MATERNAL NUR 230 PRACTICE QUESTIONS AND ANSWERS

1) A nurse in a woman's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the followi ...

1) A nurse in a woman's health clinic is providing teaching about nutritional intake to a client who is at 8 weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients? Calcium The recommendation for calcium intake during pregnancy is the same as that for women who are not pregnant: 1,300 mg/day for women younger than 19 years old and 1,000 mg/day for women between the ages of 19 and 50 years old. Vitamin E The recommendation for vitamin E intake during pregnancy is 15 mg/day, the same as that for women who are not pregnant. Iron The recommendation for iron intake during pregnancy is higher than that for women who are not pregnant. For women who are pregnant, it is 27 mg/day. For women who are not pregnant, it is 15 mg/day for women younger than 19 years old and 18 mg/day for women between the ages of 19 and 50 years old. Vitamin D The recommendation for vitamin D intake during pregnancy is 600 IU/day, the same as 2) A nurse is caring for a client who has uterine hypotonicity and is experiencing postpartum hemorrhage. Which of the following actions is the nurse's priority? Check the client's capillary refill. It is important for the nurse to monitor capillary refill in order to track baseline data for this client. However, another action is the nurse's priority. Massage the client's fundus. Uterine hypotonicity 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, causing death to occur. Therefore, the nurse's priority is to massage the client's fundus in order to minimize blood loss. Insert an indwelling urinary catheter for the client. It is important for the nurse to insert an indwelling urinary catheter in order to assess the client for hypovolemia. However, another action is the nurse's priority. Prepare the client for a blood transfusion. It is important for the nurse to prepare the client for a blood transfusion in order to replace the amount of blood lost from postpartum hemorrhage. However, another action is the nurse's priority. 3) A nurse is providing discharge teaching to a parent whose newborn has just had a circumcision. Which of the following instructions should the nurse include? Apply slight pressure with a sterile gauze pad for mild bleeding. The nurse should instruct the client to attempt to stop mild bleeding by applying pressure with sterile gauze. If bleeding continues, the client should notify the provider. Inspect the circumcision site every 6 to 8 hr. The client should change the newborn's diaper and examine the circumcision site at least every 4 hr. Use baby wipes containing alcohol to cleanse the penis with each diaper change. Baby wipes containing alcohol can irritate the skin and should be avoided until the circumcision has healed, which usually takes 5 to 6 days. During each diaper change, the penis should be washed gently with warm water and have petroleum jelly applied to the glans. Remove yellow exudate daily using a warm, wet washcloth. The client should not attempt to remove any yellow exudate from the circumcision site because it is part of the healing process, which begins within 24 hr and continues for 2 to 3 days. Disrupting it can cause pain and bleeding. 4) A nurse is teaching about effective breastfeeding to a client who is 3 days postpartum. Which of the following information should the nurse include? "Your milk will replace colostrum in about 10 days." The nurse should inform the client that milk production occurs 3 or 4 days postpartum. The breasts will feel firm and heavy. The client should continue to feed the newborn on demand during this period. "Your breasts should feel firm after breastfeeding." The nurse should inform the client that her breasts should feel softer after feeding. This change indicates that the newborn has emptied the breasts of milk. "Your newborn should urinate at least 10 times per day." The nurse should inform the client that the newborn should void six to eight times per day. The newborn should also have at least three stools per day. It is not uncommon for breastfed newborns to have a stool with each feeding. "Your newborn should appear content after each feeding." The nurse should inform the client that a baby who is sated will appear content after feedings. A baby who continues to show indications of hunger (for example, rooting, sucking on the hands, or crying) might not be effectively emptying the breasts during feedings. 5) A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? "I should have a goal of maintaining my fasting blood glucose between 100 and 120." The nurse should teach the client to maintain her fasting blood glucose level between 60 and 99 mg/dL. "I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater." The nurse should teach the client to avoid exercise during periods of hyperglycemia and when positive urine ketones are present. "I will continue taking my insulin if I experience nausea and vomiting." The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes. 6) A nurse is discussing the differences between true labor and false labor with a group of expectant parents. Which of the following characteristics should the nurse include when discussing true labor? Contractions become stronger with walking. The contractions that occur during true labor become stronger and more regular with a change in activity, such as walking. Discomfort can be suppressed with a back massage. The discomfort of false labor can be suppressed by using comfort measures, such as a back or foot massage. With true labor, the client discomfort continues regardless of the use of comfort measures. Contractions become irregular with a change in activity. The contractions that occur during true labor will become stronger and more regular with a change in activity. Discomfort is felt above the umbilicus. The discomfort experienced during the contractions of true labor is felt in the lower back and lower abdomen. Discomfort during false labor is usually felt above the umbilicus. 7) A nurse is teaching a group of parents about newborn safety. Which of the following statements by a parent indicates an understanding of the teaching? "I will put a bib on my baby at night to keep her clothing dry." The parents should avoid placing a bib around their newborns' necks at night to prevent choking and suffocation. "I will cover the crib mattress with plastic to prevent staining." The parents should avoid placing plastic over the crib mattress to prevent suffocation. "I will warm my baby's formula using the lowest setting in the microwave." The parents should avoid heating the formula in a microwave to prevent uneven warming of the formula. "I will dress my baby in flame-retardant clothing." The parents should dress their newborns in flame-retardant clothing to prevent injury. 