

Right arm remains at side during Moro reflex.

Physical Examination

1830:Absent Moro reflex noted in right arm.

Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's palsy) paralysis.

Which of the following actions should the nurse plan to implement?

For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.

Correct:

Educate the parents to begin range of motion exercises on the affected arm after 1 week is indicated.

Rationale: Passive ROM exercises of the arm are indicated to restore function of the extremity. The initiation of these exercises is delayed for approximately 1 week to prevent additional injury to the brachial plexus.

Assess for grasp reflex in the affected extremity is indicated. Rationale: With Erb-Duchenne paralysis, only the upper arm is affected. The function of the wrists and fingers should be unaffected; the nurse should assess for a palmar grasp reflex.

Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt is indicated.

Rationale: Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved by pinning the sleeve to the shirt.

Incorrect:

Instruct parents to limit physical handling for 2 weeks is contraindicated.

Rationale: Parents and guardians should participate in the physical care of their newborn to increase parental-infant attachment. Providing education and practice opportunities for the parents will decrease their fears of injuring the newborn and increase confidence and bonding.

A nurse is caring for a newborn who is 48 hr old.

Vital Signs

Day 2, 0900:

Heart rate 174/min

Respiratory rate 88/min

Temperature 36.1° C (97.0° F)

Oxygen sat 97% on room air

Diagnostic Results

Day 1, 0800: Newborn results

Blood type: A+

Urine toxicology screen: positive marijuana

Day 2, 0800: Newborn results

Total bilirubin 10 mg/dL (1.0 to 12.0 mg/dL)

Day 2, 0915: Blood glucose: 38 mg/dL (expected value greater than 40 to 45 gm/dL

Nurses Notes

Day 2, 0900:

Newborn awake, alert, and crying. Loosely wrapped in one blanket. Mild tremors noted. Yellow discoloration of mucus membranes and sclera noted. Respirations 88/min, no retractions, grunting, or nasal flaring noted. Diaper changed for small amount of urine and transitional stool.

Medical History

Apgars: 7 at 1 min and 8 at 5 min of age

Birth weight: 3,515 g (7 lb 12 oz)

Maternal blood type: O+

Uncomplicated pregnancy. Maternal use of marijuana during pregnan

Upon recognizing and analyzing newborn findings of temperature below the expected range, respiratory rate above the expected range, and hypoglycemia, the nurse's priority hypothesis is that this newborn is most likely experiencing cold stress. It is important to generate solutions and take actions that address cold stress. Therefore, the nurse should monitor the newborn's temperature and glucose levels because a newborn experiencing cold stress is at risk for developing metabolic acidosis. To evaluate the client's response to these interventions, the nurse should monitor the newborn's temperature and glucose levels.

A nurse is caring for a client who is pregnant in an antepartum clinic.

Vital Signs

0900:

Temperature 36.6° C (97.9° F)

Heart rate 88/min

Respiratory rate 18/min

Blood pressure 130/70 mm Hg

Oxygen saturation 97% on room air

1000:Heart rate 76/min

Respiratory rate 20/min

Blood pressure 138/68 mm Hg

Oxygen saturation 98% on room air

Medical History

0900:Gravida 3, Para 2

32 weeks of gestation

Client reports cramping and lower back pain that started this morning. Client denies leaking fluid.

Nurses' Notes

0900:Client placed on electronic fetal monitor.

Client reports pain as 4 on a scale of 0 to 10.

1000:FHR assessment 150/min. Average variability. No decelerations. Spontaneous accelerations noted.

​Uterine contractions occurring every 2 min, lasting 40 to 60 seconds in duration. Palpate as moderate intensity.

Vaginal examination performed. Cervix is 2 cm dilated and 50% effaced.

Which of the following findings should the nurse report to the provider?

Select the 3 findings that should be reported.

Uterine contractions is correct.

Rationale: The client is experiencing regular uterine contractions and cervical change, which are indicators of preterm labor; therefore, the nurse should notify the provider about this finding.

Fetal heart rate is incorrect.

Rationale: The fetal heart rate is within the expected reference range; therefore, the nurse should not report this finding to the provider.

Gestational age is correct.

Rationale: The client is at 32 weeks of gestation and is experiencing regular uterine contractions and cervical dilation, which indicates that the client is in preterm labor; therefore, the nurse should notify the provider about this finding.

Vaginal examination is correct.

Rationale: The client's cervix is dilated to 2 cm and is 50% effaced, which indicate the client is in preterm labor; therefore, the nurse should notify the provider about this finding.

Maternal blood pressure is incorrect.

Rationale: The client's blood pressure is within the expected reference range; therefore, the nurse should not report this finding to the provider.

A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score.

Which of the following findings should the nurse expect?

a. Minimal arm recoil

b. Popliteal angle of 90 degrees

c. Creases over the entire foot sided.

d. Raised areolas with 3 to 4 mm buds

a. Minimal arm recoil

The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil.

