NURSING 2262 ATI RN Maternal Newborn Online Practice 2019 A( Complete Solution)

1. A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? a. Reports increased urinary output i. MY ANSWER: Incr ...

1. A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? a. Reports increased urinary output i. MY ANSWER: Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain, constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations include weak rapid pulse, fruity breath odor, urine positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL. b. Diaphoresis. Diaphoresis or clammy skin is a finding of hypoglycemia. Flushed, dry skin is a manifestation of hyperglycemia. c. Reports blurred vision. Blurred or double vision is a finding of hypoglycemia. A report of dim vision is a manifestation of hyperglycemia. d. Shallow respirations. Shallow respirations are a finding of hypoglycemia. Rapid breathing is a manifestation of hyperglycemia. 2. A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take? a. Administer penicillin G 2.4 million units IM to the client. The nurse should  administer penicillin G 2.4 million units IM to a client who has syphilis. b. Instruct the client to schedule an annual pelvic examination. The nurse should instruct the client to schedule a pelvic examination every 6 months. c. Tell the client she will start medication for HIV immediately after delivery.  The nurse should tell the client that treatment for HIV will be during the prenatal and perinatal periods. Treatment with antiretroviral prophylaxis such as zidovudine, triple-drug antiretroviral therapy (ART), or highly active antiretroviral therapy (HAART) during pregnancy have been reported to decrease the transmission of the virus to the newborn. d. Report the client's condition to the local health department. i. MY ANSWER. The nurse should report the condition to the local health department. HIV is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is required to be reported. 3. A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of the medication? a. Depression. i. MY ANSWER. The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness. b. Polyuria. Fluid retention can occur due to an excess of estrogen. Polyuria is not a common adverse effect of the medication. c. Hypotension. Hypertension, rather than hypotension, is a common adverse effect of combined oral contraceptives. d. Urticaria. Urticaria is not a common adverse effect of combined oral contraceptives. 4. A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instruction should the nurse include in the teaching? a. "I can administer oxytocin 4 hours after the insertion of the medication." i. MY ANSWER. The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor. b. "You will need a full bladder prior to the insertion of the medication." The nurse should instruct the client to void prior to the administration of the medication. c. "Remain in a side-lying position for 15 minutes after the medication is inserted." The nurse should instruct the client to remain in a side-lying position for 30 to 40 min after the insertion. d. "An antacid will be given 20 minutes prior to the insertion of the medication." The nurse should avoid administering aluminum hydroxide and magnesium-containing antacids with misoprostol. 5. A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? a. Administer antiviral medication. Currently, there are no antiviral medications available to treat fifth disease. b. Schedule an ultrasound examination. i. MY ANSWER: The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth. c. Administer Haemophilus influenzae type b vaccine. The Haemophilus influenzae type b vaccine is given during infancy and childhood to protect against multiple infections caused by Haemophilus influenzae type b, not fifth disease. Currently, there are no vaccines to protect against fifth disease. d. Schedule an indirect Coombs' test. An indirect Coombs' test determines whether the client has antibodies to the Rh antigen. The titer determines the prenatal client's sensitization and if there is Rh incompatibility. 6. A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? a. Apply a cool pack for 10 min to the heel prior to the puncture. A cool pack will constrict the blood vessels, making it more difficult to obtain an adequate specimen. The nurse should apply a warm pack prior to the puncture. b. Request a prescription for IM analgesic. The pain experienced from a heel stick is too brief to warrant risking the adverse effects of parenteral analgesia. c. Use a manual lance blade to pierce the skin. A spring-loaded, automatic puncture device is recommended to minimize pain by ensuring that the depth of the puncture is not too deep, avoiding injury to the newborn. d. Place the newborn skin to skin on the mother's chest. i. MY ANSWER: Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure. 7. A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take? a. Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. i. MY ANSWER: The nurse should quickly apply gloves and insert two fingers into the vagina toward the cervix, exerting upward pressure onto the presenting part to relieve umbilical cord compression and increase oxygenation to the fetus. b. Wrap the visible cord tightly with sterile, dry gauze. The nurse should wrap the visible cord with a loose sterile towel saturated with warm 0.9% sodium chloride solution, rather than with sterile, dry gauze. c. Apply oxygen to the client at 2 L/min via nasal cannula. The nurse should apply oxygen to the client at 8 to 10 L/min via nonbreather mask. d. Place the client in the lithotomy position and apply fundal pressure. The nurse should place the client into a modified Sims position, knee-chest position, or extreme Trendelenburg to attempt to relieve the compression of the umbilical cord. 8. A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe? a. Kleihauer-Betke test i. MY ANSWER: The nurse should expect the provider to prescribe a Kleihauer-Betke test for a client who has suspected placental abruption to determine if fetal blood is in maternal circulation. This test is useful to determine if Rho-(D) immune globulin therapy should be administered to a client who is Rh-negative. b. Progesterone serum level. A progesterone serum level helps to determine if a client is pregnant and if the pregnancy is ectopic. c. Lecithin/sphingomyelin (L/S) ratio. Lecithin/sphingomyelin (L/S) ratio is done as a part of an amniocentesis to evaluate fetal lung maturity. d. Maternal Alpha-fetoprotein (AFP). Maternal Alpha-fetoprotein (AFP) is a laboratory test used to assess for neural tube defects or chromosome disorders. 