8) A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect? Decreased platelet count A client who has ITP has an autoimmune response that results in a decreased platelet count. Increased erythrocyte sedimentation rate (ESR) An increased ESR is an indication of chronic renal failure. Decreased megakaryocytes A client who has ITP will have megakaryocytes within the expected reference range. Increased WBC An increased WBC is an indication of infection 9) A nurse is caring for a newborn who was transferred to the nursery 30 min after delivery. Which of the following actions should the nurse take first? Confirm the newborn's Apgar score. The Apgar score is a physiologic assessment that occurs 1 min following birth and again at 5 min. The nurse should confirm the score when the newborn arrives in the nursery. However, there is another action the nurse should take first. Verify the newborn's identification. When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery. Administer vitamin K to the newborn. The nurse should administer IM vitamin K to the newborn soon after birth to increase clotting factors and prevent bleeding. However, the injection can be delayed until after initial bonding time and the first breastfeeding if necessary. Therefore, there is another action the nurse should take first. Determine obstetrical risk factors. The nurse should identify obstetrical risk factors to determine if interventions are required for the newborn. However, there is another action the nurse should take first. 10) A nurse is assessing a client who is in active labor and notes early decelerations in the FHR on the monitor tracing. The client is at 39 weeks of gestation and is receiving a continuous IV infusion of oxytocin. Which of the following actions should the nurse take? Discontinue the oxytocin infusion. Early decelerations in the FHR are considered benign. Early decelerations occur due to compression of the fetal head during contractions, vaginal examinations, and pushing during the second stage of labor. No interventions are necessary for early decelerations. Continue monitoring the client. Early decelerations in the FHR are considered benign. Early decelerations occur due to compression of the fetal head during contractions, vaginal examinations, and pushing during the second stage of labor. No interventions are necessary for early decelerations. Therefore, the nurse should continue to monitor the client. Request that the provider assess the client. Early decelerations in the FHR are considered benign. Early decelerations occur due to compression of the fetal head during contractions, vaginal examinations, and pushing during the second stage of labor. No interventions are necessary for early decelerations. Increase the infusion rate of the maintenance IV fluid. Early decelerations in the FHR are considered benign. Early decelerations occur due to compression of the fetal head during contractions, vaginal examinations, and pushing during the second stage of labor. No interventions are necessary for early decelerations. 11) A nurse in a provider's office is reviewing the medical record of a client who is in her first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia? Singleton pregnancy Multifetal gestation, rather than a single fetus pregnancy, increases a client's risk for the development of preeclampsia. BMI of 20 Having a BMI greater than 30 increases a client's risk for the development of preeclampsia. 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. Pregestational diabetes mellitus 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. 12) A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication? Hypertension The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension. Hypothermia Fever is a common adverse effect of carboprost. Constipation Diarrhea is a common adverse effect of carboprost. Muscle weakness Muscle weakness is not an adverse effect of carboprost. 13) A nurse is caring for a newborn who is undergoing phototherapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? Cover the newborn's eyes while under the phototherapy light. Applying an opaque eye mask prevents damage to the newborn's retinas and corneas from the phototherapy light. Keep the newborn in a shirt while under the phototherapy light. It is acceptable for the nurse to keep a diaper or other covering over the newborn's genitals and buttocks, but the nurse should remove all other clothing and blankets to expose as much body surface area as possible to the phototherapy light. Apply a light moisturizing lotion to the newborn's skin. The nurse should not apply any cream or moisture to the newborn's skin because it can absorb heat and cause burns. Turn and reposition the newborn every 4 hr while undergoing phototherapy. The nurse should turn and reposition the newborn every 2 to 3 hr to allow for maximum exposure of body surfaces to the phototherapy light. 14) A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor? Active The active phase of labor is characterized by a cervical dilatation of 4 to 7 cm and contractions every 3 to 5 min, each lasting 40 to 70 seconds. Transition The nurse should identify that the client is in the transition phase of labor. This phase is characterized by a cervical dilatation of 8 to 10 cm and contractions every 2 to 3 min, each lasting 45 to 90 seconds. Latent The latent phase of labor is characterized by cervical dilation of 0 to 3 cm and contractions every 5 to 30 min, each lasting 30 to 45 seconds. Descent The descent phase of labor is characterized by active pushing with contractions every 1 to 2 min, each lasting for 90 seconds. 15) A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.) Cholecystitis Hypertension Human papillomavirus Migraine headaches Anxiety disorder Cholecystitis is correct. A history of gallbladder disease is a contraindication for the use of oral contraceptive .Hypertension is correct. Hypertension is a contraindication for the use of oral contraceptives. Human papillomavirus is incorrect. The presence of human papillomavirus is not a contraindication for the use of oral contraceptives. Migraine headaches is correct. A history of migraine headaches is a contraindication for the use or oral contraceptives. Anxiety disorder is incorrect. The presence of an anxiety disorder is not a contraindication for the use of oral contraceptives. 