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.
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