RN Maternal Newborn Online Practice 2023 A
Studied by 0 people
Learn
Practice Test
Spaced Repetition
Match
Flashcards1/59
Earn XP
Description and Tags
Name | Mastery | Learn | Test | Matching | Spaced |
|---|
No study sessions yet.
60 Terms
Which of the following findings should the nurse report to the provider?
Uterine contractions
Fetal heart rate
Gestational age
Vaginal examination
Maternal blood pressure
Uterine contractions
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.
Gestational age
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
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.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
Administer penicillin G 2.4 million units IM to the client.
Instruct the client to schedule an annual pelvic examination.
Tell the client they will start medication for HIV immediately after delivery.
Report the client's condition to the local health department.
Report the client's condition to the local health department.
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.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
Decreased platelet count
Increased erythrocyte sedimentation rate (ESR)
Decreased megakaryocytes
Increased WBC
Decreased platelet count
A client who has ITP has an autoimmune response that results in a decreased platelet count.
A nurse in the antepartum clinic is assessing a client’s adaptation to pregnancy. The client states that they are “happy one minute and crying the next” The nurse interpret the client’s statement as an indication of which of the following?
Emotional lability
Focusing phase
Cognitive restructuring
Couvade syndrome
Emotional lability
The 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.
A nurse is assessing the newborn of client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
Large for gestational age
Hyperglycemia
Bradypnea
Vomiting
Vomiting
Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days.
A nurse is assessing 4 newborns. Which of the following findings should the nurse report to the provider?
A newborn who is 26 hr old and has erythema toxicum on their face
A newborn who is 32 hr old and has not passed a meconium stool
A newborn who is 12 hr old and has pink-tinged urine
A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
An 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.
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 142/94 mm Hg
FHR 152/min
FHR 152/min
The expected reference range for the FHR is 110/min to 160/min. Therefore, this is an expected finding by the nurse.
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?
Lays the newborn across their lap and gently sways
Places the newborn in the crib in a prone position
Offers the newborn a pacifier dipped in formula
Prepares a bottle of formula mixed with rice cereal
Lays the newborn across their lap and gently sways
This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn.
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?
Confirm the newborn's Apgar score.
Verify the newborn's identification.
Administer vitamin K to the newborn.
Determine obstetrical risk factors.
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.
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect on this medication?
Depression
Polyuria
Hypotension
Urticaria
Depression
The 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.
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
O2 saturation
Temperature
Blood pressure
Urinary output
Temperature
The greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.
A nurse is admitting a client to the labor and delivery unit when the client states, “My water just broke.” Which of the following interventions is the nurse’s priority?
Perform Nitrazine testing.
Assess the fluid.
Check cervical dilation.
Begin FHR monitoring.
Begin FHR monitoring.
The 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.
A school is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
"You should take the medication within 72 hours following unprotected sexual intercourse."
"You should avoid taking this medication if you are on an oral contraceptive."
"If you don't start your period within 5 days of taking this medication, you will need a pregnancy test."
"One dose of this medication will prevent you from becoming pregnant for 14 days after taking it."
"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.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
Oligohydramnios
Hyperemesis gravidarum
Leukorrhea
Periodic tingling of the fingers
Oligohydramnios
The 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.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse takes?
Restrict hourly fluid intake to 150 mL/hr.
Have calcium gluconate readily available.
Assess deep tendon reflexes every 6 hr.
Monitor intake and output every 4 hr.
Have calcium gluconate readily available.
The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2-3 cm min apart, each lasting 80-90 sec, and a vaginal examination reveals that their cervix is dilated to 9cm. The nurse should identify that the client is in which of the following phases of labor?
Passive descent
Active
Early
Descent
Active
The 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.
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?
1-hr glucose tolerance test
Hematocrit
Fundal height measurement
Fetal heart rate (FHR)
Fundal height measurement
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.
A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client’s newborn. Which of the following statements should the nurse make?
"The nurse will carry your baby in their arms to the nursery for scheduled procedures."
"We will document the relationship of visitors in your medical record."
"It's okay for your baby to sleep in the bed with you while in the hospital."
"Staff members who take care of your baby will be wearing a photo identification badge."
"Staff members who take care of your baby will be wearing a photo identification badge."
The 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.
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
"I should increase my protein intake to 60 grams each day."
"I should drink 2 liters of water each day."
"I should increase my overall daily caloric intake by 300 calories."
"I should take 600 micrograms of folic acid each day."
"I should take 600 micrograms of folic acid each day."
A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects.
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?
Blood pressure 105/64 mm Hg
Heart rate 98/min
Urine output of 280 mL within 8 hr
Urine negative for ketones
Blood pressure 105/64 mm Hg
The nurse should report decreased blood pressure to the provider since it can indicate dehydration.
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow?
palpate for the fetal part presenting at the inlet
determine the location of the fetal back
palpate the fundus to identify the fetal part
identify the attitude of the head
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 providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
"I will eat foods that taste good instead of balancing my meals."
