HESI PN MATERNITY-EXAM

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The nurse should identify that ketonuria is an indication of hyperemesis gravidarum. Ketonuria occurs due to the breakdown of fat The nurse should identify that a client who has hyperemesis gravidaru ... m can exhibit tachycardia due to dehydration. The nurse should identify that proteinuria is an indication of preeclampsia, ratherthan hyperemesis gravidarum. The nurse should instruct the client thatshe will better tolerate foods that are served cold or atroom temperature. The nurse should instruct the client to eat five to six small meals throughout the day. The client should avoid an empty stomach, as this The nurse should instruct the client to consume a snack high in carbohydrates, such as crackers, before getting out of bed in the Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternalOnly facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternalOnly facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternalOnly facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternalHESI PN MATERNITY-EXAM 1. A nurse is caring for a client who is at 11 weeks of gestation and reportsfrequent vomiting. Which of the following findingsshould the nurse identify as an indication that the client has hyperemesis gravidarum? Ketonuria Bradycardia Bradypnea Proteinuria 2. A nurse is reinforcing teaching with a client who is at 9 weeks of gestation and reportsfrequent episodes of nausea and vomiting. Which of the following instructions should the nurse include? Eat foods that are served hot. Drink 360 mL (12 oz) of fluids during mealtimes Consume small meals frequently each day. Eat a high-protein snack before getting out of bed. 3. A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The newborn's grandfather asksif he may take the newborn to his daughter's room. Which of the following responses should the nurse make? "I'll first need to see your photo ID before I can release the baby to you." "Let me wash my hands and then I'll take your grandson to his mother." "Please wash your hands first, then I'll allow you to carry the baby to your daughter's room." "Have your daughter call the nursery so that the staff can release the baby to you." newborn unitshould transport newborns newborn unit should transport newborns. In addition, transport of the newborn must be in a designated bassinet. newborn unitshould transport newborns. newborn unitshould transport newborns. morning to decrease nausea. increases nausea. of fluids and foods every 2 to 3 hr throughout the day. The client should avoid drinking liquid with meals because this increases the risk for nausea. The clientshould alternate consumption The nurse should identify that a client who has hyperemesis gravidarum can exhibit tachypnea due to dehydration. secondary to malnutrition orstarvation. The nurse should instruct the client to use a breast pump during engorgement to soften the breasts prior to breastfeeding. The client The nurse should instruct the client to apply cold compresses to the breasts after feedings to decrease discomfort. The client can take a The nurse should instruct the client to drink enough fluids each day to satisfy her thirst. Decreased fluid intake can decrease milk The nurse should instruct the client to breastfeed the newborn every 2 hr during engorgement. Frequent feedingssoften the breasts The nurse should identify that the greatest risk to this client is postpartum hemorrhage. Therefore, the first action the nurse should Inserting an indwelling urinary catheter isimportant to eliminate bladder distention and monitor urinary output. However, this is not Administering methylergonovine to enhance uterine contractions is an action the nurse should take to manage postpartum Administering oxygen via nonrebreather face mask is an action the nurse should take to enhance oxygenation to the cells. However, Butorphanol tartrate is an opioid medication that can cause dizziness, sedation, and hallucinations. Butorphanol tartrate is an opioid medication that has a duration of action of 3 to 4 hr. 4. A nurse isreinforcing teaching about interventionsto treat breast engorgement with a client who is breastfeeding. Which of the following instructions should the nurse include in the teaching? Avoid using a breast pump during times of engorgement. Apply warm compresses to the breasts after feedings. Decrease daily fluid intake. Breastfeed the newborn at least every 2 hr. 5. A nurse on a postpartum unit is assisting with the care of a client who has a hypotonic uterus and excessive vaginal bleeding. Which of the following actions should the nurse take first? Provide fundal massage for the client. Insert an indwelling urinary catheter forthe client. Administer methylergonovine IM to the client. Administer oxygen via nonrebreather face mask to the client. 6. A nurse isreinforcing teaching about butorphanol tartrate with a client who isin labor. Which of the following clientstatements indicates an understanding of the teaching? "This medication might make me dizzy." "This medication might cause me to breathe very fast." "This medication will last for 10 to 12 hours." "This medication will cause my stools to be loose and watery." Butorphanol tartrate is an opioid medication that has adverse effects of constipation, nausea, vomiting, confusion, and sedation. Butorphanol tartrate is an opioid medication that can cause respiratory depression. this is not the first action the nurse should take hemorrhage. However, this is not the first action the nurse should take. the first action the nurse should take. bleeding. take is to provide fundal massage to increase uterine muscle tone and express blood clotsfrom the uterus, which will decrease and decrease pain. production. warm shower immediately before breastfeeding to soften the breasts. can also use a breast pump after feedings to empty the breasts completely. Increased leukorrhea is a whitish discharge which is an expected finding due to the hormonal changes that occur during pregnancy. Varicose veins are an expected finding during pregnancy due to hormonal influence on the smooth muscle walls of veins. The growing The nurse should report frequent uterine contractions