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 [Show Less]