question

The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide? A. The kidneys and renal function are not fully developed. B. Warmth promotes sleep so the infant will grow quickly. C. A large body surface area favors heat loss to the environment. D. The thick layer of subcutaneous fat is inadequate for insulation.

answer

Thermoregulation, heat regulation, is critical to the survival of a neonate because the newborn's larger surface area (C) per unit of weight predisposes to heat loss. While keeping the infant warm may help the infant to sleep, it promotes transitional homeostasis, not growth (B). (A) is unrelated to cold stress of the newborn. (D) does not support the metabolic cascade that results from neonatal heat loss.

question

The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the nurse, "Wait..." Which response what be best for the nurse to make?

answer

Explore mother's concerns about infant receiving vitaK

question

The nurse is discussing the stages of labor with a group of women in the last month of pregnancy and provides examples of different positional techniques used during the second stage of labor. Which position should the nurse address that provides the best advantage of gravity during delivery? Lithotomy. Kneeling. Squatting. Walking.

answer

Squatting (B) helps to align the fetus with the pelvic outlet and allows gravity to assist in fetal descent and gives the client an adventitious position for birth.

question

A primigravida at 12-weeks gestation who just moved to the United States indicates she has not received any immunizations. Which immunization(s) should the nurse administer at this time? (Select all that apply.) Hepatitis B. Chickenpox. Rubella. Tetanus. Diphtheria.

answer

Tetanus. Diphtheria. Hepatitis B.

question

The father of a newborn tells the nurse, "My son just died." How should the nurse respond? "I understand how you feel." "I am sorry for your loss." "There is an angel in heaven." "You can have other children."

answer

"I am sorry for your loss." Correct

question

A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon fundal assessment, the nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement next? Observe maternal vital signs. Document the color of the lochia. Notify the healthcare provider. Assist the client to the bathroom.

answer

Fundus displacement commonly occurs in the early hours of the postpartum period due to urinary retention, so assisting the client to the bathroom (C) to void should be implement next.

question

An infant who weighs 3.8 kg is delivered vaginally at 39-weeks gestation with a nuchal cord after a 30-minute second stage. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide the parents about this finding? The pinpoint spots are benign and disappear within 48 hours. Further assessment is indicated. Petechiae occurs with forceps delivery. An increased blood volume causes broken blood vessels.

answer

The pinpoint spots are benign and disappear within 48 hours. Correct

question

The uterine contractions of a woman early in the active phase of labor are assessed by an internal uterine pressure catheter (IUPC). The nurse notes that the intrauterine pressure at the peak of the contraction ranges from 65 to 70 mm Hg and the resting tone range is 6 to 10 mm Hg. The uterine contractions occur every 3 to 4 minutes and last an average of 55 to 60 seconds. On the basis of this information, the nurse should:

answer

Document the findings, because they reflect the expected contraction pattern for the active phase of labor.

question

What action should the nurse implement to prevent conductive heat loss in a newborn?

answer

Placing a blanket on the scale provides a barrier to prevent conductive heat loss

question

While monitoring a client in active labor, the nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. Which information should the nurse report during a shift change?

answer

This is a sign of fetal accelerations; indicating fetal well being with labor progression

question

What action should the nurse implement when caring for a newborn receiving phototherapy? Reposition every 6 hours. Limit the intake of formula. Apply an oil-based lotion to the skin. Place an eyeshield over the eyes.

answer

Place an eyeshield over the eyes.

question

A 31-year old woman uses an OTC pregnancy test. She is taking phenytoin (Dilantin) for epilepsy, under stress, and not sleeping well. What could cause a false-positive result?

answer

anticonvulsants

question

A client who is breast feeding develops engorged breasts...what does nurse recommend to relieve?

answer

Continue to breast feed every two hours

question

Nonpharmacologic interventions for procedural pain in a newborn?

answer

Oral sucrose and non-nutritive sucking

question

Non-dairy sources of calcium

answer

canned sardines green, leafy vegetables

question

Infant respiratory distress intervention

answer

place under humidified oxygen hood

question

What gastrointestinal finding would be of concern in a pregnant client?

answer

Pica, can interfere with absorption with nutritive vitamins & minerals

question

Priority intervention during 4th stage of labor

answer

Assess for hemorrhage

question

Nursing intervention to be implemented when apnea monitor alarm sounds for third time

answer

Evaluate newborn's RR & color

question

Upon fundal assessment, uterus is boggy and displaced to the right and above the umbilicus. What action should be implemented first?