during the second trimester to the provider because they can cause the cervix The nurse should not expectsaturation of one perineal pad every 15 min as this indicates postpartum hemorrhage, which could lead to At 32 hr postpartum, the client's fundusshould be 1 to 2 cm below the umbilicus. The fundus should descend 1 cm per day after birth. The nurse should expect postpartum diuresis to begin approximately 12 hr after delivery. Therefore, a urine output of 3,000 mL in 24 The nurse should identify that a calcium level of 9.2 mg/dL is within the expected reference range of 7.6 to 10.4 mg/dL for a newborn. The nurse should identify that a blood glucose of 28 mg/dL is below the expected reference range of 30 to 60 mg/dL for a newborn. The nurse should identify that a temperature for a healthy newborn averages 37 C (98.6 F), with a range of 36.5C to 37.5 C (97.7F to 7. A nurse is collecting data from a client who isin her second trimester of pregnancy. Which of the following findingsshould the nurse report to the provider? Increased leukorrhea Hyperpigmentation of the face Varicose veins Frequent uterine contractions 8. A nurse is collecting data from a client who is 32 hr postpartum. Which of the following findingsshould the nurse expect? Saturation of one perineal pad every 15 min Fundus 2 cm above the umbilicus Temperature of 39° C (102.2° F) Urine output of 3,000 mL in 24 hr 9. A nurse is collecting data from a newborn whose mother had gestational diabetes mellitus. Which of the following findingsshould the nurse report to the provider? Calcium 9.2 mg/dL Heartrate 160/min Blood glucose 28 mg/dL Axillary temperature 36.5 C(97.7 F) 10. A nurse is collecting data from a client who is at 33 weeks of gestation. Which of the following findingsshould the nurse identify as an indication of a potential complication of pregnancy? 99.5 F). Therefore, the nurse should report thisfinding to the provider. rate of 80 to 100/min while asleep and up to 180/min while crying is an expected finding for a newborn. The nurse should identify that a heart rate of 160/min is within the expected reference range of 110 to 160/min for a newborn. A heart hr is an expected finding for this client. hr postpartum. The nurse should identify that a temperature higher than 38° C (100.4° F) after the first 24 hr can indicate infection in a client who is 32 hypovolemic shock. to open early and subject the client to preterm labor. fetus can exacerbate varicose veins in a pregnant woman. stimulate melanocytesthat occur during pregnancy. Hyperpigmentation of the face is also known as the "mask of pregnancy" and is an expected finding due to the hormonal changes that The nurse should identify leg cramps as a common discomfort during pregnancy caused by compression of the nerves by the enlarged The nurse should identify tingling of the fingers as a common discomfort of pregnancy caused by traction on the brachial plexus due to The nurse should identify that varicose veins are a common discomfort of pregnancy caused by increased blood volume and relaxation The nurse should identify epigastric pain as a potential complication of pregnancy. Epigastric pain is a manifestation of preeclampsia. The nurse should identify that labial edema is an expected finding following a vaginal birth. The nurse can apply ice packs to minimize The nurse should identify that a firm fundus at the level of the umbilicus 6 hr following birth is an expected finding. The nurse should identify thatsoaking a perineal pad in 15 min or less is a manifestation of postpartum hemorrhage. Therefore, the The nurse should identify that vernix in the skin folds is an expected finding in a newborn. It is a normal protective substance that is The nurse should identify that a positive Moro reflex is an expected finding in a newborn which is present from birth up to 8 weeks. The nurse should identify that an apical heart rate of 90/min while crying is below the expected reference range of 110 to 160/min for Leg cramps Tingling of fingers Varicose veins Epigastric pain 11. A nurse is caring for a client who delivered vaginally 6 hr ago. Which of the following findings should the nurse report to the provider? Labial edema Fundus firm at the umbilicus WBC count 15,000/mm3 Perineal pad soaked in 15 min 12. A nurse is collecting data from a newborn who is 8 hr old. Which of the following findings should the nurse report to the provider? Vernix in the skin folds Positive Moro reflex Apneic episode of 10 seconds Apical heart rate of 90/min while crying 13. A nurse isreviewing the medication administration record for a client who isreceiving nifedipine for gestational hypertension. The nurse should identify that which of the following medicationsis contraindicated for use with nifedipine? Magnesium sulfate a newborn. A heart rate of 80 to 100/min while asleep and up to 180/min while crying is an expected finding for a newborn normally shallow and irregular. The nurse should identify that an apneic episode of 20 seconds or less is an expected finding in a newborn. Newborns' respirations are present at birth. nurse should report this finding to the provider The nurse should identify that a WBC count of 15,000/mm3 is an expected finding 6 hr following birth. edema and pain. of vascular smooth muscle. slumping of the shoulders. uterus. Acetaminophen is a nonopioid analgesic, which is administered for the treatment of mild pain or fever. This medication issafe to Promethazine is an antiemetic, which is administered for the prevention of nausea and vomiting. This medication is safe to administer Oxytocin is a hormone, which is used to facilitate the induction of labor or to control postpartum bleeding after expulsion of the Terbutaline relaxes the smooth muscles and inhibits uterine activity. Itshould be administered subcutaneously every 4 hr. Terbutaline Terbutaline relaxes the smooth muscles and inhibits uterine activity. Itshould be administered subcutaneously every 4 hr. Terbutaline Terbutaline relaxes the smooth muscles and inhibits uterine activity. This medication should be administered subcutaneously every 4 Terbutaline relaxes the smooth muscles and inhibits uterine activity. Itshould be administered subcutaneously every 4 