16) A nurse is assessing a client who is 12 hr postpartum. The client's fundus is two fingerbreadths above the umbilicus, deviated to the right of the midline, and less firm than previously noted. Which of the following actions should the nurse take? Place the client in a side-lying position. Placing the client in a side-lying position is an action that the nurse should take for a client who is experiencing hypovolemic shock. Assist the client to the bathroom to void. A distended bladder inhibits the uterus from contracting normally and can cause uterine atony. Therefore, the nurse should assist the client to void. Obtain a prescription for IV oxytocin. Obtaining a prescription for IV oxytocin is an action that the nurse should take for a client who requires labor induction and augmentation. Administer methylergonovine. Administering methylergonovine is an action that the nurse should take for a client who is experiencing postpartum hemorrhage. 17) A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following clinical manifestations should the nurse expect? (Select all that apply.) Yellow sclera Creases over two-thirds of the soles of the feet Posterior fontanel larger than the anterior fontanel Molding of the head Lanugo on the shoulders Yellow sclera is incorrect. Yellow sclera is an indication of hyperbilirubinemia and is not an expected clinical manifestation. Creases over two-thirds of the soles of the feet is correct. Fewer creases over the soles of the feet is an indication of prematurity. Creases over the entire soles of the feet is an indication of postmaturity. 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. It is located on the top of the newborn's head and is larger than the posterior fontanel. Molding of the head is correct. Molding occurs during the birth process as the newborn travels through the birth canal, resulting in compression of the soft bones of the skull. Lanugo on the shoulders is correct. Absence of lanugo is an indication of postmaturity. Abundant lanugo is an indication of prematurity. 18) A nurse is developing an educational program for adolescents about nutrition during the third trimester of pregnancy. Which of the following statements should the nurse include in the program? "Consume three to four servings of dairy each day." Calcium intake is especially important during an adolescent's pregnancy because bone absorption of calcium is still occurring. Therefore, the nurse should instruct the adolescents to consume three to four servings of dairy per day to meet their calcium needs. "Increase your daily caloric intake by 600 to 700 calories." Consuming an additional 600 to 700 cal per day could lead to excessive weight gain, which increases the adolescent's risk for complications related to pregnancy, labor, and delivery. The nurse should instruct the adolescents that, if they have a BMI within the expected reference range prior to pregnancy, they should increase their daily caloric intake by 340 cal in the first trimester and 452 cal in the second and third trimesters. "Limit your daily sodium intake to less than 1 gram." Sodium supports the increase in blood volume that occurs during pregnancy. An adequate sodium intake is approximately 1.5 g per day. The nurse should instruct the adolescents that an adequate intake of sodium is required during pregnancy. "Increase your protein intake to 40 to 50 grams each day." Adequate protein intake is necessary to support the rapid growth of the fetus, maternal tissues, increasing blood volume, and the formation of amniotic fluid. Therefore, the nurse should instruct the adolescents to increase their daily intake of protein to approximately 71 g during the second and third trimesters of pregnancy. 19) A nurse is performing a vaginal exam on a client who is in labor and reports severe pressure and pain in the lower back. The nurse notes that the fetal head is in a posterior position. The nurse should identify that which of the following is the best nonpharmacological intervention to perform to relieve the client's discomfort? Back rub A back rub is an effective nonpharmacological intervention to assist the client with pain. However, there is a better nonpharmacological intervention the nurse should use. Counter-pressure According to evidence-based practice, counter-pressure is the best nonpharmacological technique to use when relieving the client's discomfort from the fetus being in a posterior position because this intervention lifts the fetal head off of the spinal nerve. Playing music Playing music is an effective nonpharmacological intervention to assist the client with pain. However, there is a better nonpharmacological intervention the nurse should use. Foot massage A foot massage is an effective nonpharmacological intervention to assist the client with pain. However, there is a better nonpharmacological intervention the nurse should use.  20) 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? Monitor the client's blood pressure every hour. MY ANSWER 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. 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. Monitor the FHR continuously. 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. 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. 21)A nurse is planning care for a client who is 2 hr postpartum. Which of the following interventions should the nurse plan to implement during the taking-hold phase of postpartum behavioral adjustment? Discuss contraceptive options with the client and her partner. The discussing of contraceptive options occurs during the letting-go phase. This phase focuses on moving forward as a family with interchanging members. Repeat information to ensure client understanding. The repeating of information to ensure client understanding occurs during the takingin phase. During this phase, which is experienced on the first postpartum day, the client displays dependent and passive behaviors. Due to excitement and fatigue, the client is unable to retain information. Therefore, the nurse should repeat instructions to ensure that the client understands what is being said. Listen to the client and her partner as they reflect upon the birth experience. Listening to the client and her partner reflect upon the birth experience occurs during the taking-in phase. During this phase, the new mother is focused on herself and meeting her basic needs. There is also much excitement about the newborn and the birth experience. Therefore, the nurse should allow the client to reflect, ensuring a healthy transition and a successful adaptation into the new family unit. Demonstrate to the client how to perform a newborn bath. Demonstrating to the client how to perform a newborn bath occurs during the takinghold phase. The new mother moves from being passively dependent to taking a stronger interest in her new role as a mother. She is now focusing on the care her newborn and acquiring parenting skills. The nurse should provide positive reinforcement during this phase to give the new mother confidence and promote maternal adjustment. 