1. At 42 weeks' gestation a client gives birth to an 8-lb 5-oz newborn. On examining the infant, what does the nurse expect to observe? Select all that apply.
2. A neonate born at 36 weeks' gestation, weighing 2043 g
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1. At 42 weeks' gestation a client gives birth to an 8-lb 5-oz newborn. On examining the infant, what does the nurse expect to observe? Select all that apply.
2. A neonate born at 36 weeks' gestation, weighing 2043 g (4 lb 8 oz), is placed under a radiant warmer. An infusion of D10% 0.2 NS is running through an umbilical vein catheter at a rate of 12 mL/hr. Why is it important for the nurse to check the neonate's voidings for specific gravity?
3. When checking the cervical dilation of a client in labor, a nurse notes that the umbilical cord has prolapsed. What is the priority nursing action?
4. What does a nurse expect to find when checking the vital signs of a client in the early postpartum period?
5. A 26-year-old primigravida experiencing severe abdominal pain is brought to the emergency department by ambulance with a suspected ruptured tubal pregnancy. What should the nurse do first?
6. Why should a nurse teach pregnant women the importance of conserving the "spurt of energy" before labor?
7. One minute after birth a newborn is crying vigorously and has an apical pulse of 130 beats/min. The nurse notes acrocyanosis and flexion of the extremities. What is the newborn's Apgar score?
8. What should the nurse include in the plan of care for a neonate who is undergoing phototherapy?
9. The nurse concludes that a couple with a newborn with Erb's palsy has an accurate understanding of the infant's prognosis. Which statement confirms this conclusion?
10. Pregnant women with cardiac problems must be assessed frequently. Which adaptation does the nurse suspect is the result of early decompensation?
11. A client at 37 weeks' gestation is brought to the emergency department because of sudden abdominal pain. Abruptio placentae is suspected, and the client is transferred to the birthing unit. The nurse should assess the client for:
12. A nurse assesses a primigravida who has been in labor for 5 hours. The fetal heart rate tracing is reassuring. Contractions, which are of mild intensity, are lasting 30 seconds and are 3 to 5 minutes apart. An oxytocin (Pitocin) infusion is prescribed. What is the priority nursing intervention at this time?
13. The nurse is caring for a couple after the birth of their first child. What should the nurse tell the family to do when their infant is exhibiting the behavior demonstrated in the picture?
14. A newborn's discharge from the hospital is being delayed because of a rising reticulocyte count. The infant's mother, who is being discharged, asks the nurse why her baby must stay. The nurse's response is based on an understanding that the infant must be observed for:
15. A client with mild preeclampsia is instructed to rest at home. She asks the nurse, "What do you mean by rest?" What is the most appropriate response?
16. During the postpartum period increased cardiac output with tachycardia is expected in the mother. This knowledge should motivate a nurse who is caring for a client with cardiac problems to monitor her for:
17. When the fetal head begins to crown during an emergency precipitous birth, the nurse responds by:
18. A nurse performing a newborn assessment elicits the Babinski reflex. The nurse concludes that finding indicates:
19. When a nurse brings a newborn to a mother, the mother comments about the milia on her infant's face. What information should the nurse include when responding?
20. A client who just gave birth has three young children at home. She comments to the nursery nurse that she must prop the baby during feedings when she returns home because she has too much to do and, anyway, holding babies during feedings spoils them. What is the nurse's best response?
21. An almost term client reports that her fetus is moving less this week than last week. Which responses are appropriate? Select all that apply.
22. A nurse is caring for a client in labor. What assessment finding reveals that the transition phase of labor has probably begun?
23. A client's severe preeclampsia develops into eclampsia. After the seizure, the client has a temperature of 102° F (39° C). What does the nurse suspect as the cause of the temperature?
24. The nurse is caring for a patient that has just had an amniotomy performed by the health care provider. The fetal heart rate immediately decreased from 140 to 80 beats/min. What is the priority nursing action?
25. A client is receiving an intravenous piggyback infusion of oxytocin (Pitocin) to augment labor. The nurse identifies three contractions lasting 80 to 90 seconds less than 2 minutes apart. A specific protocol is followed in response to this observation. List in order of priority the nursing actions that should be taken.
26. A nurse is assessing the newborn of a known opioid user for signs of withdrawal. What clinical manifestations does the nurse expect to identify? Select all that apply.
27. After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which signs met the criteria of 2 points? Select all that apply.
28. A client who had a severe abruptio placentae asks the nurse why there was so much bleeding. What should the nurse consider as the cause of the heavy bleeding before responding in language that the client will understand?
29. A pregnant client with type 1 diabetes is visiting the prenatal clinic for the first time. What is the primary long-term goal for this client?
30. A contraction stress test (CST) is performed on a client at 40 weeks' gestation. The findings are interpreted as negative. What does the nurse conclude from this interpretation?
31. After the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking." How should the nurse respond?
32. A nurse who is caring for a mother and her newborn infant reviews their record. In light of the data the record contains, what nursing intervention is required?
a. Chart/Exhibit 1
33. A client is admitted to the high-risk unit in preterm labor. A loading dose of 6 g of magnesium sulfate over 20 minutes is prescribed, to be followed by 2 g/hr. Premixed stock is available with 40 g of magnesium sulfate in 1000 mL of D5W. At a rate of how many milliliters should a nurse set the infusion pump to complete the loading dose? Record your answer as a whole number. ___ mL/hr
34. The husband of a client in labor asks about an indentation on his wife's abdomen. The nurse explains that it is a retraction ring (Bandl's ring). What is the next nursing action?
35. A nurse is caring for a pregnant woman with class II cardiac disease. The client has anemia with a hemoglobin level of 8 g/dL. What is the nurse's major concern for this client?
36. A nurse is estimating a newborn's gestational age. What parameters should the nurse assess? Select all that apply.
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