hr. Terbutaline The nurse should instruct the client to continue breastfeeding from both breasts, because that will assist in emptying the breasts and The nurse should discourage the use of underwire and poorly fitting bras because they can cause plugged milk ducts, increasing the Instruct the client to apply warm compresses to the affected breast. The nurse should instruct the client to apply warm compresses to the breast, which will decrease inflammation and edema. This will The nurse should plan to administer an antibiotic medication to a client who has mastitis. The client should take the antibiotic for 10 to Acetaminophen Promethazine Oxytocin 14. A nurse is planning to administer terbutaline to a client who is experiencing preterm labor. Which of the following routes of administration should the nurse plan to use? Intramuscular Intradermal Subcutaneous Topical 15. A nurse is assisting with planning care for a client who is breastfeeding and has mastitis. Which of the following recommendations should the nurse include? Instruct the client to discontinue feeding from the affected breast. Tell the client to wear an underwire bra. Administer an antiviral medication. 16. A nurse is reviewing the prenatal record of a client who is at 34 weeks of gestation. Which of the following results should the nurse identify as a desirable outcome? 14 days to eradicate the infection enable more effective emptying of the breast to prevent milk stasis, which decreases bacterial growth. risk of mastitis. decreasing pressure on the infected area. Emptying the breasts also prevents milk stasis, which decreases bacterial growth. cannot be administered topically. hr. cannot be administered intradermally. cannot be administered intramuscularly. placenta. This medication issafe to administer with nifedipine with nifedipine. administer with nifedipine. paralysis. medication is contraindicated for use with nifedipine because it can cause skeletal muscle blockade, resulting in muscle weakness or Magnesium sulfate is administered for the treatment of hypertension or to preventseizures in clients who have preeclampsia. This The nurse should identify that a negative rubella titer indicates that the client is not immune to rubella and will require immunization The nurse should identify that a reactive nonstress test indicates fetal well-being and is a desirable outcome. The nurse should identify that a hemoglobin level of 9.5 g/dL indicates anemia, which is an undesirable test result and will require The diaphragm should be left in place for at least 6 hr following intercourse. The sponge should be left in place for at least 6 hr, but less than 24 hr, following intercourse. Leaving the sponge in for 24 hr or longer The patch is changed weekly for 3 weeks, followed by 1 week in which the client does not wear the patch Assistive personnel caring for newborns should always wearidentification. The parent should not allow anyone without proper A newborn should always be wheeled in a bassinet when transported from one location to another to prevent the risk for injury and The nurse should instruct the parent to ask the nurse to care for her baby ifshe needs to take a nap because a newborn should never The parent should always make sure the newborn's security band is in place because the band helps to ensure the safety of the Negative rubella titer Reactive nonstress test 1-hr glucose tolerance screening test result of 150 mg/dL Hemoglobin 9.5 g/dL 17. A nurse is discussing family planning with a client who is requesting information about available contraceptive methods. Which of the following client statements indicates an understanding of the teaching? "When I use the diaphragm, Ishould remove it 2 hours after intercourse." "Ishould use water-soluble lubricant when my partner wears a condom." "Ishould remove the birth controlsponge 24 hours after intercourse." "When I use the birth control patch, it must be changed once a month." 18. A nurse is reinforcing teaching with a new parent about the prevention of newborn abduction. Which of the following statements by the parent indicates an understanding of the teaching? "Some assistive personnel may not have name badges." "A nurse will carry my baby back to the nursery in his arms for routine care when it is needed." "I will ask the nurse to take care of my baby in the nursery if I need to take a nap." "I can remove my baby's security band ifshe is in my room." 19. A nurse is caring for a client who is at 20 weeks of gestation and is in the clinic for a routine prenatal visit. Which of the following findingsin the data from the client's medical record should the nurse report to the provider? (Click on the "Exhibit" button below for additional information about the client. There are three tabs that contain separate categories of data.) newborn. If the security band is removed, the alarm willsound immediately be left unattended. abduction. identification to care for or remove the newborn from the room. increases the risk of toxic shock syndrome. integrity of the condom. Only water-soluble lubricants should be used with male condoms, because the use of any other lubricant may compromise the treatment testing to determine if the client has gestational diabetes mellitus. The nurse should identify that a glucose value of 140 mg/dL or higher 1 hr after ingesting 50 g of glucose indicates the need for further in the postpartum period. The height of the fundus in centimeters at 20 weeks of gestation is approximately the same asthe number of weeks of gestation plus A fetal heart rate of 160/min at 20 weeks of gestation is within the expected reference range of 110 to 160/min. The nurse should inform the client that adequate folic acid intake prior to and early during pregnancy is necessary to help prevent Folic acid will not inhibit preterm labor; rather, it prevents the development of neural tube defectsin the newborn. One cup of dried prunes contains 3 mcg of folate. Therefore, there is another food the nurse should recommend. Graphic Record BP Week 16: 120/70 mm Hg Week 20: 130/80 mm Hg Weight Week 16: 61.7 kg (136 lb) Week 20: 63 kg (138.9 lb) Nurses' Notes Fundal Height Week 16: 16 cm Week 20: 25 cm Fetal Heart Rate Week 16: 156/min Week 20: 160/min Diagnostic Results Week 16: Urine negative for albumin and glucose Week 20: Urine negative for albumin and glucose Weight Fundal height Fetal heartrate Blood pressure 20. A nurse is caring for a client who is planning to become pregnant. The client asks the nurse why folic acid supplements are necessary. The nurse should inform the client that the purpose of the folic acid supplement is to do which of the following? Facilitate the storage of iron in the fetus' liver Prevent certain kinds of birth defects Inhibit premature labor Aid in the absorption of other important nutrients 21. A nurse is reinforcing teaching about food sources that are high in folate with a group of women who are pregnant. Which of the following foods should the nurse recommend to this group as the bestsource of folate? 