Incorrect rationale:

A popliteal angle of 90° is an indicator of physical maturity with increasing gestational age after 26 weeks.

Creases over the entire sole of a newborn's foot are an indicator of physical maturity with increasing gestational age after 26 weeks.

Raised areolas with 3 to 4 mm buds is an indicator of physical maturity with increasing gestational age after 26 weeks.

A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1g orally now." Available are 250 mg tablets. How many tablets should the nurse administer?

4 tablets

A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?

a. Shortness of breath when climbing stairs

b. Swelling of feet and ankles at the end of the day

c. Headache that is unrelieved by analgesia

d. Braxton Hicks contractions

Correct: Headache that is unrelieved by analgesia

A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider.

Shortness of breath is related to the enlarging uterus interfering with the expansion of the diaphragm and is an expected manifestation at 35 weeks of gestation.

Swelling of feet and ankles is due to the enlarging uterus interfering with blood return to the heart and is an expected manifestation at 35 weeks of gestation.

Braxton Hicks contractions are an indication that the uterus is preparing for labor and is an expected manifestation at 35 weeks of gestation.

A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf.

Which of the following actions should the nurse take?

a. administer aspirin for pain

b. maintain the client on bed rest

c. massage the affected leg

d. apply cold compresses to the affected calf

Correct: Maintain the client on bed rest.

The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended.

Incorrect rationale:

A client receiving anticoagulant therapy, such as heparin, should not receive aspirin because it can lead to prolonged clotting times and increased risk of bleeding.

The nurse should avoid massaging the affected leg to decrease the risk of dislodging the clot, which could cause a pulmonary embolism.

The nurse should apply warm compresses to the affected area to promote circulation and decrease edema.

A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?

a. "The test should take 10 to 15 minutes to complete."

b. "You will lay in a supine position throughout the test."

c. You should not eat or drink for 2 hours before the test."

d. "You should press the handheld button when you feel your baby move."

d. "You should press the handheld button when you feel your baby move."

The nurse should instruct the client to press the handheld button when the fetus moves. This action will mark the fetal monitor tracing with the client's reports of fetal movement. This will assist in the interpretation of the nonstress test to determine if it is reactive or nonreactive.

Incorrect rationale:

The nurse should instruct the client that the nonstress will take approximately 20 to 30 min, but more time might be required if the fetus is in a sleep state when the testing begins.

The nurse should instruct the client to be positioned in a reclining chair or semi-Fowler's position with a slight lateral tilt to ensure optimal uterine perfusion.

The client is not required to be NPO before or during the procedure. The nurse can suggest the client drink orange juice to increase their blood glucose level which will stimulate fetal movements.

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?

a. A client who is at 11 weeks of gestation and reports abdominal cramping

b. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand

c. A client who is at 20 weeks of gestation and reports constipation for the past 4 days

d. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week

A client who is at 11 weeks of gestation and reports abdominal cramping

When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first.

Incorrect rationale:

Tingling and numbness of the right hand is nonurgent because it is a common discomfort related to pregnancy for a client who is at 15 weeks of gestation. Therefore, there is another client that the provider should see first.

Constipation is nonurgent because it is a common discomfort related to pregnancy for a client who is at 20 weeks of gestation. Therefore, there is another client that the provider should see first.

Epistaxis is nonurgent because it is a common discomfort related to pregnancy for a client who is at 8 weeks of gestation. Therefore, there is another client that the provider should see first.

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)

a. Flaccid uterus

b. Cervical laceration

c. Excess vaginal bleeding

d. Increased afterbirth crampinge. Increased maternal temperature

Flaccid uterus is correct. Oxytocin increases the contractility of the uterus.

Cervical laceration is incorrect. Bleeding resulting from a cervical laceration continues even when the uterus is contracted and firm. It will require repair by the provider.

Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding.

Increased afterbirth cramping is incorrect. The use of oxytocin will increase, rather than decrease, afterbirth cramping.

Increased maternal temperature is incorrect. The use of oxytocin will have no effect on maternal temperature.

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test.

For which of the following diagnostic tests should the nurse prepare the client?

a. percutaneous umbilical blood sampling

b. amnioinfusion

c. biophysical profile (BPP)

d. Chorionic villus sampling (CVS)

Correct: Biophysical profile (BPP)

The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli.

Incorrect:

Percutaneous umbilical blood sampling, commonly called cordocentesis, is the most common method used for fetal blood sampling and transfusion. This is not a diagnostic test used for clients who have a positive contraction stress test.

An amnioinfusion of normal saline or lactated Ringer's is instilled into the amniotic cavity through a transcervical catheter introduced into the uterus to supplement the amount of amniotic fluid. The instillation reduces the severity of variable decelerations caused by cord compression for clients who are in labor. This is not a diagnostic test used for clients who have a positive contraction stress test.