9. A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? a. Abruptio placenta i. MY ANSWER: Cocaine use increases the risk for vasoconstriction and possible abruptio placenta. b. Placenta previa. This is not a common complication associated with cocaine use. c. Preeclampsia. This is not a common complication associated with cocaine use. d. Maternal bradycardia. This is not a common complication associated with cocaine use. 10. A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect? a. 2+ deep tendon reflexes. The nurse should identify that a client who has severe preeclampsia can have hyperactive reflexes of 3+ or 4+. Deep tendon reflexes of 2+ is indicative of an active or expected response. b. Proteinuria of 200 mg in a 24-hr specimen. The nurse should identify that a client who has severe preeclampsia can have increased amount of urinary protein that is greater than 500 mg in a 24-hr specimen. c. Polyuria. The nurse should identify that a client who has severe preeclampsia can have decreased urine output or oliguria of 20 mL/hr or less than 400 to 500 mL in 24 hr. This is related to decreased perfusion of the kidneys and possible glomerular damage. d. Blurred vision i. MY ANSWER: The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field. 11. A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family’s 7-year-old child in accepting the new family member? a. Allow the sibling to hold the newborn during a bath. Allowing the sibling to hold the newborn during a bath is not an appropriate activity for a school-age child because of the safety risk. However, the parents could let the sibling assist with other things in regard to caring for the newborn. b. Make sure the sibling kisses the newborn each night. Forcing interactions between the sibling and the adoptive newborn can cause anger on the part of the sibling. It is more important to allow feelings to evolve naturally as the family unit bonds. c. Obtain a gift from the newborn to present to the sibling. i. MY ANSWER: Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that they understand their role in the family. d. Switch the sibling's room with the nursery. Switching the sibling's room with the newborn's room might cause jealousy of the newborn or cause the sibling to feel that the newborn is taking their belongings. 12. A nurse is assessing a client who is receiving morphine via IV bolus for pain following a cesarean birth. The nurse notes a respiratory rate of 8/min. which of the following medication should the nurse administer? a. Fentanyl. The nurse should administer fentanyl to the client for the relief of severe, recurrent, or persistent pain during labor. Fentanyl is most commonly administered via PCA pump or epidural, alone or with a local anesthetic agent. An adverse effect of this medication is respiratory depression. b. Butorphanol. The nurse should administer butorphanol to the client for the relief of labor pain and severe postoperative pain after cesarean birth. An adverse effect of this medication is respiratory depression. c. Naloxone i. MY ANSWER: Morphine is a common opioid analgesic used for postoperative pain management that can cause central nervous system depression and can cause respiratory depression. The nurse should administer naloxone, an opioid antagonist, to reverse the opioid-induced respiratory depression in the client. d. Meperidine. The nurse should administer meperidine to the client for the relief of severe, persistent pain. An adverse effect of this medication is respiratory depression. 13. A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. "I should increase my protein intake to 60 grams each day." A client who is pregnant should increase protein intake to 71 g each day during the second and third trimesters. b. "I should drink 2 liters of water each day." A client who is pregnant should consume 3 L of water each day. c. "I should increase my overall daily caloric intake by 300 calories." A client who is pregnant should increase caloric intake by 340 cal during the second trimester and by 452 cal during the third trimester. d. "I should take 600 micrograms of folic acid each day." A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects. 14. A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? a. Acrocyanosis. Acrocyanosis is a bluish discoloration of the hands and feet and is an expected finding in a newborn 24 to 48 hr after birth. b. Transient strabismus. Transient strabismus is a normal variation in the newborn's eyes that can persist until the third or fourth month of age. c. Jaundice. i. MY ANSWER: Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider. d. Caput succedaneum. Caput succedaneum is a benign, edematous area of the scalp and is commonly found on the occiput. 15. A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as positive parenting behavior? a. Lays the newborn across her lap and gently sways i. MY ANSWER: This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn. b. Places the newborn in the crib in a prone position. The parent should place the infant in the supine position, not a prone position, in the bassinet or crib because of the risk of sudden infant death syndrome. c. Offers the newborn a pacifier dipped in formula. Pacifiers may be used for a newborn who needs extra sucking for self-soothing. However, formula should not be placed on the tip of the pacifier because the newborn might become accustomed to it and refuse to take the pacifier in the future without added supplement. d. Prepares a bottle of formula mixed with rice cereal. Rice cereal should not be added to the bottle of a newborn because solids should not be introduced until 4 to 6 months of age. 16. A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statement should the nurse include in the teaching? a. "Obtain an informed consent prior to obtaining the specimen." The universal newborn screening is mandated by law for all newborns. Therefore, the nurse does not need to obtain informed consent prior to obtaining the specimen. b. "Collect at least 1 milliliter of urine for the test." The nurse should collect a capillary blood sample via heel stick for the newborn screening. Urine is not collected for this test. c. "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." i. The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr prior to testing. d. "Premature newborns may have false negative tests due to immature development of liver enzymes." Premature newborns have a delayed development of liver enzymes which can cause a false positive result. 