1 cup dried prunes Folic acid will not aid in the absorption of other important nutrients, but it is used to prevent neural tube defects in the newborn neural tube defects. iron in the fetus' liver. Folic acid supplements are used to prevent neural tube defects in the newborn. Maternalsupplemental iron facilitates the storage of A maternal blood pressure of 130/80 mm Hg is below the reportable value of 140/90 mm Hg or minus 2 cm. Therefore, a fundal height of 25 cm is greater than the expected finding for 20 weeks of gestation. lb) in 4 weeks is an expected finding. A client in the second trimester of pregnancy should gain approximately 0.4 kg (0.9 lb) per week. Therefore, a weight gain of 1.3 kg (2.9 A half cup of boiled potatoes contains 4 mcg of folate. Therefore, there is another food the nurse should recommend. One cup of grapes contains 3 mcg of folate. Therefore, there is another food the nurse should recommend 1/2 cup boiled potatoes 1/2 cup dried peas 1 cup grapes 22. A nurse is assisting with the neuromuscular assessment of a newborn by eliciting primitive reflexes. Which of the following images indicates a characteristic response of the tonic neck reflex? movements with the arms and legs. The nurse should identify this as the crawling reflex. When the newborn is placed on the abdomen, he will appear to make crawling same side extend, while the arm and leg on the opposite side flex. The nurse should identify this as the tonic neck reflex. When the newborn's head is quickly turned to one side, the arm and leg on the and is the best of these sources of folate for the nurse to recommend. Women who are pregnant should consume 600 mcg of folate per day. A half cup of dried green split peas provides 270 mcg of folate The clientshould not massage her breasts to treat engorgement during lactation suppression. Breaststimulation through massage can The client should not wear an underwire bra to treat engorgement during lactation suppression because it can cause plugged milk The client should not pump her breasts to treat engorgement during lactation suppression because it can cause an increase in milk Frequent application of cold cabbage leaves to the breasts can prevent engorgement during lactation suppression for a client who is When using the urgent vs. nonurgent approach to care, the nurse should determine that the priority finding is a client who is at 37 The nurse should identify that a client who is at 38 weeks of gestation and is having irregular uterine contractions might be in the 23. A nurse is reinforcing discharge teaching about methodsto prevent engorgement during lactation suppression with a client who is bottle-feeding her newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "I will massage my breasts while I take a shower." "Ishould wear an underwire bra during the day." "Ishould use a breast pump several times a day to relieve discomfort." "I will apply cold cabbage leaves to my breasts throughout the day." 24. A nurse in a prenatal clinic is caring for a group of clients. Which of the following clientsshould the nurse recommend the provider see first? A client who is at 37 weeks of gestation and reports a persistent headache A client who is at 38 weeks of gestation and reportsirregular uterine contractions A client who is at 12 weeks of gestation and reports abdominal cramping latent phase of labor. However, the nurse should recommend that the providersee another client first. preeclampsia and recommend that the provider see this client first. weeks gestation and reports a persistent headache. The nurse should identify that a persistent headache is a manifestation of well-fitting and supportive bra bottle-feeding her newborn. The clientshould also apply ice packs or cold compresses to her breasts, take mild analgesics, and wear a production. ducts, which can result in a breast infection. promote milk production. abdomen fingers widely open and the thumb and index finger form a "C" shape. The lower extremities may also extend then abduct toward the The nurse should identify this as the Moro reflex. When the newborn hears a loud noise, he will abduct then extend the arms with the the soles of the newborn's feet. The nurse should identify this as the magnet reflex. The newborn will push against the examiner's hands when pressure is applied to The nurse should identify that a client who is at 26 weeks of gestation and reports periodic numbness in the fingers might be The nurse should position the client on her side, or elevate her right hip. The client's legs should be elevated to at least a 30 angle to The nurse should administer an oxytocic medication,such as oxytocin or methylergonovine, to increase uterine contraction. The nurse should apply oxygen at 10 L/min via a nonrebreather face mask to improve the client's oxygenation. The nurse should instruct the parent that newborns will drink 15 to 30 mL (0.5 to 1 oz) of formula per feeding during the first 24 hr The nurse should instruct the parent to allow the newborn to feed for 20 to 30 min. This prevents the newborn from eating quickly and The nurse should instruct the parent to allow the newborn to self-regulate formula intake. Forcing intake can cause vomiting due to The nurse should instruct the parent to burp the newborn periodically throughout feedings to relieve gas and decrease the risk for The nurse should administer analgesics to relieve the client's pain; however, another action is the nurse's priority. A client who is at 26 weeks of gestation and reports periodic numbness in the fingers 25. A nurse on a postpartum unit is assisting in the care of a client who is experiencing hypovolemic shock. Which of the following actions should the nurse take? Place the client in high-Fowler's position. Administerterbutaline subcutaneously. Apply oxygen at 2 L/min via nasal cannula. . 