CVS is the assessment of a portion of the developing placenta, which is aspirated through a thin sterile catheter inserted through the abdominal wall or intravaginally through the cervix under ultrasound guidance. This procedure is done during the first trimester. This is not a diagnostic test used for clients who have a positive contraction stress test.

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow.

The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part.

Second, the nurse should determine the location of the fetal back.

Third, the nurse should palpate for the fetal part presenting at the inlet.

Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head.

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia.

Which of the following actions should the nurse include in the plan?

a. Feed the newborn 1 oz of water every 4 hr

b. Apply lotion to the newborn's skin three times per day

c. Remove all clothing from the newborn except the diaper

d. Discontinue therapy if the newborn develops a rash.

c. Remove all clothing from the newborn except the diaper

The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin.

Incorrect rationale:

The nurse should not feed the newborn any water or glucose water. Hydration can be maintained through regular breastfeeding or formula feeding. Water and glucose water do not increase the excretion rate of bilirubin in the stool or provide nutritional value.

The nurse should not apply lotion, ointments, or creams to a newborn who is undergoing phototherapy. Lotions, ointments, and creams can absorb heat and lead to burns.

The nurse should not discontinue phototherapy if the newborn develops a rash. A temporary, fine rash can occur during therapy. This rash requires no treatment.

The nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?

a. Reassess the client in 2 hr

b. Administer simethicone

c. Assist the client to empty their bladder

d. Instruct the client to lie on their right side

Assist the client to empty their bladder.

The nurse should assist the client to empty their bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage.

Incorrect rationale:

The nurse should assess the client more frequently after birth to determine the position of the uterus and to intervene as soon as possible if necessary.

The nurse should administer simethicone to reduce bloating, discomfort, or pain caused by excessive gas.

Lying on their right side will not resolve the client's displaced uterus.

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?

a. increased fetal movement

b. leakage of fluid from the vagina

c. upper abdominal discomfort

d. urinary frequency

b. leakage of fluid from the vagina

Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider.

Incorrect rationale:

Decreased fetal movement is a potential complication that should be reported to the provider.

Upper abdominal discomfort is not a potential complication associated with an amniocentesis.

Urinary frequency is not a potential complication associated with an amniocentesis.

A nurse is assessing the newborn of a client who took selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?

a. Large for gestational age

b. Hyperglycemia

c. Bradypnea

d. Vomiting

d. Vomiting

Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.

Incorrect rationales:

Low birth weight is an expected manifestation of fetal exposure to SSRIs.

Hypoglycemia is an expected manifestation of fetal exposure to SSRIs.

Tachypnea is an expected manifestation of fetal exposure to SSRIs.

A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

a. confirm the newborn's Apgar score

b. verify the newborn's identification

c. administer vitamin K to the newborn

d. determine obstetrical risk factors

b. verify the newborn's identification

When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery.

Incorrect rationales:

The Apgar score is a physiological assessment that occurs 1 min following birth and again at 5 min. The nurse should confirm the score when the newborn arrives in the nursery. However, there is another action the nurse should take first.

The nurse should administer IM vitamin K to the newborn soon after birth to increase clotting factors and prevent bleeding. However, the injection can be delayed until after initial bonding time and the first breastfeeding if necessary. Therefore, there is another action the nurse should take first.

The nurse should identify obstetrical risk factors to determine if interventions are required for the newborn. However, there is another action the nurse should take first.

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?

a. "You should take the medication within 72 hours following unprotected sexual intercourse."

b. "You should avoid taking this medication if you are on an oral contraceptive."

c. "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test."

d. "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it."

a. "You should take the medication within 72 hours following unprotected sexual intercourse."

Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse.

Incorrect rationales:

Levonorgestrel, an emergency contraceptive, has no effect on the other oral contraceptive the adolescent might be taking. To prevent pregnancy, this medication should be taken if an adolescent misses a dose of oral contraception.

The adolescent should be evaluated for pregnancy if they do not menstruate within 21 days following administration of this medication.

Levonorgestrel is an emergency contraceptive that prevents or delays ovulation. Therefore, the nurse should inform the client that they will not be protected from pregnancy if they have unprotected sexual intercourse in the days and weeks after receiving this medication.

A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?

a. Late decelerations

b. Moderate variability of the FHR

c. Cessation of uterine dilation

d. Prolonged active phase of labor

a. Late decelerations

Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider.

Incorrect rationales:

Moderate variability of the FHR is an expected assessment finding associated with normal fetal acid-base balance. It is not a contraindication to the administration of oxytocin.

Cessation of uterine dilation is an indication for the initiation of an oxytocin infusion to augment the client's labor progression.

A prolonged active phase of labor is an indication for the initiation of an oxytocin infusion to augment the client's labor progression.

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?

a. Swelling of the face

b. Varicose veins in the calves

c. Nonpitting 1+ ankle edema

d. Hyperpigmentation of the cheeks

a. Swelling of the face

Swelling of the face, sacral area, and fingers can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.