17. A nurse is caring for client who has uterine atony and is experiencing postpartum hemorrhage. which of the following actions is the nurse’s priority? a. Check the client's capillary refill. It is important for the nurse to monitor capillary refill to track baseline data for this client. Noninvasive assessments of cardiac output for clients who are experiencing postpartum hemorrhage include assessing: capillary refill; skin color, temperature, and turgor; level of consciousness; neck veins; and mucous membranes. However, another action is the nurse's priority. b. Massage the client's fundus. i. MY ANSWER: Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood loss. c. Insert an indwelling urinary catheter for the client. It is important for the nurse to insert an indwelling urinary catheter to assess the client for hypovolemia. The most objective assessment of oxygenation and organ perfusion is urinary output of at least 30 ml/hr. However, another action is the nurse's priority. d. Prepare the client for a blood transfusion. It is important for the nurse to prepare the client for a blood transfusion to replace the amount of blood lost from postpartum hemorrhage. It is crucial to restore circulating blood volume. However, another action is the nurse's priority. 18. A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? a. Yellow sclera is incorrect. Yellow sclera is an indication of hyperbilirubinemia and is not an expected manifestation. b. Acrocyanosis is correct. Acrocyanosis is an expected finding for at least the first 24 hr following birth. Poor peripheral perfusion leads to bluish discoloration in the newborn's hands and feet. c. Posterior fontanel larger than the anterior fontanel is incorrect. The posterior fontanel is located on the back of the newborn's head and is a small triangular shape. The anterior fontanel is diamond shaped and approximately 5 cm (2 in) long. It is located on the top of the newborn's head and is larger than the posterior fontanel. d. Positive Babinski reflex is correct. Newborns should exhibit a positive Babinski sign following birth. The nurse should stroke the newborn's foot upward from the heel to the toes. The toes should hyperextend, and dorsal flexion of the big toe should occur. The absence of this finding requires neurological evaluation. The Babinski reflex is no longer present after 1 year of age. e. Two umbilical arteries visible is correct. The nurse should observe two arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly. 19. A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions? a. The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus outward using plain water. The nurse should then wash the newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump followed by washing the newborn's legs and feet. The last step of the bath should be to clean the newborn's diaper area. 20. A nurse is assessing a client who received carboprost(Oxytocic) for postpartum hemorrhage. Which of the following findings is an adverse effect of the medication? a. Hypertension i. MY ANSWER: The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension. b. Hypothermia. Fever is a common adverse effect of carboprost. c. Constipation. Diarrhea is a common adverse effect of carboprost. d. Muscle weakness. Muscle weakness is not an adverse effect of carboprost. 21. A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take? a. Give the client orange juice. Giving the client orange juice is not an appropriate intervention for a variable deceleration in the FHR. b. Elevate the client's legs. Elevating the client's legs is an acceptable intervention for late decelerations associated with maternal hypotension. c. Have the client change position. Having the client change position is an appropriate intervention for a variable deceleration to relieve umbilical cord compression. d. Establish IV access. Establishing IV access is not indicated at this time. 22. A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? a. Determine progression of dilatation and effacement. The nurse should determine the client's dilation and effacement prior to applying an internal monitor. This action is not required prior to applying an external transducer for fetal monitoring. b. Perform Leopold maneuvers.  MY ANSWER: The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer. c. Complete a sterile speculum exam. A sterile speculum examination should be performed by the provider and is not required prior to applying an external transducer for fetal monitoring. d. Prepare a Nitrazine paper test. A Nitrazine paper test is performed to assess the components (pH level) of vaginal fluid to determine if the membranes have ruptured. This action is not required prior to applying an external transducer for fetal monitoring. 23. A nurse in a prenatal clinic is assessing a group of clients. Which of the clients should the nurse see first? a. A client who is at 11 weeks of gestation and reports abdominal cramping  MY ANSWER: When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of gestation and reports a abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first. b. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand. Tingling and numbness of the right hand is nonurgent because it is a common discomfort related to pregnancy for a client who is at 15 weeks of gestation. Therefore, there is another client that the provider should see first. c. A client who is at 20 weeks of gestation and reports constipation for the past 4 days. Constipation is nonurgent because it is a common discomfort related to pregnancy for a client who is at 20 weeks of gestation. Therefore, there is another client that the provider should see first. d. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week. Epistaxis is nonurgent because it is a common discomfort related to pregnancy for a client who is at 8 weeks of gestation. Therefore, there is another client that the provider should see first. 24. A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications? a. Excessive bleeding. A client who is pregnant and has gonorrhea is not at an increased risk for excessive bleeding. b. Oligohydramnios. A client who is pregnant and has gonorrhea is not at an increased risk for oligohydramnios. Oligohydramnios is a decrease in amniotic fluid and is associated with congenital anomalies such as renal agenesis and intrauterine growth restriction. c. Premature rupture of membranes i. MY ANSWER: The nurse should identify that a client who is pregnant and has gonorrhea is at an increased risk for premature rupture of membranes, chorioamnionitis, preterm birth, neonatal sepsis, and intrauterine growth restriction. d. Proteinuria. A client who is pregnant and has gonorrhea is not at an increased risk for proteinuria. Proteinuria is associated with preeclampsia. 25. A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? a. A newborn who is 26 hr old and has erythema toxicum on his face. Erythema toxicum is a transient rash that can appear anywhere on a newborn's body during the first 24 to 72 hr following birth and can last up to 3 weeks. This finding requires no treatment. b. A newborn who is 32 hr old and has not passed a meconium stool. A newborn should pass the first meconium stool within the first 24 to 48 hr following birth. Failure to pass a meconium stool can indicate a bowel obstruction or congenital disorder. This finding is within the expected reference range. c. A newborn who is 12 hr old and has pink-tinged urine. Pink-tinged urine is an indication of uric acid crystals and is an expected finding for a newborn during the first week following birth. d. A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F) i. MY ANSWER: An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider. 26. A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take? a. Administer aspirin for pain. A client receiving anticoagulant therapy, such as heparin, should not receive aspirin because it can lead to prolonged clotting times and increased risk of bleeding. b. Maintain the client on bed rest. i. MY ANSWER: The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended. c. Massage the affected leg every 12 hr. The nurse should avoid massaging the affected leg to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. d. Apply cold compresses to the affected calf. The nurse should apply warm compresses to the affected area to promote circulation and decrease edema. 27. A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include? a. "You can resume sexual activity in 1 week." The nurse should instruct the client that it is safe to resume sexual activity once all vaginal bleeding has stopped and the incision has healed, which can take 2 to 6 weeks. However, it is highly recommended that the client wait until after her 6- week follow-up with the provider because the incision and healing process should be assessed before sexual activity is resumed. b. "You won't need to do Kegel exercises since you had a cesarean." The nurse should instruct the client to continue to perform Kegel exercises to maintain tone of the pelvic muscles. Maintaining tone of the pelvic floor muscles helps to maintain urinary continence in the future. c. "You can still become pregnant if you are breastfeeding." i. MY ANSWER: The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding. d. "You are safe to start adding sit-ups to your exercise routine in 2 weeks." The nurse should instruct the client to avoid abdominal exercises for 4 to 6 weeks following a cesarean birth. The nurse can instruct the client to perform other exercises such as walking, arm raises, and leg rolls. 28. A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? a. Heart rate 154/min is correct. The expected reference range for a newborn's heart rate is from 110/min to 160/min while awake. b. Axillary temperature 36° C (96.8° F) is incorrect. A healthy newborn's temperature averages 37° C (98.6° F), with a range of 36.5° to 37.5° C (97.7° to 99.5° F). c. Respiratory rate 58/min is correct. The expected reference range for a newborn's respiratory rate is from 30/min to 60/min. d. Length 43 cm (16.9 in) is incorrect. The expected reference range for a newborn's length is from 45 to 55 cm (17.7 to 21.7 in). e. Weight 2.6 kg (5 lb 12 oz) is correct. The expected reference range for a newborn's weight is from 2,500 to 4,000 g (5.5 lb to 8.8 lb). 29. A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? a. Deep tendon reflexes 4+. Deep tendon reflexes (DTRs) are an indication of the balance between the cerebral cortex and spinal cord. The nurse should expect the client's DTR to be 2+. Therefore, a DTR of 4+ indicates hyperreflexia. b. Fundal height 14 cm. From gestational weeks 18 to 32, the height of the fundus is approximately equal to the number of weeks of gestation plus or minus 2 cm. Therefore, the nurse should expect the fundal height for this client should be 16 to 20 cm. c. Urine protein 2+. The nurse should expect the urine protein for this client to be less than 1+. A urine protein concentration of 2+ is an indication of preeclampsia. Therefore, the nurse should investigate this finding further. d. FHR 152/min i. The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse. 30. A nurse is reviewing the prenatal laboratory results for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider? a. Hemoglobin 10 g/dL i. MY ANSWER: A hemoglobin of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this finding to the provider to obtain a prescription for ferrous iron supplementation because of anemia. b. WBC count 10,000/mm3. This finding is within the expected reference range of 5,000 to 15,000/mm3 and does not require reporting to the provider. c. Platelets 250,000/mm3. This finding is within the expected reference range of 150,000 to 400,000/mm3 and does not require reporting to the provider. d. Fasting blood glucose 90 mg/dL. This finding is within the expected reference range of 60 to 105 mg/dL and does not require reporting to the provider. 