26. A nurse is reinforcing teaching about formula feeding a newborn with a group of new parents. Which of the following instructions should the nurse include? Give approximately 240 mL (8 oz) per feeding. Allow 20 to 30 min for feedings. Ensure that the newborn empties the bottle. Wait to burp the newborn until the end of the feeding. 27. A nurse is caring for a client 6 hr after a vaginal birth who is going to breastfeed her newborn. The client reports perineal pain of 6 on a scale from 0 to 10. The nurse also notes mild perineal edema and ecchymosis, with a fundus that is 2 cm above the umbilicus with deviation to the right. Which of the following actions is the nurse's priority? Administer analgesics. Apply an ice pack to the perineum. vomiting. overeating. swallowing too much air. of formula at each feeding. while gradually increasing intake as they grow. By the end of the second week of life, most newborns consume 90 to 150 mL (3 to 5 oz) to oliguria The nurse should insert an indwelling urinary catheter to monitor output closely. Decreased kidney perfusion caused by shock can lead Terbutaline is a tocolytic that causes uterine relaxation, which will increase bleeding. increase venousreturn. provider see another client first experiencing brachial plexustraction syndrome from drooping of the shoulders. However, the nurse should recommend that the miscarriage. However, the nurse should recommend that the providersee another client first. The nurse should identify that a client who is at 12 weeks of gestation and reports abdominal cramping might be experiencing a Insert an indwelling urinary catheter The nurse should assist the client with breastfeeding to promote uterine involution; however, another action isthe nurse's priority. The nurse should reinforce to the parent that the current recommendations include keeping infants in a rear-facing carseat until they The nurse should reinforce to the parent that in the event that a newborn cannot ride in the rearseat, the parent must disable the The nurse should reinforce to the parent to use the vehicle's seat belts to secure the newborn's seat and provide adequate protection The nurse should reinforce to the parent to avoid placing the carseat at a 90 angle because it can compromise the newborn's airway. Diuresis is correct. This is an expected finding that results from the loss of excess fluid that is retained during pregnancy. The nurse will perform intermittent monitoring of the FHR with a Dopplerstethoscope while the client is in the shower or bathtub. Assist the client with breastfeeding. Help the client ambulate to the toilet. 28. A nurse isreinforcing teaching about carseatsafety with a parent of a newborn. Which of the following statementsshould the nurse identify as an indication that the client understands the instructions? "My baby should be in a rear-facing carseat until he is 6 months old and 15 pounds." "If my baby rides in a car with no back seat, the passenger air bag must be turned off." "It is dangerous to secure the carseat using the vehicle's seat belts." "I will place my baby's car seat at a 90 degree angle in the back seat." 29. A nurse is caring for a client during the postpartum period. Which of the following findingsshould the nurse expect during the first 24 hr following delivery? (Select all that apply.) Diuresis Soft, boggy uterus upon palpation Discharge of clear, yellow fluid from the breasts Lochia serosa Lower abdominal cramping 30. A nurse isreinforcing teaching with a client who requests hydrotherapy for pain management during labor. Which of the following statements should the nurse include? "You will have an internal fetal monitor applied prior to hydrotherapy." Placement of an internal fetal monitoris contraindicated for hydrotherapy due to the risk of electric shock. Lower abdominal cramping is correct. This is an expected finding and results from the contraction of the uterus as it decreases in size Lochia serosa is incorrect. Lochia serosa is vaginal discharge that is pink or brown, which occurs 3 to 4 days after delivery. pregnancy. Colostrum is present for 3 to 5 days until the mother's milk appears and can leak from the breasts beginning in the third trimester of Discharge of clear, yellow fluid from the breasts is correct. This fluid, called colostrum, is an expected finding in the postpartum period. bleeding. Soft, boggy uterus upon palpation is incorrect. This is not an expected finding in the postpartum period and can cause excessive The parent should position the seat so that the newborn is at a 45 angle in a motor-vehicle crash. front passenger air bag to prevent potential injuries caused by air bag deployment. are at the maximum height and weight for the car seat or at a minimum of 2 years of age. assist the client to empty her bladder, which will allow the uterus to contract The greatest risk for this client is postpartum hemorrhage from uterine atony. Therefore, the priority intervention by the nurse is to the nurse's priority. The nurse should apply an ice pack to the client's perineum to reduce swelling and relieve the client's pain; however, another action is The client may remain in the tub for as long as she desires and as long as the FHR remains within the expected reference range. Using The nurse should instruct the client that hydrotherapy is initiated once active labor begins. The use of hydrotherapy during the latent The water temperature should be between 36° to 37° C (96.8° to 98.6° F) during hydrotherapy to prevent the client from overheating. The nurse should inform the client that her blood pressure will be taken every 15 to 30 min while receiving magnesium sulfate. The nurse should restrict the client's fluid intake to no more than 125 mL per hr to prevent fluid overload. The nurse should inform the client that the fetal heart rate will be continually monitored while she isreceiving magnesium sulfate to The nurse should identify that a Hgb level of 20 g/dL is within the expected reference range of 14 to 24 g/dL for a newborn. The nurse should identify that a glucose level of 50 mg/dL is within the expected reference range of 30 to 60 mg/dL for a newborn. The nurse should expect a glucocorticoid,such as dexamethasone, to promote the acceleration of fetal lung maturity. "You will need to limit your time in the tub to no more than 20 minutes." "You will need to be in active labor before using hydrotherapy." "You will need to keep the water temperature above 98.6 degrees Fahrenheit during hydrotherapy." 