Incorrect rationales:

Varicose veins are an expected finding in the second trimester. The increase in hormones during pregnancy causes the relaxation of the smooth muscle of the vascular system, leading to vessel dilation and vasocongestion. Additionally, the weight of the enlarging uterus on the pelvic veins decreases the return of blood from the lower extremities.

Nonpitting edema of the lower extremities is an expected finding in the third trimester. Warm weather, sitting or standing for prolonged periods of time, and tight clothing can increase edema.

Hyperpigmentation of the cheeks, areola, vulva, and linea nigra are expected findings in the second trimester. The anterior pituitary increases the production of melanocyte-stimulating hormone, which leads to hyperpigmentation of the skin.

A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?

a. Lays the newborn across their lap an gently sways

b. Places the newborn in the crib in a prone position

c. Offers the newborn a pacifier dipped in formula

d. Prepares a bottle of formula mixed with rice cereal

a. Lays the newborn across their lap an gently sways

This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn.

Incorrect rationales:

The guardian should place the infant in the supine position, not a prone position, in the bassinet or crib because of the risk of sudden infant death syndrome.

Pacifiers may be used for a newborn who needs extra sucking for self-soothing. However, formula should not be placed on the tip of the pacifier because the newborn might become accustomed to it and refuse to take the pacifier in the future without added supplement.

Rice cereal should not be added to the bottle of a newborn because solids should not be introduced until 4 to 6 months of age.

A nurse in a clinic is caring for a 16-year-old adolescent.

VS 1300:Blood pressure 118/72 mm Hg

Heart rate 100/min

Respiratory rate 20/min

Temperature 38.3° C (101° F)

Prescriptions

300:Standing prescriptions for clients who present with abdominal pain:

Obtain laboratory tests:

Urinalysis

Cervical culture

C-reactive protein

Beta hCG

History and Physical:

Adolescent is sexually active with two current partners.

IUD in place. Reports not using condoms during sexual activity.

History of type 1 diabetes mellitus

Nurses' Notes

1300:Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours.

Reports painful urination and pain during sexual intercourse with minimal vaginal itching. Tenderness with palpation to lower abdomen, guarding abdomen observed. Greenish vaginal discharge observed. Reports

Abdominal assessment is correct. Abdominal tenderness with palpation is not an expected finding with an abdominal assessment; therefore, the nurse should report this finding to the provider.

Vaginal discharge is correct. Greenish vaginal discharge indicates that the adolescent has an infection, which is not an expected finding; therefore, the nurse should report this finding to the provider.

Heart rate is incorrect. The adolescent's heart rate of 100/min is within the expected reference range; therefore, the nurse does not need to report this finding to the provider.

Temperature is correct. The client's temperature of 38.3° C (101° F) is above the expected reference range. An elevated temperature could signal infection or inflammation; therefore, the nurse should report this finding to the provider.

Dyspareunia is correct. Dyspareunia is painful intercourse, which can be associated with STIs; therefore, the nurse should report this finding to the provider.

Condom usage is correct. Sexual activity without the use of condoms increases the risk of contracting STIs; therefore, the nurse should report this finding to the provider.

Abdominal pain is consistent with gonorrhea. Gonorrhea can present with reports of acute or chronic lower abdominal pain.

Greenish discharge is consistent with trichomoniasis and gonorrhea. Green-yellow discharge can occur in both trichomoniasis and gonorrhea. Candidiasis causes thick, white, lumpy discharge.

Diabetes is consistent with candidiasis. Diabetes is a predisposing factor for yeast infections because high glucose levels provide an environment with enough glucose to allow the growth of yeast.

Pain on urination is consistent with trichomoniasis, gonorrhea, and candidiasis. Dysuria is a manifestation of trichomoniasis, gonorrhea, and candidiasis and can be the result of urine flowing over an irritated and inflamed vulva and surrounding skin.

Absence of condom use is consistent with trichomoniasis and gonorrhea. Sexual activity without the use of a condom can result in the transmission of STIs. Candidiasis is a vaginal infection that is not sexually transmitted.

The nurse is reviewing laboratory results in the adolescent's medical record

The nurse is reviewing the adolescent's medical record. Which of the following conditions is the client most likely developing?

Box 1

Pelvic inflammatory disease is correct. Pelvic inflammatory disease (PID) is an infection that involves the pelvic reproductive organs. There are several causative agents that lead to infection, including Neisseria gonorrhoeae and C. trachomatis. PID occurs as a result from untreated infections ascending from the vagina. Manifestations include fever, increased C-reactive protein, nausea, and vomiting; therefore, the nurse should suspect the adolescent is developing PID.

Ectopic pregnancy is incorrect. Ectopic pregnancy is characterized by lower abdominal pain on one side, vaginal spotting or bleeding, and a delayed menstrual period. The adolescent reports having a normal menstrual period 3 weeks ago. The beta hCG test was negative and there are no other indications that the adolescent has an ectopic pregnancy; therefore, there is another condition the adolescent is most likely developing.