31. A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? a. Feed the newborn 1 oz of water every 4 hr. The nurse should not feed the newborn any water or glucose water. Hydration can be maintained through regular breastfeeding or formula feeding. Water and glucose water do not increase the excretion rate of bilirubin in the stool or provide nutritional value. b. Apply lotion to the newborn's skin three times per day. The nurse should not apply lotion, ointments, or creams to a newborn who is undergoing phototherapy. Lotions, ointments, and creams can absorb heat and lead to burns. c. Remove all clothing from the newborn except the diaper.  MY ANSWER: The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin. d. Discontinue therapy if the newborn develops a rash. The nurse should not discontinue phototherapy if the newborn develops a rash. A temporary, fine rash can occur during therapy. This rash requires no treatment. 32. A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse’s priority following the procedure? a. Check the client's temperature. The nurse should check the client's temperature to monitor for infection following an amniocentesis. However, this is not the priority nursing intervention. b. Observe for uterine contractions. The nurse should observe for uterine contractions to identify preterm labor following an amniocentesis. However, this is not the priority nursing intervention. c. Administer Rho(D) immune globulin. The nurse should administer Rho(D) immune globulin following an amniocentesis to prevent Rh sensitization. However, this is not the priority nursing intervention. d. Monitor the FHR.  The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis. 33. A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider? a. Fundal height 34 cm. A client who is at 32 weeks of gestation should have a fundal height about the same as the number of weeks of gestation, plus or minus 2 cm. b. Report of decreased fetal movement i. MY ANSWER: The nurse should identify that a client who reports decreased fetal movement could be experiencing a complication related to fetal well-being. A decrease in fetal movement can indicate fetal distress. c. Report of occasional ankle swelling. The nurse should identify that occasional ankle edema is a common discomfort associated with a client who is at 32 weeks of gestation. d. BP 110/80 mm Hg. The nurse should identify that during pregnancy the client's blood pressure should remain the same or be slightly decreased. A blood pressure of 110/80 mm Hg is within the expected reference range of less than 120 mm Hg systolic and less than 80 mm Hg diastolic. 34. A nurse is admitting a client to the labor and delivery unit when the client states, “my water just broke”. Which of the following interventions is the nurse’s priority? a. Perform Nitrazine testing. The nurse should perform a Nitrazine test to determine the pH of the fluid. An alkaline pH can indicate rupture of membranes. However, this is not the first action the nurse should take. b. Assess the fluid. The nurse should observe the characteristics of the fluid to document color, odor, and amount. However, this is not the first action the nurse should take. c. Check cervical dilation. The nurse should check the client's cervical dilation to assess progress of labor. However, this is not the first action the nurse should take. d. Begin FHR monitoring. i. The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take. 35. A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? a. Biophysical profile  MY ANSWER: A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound. b. Amniocentesis. An amniocentesis is used to determine lung maturity, detect congenital anomalies, and diagnose fetal hemolytic disease. c. Cordocentesis. A cordocentesis is used to identify fetal blood type and RBC when there is a risk of isoimmune hemolytic anemia. d. Kleihauer-Betke test. The Kleihauer-Betke test is used to determine the amount of fetal blood in the maternal circulation when there is a risk of Rh-isoimmunization. 36. A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 ml D5W. the nurse should set the IV infusion pump to administer how many ml/hr? Follow these steps for the Ratio and Proportion method of calculation: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 2 g Step 3: What is the dose available? Dose available = Have 20 g Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 500 mL Step 6: Set up an equation and solve for X. X mL = 50 mL Step 7: Round if necessary. Step 8: Determine whether the amount to administer makes sense. If there are 20 g of magnesium sulfate in 500 mL D5W and the prescription reads 2 g, it makes sense to administer 50 mL. The nurse should administer magnesium sulfate 50 mL/hr IV. 37. A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider? a. BUN 25 mg/dL  MY ANSWER: The nurse should report an elevated BUN to the provider since it can indicate dehydration. b. Serum creatinine 0.8 mg/dL. A serum creatinine level of 0.8 mg/dL is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. c. Urine output of 280 mL within 8 hr. A urine output of 280 mL within 8 hr is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. d. Urine negative for ketones. Testing the urine for ketones is the most important laboratory test for a client who has hyperemesis gravidarum. Urine testing positive for ketones is an indication of Have Desired = Quantity X 20 g 2 g = 500 mL X mL dehydration, which increases the risk of preterm labor. A negative test result is an expected finding. Therefore, the nurse does not need to report this finding to the provider. 