A nurse is assessing a client on the first postpartum day. Findings include fundus firm and one fingerbreadth above and to the right of the umbilicus,
... [Show More] moderate lochia rubra with small clots, temperature 37.3 C (99.2 F), and pulse rate 52/min. Which of the following actions should the nurse take?
Report the vital signs to the provider.
Massage the fundus.
Ask the client when she last voided.
Administer an oxytocic agent. - ✔✔Ask the client when she last voided
Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be found firm at midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void.
A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication?
IV narcotics administered to the mother during labor
Maternal drug use
Hyaline membrane disease
Meconium aspiration - ✔✔IV narcotics administered to the mother during labor
The nurse should administer naloxone to reverse respiratory depression due to acute narcotic toxicity, which can result from IV narcotics administration during labor.
A nurse is discussing epidural anesthesia with a client who is receiving oxytocin for induction of labor. Which of the following statements should the nurse make?
"An epidural given too early during labor can cause maternal hypertension."
"An epidural given too early during labor will not be effective in active labor."
"An epidural given too early can cause fetal depression."
"An epidural given too early can prolong labor." - ✔✔An epidural given too early can prolong labor
Clients who receive anesthesia before the active phase of labor usually find the progression of their labor to slow. The medication depresses the central nervous system. Therefore, it will take longer for the cervix to dilate and efface.
A nurse is caring for a client who is pregnant and reports nausea and vomiting. Which of the following instructions should the nurse provide the client?
"You should eat some crackers before rising from bed in the morning."
"You should eat foods served at warm temperatures."
"You should sip whole milk with breakfast."
"You should brush your teeth immediately after meals." - ✔✔You should eat some crackers before rising from bed in the morning
Morning sickness is caused by the buildup of human chorionic gonadotropin (hCG) in the mother's system. Dry foods eaten before rising in the morning tend to reduce the risk of nausea in clients who are pregnant.
A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) Immune Globulin?
While the client is in labor
Following an episode of influenza during pregnancy
Prior to a blood transfusion
At 28 weeks of gestation - ✔✔At 28 weeks of gestion
The nurse should administer Rh(D) Immune Globulin to a client who is pregnant and has Rh-negative blood at 28 weeks of gestation. Rh(D) Immune Globulin consists of passive antibodies against the Rh factor, which will destroy any fetal RBCs in the maternal circulation and block maternal antibody production.
A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy?
Respiratory depression
Hypothermia
Hypoglycemia
Jaundice - ✔✔Respiratory depression
Magnesium sulfate can cause respiratory and neuromuscular depression in the newborn. The nurse should monitor the newborn for clinical manifestations of respiratory depression.
A nurse is caring for a newborn who was born to a client who has a narcotic use disorder. Which of the following nursing actions should the nurse identify as a contraindication for the care of the newborn?
Promoting maternal-newborn bonding
Tight swaddling of the newborn
Small frequent feedings
Frequent stimulation - ✔✔Frequent stimulation
This newborn needs a quiet, calm environment with minimal stimulation to promote rest and reduce stress. A stimulating environment can trigger irritability and hyperactive behaviors.
A nurse is caring for a client who is in labor. A vaginal examination reveals the following information: 2cm, 50%, +1, right occiput anterior. Based on this information, which of the following position should the nurse document in the medical record?
Transverse
Breech
Vertex
Mentum - ✔✔Vertex
ROA describes the relationship of the presenting part of the fetus to the client's pelvis. In this case, the occipital bone is the presenting part and is located anteriorly in the client's right side. Based on the presentation of the fetus, the position is vertex.
A nurse is caring for a client who desires an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for the use of this device?
Hypertension
Menorrhagia
History of multiple gestations
History of thromboembolic disease - ✔✔Menorrhagia
An IUD is a small plastic or copper device placed inside the uterus that changes the uterine environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia, severe dysmenorrhea, or history of ectopic pregnancy.
A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. Which of the following actions should the nurse include in the plan of care?
Keep four side rails up while the client is in bed.
Monitor fetal heart rate every hour.
Insert an indwelling urinary catheter.
Check the cervix prior to analgesic administration. - ✔✔Check the cervix prior to analgesic administration
Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix is dilated. If administered too close to the time of delivery, the analgesic could cause respiratory depression in the newborn.
A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse provide to the client about the treatment plan?
"Your partner needs to be cultured and be treated with metronidazole only if his cultures are positive."
"You and your partner need to take the medication and use a condom during intercourse until cultures are negative."
"If both you and your partner are treated simultaneously, you may continue to engage in sexual intercourse."
"Only you will need to take the metronidazole, but you should not have intercourse until your culture is negative." - ✔✔You and your partner need to take the medication and use a condom during intercourse until cultures are negative
Trichomonas vaginalis is the organism that causes the sexually transmitted infection trichomoniasis. Both men and women can be infected with trichomoniasis. Clinical findings include yellowish to greenish, frothy, mucopurulent, copious discharge with an unpleasant odor, as well as itching, burning, or redness of the vulva and vagina. Trichomoniasis can be treated easily with metronidazole. However, for the treatment to work, it is important to make sure both sexual partners receive treatment to prevent reinfection. Instruct the client to use condoms during sexual intercourse while being treated.
A nurse is caring for four newborns. Which of the following newborns is at greatest risk for hypoglycemia?
A newborn who is large for gestational age
A newborn who has an Rh incompatibility
A newborn who has pathologic jaundice
A newborn who has fetal alcohol syndrome - ✔✔A newborn who is large for gestational age [Show Less]