At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villi
... [Show More] sampling (CVS) procedure. What assessment finding requires immediate intervention?
-uterine cramping
-abdominal tenderness
-systolic bp <100 mmHg
-intermittent nausea -ANS A. Uterine cramping
A client states, "During the three months I've been pregnant, it seems like I have had to go to the bathroom every five minutes." Which explanation should the nurse provide to this client?
-the client may have a bladder or kidney infection
-bladder capacity increases during pregnancy
-during pregnancy a woman is especially sensitive to body functions
-the growing uterus is putting pressure on the bladder -ANS D. The growing uterus is putting pressure on the bladder.
The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute, and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first?
-check the infant's ABGs
-notify the pediatrician of the infants VS
-assess the infant's blood glucose level
-encourage the infant to take the breast or sugar water -ANS C. Assess the infant's blood glucose level
An infant in respiratory distress is placed on pulse ox. The O2 sat is 85%. What is the priority nursing intervention?
-evaluate the blood pH
-begin humidified oxygen via hood
-stimulate infant crying
-place the infant under a radiant warmer -ANS B. Begin humidified oxygen via hood
When assessing a newborn infant's heart rate, which technique is most important for the nurse to use?
-quiet the infant before counting the HR
-listen at the apex of the heart
-count the HR for at least one full minute
-palpate the umbilical cord -ANS C. Count the heart rate for at least one full minute
The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the nurse, "Wait! I don't want my baby to have a shot." Which response would be best for the nurse to make?
-inform the mother that the injection was prescribed by the HCP
-explore the mother's concerns about the infant receiving an injection of vitamin K
-explain that vitamin K is required by state law and compliance is mandatory
-remind the mother that all babies receive this shot and it is relatively painless -ANS B. Explore the mother's concerns about the infant receiving an injection of vitamin K
The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan?
-avoid alcohol bc it is excreted in breast milk
-avoid spicy foods to prevent infant colic
-increase caloric intake by approx. 500 calories/day
-double prenatal milk intake to improve vitamin D transfer to the infant -ANS A. Avoid alcohol because it is excreted in breast milk
Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor?
-brighten the lighting so the mother can view the infant
-complete the newborn assessment as quickly as possible
-provide positive reinforcement for maternal care of infant
-encourage early initiation of breast or formula feeding -ANS D. Encourage early initiation of breast of formula feeding
A client at 8-weeks gestation asks the nurse about the risk fora congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur?
-it depends on what the causative factors are for a CHD
-we don't really know what or when CHDs occur
-they usually occur in the first trimester of pregnancy
-the heart develops in the third to fifth weeks after conception -ANS D. The heart develops in the third to fifth weeks after conception
A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. What information should the nurse provide?
-many women imagine what their baby is like by interpreting fetal movements
-the fetus in utero is capable of hearing and does respond to the mothers voice
-the HCP should address her concerns about her baby hearing function
-the interaction b/w the mothers voice and the fetus's response ensures bonding -ANS B. The fetus in utero is capable of hearing and does respond to the mother's voice
A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide?
-this is a demonstration of the fetus acoustical reflux
-the fetus can respond to sound by 24 weeks
-it is a coincidence the fetus responded at the same time
-report behavior to HCP -ANS B. The fetus can respond to sound by 24-weeks gestation
A woman whose pregnancy is confirmed asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide?
-excretes prolactin and insulin
-produces nutrients for fetal nutrition
-secretes both estrogen and progesterone
-forms a protective, impenetrable barrier -ANS C. Secretes both estrogen and progesterone
Which cardiovascular findings should the nurse assess further in a client who is at 20-weeks gestation?
-decrease in pulse rate
-decrease in BP
- increase in heart sounds
-increase in RBC production -ANS A. Decrease in pulse rate
A 31-year-old woman uses an over-the-counter (OTC) pregnancy test that is positive one week after a missed period. At the clinic, the client tells the nurse she takes phenytoin (Dilantin) for epilepsy, has a history of irregular periods, is under stress at work, and is not sleeping well. The client's physical examination and ultrasound do not indicate that she is pregnant. How should the nurse explain the most likely cause for obtaining false-positive pregnancy test results?
-having an irregular menstrual cycle
-using an anticonvulsant for epilepsy
-taking the pregnancy test too early
-being under too much stress at work -ANS B. Using an anticonvulsant for epilepsy
Which gastrointestinal findings should the nurse be concerned about in a client at 28-weeks gestation?
-pica
-pyrosis
-ptyalism
-decreased peristalsis -ANS A. PICA
During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide?
-discontinue all forms of contraception
-make sure to include adequate folic acid in the diet
-lose weight so more is gained during pregnancy
-continue to take any meds that are taken regularly -ANS B. Make sure to include adequate folic acid in the diet
Which statement by a client who is pregnant indicates to the nurse an understanding of the role of protein during pregnancy?
-protein helps the fetus grow while I'm pregnant
-gestational diabetes is prevented by eating protein
-anemia is averted by consuming enough protein
-my baby will develop strong teeth after he is born -ANS A. "Protein helps the fetus grow while I am pregnant."