38. A nurse is assessing a later preterm newborn. Which of the following manifestations is an indication of hypoglycemia? a. Hypertonia. A newborn who has hypoglycemia can exhibit hypotonia. b. Increased feeding. A newborn who has hypoglycemia can exhibit poor feeding behaviors. c. Hyperthermia. A newborn who has hypoglycemia can exhibit hypothermia. d. Respiratory distress  MY ANSWER: Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures. 39. A nurse in a provider’s office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia? a. Singleton pregnancy. Multifetal gestation, rather than a single fetus pregnancy, increases a client's risk for the development of preeclampsia. b. BMI of 20. Having a BMI greater than 30 increases a client's risk for the development of preeclampsia. c. Maternal age 32 years. A maternal age of younger than 19 or older than 40 increases the client's risk for the development of preeclampsia. d. Pregestational diabetes mellitus  MY ANSWER: Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis. 40. A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client’s medical record, which of the following findings should the nurse report to the provider? a. 1-hr glucose tolerance test. A glucose tolerance test result of 120 mg/dL is within the expected reference range for this client. A value of 130 to 140 mg/dL or greater for a 1-hr glucose tolerance test indicates a positive test result and should be reported to the provider. b. Hematocrit. A hematocrit of 34% is within the expected reference range for this client. The level should be greater than 33%. c. Fundal height measurement 30cm i. MY ANSWER: A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider. d. Fetal heart rate (FHR). This FHR is within the expected reference range of 110/min to 160/min for a client at 26 weeks of gestation. 41. A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider? a. Substernal retractions MY ANSWER: the nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection or respiratory distress in the newborn. The nurse should report these findings to the provider for immediate intervention. b. Acrocyanosis. Acrocyanosis is an expected finding in the newborn for the first 24 hr following birth. c. Overlapping suture lines. Overlapping suture lines with molding are an expected variation for newborns who were delivered vaginally. d. Head circumference 33 cm (13 in). A head circumference of 33 cm is within the expected reference range for a newborn following birth. 42. A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the clients head to one side, which of the following actions should the nurse take immediately after the seizure? a. Monitor the FHR. The nurse should monitor the FHR to assess fetal well-being. However, this is not the action the nurse should take next. b. Assess uterine activity. The nurse should assess uterine activity for potential complications of the seizure. However, this is not the action the nurse should take next. c. Administer oxygen via a nonrebreather mask. i. MY ANSWER: When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask at 10 L/min to ensure adequate oxygenation to the fetus. d. Start a bolus of IV fluids. The nurse should start IV fluids following the seizure to ensure adequate hydration. However, this is not the action the nurse should take next. 43. A nurse is providing teaching about nonpharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items? a. Cold cabbage leaves  MY ANSWER: The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement. The nurse should instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the application for two to three sessions as needed. More frequent applications could decrease the client's milk supply. b. Purified lanolin cream. Purified lanolin cream is an over-the-counter product that is recommended for the treatment of sore nipples. c. A snug-fitting support bra. A snug-fitting support bra is recommended to suppress lactation for a client who is not breastfeeding. The bra prevents strain on the breast muscles and places the breasts in proper alignment to decrease engorgement. d. Breast shells. Breast shells are recommended for clients who are postpartum and have sore nipples. They are used as a barrier to keep clothing away from the nipples and to allow air to circulate. 44. A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? a. Lochia serosa vaginal drainage. A client who is 4 to 10 days postpartum will report lochia serosa. b. Vaginal pressure. ***lochia rubra***  MY ANSWER: The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues. c. Intermittent vaginal pain. A client who has a vaginal hematoma will report persistent vaginal or rectal pain. d. Yellow exudate vaginal drainage. A client who is 1 day postpartum and has a vaginal hematoma will report lochia rubra. 45. A nurse is assessing a newborn who was born at 26 weeks of gestation using the new ballard scale. Which of the following findings should the nurse expect? a. Minimal arm recoil  MY ANSWER: The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil. b. Popliteal angle of 90°. A popliteal angle of 90° is an indicator of physical maturity with increasing gestational age after 26 weeks. c. Creases over the entire foot sole. Creases over the entire sole of a newborn's foot are an indicator of physical maturity with increasing gestational age after 26 weeks. d. Raised areolas with 3 to 4 mm buds. Raised areolas with 3 to 4 mm buds is an indicator of physical maturity with increasing gestational age after 26 weeks. 46. A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates and understanding of the teaching? a. "My sister will be able to carry my baby from the nursery to my room when she arrives." A newborn should always be transported in a bassinet when outside the parent's room. b. "The nurse will match my wrist band to my baby's crib card when they bring him to me." The nurse will match the newborn's identification number with the parent's identification number when they bring the newborn to the parent's room. c. "The person who comes to take my baby's pictures will be wearing a photo identification badge."  