Vaginal examinations reveal that a laboring client cervix is dilated 2cm, 70% effaced, with presenting part at -2 station. The client tells the nurse " I need my epidural now! This hurt!" The nurse response to the client
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Vaginal examinations reveal that a laboring client cervix is dilated 2cm, 70% effaced, with presenting part at -2 station. The client tells the nurse " I need my epidural now! This hurt!" The nurse response to the client should be based on which information. - ANSWER Administering an epidural at this point would slow the labor process.
The client will need to be catheterized before the epidural can be administered. A client who is HIV+ is receiving zidovudine during labor. Which information should the nurse provide to the client? - ANSWER This treatment helps prevent transmission of the virus to the fetus.
A newborn's head circumference is 12 inches (30.5cm), and his chest measurement is 13 inches (33cm). The nurse notes that this infant has no molding, and was at breech presentation delivery by c section. What action should the nurse take based on these data? - ANSWER Record the finding on the chart. They are within normal limits.
A three hour old newborn of a gestational diabetic mother who is asymptomatic and successful breastfed after birth, heel stick glucose level is 36 mg/dL. Which intervention should the nurse do first? - ANSWER Assist the mother to breastfeed the infant
The nurse is caring for a female client, a primigravida with preeclampsia. Finding include +2 proteinuria, BP 172/112 mmHg, Facial and hand sweating, complaints of blurry vision, and a severe frontal headache. Which medication should the nurse anticipate for this client? - ANSWER Magnesium sulfate
When planning care for a laboring client, the nurse identifies the need to withhold solid foods while the client is in labor. What is the most important reason for this nursing intervention? - ANSWER An increase risk for aspiration can occur if general analgesic is needed.
Which action should the nurse take if an infant, who wa born yesterday weighing 7.5 lbs - ANSWER Inform and assure the mother that this is normal weight loss.
A client at 20 week gestation comes to the antepartum clinic complaining of vaginal warts. HPV What information should the nurse provide? - ANSWER The client should be treated with acyclovir.
At 34 weeks gestation, a primigravida is assessing at her bimonthly clinic visit. Which assessment finding is important for the nurse to report to the HCP. - ANSWER Weight gain of 7 lbs
A client in preterm labor has had an infusion of magnesium sulfate running 8 hrs. Current assessment finding are: RR 14 bpm, UOP 24 - ANSWER The finding indicate potential toxicity to magnesium sulfate and close follow up is indicated.
the nurse notes that a newborn at 24hrs of age has a large cephalhematoma. Which intervention has the highest priority. - ANSWER Assess the infant for jaundice every 8 hours
The charge nurse working on a postpartum unit is making assignments for a staff consisting of a nurse, practical nurse and 2 unlicensed assistive personnel. which client should the charge nurse assign to the practical nurse? - ANSWER A multagraida who delivered during c section 20 min ago and needs her vital signs taken.
The nurse is providing anticipatory guidance for an African-American client who is at 24-weeks gestation. Which prenatal lab assessment, prescribed at 28-weeks, should the nurse includes - ANSWER One-hour glucose screen
A new mother asks the nurse why her infant son has a needle mark on his leg. Which response is best for the nurse to provide the mother? - ANSWER Your baby was given an injection of vitamin K to prevent bleeding
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's... - ANSWER Heat loss
An oxytocin induction was started for a gravid client 6 hours ago. When assessing the FHR on the electronic fetal monitor, the nurse notes a "U-shaped" pattern... Which intervention should the nurse implement first? - ANSWER Change the position of the client
A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that began one hour ago. The nurse's assessment reveals approximately 30 ml of bright red vaginal bleeding, FHR of 130 to 140 beats/min, no contraction, and no complaints of pain. What is the most likely case of this client's bleeding? - ANSWER placenta previa
A pregnant woman in the first trimester of pregnancy has a Hb 8.6 mg/dL and HCT 25.1%. What food should the nurse encourage this client to include in her diet? - ANSWER Chicken
A gravida 3 para 3 who is Rh-negative delivers a full-term infant at home with the assistance of a nurse-midwife. Two days later, the client calls the clinic to ask if it is necessary to see the healthcare provider since the infant is healthy, and she is not having any complications. The woman's history indicates that both previously born infants were Rh-negative. Which response should the nurse provide? - ANSWER The newborn's blood type should be tested to determine the need for RhoGAM .
Following the vaginal delivery of a 10 pound infant, the nurse assess a new mothers vaginal bleeding and finds that she has saturated two pad
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