31. A nurse isreinforcing teaching with a client who has preeclampsia and isreceiving magnesium sulfate via continuousIV infusion. Which of the following statements should the nurse include in the teaching? "We will monitor your blood pressure every 2 hours." "Yourfluid intake will be limited to no more than 125 milliliters per hour." "You might notice that you will begin breathing faster than normal." "We will monitor your baby's heart rate once per hour." 32. A nurse is reviewing the laboratory results of a 4-hr-old newborn. Which of the following findingsshould the nurse report to the provider? Hemoglobin 20 g/dL Platelet count 120,000/mm3 Glucose 50 mg/dL WBC count 20,000/mm3 33. A nurse is caring for a client who is pregnant and has a prescription for nifedipine. Which of the following outcomesshould the nurse expect from this medication? Fetal lung maturity Maternal blood glucose control The nurse should expect an oral hypoglycemic agent,such as glyburide, to help control blood glucose. newborn The nurse should identify that a WBC count of 20,000/mm3 is within the expected reference range of 9,000 to 30,000/mm3 for a for a newborn. Therefore, the nurse should report this finding to the provider. The nurse should identify that a platelet count of 120,000/mm3 is below the expected reference range of 150,000 to 300,000/mm 3 assess for changes that might indicate fetal distress every 15 min. The nurse should identify that magnesium sulfate causes respiratory depression. The nurse should monitor the client'srespiratory rate Hypotension is an adverse effect of this medication. The client's shoulders should remain out of the water during hydrotherapy to allow dissipation of heat. phase of labor can decrease the strength and frequency of contractions and slow the progression of labor. periods of time. hydrotherapy for 30 to 60 min, followed by a break, can alleviate pain more effectively than remaining in the water for extended Nifedipine is a calcium channel blocker used to decrease uterine contractions by relaxing the smooth muscle of the uterus. Acrocyanosis is incorrect. Acrocyanosis is a bluish discoloration of the hands and feet of the newborn and is an expected finding during The nurse should administer phytonadione using a 5/8-inch needle. A needle that is too long can cause injury to the nerves. The nurse should administer a single dose of phytonadione to the newborn and instruct the guardian that the injection does not need The nurse should identify that 2+ proteinuria is a manifestation of preeclampsia. Therefore, the nurse should report thisfinding to the The nurse should identify that leukorrhea is a greyish, mucus-like discharge and is an expected finding throughout pregnancy due to The nurse should identify thatspider nevi, or vascularspiders, are an expected finding during pregnancy due to an increase in estrogen Cessation of uterine contractions Resolution of maternal nausea 34. A nurse is assisting with collecting data from a newborn who was born 2 hr ago and has respiratory distress. Which of the following findings should the nurse report to the provider? (Select all that apply.) Acrocyanosis Tachypnea Nasal flaring Retractions Expiratory grunting the first 24 hr after birth. newborn. Nasal flaring is correct. Nasal flaring is a finding associated with respiratory distress in the newborn. Retractionsis correct. Retractions are a finding associated with respiratory distress in the newborn. 35. A nurse is planning to administer phytonadione to a newborn. Which of the following actionsshould the nurse take? Administer phytonadione 24 hr after birth. Use a 1-inch needle for administration. Use the vastus lateralis asthe injection site. Reinforce to the guardian that the injection should be repeated in 2 weeks. 36. A nurse is caring for a client who is at 30 weeks of gestation. Which of the following findings should the nurse report to the provider? 2+ urinary protein Leukorrhea Spider nevi 30 cm fundal height production. hormonal changes that cause the cervix to produce this mucoid fluid. provider. to be repeated The nurse should inject phytonadione into the vastuslateralis because this is the most developed muscle in the newborn. The nurse should administer phytonadione immediately after birth or after initial breastfeeding to prevent hemorrhagic disease. Expiratory grunting is correct. Expiratory grunting is a finding associated with respiratory distress in the newborn Tachypnea is correct. Tachypnea is a respiratory rate greater than 60/min and is a finding associated with respiratory distressin the The nurse should expect an antiemetic,such as metoclopramide, to decrease maternal nausea The nurse should identify that a maternal temperature greater than 38 C (100.4 F) is elevated and indicative of complications such as The nurse should identify that contractions occurring every 3 to 5 min is an expected finding for a client who is in active labor. The nurse should report a prolonged deceleration of the FHR to the charge nurse because it can be a manifestation of an emergent The nurse should not prepare the client for a pudendal nerve block during the active phase of labor. A pudendal nerve block should be The nurse should not administer a sedative to the client during the active phase of labor, as it can cause respiratory depression in the The nurse should encourage the client to push during the second stage of labor, when the cervix is dilated to 10 cm. The first action the nurse should take using the nursing process is to collect data from