answer

Client should void to empty bladder; assist to bathroom

question

A client has been admitted for observation after undergoing CVS for Down Syndrome. What is priority assessment?

answer

Monitor client for uterine cramping

question

A client is receiving an oxytocin infusion for induction of labor. When the client begins active labor, the fetal heart rate (FHR) slows at the onset of several contractions with subsequent return to baseline before each contraction ends. What action should the nurse implement? Discontinue the oxytocin infusion. Insert an internal monitor device. Document the finding in the client record. Change the woman's position.

answer

Document the finding in the client record. Correct

question

Postpartum hemorrhage prescription

answer

Oxytocin

question

The nurse notes an irregular bluish hue on the sacral area of an infant. How should the nurse document this finding?

answer

Mongolian spots

question

Which action is the most important for the nurse to implement for a client at 36 weeks gestation who is admitted with vaginal bleeding?

answer

Determine FHR and maternal vital signs

question

The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at 32-weeks gestation who has severe preeclampsia with pulmonary edema. As the PAC enters the right ventricle, what is the priority nursing assessment? A. Monitor for premature ventricular contractions. B. Note any complaint of sudden chest pain. C. Assess fetal response to the procedure. D. Observe for maternal blood pressure change

answer

Monitor for premature ventricular contractions.

question

The nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics. The infant expels a bloody stool. What nursing action should the nurse implement? A. Decrease the amount of the feeding. B. Obtain a rectal temperature. C. Assess for abdominal distention. D. Institute contact precautions

answer

C. Assess for abdominal distention.

question

Which procedure evaluates fetal movement & fetal heart activity?

answer

Non-stress test

question

Purpose of folic acid?

answer

reduces risk for neural tube defects

question

What instruction most important to mother who is breastfeeding?

answer

Avoid alcohol

question

A client comes into clinic and complains that her left breast is erythamatous and painful. The client asks "Can I still breastfeed?" What is the best response?

answer

Continue breast feeding

question

While assessing a newborn, the nurse observes diffuse edema of soft tissues of the scalp that cross the suture lines. How should nurse document these findings?

answer

caput succadaneum

question

Permanent skin changes from pregnancy?

answer

striae gravidarum

question

A client in labor receives an epidural block. What intervention should the nurse implement first?

answer

Monitor BP

question

Pregnant client reports urinary frequency. What is the cause

answer

Growing uterus is putting pressure on the bladder.

question

Positive sign of pregnancy?

answer

fetal heart tones heard with doppler

question

A client has been in labor for 8 hours when her membranes rupture. What action should nurse 1st implement?

answer

Assess FHR & pattern

question

An infant with hyperbilirubinemia is receiving phototherapy. What intervention should be implemented?

answer

Monitor temperature

question

A client is bearing down with contractions crying out "the baby is coming!" What immediate action?

answer

visualize perineum for bulging

question

A woman asks nurse what the function of the placenta is in early pregnancy?

answer

secretes estrogen & progesterone

question

Discharge teaching for client released from hospital after placement of cerclage. What is important?

answer

Report uterine cramping or low back ache

question

A nulliparous client telephones to report she is in labor. What action should nurse implement?

answer

Ask client why she thinks she is in labor

question

Which newborn assessment finding suggests fetal alcohol syndrome?

answer

flat nasal bridge

question

A newborn infant is jaundiced due to Rh incompatibility. Which is important to report to HCP?

answer

bilirubin

question

A client is experiencing "back" labor and complains of intense pain in the lower lumbar-sacral area. What action should the nurse implement?

answer

Apply counter pressure against sacrum

question

A client at 28 weeks gestation experiences blunt abdominal trauma. Which should the nurse assess first for signs of internal bleeding?

answer

Changes in FHR patterns

question

During a preconception counseling session, what info should nurse provide?

answer

Include adequate folic acid in diet

question

Nurse administers Demerol Iv push 25 mg to laboring client who delivers in 90 minutes. What should be administered to infant?

answer

Narcan

question

What finding should nurse report for concealed hemorrhage in abruptio placenta?

answer

Hard board like abdomen

question

A macrosomic infant by forceps delivery should be assessed for

answer

serum glucose levels, signs of hypoglycemia

question

Risks for congenital heart defect occurring?

answer

Heart develops 3-5 weeks after conception

question

Nursing action for newborn experiencing symptoms fo drug withdrawal?

answer

swaddle snugly and hold tightly

question

Which finding indicates a 4-day old infant is receiving adequate breast milk?

answer

saturates 6-8 diapers a day

question

A client said she dropped a cooking utensil and her baby jumped in response. What information does nurse provide?