Pyelonephritis is incorrect. Pyelonephritis is an inflammation of the upper urinary tract and kidneys and usually develops following a bladder infection. It is characterized by fever, flank pain, dysuria, and urgency. The adolescent's urinalysis has a negative leukocyte esterase and an absence of white blood cells and bacteria. These findings do not indicate the presence of a bladder infection; therefore, there is another condition the adolescent is most likely developing.

Box 2

C-reactive protein is correct. The adolescent's C-reactive protein is elevated, which is a manifestation of PID.

Beta hCG level is incorrect. The beta hCG test was negative and there are no other indications the adolescent has an ectopic pregnancy; therefore, there is another condition the adolescent is most likely developing.

Urinalysis is incorrect. The adolescent's urinalysis has a negative leukocyte esterase and an absence of white blood cells and ni

Ceftriaxone and doxycycline are correct. The nurse suspects that the adolescent is experiencing pelvic inflammatory disease (PID); Therefore, the nurse should anticipate a provider's prescription for ceftriaxone and doxycycline. The recommended treatment for PID in an outpatient setting is ceftriaxone administered as a single dose intramuscularly, along with doxycycline administered orally 2x/day for 14 days. The treatment regimen may change following the results of the cervical culture.

Acyclovir, fluconazole, and imiquimod are incorrect. Acyclovir is an antiviral used to treat herpes infections by interfering with the virus' DNA synthesis. The adolescent has no manifestations of genital herpes. Therefore, the nurse should not anticipate a provider's prescription for acyclovir. Fluconazole is an antifungal used to treat various fungal infections, including candidiasis. The adolescent has no manifestations of candidiasis or any fungal infection. Therefore, the nurse should not anticipate a provider's prescription for fluconazole. Imiquimod is a topical anti-tumor medication used to treat keratoses, tumors of the skin, and genital warts. The adolescent does not have manifestations of genital warts. Therefore, the nurse should not anticipate a provider's prescription for imiquimod.

Dropdown 1

Providing education on medications is correct. The nurse should first educate the adolescent regarding medications because clients have the right to know the purpose and potential adverse reactions of all prescribed medications before receiving them. An understanding of the prescribed medications will increase the likelihood that the adolescent will adhere to the prescribed therapy.

Scheduling follow-up appointments and administering doxycycline is incorrect. The nurse should schedule the adolescent for a follow-up appointment; however, there is another action that the nurse should take first. The nurse should not administer doxycycline because it is a prescription for the adolescent to begin once discharged, and the prescription will be provided to the adolescent upon discharge; therefore, there is another action that the nurse should take.

Dropdown 2

Administering ceftriaxone is correct. Ceftriaxone is designated as a NOW prescription, which means it should be given within 90 min of the provider writing the prescription. The nurse should administer ceftriaxone after educating the adolescent about the purpose and potential adverse reactions of the medication.

Administering metronidazole and educating on condom use is incorrect. The nurse should not administer metronidazole because it is a prescription for the adolescent to begin once discharged, and the prescription will be provided to the adolescent upon discharge; therefore, there is another action that the nurse should take. The nurse should educate the adolescent regarding condom use; however, there is another action that the nurse should take first.

"I should continue taking all my medications even if I don't show any symptoms" indicates an understanding of the teaching. The nurse instructed the adolescent to complete all of their medications, even if they begin to feel better.

"If I continue to get this type of infection, it can affect my ability to have kids in the future" indicates an understanding of the teaching. The nurse instructed the adolescent that repeated instances of PID can cause infertility.

"I should go to the emergency department if my urine turns dark" indicates the need for further education. The nurse informed the adolescent that while taking metronidazole their urine might turn dark, they should not be alarmed because dark urine is an adverse effect of taking this medication.

"As long as I keep my IUD, I don't need to use condoms" indicates the need for further education. The nurse informed the adolescent that they should use a condom to decrease the risk of contracting an STI; IUDs effectively prevent pregnancy, not STIs.

"I'm more likely to get a sunburn while taking these medications" indicates an understanding of the teaching. The nurse informed the adolescent that they might experience increased sensitivity to sunlight while using doxycycline and that they should use sunscreen and wear protective clothing while taking the medication.

When using the urgent vs. nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority.

A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)Exhibit 1: Graphic Record​Blood pressure 130/78 mm Hg, Respiratory rate 20/min, Heart rate 90/minExhibit 2: Diagnostic Results​Hemoglobin 12 g/dL, Hematocrit 34%, 1-hr glucose tolerance test 120 mg/dLExhibit 3: Progress NotesFundal height 30 cm, Good fetal movement, Not experiencing headache, dizziness, blurred vision, or vaginal bleeding, Fetal heart rate 110/mina. 1-hr glucose tolerance testb. Hematocritc. Fundal height measurementd. Fetal heart rate (FHR)

Correct: A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider.