MY ANSWER: All personnel working on the unit should be wearing a photo identification badge. The nurse should instruct the parent to never allow anyone who is not wearing an identification badge to come in contact with the newborn. d. "My baby doesn't need to wear the electronic security bracelet when he's in my room." The newborn should wear the electronic security bracelet at all times. The bracelet is set to alarm if anyone removes the bracelet or if the newborn is brought near an exit door. 47. A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider? a. Report of visual disturbances  Visual disturbances such as blurred vision are a potential prenatal complication associated with hypertension. The nurse should report this finding to the provider so that additional fetal and maternal evaluation can be performed. b. Report of tingling of the fingers. Tingling or numbness of the fingers is called brachial plexus traction syndrome resulting from drooping of shoulders during pregnancy. This is a common discomfort that occurs during the second trimester. c. Report of urinary frequency. Reports of urinary frequency is a common discomfort that occurs during the third trimester because of the reduction in bladder capacity due to the enlarged uterus. d. Report of leg cramps. Leg cramps are a common discomfort that occurs during the third trimester because the nerves that supply lower extremities are compressed due to the enlarging uterus. 48. A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates and understanding of the teaching? a. "I will not gain more than 15 to 20 pounds during my pregnancy." The recommended weight gain during pregnancy for a client who has a BMI within the expected reference range is 25 to 35 lb (11.3 to 15.9 kg). The recommended weight gain during pregnancy for a client who has a BMI above the expected reference range is 15 to 20 lb (6.8 to 9.1 kg). b. "I will likely need to use alternative positions for sexual intercourse."  MY ANSWER: The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This client statement indicates that she understands the nurse's teaching about the physiological changes that occur during pregnancy. c. "I'm glad I had a breast reduction years ago, so they will not enlarge with my pregnancy." The mammary glands of the breasts grow during pregnancy, causing progressive enlargement during the second and third trimesters of pregnancy. A breast reduction will not prevent this from occurring. d. "I'm glad I have a light complexion and will not get any stretch marks." Stretch marks can occur as a response to pregnancy regardless of the client's complexion. 49. A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12mg IM. Which of the following outcomes should the nurse expect? a. Decreased uterine contractions. This is not an expected outcome of betamethasone. b. An increase in the client's hemoglobin levels. This is not an expected outcome of betamethasone. c. A reduction in respiratory distress in the newborn.  MY ANSWER: Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress. d. Increased production of antibodies in the newborn. This is not an expected outcome of betamethasone. 50. A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medication should the nurse anticipate administering if the client develops magnesium toxicity? a. Calcium gluconate i. MY ANSWER: The nurse should anticipate administering calcium gluconate if the client develops magnesium toxicity. Calcium gluconate is the antidote. b. Hydralazine. Hydralazine is an antihypertensive medication that can be administered to clients who have hypertension during pregnancy, rather than functioning as the antidote to magnesium toxicity. c. Medroxyprogesterone acetate. Medroxyprogesterone acetate is an injectable contraceptive hormone, rather than functioning as the antidote to magnesium toxicity. d. Methylergonovine. Methylergonovine is used to treat postpartum hemorrhage, rather than functioning as the antidote to magnesium toxicity. 51. A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? a. Client reports nausea. Nausea is an expected adverse effect of magnesium sulfate. The nurse should reassure the client and provide comfort measures. b. Urinary output of 40 mL/hr. Oliguria is a manifestation of magnesium toxicity. The nurse should report a urinary output of less than 25 to 30 mL/hr to the provider. c. Respiratory rate 10/min.  MY ANSWER: The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available. d. Client reports feeling flushed. Flushing and feeling hot is an expected adverse effect of magnesium sulfate. The nurse should reassure the client and provide comfort measures. 52. A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider? a. Late decelerations  MY ANSWER: Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider. b. Moderate variability of the FHR. Moderate variability of the FHR is an expected assessment finding associated with normal fetal acid-base balance. It is not a contraindication to the administration of oxytocin. c. Cessation of uterine dilation. Cessation of uterine dilation is an indication for the initiation of an oxytocin infusion to augment the client's labor progression. d. Prolonged active phase of labor. A prolonged active phase of labor is an indication for the initiation of an oxytocin infusion to augment the client's labor progression. 53. A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include? a. "The test should take 10 to 15 minutes to complete." The nurse should instruct the client that the nonstress will take approximately 20 to 30 min, but more time might be required if the fetus is in a sleep state when the testing begins. b. "You will lay in a supine position throughout the test." The nurse should instruct the client to be positioned in a reclining chair or semi-Fowler's position with a slight lateral tilt to ensure optimal uterine perfusion. c. "You should not eat or drink for 2 hours before the test." The client is not required to be NPO before or during the procedure. The nurse can suggest the client drink orange juice to increase her blood glucose level which will stimulate fetal movements. d. "You should press the handheld button when you feel your baby move."  