22) 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? 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. 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. 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. Place the newborn skin to skin on the mother's chest. 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. 23) 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? Late decelerations Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider. 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. 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. 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. 24) 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? 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. 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. Weight gain of 2.2 kg (4.8 lb) 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. 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 provide 25) 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? 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. 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. 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. 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. 26) A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care? Place the client in a supine position for 30 min following the first dose of anesthetic solution. The nurse should plan to position the client upright in order to allow the anesthetic solution to flow downward. If additional pain management is needed for a cesarean birth, the nurse can place the client supine with her head and shoulders elevated and at a lateral tilt to increase perfusion to the fetus. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution. The nurse should plan to administer 500 to 1,000 mL of lactated Ringer's or 0.9% sodium chloride 15 to 30 min prior to the administration of the first dose of anesthetic solution in order to decrease the maternal risk for hypotension. The nurse should not administer dextrose because it can cause maternal hyperglycemia and neonatal hypoglycemia. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. The nurse should plan to obtain a baseline blood pressure prior to the initiation of anesthetic solution. The nurse should then continue to monitor the client's blood pressure every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution. The nurse should not plan to restrict the client's intake prior to the epidural placement and the 27) A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's secretions. Which of the following instructions should the nurse include? Insert the syringe tip before compressing the bulb. The client should compress the bulb before inserting the syringe tip. Compressing the bulb after it is in the newborn's nares or mouth could push the secretions and mucus further inside. Suction each of the nares before suctioning the mouth. The client should suction the mouth before suctioning the nares. Otherwise, the newborn could gasp and inhale pharyngeal secretions when the syringe tip touches the nares. Insert the tip of the syringe into the center of the newborn's mouth. The client should insert the tip of the syringe into the side of the newborn's mouth. Inserting it into the center of the newborn's mouth can trigger the gag reflex. Stop suctioning when the newborn's cry sounds clear. The nurse should instruct the client to stop suctioning when the newborn's cry no longer sounds like it is coming through a bubble of fluid or mucus. 28) A nurse is assessing a late preterm newborn. Which of the following clinical manifestations is an indication of hypoglycemia? Hypertonia A newborn who has hypoglycemia can exhibit hypotonia. Increased feeding MY ANSWER A newborn who has hypoglycemia can exhibit poor feeding behaviors. Hyperthermia A newborn who has hypoglycemia can exhibit hypothermia. Respiratory distress Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a clinical manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures. 29) A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? 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. This finding requires no treatment. 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. 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. A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F) 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. 30) A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)  Palpate the fundus to identify the fetal part.  Determine the location of the fetal back.  Palpate for the fetal part presenting at the inlet  Identify the attitude of the head. The first step the nurse should take when performing Leopold maneuvers is to palpate the client's fundus to identify the fetal part. Second, the nurse should determine the location of the fetal back. Third, the nurse should palpate for the fetal part presenting at the inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the head. 31) 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? 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. 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. 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. Begin FHR monitoring. 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 wellbeing. Therefore, this is the priority action the nurse should take. 32) A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? "I will eat foods that appeal to my taste instead of trying to balance my meals." Clients who have hyperemesis gravidarum should eat to taste to avoid nausea. "I will avoid having a snack at bedtime." Clients who have hyperemesis gravidarum should avoid going to bed with an empty stomach. The nurse should instruct the client to eat a healthy snack before going to bed. "I will have 8 ounces of hot tea with each meal." Clients who have hyperemesis gravidarum should alternate liquids and solids every 2 to 3 hr to avoid an empty stomach and over filling at each meal. "I will pair my sweets with a starch instead of eating them alone." Clients who have hyperemesis gravidarum should eat protein following a sweet snack. 