4) A nurse is teaching a group of parents about newborn safety. Which of the following statements by a parent indicates an understanding of the teaching?
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"I will put a bib on my baby at night to keep her clothing dry."
The parents should avoid placing a bib around their newborns' necks at night to prevent choking and suffocation.
"I will cover the crib mattress with plastic to prevent staining."
The parents should avoid placing plastic over the crib mattress to prevent suffocation.
"I will warm my baby's formula using the lowest setting in the microwave."
The parents should avoid heating the formula in a microwave to prevent uneven warming of the formula.
"I will dress my baby in flame-retardant clothing."
The parents should dress their newborns in flame-retardant clothing to prevent injury.
5) 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
A client who has ITP has an autoimmune response that results in a decreased platelet count.
Increased erythrocyte sedimentation rate (ESR) An increased ESR is an indication of chronic renal failure.
Decreased megakaryocytes
A client who has ITP will have megakaryocytes within the expected reference range.
Increased WBC
An increased WBC is an indication of infection
6) A nurse is caring for a newborn who was transferred to the nursery 30 min after delivery. Which of the following actions should the nurse take first?
Confirm the newborn's Apgar score.
The Apgar score is a physiologic 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.
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.
Administer vitamin K to the newborn.
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.
Determine obstetrical risk factors.
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.
7) A nurse is assessing a client who is in active labor and notes early decelerations in the FHR on the monitor tracing. The client is at 39 weeks of gestation and is receiving a continuous IV infusion of oxytocin. Which of the following actions should the nurse take?
Discontinue the oxytocin infusion.
Early decelerations in the FHR are considered benign. Early decelerations occur due to compression of the fetal head during contractions, vaginal examinations, and pushing during the second stage of labor. No interventions are necessary for early decelerations.
Continue monitoring the client.
Early decelerations in the FHR are considered benign. Early decelerations occur due to compression of the fetal head during contractions, vaginal examinations, and pushing during the second stage of labor. No interventions are necessary for early decelerations. Therefore, the nurse should continue to monitor the client.
Request that the provider assess the client.
Early decelerations in the FHR are considered benign. Early decelerations occur due to compression of the fetal head during contractions, vaginal examinations, and pushing during the second stage of labor. No interventions are necessary for early decelerations.
Increase the infusion rate of the maintenance IV fluid.
Early decelerations in the FHR are considered benign. Early decelerations occur due to compression of the fetal head during contractions, vaginal examinations, and pushing during the second stage of labor. No interventions are necessary for early decelerations.
11) A nurse in a provider's office is reviewing the medical record of a client who is in her first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia?
Singleton pregnancy
Multifetal gestation, rather than a single fetus pregnancy, increases a client's risk for the development of preeclampsia.
BMI of 20
Having a BMI greater than 30 increases a client's risk for the development of preeclampsia.
Maternal age 32 years
A maternal age of younger than 19 or older than 40 increases the client's risk for the development of preeclampsia.
Pregestational diabetes mellitus
Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis.
12) A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication?
Muscle weakness is not an adverse effect of carboprost.
13) A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take?
Cover the newborn's eyes while under the phototherapy light.
Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light.
Keep the newborn in a shirt while under the phototherapy light.
It is acceptable for the nurse to keep a diaper or other covering over the newborn's genitals and buttocks, but the nurse should remove all other clothing and blankets to expose as much body surface area as possible to the phototherapy light.
Apply a light moisturizing lotion to the newborn's skin.
The nurse should not apply any cream or moisture to the newborn's skin because it can absorb heat and cause burns.
Turn and reposition the newborn every 4 hr while undergoing phototherapy.
The nurse should turn and reposition the newborn every 2 to 3 hr to allow for maximum exposure of body surfaces to the phototherapy light.
14) A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
Active
The active phase of labor is characterized by a cervical dilatation of 4 to 7 cm and contractions every 3 to 5 min, each lasting 40 to 70 seconds. Transition
The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds. Latent
The latent phase of labor is characterized by cervical dilation of 0 to 3 cm and contractions every 5 to 30 min, each lasting 30 to 45 seconds. Descent
The descent phase of labor is characterized by active pushing with contractions every 1 to
2 min, each lasting for 90 seconds.
15) A nurse 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? (Select all that apply.) Cholecystitis
Hypertension
Human papillomavirus
Migraine headaches
Anxiety disorder
Cholecystitis is correct. A history of gallbladder disease is a contraindication for the
use of oralcontraceptive .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 or oral contraceptives.
Anxiety disorder is incorrect. The presence of an anxiety disorder is not a contraindication for the use of oral contraceptives.
16) A nurse is assessing a client who is 12 hr postpartum. The client's fundus is two fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take?
Place the client in a side-lying position.
Placing the client in a side-lying position is an action that the nurse should take for a client who is experiencing hypovolemic shock.
Assist the client to the bathroom to void.
A distended bladder inhibits the uterus from contracting normally and can cause uterine atony. Therefore, the nurse should assist the client to void.
Obtain a prescription for IV oxytocin.
Obtaining a prescription for IV oxytocin is an action that the nurse should take for a client who requires labor induction and augmentation.
Administer methylergonovine.
Administering methylergonovine is an action that the nurse should take for a client who is experiencing postpartum hemorrhage.
17) A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following clinical manifestations should the nurse expect? (Select all that apply.)
Yellow sclera
Creases over two-thirds of the soles of the feet
Posterior fontanel larger than the anterior fontanel
Molding of the head
Lanugo on the shoulders
Yellow sclera is incorrect. Yellow sclera is an indication of hyperbilirubinemia and is not an expected clinical manifestation.