the client; therefore, the first action the nurse The nurse might need to place the newborn under a radiant warmer to prevent cold stress. However, there is another action the nurse The nurse might need to provide nonnutritive sucking to help the newborn conserve energy. However, there is another action the The nurse might need to swaddle the newborn to minimize energy expenditure. However, there is another action the nurse should 37. A nurse is assisting with the care of a client who is at 40 weeks of gestation and is in active labor. Which of the following findings should the nurse report to the charge nurse? Maternal temperature of 37.5 C (99.5 F) Contractions every 3 min Presence of bloody show Prolonged deceleration of FHR 38. A nurse is assisting in the care of a client during the active phase of labor. Which of the following actions should the nurse take to promote the client's comfort? Prepare the client for a pudendal nerve block. Administer a sedative to the client. Encourage the client to push. Have the client perform relaxing breathing techniques. 39. A nurse is caring for a newborn who islarge for gestational age and isjittery. Which of the following actions should the nurse take first? Check the newborn's blood glucose level. Place the newborn under a radiant warmer. Provide nonnutritive sucking. Swaddle the newborn. take first nurse should take first. should take first. should take isto check the newborn's blood glucose level. The nurse should encourage the client to perform relaxation techniques to promote comfort during the active phase of labor newborn. Sedatives should be administered no less than 12 hr prior to birth of the newborn. administered during the second stage of labor, 10 to 20 min before the birth of the newborn. pattern condition,such as uterine rupture or umbilical cord prolapse. The charge nurse should notify the provider about this change in FHR progresses. The nurse should identify that bloody show is an expected finding for a client who is in active labor. Bloody show can increase as labor infection. The nurse should identify that a fundal height of 30 cm is an expected finding for a client who is at 30 weeks of gestation The nurse should expect the charge nurse to administer calcium gluconate, which is an antidote for magnesium sulfate toxicity. The The nurse should identify that naloxone isthe antidote for opioid toxicity, which reversesthe effects of opioids. The nurse should identify that diphenhydramine is an antihistamine used for the treatment of allergies and decreases the symptoms The nurse should instruct a client who has varicose veins to apply supportstockings before getting out of bed. The nurse should instruct the client to avoid crossing her legs while sitting to prevent varicose veins. Hepatitis B is notspread through casual contact; therefore, the nurse should not instruct the client to avoid crowds. The nurse should The nurse should instruct the client she will need to begin receiving the hepatitis B vaccine series within 14 days of the last known The nurse should explain to the client thatshe will need to receive the hepatitis immune globulin to decrease the risk of transmission 40. A nurse is assisting with the care of a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. The client has a respiratory rate of 10/min. Which of the following medications should the nurse expect a charge nurse to administer to the client? Calcium gluconate Naloxone Protamine sulfate Diphenhydramine 41. A nurse in an antepartum clinic isreinforcing teaching about how to preventsupine hypotension with a client who is at 16 weeks of gestation. Which of the following responses by the client indicates an understanding of the teaching? "I will apply support stockings 30 minutes after getting out of bed." "I will lie on my lef t side with my head elevated on a pillow." "I will cross my legs when sitting." "I will limit my salt intake." 42. A nurse in a prenatal clinic is caring for a client who is at 16 weeks of gestation and has a positive hepatitis B test result. Which of the following actions should the nurse take? Instruct the client to avoid crowds until a repeat hepatitis B test is negative. Tell the client thatshe will need to start the hepatitis B vaccine series after delivery. Explain to the client that she will receive the hepatitis B immune globulin immediately. Inform the client that hepatitis B cannot be transmitted to the fetus. providersto begin prophylactic treatment. to the fetus. The nurse should also instruct the client that all sexual partners and members of the client's household should see their exposure to the virus, or following a positive test result. Immunization is safe during pregnancy. and toothbrushes, using a condom for intercourse, and notsharing drinking glasses and silverware. instruct the client to decrease the risk of transmission of the virus by practicing thorough hand washing techniques, notsharing razors g of salt per day The nurse should instruct the client to maintain an adequate intake ofsodium during pregnancy. The clientshould consume 1.5 to 2.3 prevents compression of the vena cava and subsequent hypotension. inferior vena cava in the supine position, which decreases blood pressure and causes dizziness and fainting. Lying on the left side The nurse should instruct the client to avoid lying supine during pregnancy to prevent supine hypotension. The uterus compresses the associated with an excess of histamines The nurse should identify that protamine sulfate is the antidote for heparin toxicity. charge nurse will administer this medication as an IV bolus. The nurse should identify that a BUN of 14 mg/dL is within the expected reference range of 10 to 20 mg/dL. The nurse should identify that a hematocrit of 30% is below the expected reference range of greater than 33% for a client who is The nurse should identify that a creatinine of 1.0 mg/dL is within the expected reference range of 0.5 to 1.0 mg/dL for a female client The nurse should identify that hyperglycemia is not an adverse effect of methylergonovine. The nurse should identify that urinary retention is not an adverse effect of methylergonovine. The nurse should report blurred vision to the provider as it is an indication that the client might have preeclampsia. The nurse should identify that 10 fetal movements in a 2-hr period is an expected finding at 36 weeks of gestation. 