33)A nurse is providing discharge teaching to a client who is postpartum. For which of the following clinical manifestations should the nurse instruct the client to monitor and report to the provider? Persistent abdominal striae Persistent abdominal striae are caused by the separation of the underlying connective tissue and are an expected postpartum finding. Temperature 37.8° C (100.2° F) The nurse should instruct the client to report a temperature of 38° C (100.4° F) or higher because it could be an indication of infection. Unilateral breast pain Chills, fever, malaise, and unilateral breast pain can be indications of mastitis, an infection of the breast tissue. The nurse should instruct the client to report this clinical manifestation to the provider. Brownish-red discharge on day 5 Brownish-red discharge is an expected clinical manifestation during days 3 to 10. The client should report a large amount of lochia and large clots to the provider. 34) A nurse is assessing a client who is at 26 weeks of gestation. Which of the following clinical manifestations should the nurse report to the provider? Leukorrhea Leukorrhea is an expected clinical manifestation during all stages of pregnancy. It is a white discharge that is the result of hormone secretion during pregnancy. Supine hypotension Supine hypotension is an expected clinical manifestation during the second and third trimesters. It is the result of pressure on the ascending vena cava from the gravid uterus. Periodic numbness of the fingers Periodic numbness of the fingers is an expected clinical manifestation during the second and third trimesters. It occurs from the slumping of the shoulders during pregnancy. Decreased urine output Decreased urine output, increased blood pressure, proteinuria, and decreased fetal activity can be indications of preeclampsia and should be reported to the provider. 35)A nurse is caring for a client who is at 40 weeks of gestation and is in early labor. The client has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate? Epidural analgesia The placement of an epidural catheter places the client at risk for bleeding. Therefore, a low platelet count is a contraindication for the placement of an epidural. Naloxone hydrochloride Naloxone hydrochloride is an opioid antagonist used to reverse respiratory depression in newborns. Attention-focusing Attention-focusing and distraction techniques are types of nonpharmacological care that are effective in relieving labor pain. Pudendal nerve block A pudendal nerve block is administered during the third stage of labor for the repair of an episiotomy or laceration. 36) A nurse is teaching a client who is at 24 weeks of gestation regarding a 1-hr glucose tolerance test. Which of the following statements should the nurse include in her teaching? "You will need to drink the glucose solution 2 hours prior to the test." The nurse should instruct the client to drink the glucose solution 1 hr prior to the test. "Limit your carbohydrate intake for 3 days prior to the test." The nurse should teach the client that she should not limit her carbohydrate intake. "A blood glucose of 130 to 140 is considered a positive screening result." The nurse should teach the client that a blood glucose level of 130 to 140 mg/dL is considered a positive screening. If the client receives a positive result, she will need to undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus. "You will need to fast for 12 hours prior to the test." The nurse should teach the client that fasting is not required for a 1-hr glucose tolerance test. 37) A nurse is assessing a full-term newborn 15 min after birth. Which of the following findings requires intervention by the nurse Heart rate 168/min During the first phase of a newborn's transition to extrauterine life, which is up to 30 min after birth, a heart rate between 160 to 180/min is an expected clinical manifestation. Respiratory rate 18/min During the first phase of a newborn's transition to extrauterine life, which is up to 30 min after birth, the respiratory rate can range between 20 to 100/min. A respiratory rate this low at this time requires further evaluation and intervention by the nurse. Tremors During the first phase of a newborn's transition to extrauterine life, which is up to 30 min after birth, the expected clinical manifestations include tremors, crying, and startling motions. Fine crackles During the first phase of a newborn's transition to extrauterine life, which is up to 30 min after birth, fine crackles and nasal flaring are expected clinical manifestations. 38) A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test. Which of the following statements should the nurse include in the teaching? "You will receive IV fluid prior to this test." The nurse should state that IV fluids are initiated for the oxytocin-stimulated contraction test. "The procedure will take approximately 10 to 15 minutes." The nurse should instruct the client that the procedure will take 20 to 40 min. "You will be offered orange juice to drink during the test." A nonstress test is performed to measure fetal activity. Having the client drink orange juice, or another beverage high in glucose, will stimulate the fetus during the procedure, helping to obtain results. "You will need to sign an informed consent form each time you have this test." A nonstress test is a noninvasive procedure. Therefore, informed consent does not need to be obtained. 39) A nurse is caring for a client who has recently experienced a perinatal death. Which of the following statements should the nurse make to the client? "It must be a comfort to know you have another child." The nurse is making a statement that minimizes the significance of the death of the client's newborn. This type of response from the nurse will not facilitate further communication. "I'm sad for you." The nurse is offering empathy to the client to facilitate further communication about the perinatal death. "There is usually something wrong with the baby." The nurse is making a statement that minimizes the significance of the death of the client's newborn. This type of response from the nurse will not facilitate further communication. "You will always have an angel in heaven." The nurse is making a statement that uses a cliché. This type of response from the nurse will not facilitate further communication 40) A nurse is planning care for a client who is at 24 weeks of gestation and reports daily mild headaches. Which of the following instructions should the nurse include in the plan of care? Administer ibuprofen 400 mg twice each day. Daily ibuprofen administration can lead to increased bleeding and premature closure of the ductus arteriosus in the fetus. Recommend that the client perform conscious relaxation techniques daily. The nurse should include conscious relaxation techniques in the plan of care as a way to relieve tension and reduce stress, which can help to decrease and eliminate headaches. Give the client ginseng tea with each meal. The nurse should not give the client ginseng tea with each meal because it is contraindicated for use during pregnancy. Instruct the client to soak in a bath with a water temperature of 105° F for 15 min daily. Soaking in a bath with a water temperature of 105° F for 15 min daily can cause maternal hyperthermia, interfering with cell metabolism and possibly causing birth defects. The water temperature should be maintained at 96.8° F to 98.6° F. . 