Creases over two-thirds of the soles of the feet is correct. Fewer creases over the soles of the feet is an indication of prematurity. Creases over the entire soles of the feet is an indication of postmaturity.
Posterior fontanel larger than the anterior fontanel is incorrect. The posterior fontanel is located on the back of the newborn's head and is a small triangular shape. The anterior fontanel is diamond shaped and approximately 5 cm. It is located on the top of the newborn's head and is larger than the posterior fontanel.
Molding of the head is correct. Molding occurs during the birth process as the newborn travels through the birth canal, resulting in compression of the soft bones of the skull.
Lanugo on the shoulders is correct. Absence of lanugo is an indication of postmaturity. Abundant lanugo is an indication of prematurity.
18) A nurse is developing an educational program for adolescents about nutrition during the third trimester of pregnancy. Which of the following statements should the nurse include in the program?
"Consume three to four servings of dairy each day."
Calcium intake is especially important during an adolescent's pregnancy because bone absorption of calcium is still occurring. Therefore, the nurse should instruct the adolescents to consume three to four servings of dairy per day to meet their calcium needs. "Increase your daily caloric intake by 600 to 700 calories."
Consuming an additional 600 to 700 cal per day could lead to excessive weight gain, which increases the adolescent's risk for complications related to pregnancy, labor, and delivery. The nurse should instruct the adolescents that, if they have a BMI within the expected reference range prior to pregnancy, they should increase their daily caloric intake by 340 cal in the first trimester and 452 cal in the second and third trimesters.
"Limit your daily sodium intake to less than 1 gram."
Sodium supports the increase in blood volume that occurs during pregnancy. An adequate sodium intake is approximately 1.5 g per day. The nurse should instruct the adolescents that an adequate intake of sodium is required during pregnancy. "Increase your protein intake to 40 to 50 grams each day."
Adequate protein intake is necessary to support the rapid growth of the fetus, maternal tissues, increasing blood volume, and the formation of amniotic fluid. Therefore, the nurse should instruct the adolescents to increase their daily intake of protein to approximately 71 g during the second and third trimesters of pregnancy.
19) A nurse is performing a vaginal exam on a client who is in labor and reports severe pressure and pain in the lower back. The nurse notes that the fetal head is in a posterior position. The nurse should identify that which of the following is the best nonpharmacological intervention to perform to relieve the client's discomfort?
Back rub
A back rub is an effective nonpharmacological intervention to assist the client with pain. However, there is a better nonpharmacological intervention the nurse should use. Counter-pressure
According to evidence-based practice, counter-pressure is the best nonpharmacological technique to use when relieving the client's discomfort from the fetus being in a posterior position because this intervention lifts the fetal head off of the spinal nerve. Playing music
Playing music is an effective nonpharmacological intervention to assist the client with pain. However, there is a better nonpharmacological intervention the nurse should use. Foot massage
A foot massage is an effective nonpharmacological intervention to assist the client with pain. However, there is a better nonpharmacological intervention the nurse should use.
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20) A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?
Monitor the client's blood pressure every hour.
MY ANSWER
The nurse should monitor the client's vital signs, including blood pressure, every 15 to 30 min. Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring.
Restrict the total hourly intake to 200 mL.
The nurse should restrict the client's total hourly intake to no more than 125 mL. Clients who have preeclampsia can have an alteration in kidney function, leading to increases in edema.
Monitor the FHR continuously.
Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The FHR and uterine contractions should be monitored continuously while the client is receiving magnesium sulfate.
Administer protamine sulfate for manifestations of toxicity.
The nurse should administer calcium gluconate if the client shows manifestations of magnesium sulfate toxicity. Findings of toxicity include loss of deep-tendon reflexes, respiratory depression, slurred speech, and cardiac arrest.
21)A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment?
Discuss contraceptive options with the client and her partner.
The discussing of contraceptive options occurs during the letting-go phase. This phase focuses on moving forward as a family with interchanging members.
Repeat information to ensure client understanding.
The repeating of information to ensure client understanding occurs during the taking-in phase. During this phase, which is experienced on the first postpartum day, the client displays dependent and passive behaviors. Due to excitement and fatigue, the client is unable to retain information. Therefore, the nurse should repeat instructions to ensure that the client understands what is being said.
Listen to the client and her partner as they reflect upon the birth experience.
Listening to the client and her partner reflect upon the birth experience occurs during the taking-in phase. During this phase, the new mother is focused on herself and meeting her basic needs. There is also much excitement about the newborn and the birth experience. Therefore, the nurse should allow the client to reflect, ensuring a healthy transition and a successful adaptation into the new family unit.
Demonstrate to the client how to perform a newborn bath.
Demonstrating to the client how to perform a newborn bath occurs during the taking-hold phase. The new mother moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new mother confidence and promote maternal adjustment.
22) A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn?
Apply a cool pack for 10 min to the heel prior to the puncture.
A cool pack will constrict the blood vessels, making it more difficult to obtain an adequate specimen. The nurse should apply a warm pack prior to the puncture.
Request a prescription for IM analgesic.
The pain experienced from a heel stick is too brief to warrant risking the adverse effects of parenteral analgesia.
Use a manual lance blade to pierce the skin.
A spring-loaded, automatic puncture device is recommended to minimize pain by ensuring that the depth of the puncture is not too deep, avoiding injury to the newborn.
Place the newborn skin to skin on the mother's chest.
Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure.
23) A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
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. Moderate variability of the FHR
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
Cessation of uterine dilation is an indication for the initiation of an oxytocin infusion to augment the client's labor progression. Prolonged active phase of labor
A prolonged active phase of labor is an indication for the initiation of an oxytocin infusion to augment the client's labor progression.
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