A client in her second trimester of pregnancy asks if it is safe for her to have a drink with dinner. How should the nurse respond to the client?
-during second trimester beer can be consumed without harm to the fetus
-wine can be consumed several times a week after the first trimeter
-only one drink with the evening meal is not harmful to the fetus
-abstinence is strongly recommended throughout the pregnancy -ANS D. Abstinence is strongly recommended throughout the pregnancy
A female client who wants to deliver at home asks the nurse to explain the role of a nurse-midwife in providing obstetric care. What information should the nurse provide?
-birth in the home setting is the preference for a using a midwife for delivery
-the pregnancy should progress normally and be considered low risk
-natural child birth without analgesia is used to manage pain during labor
-an obstetrician should also follow the client during pregnancy -ANS B. The pregnancy should progress normally and be considered low risk
When discussing birth in a home setting with a group of pregnant women, which situation should the nurse include about the safety of a home birth?
-only the woman and her midwife should be present during the delivery
-the woman should live no more than 15 min from the hospital
-the woman's extended family should be allowed to attend the home birth
-medical backup should be available quickly in case of complications -ANS D. Medical backup should be available quickly in case of complications
The nurse is discussing the stages of labor with a group of women in the last month of pregnancy and provides examples of different positional techniques used during the second stage of labor. Which position should the nurse address the best advantage of gravity during delivery?
-walking
-squatting
-kneeling
-lithotomy -ANS B. Squatting
A client in the first stage of labor is using a shallow pattern of rapid breaths that is twice the normal adult breathing rate. The client complains of feeling light headed, dizzy, and states that her fingers are tingling. What action should the nurse implement?
-notify the HCP
-help her breathe into a paper bag
-administer oxygen via nasal cannula
-tell the client to show her breathing -ANS B. Help her breathe into a paper bag
A client in active labor at 39-weeks gestation tells the nurse she feels a wet sensation on the perineum. The nurse notices pale, straw-colored fluid with small white particles. After reviewing the fetal monitor strip for fetal disturbance, what action should the nurse take?
-escort the client to the bathroom
-offer the client a bed pan
-perform a nitrazine test
-clean the perineal area -ANS C. Perform a nitrazine test
A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to 70 mmHg at the peak. Based on this information, what action should the nurse implement?
-notify HCP
-bring delivery table to room
-prepare to administer oxytocin
-document findings -ANS D. Document the findings in the client record
A multiparous client has been in labor for 8 hours when her membranes rupture. What action should the nurse implement first?
-prepare client for imminent birth
-asses FHR and pattern
-document characteristics of fluid
-notify HCP -ANS B. Assess the fetal heart rate and pattern
Which action should the nurse implement caring for a newborn immediately after birth?
-keep newborn airway clear
-foster parent-newborn attachment
-administer eye prophylaxis and vitamin k
-dry the newborn and wrapping in blanket -ANS A. Keep the newborn's airway clear
During an assessment of a multiparous client who delivered an 8 lb 7 oz infant 4 hours ago, the nurse notes the client's perineal pad is completely saturated within 15 minutes. What action should the nurse implement next?
-perform fundal massage
-assess bp
-notify the HCP
-encourage the client to void -ANS A. Perform fundal massage
The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply) -ANS B. Chest breathing with nasal flaring
C. Diaphragmatic with chest retraction
F. Grunting heard with a stethoscope
What action should the nurse implement when caring for a newborn receiving phototherapy?
-reposition every 6 hr
-place eye shield over eyes
-limit intake of formula
-apply oil based lotion to skin -ANS B. Place an eyeshield over the eyes
Which finding indicates to the nurse that a 4 day old infant is receiving adequate breast milk?
-gain 1-2 oz per week
-saturates 6-8 diapers per day
-rests for 6 hours b/w feedings
-defecates at least once per 24 hours -ANS B. Saturates 6 to 8 diapers per day
The nurse is providing discharge teaching for a gravid client who is being released from the hospital after placement of cerclage. Which instruction is the most important for the client to understand?
-plan for a possible cesarean birth
-arrange for home uterine monitoring
-make arrangements for care at home
-report uterine cramping or low backache -ANS D. Report uterine cramping or low backache
A client at 28 weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client?
-contraction stress test
-internal fetal monitoring
-abdominal ultrasound
-lecithin-sphingmyelin ratio -ANS C. Abdominal ultrasound
The nurse is planning for the care of a 30 year old primigravida with pre-gestational diabetes. What is the most important factor affecting this client's pregnancy outcome?
-mothers age
-amount of insulin required prenatally
-degree of glycemic control during pregnancy
-number of years since diabetes was diagnosed -ANS C. Degree of glycemic control during pregnancy
A client with asthma who is 8 hours post delivery is experiencing postpartum hemorrhage. Which prescription should the nurse administer?
-oxytocin
-ibuprofen
-fentanyl
-hemabate -ANS A. Oxytocin (Pitocin) [Show Less]