Incorrect rationale:

A glucose tolerance test result of 120 mg/dL is within the expected reference range for this client and does not need to be reported to the provider. The expected value 180-190 mg/dL for a 1-hr glucose tolerance test.

A hematocrit of 34% is within the expected reference range for this client and does not need to be reported to the provider. The expected level should be greater than 33% to 47%.

This FHR is within the expected reference range of 110/min to 160/min for a client at 26 weeks of gestation.

A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had amniocentesis. Which of the following interventions is the nurse's priority following the procedure?a. check the client's temperatureb. observe for uterine contractionsc. administer Rh (D) immune globulind. monitor the FHR

d. monitor the FHR

The greatest risk to this client and their fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis.

Incorrect rationale:

The nurse should check the client's temperature to monitor for infection following an amniocentesis. However, this is not the priority nursing intervention.

The nurse should observe for uterine contractions to identify preterm labor following an amniocentesis. However, this is not the priority nursing intervention.

The nurse should administer Rho(D) immune globulin following an amniocentesis to prevent Rh sensitization. However, this is not the priority nursing intervention.

Incorrect rationale:

The nurse should restrict hourly fluid intake to no more than 125 mL/hr. The client's urine output should be 30 mL/hr or greater.

The nurse should assess deep tendon reflexes every 1 to 4 hr during continuous infusion of magnesium sulfate.

The nurse should monitor intake and output hourly for clients who are receiving a continuous infusion of magnesium sulfate.

The nurse should report the condition to the local health department. HIV is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is required to be reported.

Incorrect rationale:

The nurse should administer penicillin G 2.4 million units IM to a client who has syphilis.

The nurse should instruct the client to schedule a pelvic examination every 6 months.

The nurse should tell the client that treatment for HIV will be during the prenatal and perinatal periods. Treatment with antiretroviral prophylaxis such as zidovudine, triple-drug antiretroviral therapy (ART), or highly active antiretroviral therapy (HAART) during pregnancy have been reported to decrease the transmission of the virus to the newborn.

The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution.

Incorrect rationale:

The nurse should plan to position the client upright to allow the anesthetic solution to flow downward. If additional pain management is needed for a cesarean birth, the nurse can place the client supine with their head and shoulders elevated and at a lateral tilt to increase perfusion to the fetus.

The nurse should plan to administer 500 to 1,000 mL of lactated Ringer's or 0.9% sodium chloride 15 to 30 min prior to the administration of the first dose of anesthetic solution to decrease the maternal risk for hypotension. The nurse should not administer dextrose because it can cause maternal hyperglycemia and neonatal hypoglycemia.

The nurse should not plan to restrict the client's intake prior to the epidural placement and the first dose of anesthetic solution because NPO status is not indicated for this procedure.

Decreased platelet count

MY ANSWER

A client who has ITP has an autoimmune response that results in a decreased platelet count.

Incorrect rationale:

An increased ESR is an indication of chronic renal failure.

A client who has ITP will have megakaryocytes within the expected reference range.

An increased WBC is an indication of infection.

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?

a. Blood pressure 105/64 mm Hg

b. Heart rate 98/min

c. urine output of 280 mL within 8 hr

d. urine negative for ketones

Correct: Blood pressure 105/64 mm Hg

The nurse should report decreased blood pressure to the provider since it can indicate dehydration.

Incorrect rationale:

A heart rate of 98/min is within the expected range. Therefore, the nurse does not need to report this finding to the provider.

A urine output of 280 mL within 8 hr is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider.

Testing the urine for ketones is the most important laboratory test for a client who has hyperemesis gravidarum. Urine testing positive for ketones is an indication of dehydration, which increases the risk of preterm labor. A negative test result is an expected finding. Therefore, the nurse does not need to report this finding to the provider.

"I will continue taking my insulin if I experience nausea and vomiting."

MY ANSWER

The nurse should teach the client to continue to take their insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes.

Incorrect rationale:

The nurse should teach the client that their blood glucose levels are normally reduced and insulin response is enhanced during the first trimester of pregnancy which may require less insulin to control blood glucose levels.

The nurse should teach the client to avoid exercise during periods of hyperglycemia and when positive urine ketones are present.

The nurse should teach the client to avoid snacks and foods that are high in refined sugar.

Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.

Incorrect rationale:

A newborn who has hypoglycemia can exhibit hypotonia.

A newborn who has hypoglycemia can exhibit poor feeding behaviors.

A newborn who has hypoglycemia can exhibit hypothermia.

Determine progression of dilatation and effacement.The nurse should determine the client's dilation and effacement prior to applying an internal monitor. This action is not required prior to applying an external transducer for fetal monitoring.

Perform Leopold maneuvers.MY ANSWERThe nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer.

Complete a sterile speculum exam.A sterile speculum examination should be performed by the provider and is not required prior to applying an external transducer for fetal monitoring.