41) A nurse is performing a vaginal examination for a client who is in active labor and reports back pain. The nurse determines that the client is 8 cm dilated, 100% effaced, -2 station, and that the fetus is in the occiput posterior position. Which of the following actions should the nurse take? Perform effleurage during contractions. To perform effleurage, the nurse lightly strokes the client's abdomen as the client breaths through the contractions. It is used during the first stage of labor to distract the client from the pain of contractions, but it will not facilitate the rotation of the fetal head. Place the client in lithotomy position. Placing the client in the lithotomy position will prevent the rotation of the fetal head. The client will likely be placed in the lithotomy position once the fetus has rotated and she is ready to begin pushing with contractions. Assist the client to the hands and knees position. The nurse should assist the client into the hands and knees position during contractions. This position can help relieve her back pain and it will enable the rotation of the fetus from the posterior to an anterior occiput position. Apply a scalp electrode to the fetus. Applying a scalp electrode to the fetus is an invasive procedure that is performed to monitor the FHR. There is no indication for internal monitoring at this time. 42) A nurse is caring for a client who is at 22 weeks of gestation and reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take? Tell the client to follow up with a dermatologist. An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an increase in the pigmentation of the skin during pregnancy. Treatment by a dermatologist will not affect the client's condition. Explain to the client this is an expected occurrence. Chloasma, also referred to as the mask of pregnancy, is a blotchy, brown hyperpigmentation of the skin over the cheeks, nose, and forehead. It is seen most often in dark-skinned women and is caused by an increase in melanotropin during pregnancy. This condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to 70% of women. Therefore, the nurse should reassure the client that this is an expected occurrence which usually fades after delivery. Instruct the client to increase her intake of vitamin D. An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an increase in the pigmentation of the skin during pregnancy. Increasing her vitamin D intake will not affect the client's condition. Inform the client she might have an allergy to her skin care products. An increase in melanotropin causes chloasma, which is an expected finding. It is caused by an increase in the pigmentation of the skin during pregnancy. Changing skin care products will not affect the client's condition. 43) A nurse is preparing to administer magnesium sulfate 2 g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) mL/hr MY ANSWER Ratio and Proportion 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. Have/Quantity = Desired/X 20 g/500 mL = 2 g/X mL X = 50 STEP 7: Round if necessary. STEP 8: Reassess to 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. Desired Over Have 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. Desired x Quantity/Have = X 2 g x 500 mL/20 g = X mL 50 = X STEP 7: Round if necessary. STEP 8: Reassess to 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 50 mL/hr IV. Dimensional Analysis STEP 1: What is the unit of measurement the nurse should calculate? mL STEP 2: What is the quantity of the dose available? 500 mL STEP 3: What is the dose available? Dose available = Have 20 g STEP 4: What is the dose the nurse should administer? Dose to administer = Desired 2 g STEP 5: Should the nurse convert the units of measurement? No STEP 6: Set up an equation and solve for X. X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired/ X mL = 500 mL/20 g x 2 g/ X = 50 STEP 7: Round if necessary. STEP 8: Reassess to 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. 44) 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? 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 baby. 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. Obtain a gift from the newborn to present to the sibling. Presenting a gift from the newborn to the sibling is a strategy to facilitate a schoolage sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that he understands his role in the family. 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 his belongings.Bottom of Form 45) A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has determined the fetal position as left occipital anterior. To which of the following areas of the client's abdomen should the nurse apply the ultrasound transducer in order to assess the point of maximum intensity of the fetal heart? Left upper quadrant The fetal heart tones of a fetus in the left sacrum anterior position are best heard in the left upper quadrant. Right upper quadrant The fetal heart tones of a fetus in the right sacrum anterior position are best heard in the right upper quadrant. Left lower quadrant The fetal heart tones of a fetus in the left occipital anterior position are best heard in the left lower quadrant. Right lower quadrant The fetal heart tones of a fetus in the right occipital anterior position are best heard in the right lower quadrant. 46) A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching? "You should take the medication within 72 hours following unprotected sexual intercourse." Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse. "You should avoid taking this medication if you are on an oral contraceptive." Levonorgestrel, an emergency contraceptive, has no effect on the other oral contraceptive the adolescent might be taking. To prevent pregnancy, this medication should be taken if an adolescent misses a dose of oral contraception. "If you don't start your period within 5 days of taking this medication, you will need a pregnancy test." The adolescent should be evaluated for pregnancy if she does not menstruate within 21 days following administration of this medication. "One dose of this medication will prevent you from becoming pregnant for 14 days after taking it." Levonorgestrel is an emergency contraceptive that prevents or delays ovulation. Therefore, the nurse should inform the client that she will not be protected from pregnancy if she has unprotected sexual intercourse in the days and weeks after receiving this medication. 47) A nurse is teaching clients in a prenatal class about the importance of taking folic acid during pregnancy. The nurse should instruct the clients to consume an adequate amount of folic acid from various sources to prevent which of the following fetal abnormalities? Neural tube defect The nurse should inform the clients that neural tube defects are more common in newborns born to mothers who had inadequate folic acid intake. Food sources of folic acid include fortified cereals and grain products, oranges, artichokes, liver, broccoli, and asparagus. Trisomy 21 Trisomy 21 occurs when two gametes (egg and sperm) combine and one gamete has an extra chromosome. Babies who are born with this disorder have 47 chromosomes in most or all of their cells. Cleft lip Cleft lips are more common in newborns born to mothers who have been exposed to environmental factors, such as infection or smoking, or who have predisposing genetic factors. Atrial septal defect An atrial septal defect is an abnormal opening between the atria. It is more common in newborns born to mothers who have septal defects. 48) A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of spina bifida occulta? The nurse should identify this as an image of spina bifida occulta. External indications of this neural tube defect include a dimpled area over the defect and the presence of a birthmark or hairy patch above the area. The nurse should identify this as an image of spina bifida manifesta in the form of a myelomeningocele that is closed. External indications of this neural tube defect include a herniated sac over the site of the defect that is covered with skin. The nurse should identify this as an image of spina bifida manifesta in the form of a myelomeningocele that is open. External indications of this neural tube defect include an open area over the defect that allows for leakage of cerebrospinal fluid and entry of microorganisms. The nurse should identify this as an image of Mongolian spots. These bluish-black pigmented areas are most commonly found on the buttocks and back of newborns of Mediterranean, Asian, African, and Latin American ethnicity and can be incorrectly identified as areas of ecchymosis. 49) A nurse is providing discharge teaching to the parents of a newborn about using a car seat properly. Which of the following instructions should the nurse include? Place the shoulder harness in the slots above the newborn's shoulders. The nurse should instruct the parents to place the shoulder harness in the slots that are at or just below the newborn's shoulders. Place the retainer clip at the level of the newborn's waist. The nurse should instruct the parents to place the retainer clip at the level of the newborn's axillae. Position the newborn at a 60º angle in the car seat. The nurse should instruct the parents to position the newborn at a 45º angle to minimize the risk of airway obstruction from slumping forward. Position the car seat rear-facing in the back seat of the vehicle. The nurse should instruct the parents to position the car seat rear-facing in the back seat of the vehicle because it avoids injury from front seat airbags and protects the newborn's heavy head and weak neck in the event of a sudden stop or collision. Infants and toddlers should remain rear-facing in the backseat until they are 2 years old or reach the height and weight requirements of the car seat manufacturer. 50) 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 an understanding of the teaching? "I will not gain more than 15 to 20 pounds during my pregnancy." The recommended weight gain for a woman who has a BMI within the expected reference range is 25 to 35 lb. The recommended weight gain for a woman who has a BMI above the expected reference range is 15 to 20 lb. "I will likely need to use alternative positions for sexual intercourse." 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. "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. "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. 51) A nurse is reviewing the medical record at 1800 for a client who is at 34 weeks of gestation. Based on the chart findings and documentation, the nursing plan of care should include which of the following actions? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) EXHIBIT Administer terbutaline. The nurse should administer terbutaline to stop contractions because the laboratory results indicate that the fetus's lungs are not mature enough for delivery. Discuss possible genetic anomalies with the client. There is no indication of genetic anomalies based on the results of the amniocentesis. Administer nalbuphine. Nalbuphine is an analgesic used for moderate to severe pain. A report of 2/10 is mild pain. Discontinue external fetal monitoring. The nurse should not discontinue external fetal monitoring. Because the client is exhibiting manifestations of preterm labor, fetal well-being and contraction patterns should be continuously monitored.  Exhibit 1 Laboratory Results Lecithin/sphingomyelin (L/S) ratio 1.4:1 Phosphatidylglycerol (PG) absent ABO-Rh B-negative  Exhibit 2 Medication Administration Record Terbutaline 0.25 mg SQ every hr PRN contractions Rho(D) immune globulin 300 mcg IM once Nalbuphine 10 mg IV every 3 hr PRN pain  Exhibit 3 Progress Notes 1655 – Amniocentesis completed, tocotransducer and external fetal monitor applied 1700 – Fetal heart rate 130/min with moderate variability Uterine contractions q 5 to 8 min lasting 30 to 60 sec duration Uterine contractions palpated at 1+ intensity Client reports uterine contraction pain 2/10 52) A charge nurse on the postpartum unit is observing a newly licensed nurse who is preparing to administer pain medication to a client. The charge nurse should intervene when the newly licensed nurse uses which of the following secondary identifiers to identify the client? The client's room number Using the client's room number is not an acceptable identifier and places the client at risk for a medication error. Therefore, the charge nurse should intervene. The client's telephone number The nurse should use at least two acceptable identifiers to confirm the client's identity before administering medication. Using the client's telephone number is an approved method for client identification. The client's birth date The nurse should use at least two acceptable identifiers to confirm the client's identity before administering medication. Using the client's birth date is an approved method for client identification. The client's medical record number The nurse should use at least two acceptable identifiers to confirm the client's identity before administering medication. Using the client's medical record number is an approved method for client identification.  