43. A nurse isreviewing the laboratory results of a client who is at 32 weeks of gestation. Which of the following laboratory findings should the nurse report to the provider? BUN 14 mg/dL Platelet count 200,000/mm3 Hematocrit 30% Creatinine 1.0 mg/dL 44. A nurse is caring for a client who hasreceived methylergonovine. Which of the following should the nurse identify and document as an adverse effect of the medication? Hyperglycemia Hypertension Urinary retention Hyporeflexia 45. A nurse is collecting data from a client who is at 36 weeks of gestation during a prenatal examination. Which of the following findingsshould the nurse report to the provider? Blurred vision Nonpitting ankle edema 10 fetal movements in 2 hr Leg cramps 46. A nurse is caring for a newborn who isreceiving phototherapy. Which of the following actionsshould the nurse take? Reposition the newborn every 4 hr. Feed the newborn 30 mL (1 oz) of glucose water four times per day. The nurse should reposition the newborn every 2 to 3 hr during phototherapy to expose all body surfaces to the light. The nurse should identify that leg cramps are an expected finding at 36 weeks of gestation due to compression of nerves The nurse should identify that nonpitting ankle edema is an expected finding at 36 weeks of gestation. The nurse should identify that hyporeflexia is not an adverse effect of methylergonovine. methylergonovine can cause both hypertension and hypotension. nausea, vomiting, cramping, headache, and dizziness. The nurse should report changes in blood pressure to the provider because Methylergonovine is an oxytocic agent thatstimulates uterine contractions and is used for postpartum hemorrhage. It can cause aged 18 to 40 years pregnant. A low Hct is an indication of anemia. Therefore, the nurse should report this finding to the provider. The nurse should identify that a platelet count of 200,000/mm3 is within the expected reference range of 150,000 to 400,000/mm3. the infection occurs before the end of the third trimester The nurse should instruct the client that hepatitis B can cross the placenta and cause an infection in the fetus. This risk is reduced when The nurse should not apply lotion to the newborn's skin as it can absorb heat and cause burns. The nurse should plan to apply petrolatum gauze to the penis for the first 24 hr after circumcision if a Gomco or Mogen clamp was The nurse should wash the penis gently with plain warm water with each diaper change. Soap should be avoided until the site is The nurse should apply the diaper loosely over the penis to avoid pressure on the circumcision site. The clientshould avoid shaking powder onto the newborn's skin due to the possible risk of inhalation, resulting in respiratory distress. Keeping the newborn wrapped while washing her hair helps prevent heat loss. The nurse should instruct the client to take ferroussulfate on an empty stomach. Taking the medication with milk can inhibit Apply a thin layer of lotion to the newborn's skin. 24Place an opaque mask over the newborn's eyes. 47. A nurse is contributing to the plan of care for a newborn who was circumcised with a plastic bell device. Which of the following actions should the nurse include in the plan? Apply petrolatum gauze to the site with each diaper change. Use a mild soap and warm water to wash the site twice each day after the procedure. Apply the diaper snugly over the site. Apply pressure with sterile gauze if bleeding occurs at the site. 48. A nurse is observing a client bathe her 1-day-old newborn. Which of the following actions should the nurse identify as an indication that the client understands how to bathe her newborn? The clientshakes powder from the container onto the newborn's skin. The client uses a cotton-tipped swab to clean the newborn's ears. The client washes the newborn's hair before unwrapping her. The client rinses the newborn under warm, running water. 49. A nurse isreinforcing teaching with a client who has a new prescription for ferroussulfate. Which of the following instructions should the nurse include? "Take the medication with an 8-ounce glass of milk." "Increase your fluid intake with this medication." absorption. The nurse should recommend taking this medication with water or juice. temperature could change Rinsing the newborn under running water can result in a scalding injury or hypothermia in the newborn because the water the newborn's ears. Cotton-tipped swabs can cause injury to the newborn's ears. Instead, the parentshould use moistened cotton or a washcloth to wipe square if bleeding occurs. If this does notstop the bleeding, the nurse should notify the provider The nurse should frequently monitor the site for bleeding following the procedure and apply gentle pressure using a sterile gauze healed, usually 5 to 6 days after the procedure. used. should remove the mask for feedings The nurse should place an opaque mask over the newborn's eyes during phototherapy to prevent damage to the retinas. The nurse or glucose water can delay excretion of bilirubin. The nurse should ensure the newborn is adequately hydrated through frequent breast or formula feeding. Supplementation with plain The nurse should instruct the client to consume citrus fruits because vitamin C increases the absorption of ferroussulfate. "Avoid eating citrusfruits while taking this medication." "Take a double dose of the medication if you miss a dose." 50. A nurse is preparing to administer clindamycin 450 mg PO to a client who has endometritis. The amount available is clindamycin 150 mg/capsule. How many capsules should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 3 Capsules 1 Cap/150mg x 450mg the client to take two doses at once The nurse should instruct the client to take a missed dose within 13 hr of its scheduled time. However, the nurse should not instruct likelihood of constipation. The nurse should instruct the client to drink at least 2 L of fluid per day while taking ferrous sulfate because this will decrease the [Show More]

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