Prepare a Nitrazine paper test.A Nitrazine paper test is performed to assess the components (pH level) of vaginal fluid to determine if the membranes have ruptured. This action is not required prior to applying an external transducer for fetal monitoring.

"I will eat foods that taste good instead of balancing my meals."MY ANSWERClients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet.

"I will avoid having a snack before I go to bed each night."Clients who have hyperemesis gravidarum should avoid going to bed with an empty stomach. The nurse should instruct the client to eat a healthy snack before going to bed.

"I will have a cup of hot tea with each meal."Clients who have hyperemesis gravidarum should alternate liquids and solids every 2 to 3 hr to avoid an empty stomach and over filling at each meal.

"I will eliminate products that contain dairy from my diet."Clients who have hyperemesis gravidarum do not need to eliminate dairy products from their diet. The client should be encouraged to consume dairy products, because they are less likely to cause nausea than other foods.

When generating solutions, inserting a large bore intravenous catheter is indicated. Clients who have third trimester vaginal bleeding may experience a sudden hemorrhage and require fluid resuscitation or the administration of blood products. The nurse should weigh perineal pads. Weighing perineal pads after use will provide a more accurate assessment of the volume of blood loss that the client is experiencing.

When generating solutions, the nurse should not administer methotrexate or assess for cervical dilation because it is contraindicated for this client. Methotrexate is an antimetabolite and folic acid antagonist which destroys rapidly dividing cells. It can be administered during pregnancy to medically resolve an ectopic pregnancy during the first trimester. Assessing cervical dilation is contraindicated for any pregnant client who is experiencing vaginal bleeding. Manipulation of the cervix during the examination may result in further damage to the placenta and compromise the well-being of the client and fetus.

A newborn who is 26 hr old and has erythema toxicum on their faceErythema toxicum is a transient rash that can appear anywhere on a newborn's body during the first 24 to 72 hr following birth and can last up to 3 weeks. This finding requires no treatment.

A newborn who is 32 hr old and has not passed a meconium stoolA newborn should pass the first meconium stool within the first 24 to 48 hr following birth. Failure to pass a meconium stool can indicate a bowel obstruction or congenital disorder. This finding is within the expected reference range.

A newborn who is 12 hr old and has pink-tinged urinePink-tinged urine is an indication of uric acid crystals and is an expected finding for a newborn during the first week following birth.

A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)MY ANSWERAn axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider.

DepressionMY ANSWERThe nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness.

PolyuriaFluid retention can occur due to an excess of estrogen. Polyuria is not a common adverse effect of the medication.

HypotensionHypertension, rather than hypotension, is a common adverse effect of combined oral contraceptives.

UrticariaUrticaria is not a common adverse effect of combined oral contraceptives.

Perform Nitrazine testing.The nurse should perform a Nitrazine test to determine the pH of the fluid. An alkaline pH can indicate rupture of membranes. However, this is not the first action the nurse should take.

Assess the fluid.The nurse should observe the characteristics of the fluid to document color, odor, and amount. However, this is not the first action the nurse should take.

Check cervical dilation.The nurse should check the client's cervical dilation to assess progress of labor. However, this is not the first action the nurse should take.

Begin FHR monitoring.MY ANSWERThe greatest risk to the client and their fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take.

Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptives. Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives. Human papillomavirus is incorrect. The presence of human papillomavirus is not a contraindication for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives. Anxiety disorder is incorrect. The presence of an anxiety disorder is not a contraindication for the use of oral contraceptives.

Assessing the client's O2 saturation is important during labor. However, another assessment is the nurse's priority.

TemperatureMY ANSWERThe greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.

Blood pressureAssessing the client's blood pressure is important. However, another assessment is the nurse's priority.

Urinary outputAssessing the client's urinary output is important during labor. However, another assessment is the nurse's priority.

Decreased heart rateThe heart rate will increase when a newborn is experiencing pain.

Chin quiveringMY ANSWERBehavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow.

Pinpoint pupilsWhen experiencing pain, a newborn's pupils typically dilate.

Slowed respirationsWhen experiencing pain, a newborn's respirations are typically rapid and shallow.

Emotional labilityMY ANSWERThe nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.

Focusing phaseThe focusing phase is the third phase of the client's partner's emotional response to the pregnancy. It is characterized by their active involvement in the pregnancy and their relationship with the child.

Cognitive restructuringCognitive restructuring is accepting the idea of pregnancy and assimilating it into the client's life. The degree of acceptance is shown in the cemotional responses.

Couvade syndromeCouvade syndrome is pregnancy-like manifestations experienced by the expectant father. Manifestations include nausea, weight gain, and other physical manifestations of pregnancy.

Passive descentThe passive descent phase of labor is in the second stage of labor and is characterized by a period of calm and rest. The fetus continues to descend and rotate through the birth canal.