53) A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following clinical manifestations should the nurse expect? Bruising over the buttocks A breech delivery can cause bruising over the buttocks and swollen genitalia. Hard modules on the roof of the mouth Inclusion cysts, or hard modules on the roof of the mouth, can be an expected finding. Petechiae over the head Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck. Bilateral periauricular papillomas Bilateral periauricular papillomas are benign skin tags that can be an expected finding. 54) A nurse is speaking with a client who is trying to make a decision about uterine tube occlusion. The client asks, "What effects will this procedure have on my sex life?" Which of the following responses should the nurse make? "I think that is something you should discuss with your doctor when she comes in." The nurse is dismissing the client's question, providing no information to help the client make an informed decision. "This process should have no effect on your sexual performance or adequacy." The nurse is giving the client the information she is seeking. Sexual function depends on various hormonal and psychological factors. Therefore, tubal occlusion should have no physiological effect on sexual performance or adequacy. It can actually enhance enjoyment of sex because there is no fear of pregnancy. "You'll be fine. I can't imagine you and your partner will have any problems with sexual function." The nurse is giving the client unwarranted reassurance without addressing the information the client is seeking. "If this concerns you, perhaps you should reconsider and use another form of contraception." The nurse is giving the client unwarranted advice which might imply that there is a reason to be concerned about the effect of the procedure on sexual functions 55) A nurse is providing prenatal teaching to a client who is at 26 weeks of gestation. Which of the following positions should the nurse recommend for the client to increase circulation to the placenta? Supine The supine position decreases blood return to the right atrium and the placenta. Fowler's The Fowler's position compresses the vena cava, decreasing placental circulation. Side-lying In order to increase placental circulation, the nurse should recommend the side-lying position to a client who is pregnant, which avoids the compression of the vena cava. Decreased circulation in the uterus can lead to having a child who is small for gestational age. Trendelenburg The Trendelenburg position is used to provide postural drainage of the lower lung lobes. It is accomplished when the head of the bed is lower than the foot of the bed, in a straight incline. There is no indication this would be a recommended position for a client who is pregnant or that it would increase circulation to the placenta. 56) 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 an understanding of the teaching? "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 mother's room. "The nurse will match my wrist band to my baby's crib card when she brings him to me." The nurse will match the newborn's identification number with the mother's identification number when she brings the baby to the mother's room. "The person who comes to take my baby's pictures will be wearing a photo identification badge." All personnel working on the unit should be wearing a photo identification badge. The nurse should teach the mother to never allow anyone who is not wearing an identification badge to come in contact with her newborn. "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. 57) 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? Lochia serosa vaginal drainage A client who is 4 to 10 days postpartum will report lochia serosa. Vaginal pressure 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. Intermittent vaginal pain A client who has a vaginal hematoma will report persistent vaginal or rectal pain. Yellow exudate vaginal drainage A client who is 1 day postpartum and has a vaginal hematoma will report lochia rubra. 58) 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? Cold cabbage leaves 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. Purified lanolin cream Purified lanolin cream is an over-the-counter product that is recommended for the treatment of sore nipples. 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. 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. 59) 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? "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. "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 in order to maintain tone of the pelvic muscles. Maintaining tone of the pelvic floor muscles helps to maintain urinary continence in the future. "You can still become pregnant if you are breastfeeding." 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. "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 (for example, walking, arm raises, and leg rolls). 60) A nurse is assessing a newborn who is 12 hr old. Which of the following clinical manifestations requires intervention by the nurse? Acrocyanosis of the extremities Acrocyanosis of the extremities is an expected clinical manifestation in newborns. Acrocyanosis is a bluish discoloration of the newborn's hands and feet. Murmur at the left sternal border An audible murmur heard at the left sternal border is an expected clinical manifestation in newborns. Substernal chest retractions while sleeping Substernal chest retractions can indicate respiratory distress syndrome in the newborn. This clinical manifestation requires further assessment and intervention by the nurse. Positive Babinski reflex A positive Babinski reflex is an expected clinical manifestation in newborns. This reflex is elicited when a newborn's sole is stroked and, in response, the toes hyperextend and the large toe dorsiflexes.