answer

Fetus can respond to sound by 24 weeks

question

Which finding indicates nurse to discontinue oxytocin?

answer

FHR is 180 w/o variability

question

Nursing intervention to enhance bonding during 4th stage of labor?

answer

Encourage early initiation of breast/formula feeding

question

Client concerned about weight gain of 17 pounds

answer

weight gain acceptable for number of weeks pregnant

question

newborn in on a 4 hour feeding schedule of formula. To meet daily caloric needs, how many ounces are recommended?

answer

3.5 ounces (19-21 ounces/day)

question

A 36 week gestation client w/ pregnancy-induced hypertension (PIH) is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report?

answer

Magnesium toxicity causes respiratory depression, so RR of 11 breaths per minute is vital.

question

What nursing action should be implemented when intermittently gavage-feeding a preterm infant?

answer

Allow formula to flow by gravity

question

A client who is at 24 weeks gestation presents to the ER holding her arm and complaining of pain. The client reports she fell down the stairs. Which observation should alert the nurse to a possible battering situation?

answer

Other parts of her body have injuries in different stages of healing

question

Which client should the nurse report to the HCP as needing a prescription for Rh Immune Globulin (Rhogham)?

answer

Primigravida mother who is Rh negative

question

What action should the nurse implement with the family when an infant is born with anencephaly?

answer

Prepare the family explore ways to cope with imminent death of the infant

question

What procedure should the nurse follow to implement a glucose screening?

answer

1. Wrap infant's foot with heel warmer for 5 minutes 2. Cleanse puncture site on the lateral aspect of the heel 3. Restrain the newborns foot with your free hand 4. Collect a spring-loaded automatic puncture device

question

The nurse on a postpartum unit receives report for 4 clients during a change of shift. Which client should the nurse assess for risk of postpartum hemorrhage?

answer

A multiparous client receiving magnesium sulfate during induction for severe preeclampsia

question

The nurse is assessing a full term newborn's breathing pattern. Which findings should the nurse assess further?

answer

1. chest breathing with nasal flaring 2. Diaphragmatic with chest retraction 3. Grunting heard with stethoscope

question

A neonate who is receiving an exchange transfusion for hemolytic disease develops respiratory distress, tachycardia, and a cutaneous rash. What nursing interventions should be implemented first?

answer

Stop the transfusion

question

Which statement by a client who is pregnant indicates to the nurse an understanding of the role of protein during pregnancy?

answer

Protein helps the fetus grow

question

Which action should nurse implement when caring for a newborn immediately after birth?

answer

Keep the newborn's airway clear

question

A client at 35 weeks gestation visits for prenatal checkup. Which complaint by the client warrants further assessment by the nurse?

answer

Periodic abdominal pain

question

A client at 8 months gestation tells the nurse that she knows her baby listens to her, but her husband tells her she is imagining things. What info should he nurse provide?

answer

The fetus is capable of hearing and does respond to the mothers voice

question

What prescription should the nurse administer to a newborn to reduce complications related to birth trauma?

answer

Vitamin K

question

A preterm infant with an apnea monitor experiences an apneic episode . Which action should the nurse implement first?

answer

Gently rub the infants feet or back

question

A gravid client develops maternal hypotension following regional anesthesia. What interventions should the nurse implement?

answer

1. Administer O2 2. Increase IV fluids 3. Place in lateral position 4. Monitor fetal status

question

Which cardiovascular finding should the nurse assess further in a client who is at 20 weeks gestation?

answer

Decrease pulse rate

question

A client delivers twins, one is stillborn, another is in ICU. As the nurse provides assistance to the bathroom, the client softly crying states, "I wish my baby could have lived". Which response is best for the nurse to provide?

answer

I am sorry for your loss. Do you want to talk about it?

question

A nurse assesses a male newborn with vital signs axillary temperature 95.1, HR 136 bpm, RR 48. Which action should nurse take first?

answer

Assess infant's blood glucose, as low temp is a sign of hyperthermia/hypoglycemia

question

The nurse is planning for care of 30 year old primigravida with pre-gestational diabetes. What is the most important factor?

answer

Degree of glycemic control during pregnancy

question

A client who want to deliver at home asks the nurse to explain the role of a nurse midwife. What information should the nurse provide?

answer

The pregnancy should progress normally and should be considered low risk

question

A client at 29 weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide?

answer

Ultrasonography

question

Which finding in the medical history of a postpartum client should the nurse withhold the administration of a routine standing order for methylergonovine maleate (Methergine)?

answer

pregnancy induced hypertension

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