ActiveMY ANSWERThe nurse should identify that the client is in the active phase of labor. This phase is characterized by a cervical dilatation of 6 to 10 cm and contractions every 1.5 to 5 min, each lasting 40 to 90 seconds.

EarlyThe early phase of labor is characterized by cervical dilation of 0 to 5 cm and contractions every 2 to 30 min, each lasting 30 to 40 seconds.

DescentThe descent phase of labor is characterized by active pushing with contractions every 1 to 2 min, each lasting for 90 seconds.

Acrocyanosis is a bluish discoloration of the hands and feet and is an expected finding in a newborn 24 to 48 hr after birth.

Transient strabismusTransient strabismus is a normal variation in the newborn's eyes that can persist until the third or fourth month of age.

JaundiceMY ANSWERJaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider.

Caput succedaneumCaput succedaneum is a benign, edematous area of the scalp and is commonly found on the occiput.

OligohydramniosMY ANSWERThe nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis.

Hyperemesis gravidarumHyperemesis gravidarum is not an indication for further fetal assessment using electronic fetal monitoring unless complications occur.

LeukorrheaLeukorrhea is a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring unless complications occur.

Periodic tingling of the fingersPeriodic tingling of the fingers is a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring.

"The nurse will carry your baby in their arms to the nursery for scheduled procedures."The nurse should instruct the client that newborns will be transported in their bassinets and never carried outside the client's room in their arms to reduce the risk for falls.

"We will document the relationship of visitors in your medical record."The nurse should instruct the client that they can have anyone visit them on the unit. There is no documentation of a visitor's relationship to the client entered into the medical record.

"It's okay for your baby to sleep in the bed with you while in the hospital."The nurse should instruct the client that bed sharing is not a safe practice in the hospital or home environment because it can cause injury to the newborn. The nurse should instruct the client that their newborn should sleep supine in a bassinet or crib.

"Staff members who take care of your baby will be wearing a photo identification badge."MY ANSWERThe nurse should instruct the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of the newborn's safety. Some units' staff members wear special badges or a specific color scrubs.

Determine respiratory function.MY ANSWERThe priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation.

Increase the IV fluid rate.The nurse should increase the IV fluid rate to maintain circulation. However, this is not the first action the nurse should take.

Access emergency medications from cart.The nurse should access emergency medication to assist in resuscitative efforts. However, this is not the first action the nurse should take.

Collect a maternal blood sample for coagulopathy studies.The nurse should collect a maternal blood sample in preparation for a blood transfusion. However, this is not the first action the nurse should take.

Substernal retractionsMY ANSWERThe nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection or respiratory distress in the newborn. The nurse should report these findings to the provider for immediate intervention.

AcrocyanosisAcrocyanosis is an expected finding in the newborn for the first 24 hr following birth.

Overlapping suture linesOverlapping suture lines with molding are an expected variation for newborns who were delivered vaginally.

Head circumference 33 cm (13 in)A head circumference of 33 cm is within the expected reference range for a newborn following birth.

Ensure that the parent's identification band number matches the newborn's identification band number.MY ANSWERThe nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the number on the parent's identification band to the number on the newborn's identification band.

Ask the parent to verify their name and date of birth.Asking the parent to verify their name and date of birth will not ensure that the newborn is being given to the correct parent. Proper identification of the newborn's parent is an important safety standard.

Check the newborn's security tag number to ensure it matches the newborn's medical record.Comparing the newborn's security tag number to the newborn's medical record does not ensure the newborn is being transferred to the correct parent.

Match the newborn's date and time of birth to the information in the parent's medical record.It is not necessary for the nurse to check the parent's medical record. The nurse should match the information on the parent's identification band to the information on the newborn's identification band.

Frequent vomiting with weight loss of 3 lb in 1 weekMY ANSWERThe nurse should recognize that frequent vomiting with a weight loss of 3 lb in 1 week may indicate hyperemesis gravidarum and should be reported to the provider. The client could experience electrolyte imbalances due to hyperemesis gravidarum.

Reports of mood swingsThe nurse should recognize that emotional lability is a common finding during the first trimester of pregnancy.

Nosebleeds occurring approximately 3 times per weekThe nurse should recognize that frequent episodes of epistaxis is a common finding during the first trimester of pregnancy.

Increased vaginal dischargeThe nurse should recognize that increased vaginal discharge, or leukorrhea, is a common finding during the first trimester of pregnancy.

"I should increase my protein intake to 60 grams each day."A client who is pregnant should increase protein intake to 71 g each day during the second and third trimesters.

"I should drink 2 liters of water each day."A client who is pregnant should consume 3 L of water each day.

"I should increase my overall daily caloric intake by 300 calories."A client who is pregnant should increase caloric intake by 340 cal during the second trimester and by 452 cal during the third trimester.

"I should take 600 micrograms of folic acid each day."MY ANSWERA client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects.