A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical
findings should the nurse expect?
Facial petechiae- seen over the presenting part with soft
...
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical
findings should the nurse expect?
Facial petechiae- seen over the presenting part with soft tissue injuries
-nuchal cord: umbilical cord around fetal neck. Will cause variable deceleration of FHR. Intervention: repositi on client from side to
side or into knee chest, discontinue oxytocin if being infused, oxygen
2. A nurse is monitoring a newborn whose mother reports recent opiate use for neonatal abstinence syndrome. Which of the following
findings indicates narcotic withdrawal?
1. Respiratory rate 50/min
2. Unequal pupils
3. Hypotonia
4. Excessive crying
Substance withdrawal in the newborn occurs when the mother uses drugs during pregnancy.
Hitch pitch shrill cries, incessant crying, tremors, increae deep tendon reflexes, disturbed sleep pattern, hypertonicity,
convulsions
Nasal congestion w/ flaring, apnea, tachypnea <60/min
3. A nurse is caring for a client who is in the second stage of labor. The nurse observes the fetal head retract against the clients
perineum immediately following emergence . Which of the following actions should the nurse take?
1. Assess fetal position using Leopold maneuvers
2. Reposition the client in a left lateral position??? Not sure
3. Apply pressure to the clients suprapubic area
4. Empty the client’s bladder using Crede’s maneuver
Pg 189) Prepare to apply suprapubic pressure to aid in the delivery of the anterior shoulder, which is located inferior to
the maternal symphysis pubis.
4. A client and her partner ask the nurse for information about permanent contraception. Which of the following statements should
the nurse include in the counseling?
1. “A man is usually sterile immediately after a vasectomy”- must use birth control after procedure. Is not effective until 20
ejaulations or 1 week to several months to allow all sperm to clear
2. “The menstrual cycle is shorter after a tubal ligation”
3. “Most sterilization procedures are considered irreversible”
4. “A woman should use contraception for 1-2 months after a tubal ligation”
5. A nurse is providing education to a client who is to receive misoprostol for induction of labor. Which of the following instructions
should the nurse include in the teaching?
1. “ I will insert a urinary catheter before I administer the medication” -??
2. “I will begin an oxytocin infusion w/in 2 hrs of your last dose of medication”
3. “You will like on your side for 40 minutes after I administer the medication
4. “You will receive an antacid containing magnesium before the medication”
-uterine stimulant. Controls postpartum hemorrhage. Assess uterine tone and vaginal bleeding
-postpartum hemorrhage nursing care: massage fundas. Insert urinary catheter to assess kidney functions to obtain accurate urinary
output for bladder distention. Elevate legs.
6. A nurse is assessing a client who is in her second trimester for common physiological changes during pregnancy. The nurse notes a
blotchy discoloration on the client’s forehead, nose & cheeks. Which of the following changes should the nurse document p. 17
chapter 3
1. Linea nigra-dark line pigmentation from umbilicus to the pubic area.
2. Epulis- not found on ati book, but it is a tumor on the mouth caused by gingervitis.
3. Striae gravidarum - stretch marks found on abdomen and thigh
4. Chloasma -increase pigmentation on the face
7. A charge nurse is discussing STIs w/ a newly licensed nurse. Which of the following infections should the nurse include in the
teaching as an indication for a cesarean birth p . 50 ch 8
1. Gonorrhea- spread genital to genital
2. Chlamydia
3. HIV
4. Syphilis
- INDICATIONS for C-Section
::::::: Malpresentation, Non-reassuring fetal heart tones
Placental abnormalities, Placenta previa, Abruptio placentae, active genital herpes, DM, eclampsia, previous C-birth,
dystocia, multiple gestations, umbilical cord prolapse
8. A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the
nurse include in the plan of care? Ch 27 p. 318
1. Increase the newborn’s visual stimulation
2. Swaddle the newborn in a flexed position - to reduce self stimulation and protect skin from abrasions.
3. Weigh the newborn every other day
4. Discourage prenatal interaction until after a social service evaluation
Interventions-offer small feedings, swaddle newborn with legs flexed, reduce environmental stimuli,
9. A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should
the nurse include?
1. Offer the newborn 30mL (1 oz) of water between feedings
2. Allow the baby to feed at least every 2 hrs
3. Feed the newborn 5-10 mins per breast - 15-20 minutes per breast
4. Expect 2 -4 wet diapers every 24 hrs -6-8 a day
-should breastfeed every 2-3 hours for the first 6 months. Should occur 8-12 times a day. And feed on demand. Cramps are normal
during breastfeeding. Stimulating the nipple causes let down reflex of milk.
10. A nurse is assessing a client immediately following the placement of an epidural. The nurse obtains a maternal blood pressure of
96/54 mmHg and a fetal heart rate of 102/min. Which of the following actions should the nurse take?
1. Administer naloxone to the client
2. Position the client in a lateral position- is this the same as side lying?
3. Place the client in knee chest position - do this for variable deceleration od FHR
4. Prepare the client for an amnioinfusion
11. A nurse is caring for a client who is in labor and is prescribed an amnioinfusion. Which of the following findings is an indication for
this procedure p . 102 ch 15
1. Fetal macrosomia
2. Variable decelerations -process of instilling normal saline in amniotic cavity into the uterus to supplement the amount of
fluids to reduce variable decelerations causs by cord compression
3. Early decelerations- slowing of the FHR with the start of contraction with return of the FHR to baseline at the end of
contraction
4. Increased uterine tone
12. A nurse is providing discharge instructions to a client who delivered a newborn via cesarean birth 4 days ago. The nurse should
instruct the client to contact the provider for which of the following findings.
1. Newborn has fewer than 4 wet diapers in 24hrs-6-8/day
2. The newborns cord stump will detach after 1 week- falls off around 10-14 days
3. The newborn sleeps 16hrs a day- normal 16-19 hours/day
4. The newborn has loose stools - normal from milk
13. A nurse is caring for a client who has had a pudendal nerve block. The nurse should monitor for which of the following findings as an
adverse effect p. 81 chapter 12
1. Maternal hypertension
2. Decreased ability to bear down
3. Fetal bradycardia
4. Uterine hyperstimulation
Is a local anesthesia to the perine
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