"I will avoid having a snack before I go to bed each night."
"I will have a cup of hot tea with each meal."
"I will eliminate products that contain dairy from my diet."
"I will eat foods that taste good instead of balancing my meals."
Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet.
A nurse is transporting a newborn back to the parent’s room following a procedure. Which of the following actions should the nurse take prior to leaving the newborn with their parent?
Ensure that the parent's identification band number matches the newborn's identification band number.
Ask the parent to verify their name and date of birth.
Check the newborn's security tag number to ensure it matches the newborn's medical record.
Match the newborn's date and time of birth to the information in the parent's medical record.
Ensure that the parent's identification band number matches the newborn's identification band number.
The 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.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
Acrocyanosis
Transient strabismus
Jaundice
Caput succedaneum
Jaundice
Jaundice 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.
Which of the following findings should the nurse report to the provider?
Abdominal assessment
Vaginal discharge
Heart rate
Temperature
Dyspareunia
Condom usage
Abdominal assessment
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
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.
Temperature
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
Dyspareunia is painful intercourse, which can be associated with STIs; therefore, the nurse should report this finding to the provider.
Condom usage
Sexual activity without the use of condoms increases the risk of contracting STIs; therefore, the nurse should report this finding to the provider.
A nurse in a clinic is caring for a 16 year old adolescent. Which of the following conditions should the nurse identify as being consistent with the adolescent assessment findings?
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 the adolescent’s medical record. Which of the following conditions is the client most likely developing?
The adolescent is most likely developing _______ as evidenced by __________
pelvic inflammatory disease, ectopic pregnancy, pyelonephritis
beta hCG level, urinalysis, C-reactive protein
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.
C-reactive protein is correct. The adolescent's C-reactive protein is elevated, which is a manifestation of PID.
The nurses suspects the adolescent is experiencing pelvic inflammatory disease and is planning care. Which of the following prescriptions should the nurse expect the provide to prescribe?
The nurse should anticipate a provider’s prescription for ______ and ______
Doxyclyine, Imiquimod, Acyclovir, Fluconazole, Ceftriaxone
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.
The nurse is reviewing the provider’s prescriptions in the adolescent’s medical chart
The nurse should first implement _____ and ____
administering doxycycline, scheduling follow up appointments, providing education on medication
administering metronidazole, administering ceftriaxone, educating on condom use
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.
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.
The nurse has just reviewed discharge instructions with the adolescent. Which of the following indicates whether the adolescent understands the teaching or requires fiuther education?
"I should continue taking all my medications even if I don't show any symptoms." |
|---|
"If I continue to get this type of infection, it can affect my ability to have kids in the future." |
"I should go to the emergency department if my urine turns dark." |
"As long as I keep my IUD, I don't need to use condoms." |
"I'm more likely to get a sunburn while taking these medications." |
"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.
A nurse is in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client’s history should the nurse recognize as a contraindication to oral contraceptives?
Cholecystitis
Hypertension
Human papillomavirus
Migraine headaches
Anxiety disorder
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.
Migraine headaches is correct. A history of migraine headaches is a contraindication for the use of oral contraceptives.
A 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?
Reassess the client in 2 hr.
Administer simethicone.
Assist the client to empty their bladder.
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.
A nurse on an antepartum unit is caring for 4 clients. Which of the following clients should the nurse identify as the priority?
A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL (less than 95 mg/dL)
A client who is at 34 weeks of gestation and reports epigastric pain
A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL (11 to 16 g/dL)
A client who is at 39 weeks of gestation and reports urinary frequency and dysuria
A client who is at 34 weeks of gestation and reports epigastric pain
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 is assessing a late preterm newborn. Which of the following manifestations is an indication of an hypoglycemia?
Hypertonia
Increased feeding
Hyperthermia
Respiratory distress
Respiratory distress
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.
A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
Frequent vomiting with weight loss of 3 lb in 1 week
Reports of mood swings
Nosebleeds occurring approximately 3 times per week
Increased vaginal discharge
Frequent vomiting with weight loss of 3 lb in 1 week
The 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.
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?
Percutaneous umbilical blood sampling
Amnioinfusion
Biophysical profile (BPP)
Chorionic villus sampling (CVS)
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.
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.
Instruct the client to press the provided button each time fetal movement is detected.
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.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to an applying an external transducer for fetal monitoring?
Determine progression of dilatation and effacement.
Perform Leopold maneuvers.
Complete a sterile speculum exam.
Prepare a Nitrazine paper test.
Perform Leopold maneuvers.
The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer.
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?
Late decelerations
Moderate variability of the FHR
Cessation of uterine dilation
Prolonged active phase of labor
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.
A nurse is caring for a client who is at 15 weeks of gestation, Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse’s priority following the procedure?
Check the client's temperature.
Observe for uterine contractions.
Administer Rho(D) immune globulin.
Monitor the FHR.
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.
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
Place the client in a supine position for 30 min following the first dose of anesthetic solution.
Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution.
Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.
Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution.
Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.
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.
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
Decreased heart rate
Chin quivering
Pinpoint pupils
Slowed respirations
Chin quivering
Behavioral responses to a newborn's pain include facial expressions such as chin quivering, grimacing, and furrowing of the brow.
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? (Round the answer to the nearest whole number)
1g = 1000mg
1 tablet/ 250 mg x 1000mg = 4 tablets
A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?
Determine respiratory function.
Increase the IV fluid rate.
Access emergency medications from cart.
Collect a maternal blood sample for coagulopathy studies.
Determine respiratory function.
The 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.
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?
Swelling of the face
Varicose veins in the calves
Nonpitting 1+ ankle edema
Hyperpigmentation of the cheeks
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.
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
A client who is at 11 weeks of gestation and reports abdominal cramping
A client who is at 15 weeks of gestation and reports tingling and numbness in right hand
A client who is at 20 weeks of gestation and reports constipation for the past 4 days
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.
A nurse is teaching a client who is at 37 weeks of gestation and has prescription for a nonstress test. Which of the following instructions should the nurse inclufde?
"The test should take 10 to 15 minutes to complete."
"You will lay in a supine position throughout the test."
"You should not eat or drink for 2 hours before the test."
"You should press the handheld button when you feel your baby move."
"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.
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?
Flaccid uterus
Cervical laceration
Excess vaginal bleeding
Increased afterbirth cramping
Increased maternal temperature
Flaccid uterus is correct. Oxytocin increases the contractility of the uterus.
Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding.
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?
Minimal arm recoil
Popliteal angle of 90°
Creases over the entire foot sole
Raised areolas with 3 to 4 mm buds
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.
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.
Lethargy |
|---|
Ecchymotic caput succedaneum |
Yellow sclera and oral mucosa |
Decreased temperature |
Respiratory distress |
Poor feeding |
Decreased temperature, poor feeding, respiratory distress, and lethargy are consistent with hypoglycemia.
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.
Decreased temperature, yellow sclera and oral mucosa, poor feeding, respiratory distress, and lethargy are consistent with sepsis.
Which of the following findings should the nurse report to the provider/
Respiratory findings
Temperature
Oxygen saturation
Central nervous system findings
Gastrointestinal findings
Central nervous system findings is correct. 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 is correct. The newborn is displaying poor feeding and loose stools. These findings are manifestations of NAS and should be reported to the provider.
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?
Feed the newborn 1 oz of water every 4 hr.
Apply lotion to the newborn's skin three times per day.
Remove all clothing from the newborn except the diaper.
Discontinue therapy if the newborn develops a rash.
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.
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates and understanding of the teaching?
"I will need to increase my insulin doses during the first trimester."
"I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater."
"I will continue taking my insulin if I experience nausea and vomiting."
"I will ensure that my bedtime snack is high in refined sugar."
"I will continue taking my insulin if I experience nausea and vomiting."
The nurse should teach the client to continue to take their insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Potential Conditions: cold stress, acute blirubinencephalopathy, NAS, respiratory distress
Actions to Take: plan to initiate phototherapy, perform neonatal abstinence system scoring, obtain a prescription on for arterial blood, encourage birthing parent to breastfeed, place newborn skin to skin on birthing
Parameter to monitor: blood glucose level, stool output, lung sounds, bilirubin level, temperature
Potential condition: cold stress
actions to take: encourage birthing parent to breastfeed, place newborn skin to skin on birthing
parameter to monitor: blood glucose, temperature
Which of the following actions should the nurse plan to implement?
Educate the parents to begin range of motion exercises on the affected arm after 1 week. |
|---|
Assess for grasp reflex in the affected extremity. |
Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. |
Instruct parents to limit physical handling for 2 weeks. |
Educate the parents to begin range of motion exercises on the affected arm after 1 week is indicated. 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. 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. Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved by pinning the sleeve to the shirt.
Instruct parents to limit physical handling for 2 weeks is contraindicated. 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.
Which of the following nursing actions should the nurse plan to take?
Assess cervical dilation. |
|---|
Weigh perineal pads. |
Administer methotrexate. |
Insert a large bore intravenous catheter. |
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
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 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?
Shortness of breath when climbing stairs
Swelling of feet and ankles at the end of the day
Headache that is unrelieved by analgesia
Braxton Hicks contractions
Headache that is unrelieved by analgesia
A headache that is unrelieved by analgesia can indicate preeclampsia and should be reported to the provider.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
Substernal retractions
Acrocyanosis
Overlapping suture lines
Head circumference 33 cm (13 in)
Substernal retractions
The 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.
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?
Increased fetal movement
Leakage of fluid from the vagina
Upper abdominal discomfort
Urinary frequency
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.
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?
Administer aspirin for pain.
Elevate the affected leg.
Massage the affected leg every 12 hr.
Apply cold compresses to the affected calf.
Elevate the affected leg.
The client should elevate the affected leg to relieve pain and swelling by improving circulation.