A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical
findings should the nurse expect?
Facial petechiae- seen over the presenting part with so
...
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical
findings should the nurse expect?
Facial petechiae- seen over the presenting part with soft tissue injuries
-nuchal cord: umbilical cord around fetal neck. Will cause variable deceleration of FHR. Intervention: repositi on client from side to
side or into knee chest, discontinue oxytocin if being infused, oxygen
2. A nurse is monitoring a newborn whose mother reports recent opiate use for neonatal abstinence syndrome. Which of the following
findings indicates narcotic withdrawal?
1. Respiratory rate 50/min
2. Unequal pupils
3. Hypotonia
4. Excessive crying
Substance withdrawal in the newborn occurs when the mother uses drugs during pregnancy.
Hitch pitch shrill cries, incessant crying, tremors, increae deep tendon reflexes, disturbed sleep pattern, hypertonicity,
convulsions
Nasal congestion w/ flaring, apnea, tachypnea <60/min
3. A nurse is caring for a client who is in the second stage of labor. The nurse observes the fetal head retract against the clients
perineum immediately following emergence . Which of the following actions should the nurse take?
1. Assess fetal position using Leopold maneuvers
2. Reposition the client in a left lateral position??? Not sure
3. Apply pressure to the clients suprapubic area
4. Empty the client’s bladder using Crede’s maneuver
Pg 189) Prepare to apply suprapubic pressure to aid in the delivery of the anterior shoulder, which is located inferior to
the maternal symphysis pubis.
4. A client and her partner ask the nurse for information about permanent contraception. Which of the following statements should
the nurse include in the counseling?
1. “A man is usually sterile immediately after a vasectomy”- must use birth control after procedure. Is not effective until 20
ejaulations or 1 week to several months to allow all sperm to clear
2. “The menstrual cycle is shorter after a tubal ligation”
3. “Most sterilization procedures are considered irreversible”
4. “A woman should use contraception for 1-2 months after a tubal ligation”
5. A nurse is providing education to a client who is to receive misoprostol for induction of labor. Which of the following instructions
should the nurse include in the teaching?
1. “ I will insert a urinary catheter before I administer the medication” -??
2. “I will begin an oxytocin infusion w/in 2 hrs of your last dose of medication”
3. “You will like on your side for 40 minutes after I administer the medication
4. “You will receive an antacid containing magnesium before the medication”
-uterine stimulant. Controls postpartum hemorrhage. Assess uterine tone and vaginal bleeding
-postpartum hemorrhage nursing care: massage fundas. Insert urinary catheter to assess kidney functions to obtain accurate urinary
output for bladder distention. Elevate legs.
6. A nurse is assessing a client who is in her second trimester for common physiological changes during pregnancy. The nurse notes a
blotchy discoloration on the client’s forehead, nose & cheeks. Which of the following changes should the nurse document p. 17
chapter 3
1. Linea nigra-dark line pigmentation from umbilicus to the pubic area.
2. Epulis- not found on ati book, but it is a tumor on the mouth caused by gingervitis.
3. Striae gravidarum - stretch marks found on abdomen and thigh
4. Chloasma -increase pigmentation on the face
7. A charge nurse is discussing STIs w/ a newly licensed nurse. Which of the following infections should the nurse include in the
teaching as an indication for a cesarean birth p . 50 ch 8
1. Gonorrhea- spread genital to genital
2. Chlamydia
3. HIV
4. Syphilis
- INDICATIONS for C-Section
::::::: Malpresentation, Non-reassuring fetal heart tones
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