MY ANSWER: The nurse should instruct the client to press the handheld button when the fetus moves. This action will mark the fetal monitor tracing with the client's reports of fetal movement. This will assist in the interpretation of the nonstress test to determine if it is reactive or nonreactive. 54. A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect? a. Bruising over the buttocks. A breech birth can cause bruising over the buttocks and swollen genitalia. b. Hard nodules on the roof of the mouth. Inclusion cysts, or whitish hard nodules on the gums or roof of the mouth, can be an expected finding. These are also called Epstein pearls. c. Petechiae over the head  MY ANSWER: Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck. d. Bilateral periauricular papillomas. Bilateral periauricular papillomas are benign skin tags that can be an expected finding. 55. A nurse is transporting a newborn back to the parent’s room following a procedure. Which of the following actions should the nurse take? a. Verify that the parent's identification band matches the newborn's identification band. i. MY ANSWER: The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the information on the parent's identification band to the information on the newborn's identification band. b. Scan the newborn's identification band to verify their identity. Scanning the newborn's identification band to verify their identity does not ensure the newborn is being transferred to the correct parent. c. Check the newborn's security tag number to ensure it matches the newborn's medical record. Comparing the newborn's security tag number to the newborn's medical record does not ensure the newborn is being transferred to the correct parent. d. Match the newborn's date and time of birth to the information in the parent's medical record. It is not necessary for the nurse to check the parent's medical record. The nurse should match the information on the parent's identification band to the information on the newborn's identification band. 56. A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? a. Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period. b. Bathe the client within 12 hr following birth. Bathing the client within 12 hr following birth should not be included in the plan of care because traditional Hispanic practices include delaying bathing for 14 days following birth. c. Ambulate the client within 24 hr following birth. Ambulating the client within 24 hr following birth should not be included in the plan of care because traditional Hispanic practices include bed rest for 3 days following birth. d. Offer the client a glass of cold milk with her first meal. Offering the client a glass of cold milk with her first meal should not be included in the plan of care because traditional Hispanic practices include drinking warm beverages following birth. 57. A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following images indicates the first step of leopold maneuvers? The nurse should identify this image as the fourth step of Leopold maneuvers. During this step, the nurse faces the client's feet and uses the fingertips to palpate the cephalic prominence. This assessment allows the nurse to determine the attitude of the fetal head. The nurse should identify this image as the third step of Leopold maneuvers. During this step, the nurse determines which fetal part is presenting in the pelvic inlet. The nurse gently grasps the lower uterine segment between the thumb and forefingers, pressing in slightly. Y ANSWER Evidence-based practice indicates the nurse should perform this step first when performing Leopold maneuvers. During this step, the nurse palpates the client's abdomen with the palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus. The nurse should identify this image as the second step of Leopold maneuvers. During this step, the nurse uses the palms of the hands to determine the location of the smooth fetal back and the irregularly shaped, smaller fetal parts. 58. A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous iv infusion. Which of the following interventions should the nurse include in the plan? a. Monitor the client's blood pressure every hour. The nurse should monitor the client's vital signs, including blood pressure, every 15 to 30 min. Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. b. Restrict the total hourly intake to 200 mL. The nurse should restrict the client's total hourly intake to no more than 125 mL. Clients who have preeclampsia can have an alteration in kidney function, leading to increases in edema. c. Monitor the FHR continuously.  MY ANSWER: Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The FHR and uterine contractions should be monitored continuously while the client is receiving magnesium sulfate. d. Administer protamine sulfate for manifestations of toxicity. The nurse should administer calcium gluconate if the client shows manifestations of magnesium sulfate toxicity. Findings of toxicity include loss of deep-tendon reflexes, respiratory depression, slurred speech, and cardiac arrest. 59. A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? a. Blood pressure 136/88 mm Hg. A blood pressure of 136/88 mm Hg is within the expected reference range for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provider. b. Report of insomnia. A regular occurrence of insomnia can be expected for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provider. c. Weight gain of 2.2 kg (4.8 lb)  MY ANSWER: A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider. d. Report of Braxton Hicks contractions. Braxton Hicks contractions can be expected for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provider. 60. A nurse is caring for a client who is at 36 weeks of gestation and has prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for and ultrasound? a. To estimate the fetal weight. This is not an indication for an ultrasound prior to an amniocentesis. b. To locate a pocket of fluid.  MY ANSWER: An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus. c. To determine multiparity. This is not an indication for an ultrasound prior to an amniocentesis. d. To prescreen for fetal anomalies. This is not an indication for an ultrasound prior to an amniocentesis.