hesi test practice questions – Flashcards
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A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate?
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Tachycardia and a feeling of nervousness.
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side effects of magnesium sulfate
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Depressed reflexes and increased respirations. A flushed, warm feeling and a dry mouth.
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Terbutaline sulfate (Brethine), a beta-sympathomimetic drug,
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stimulates beta- adrenergic receptors in the uterine muscle to stop contractions
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primary side effect. Terbutaline sulfate (Brethine), a
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Tachycardia and a feeling of nervousness.
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secondary side effect of Terbutaline sulfate (Brethine), a
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Drowsiness and bradycardia.
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The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take?
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Observe the mother for other attachment behaviors.
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To assess for other attachment behaviors, continued observation of the new mother's interactions with her infant
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Observe the mother for other attachment behaviors. helps the nurse determine problems in attachment. Ask the mother why she won't look at the infant may cause undue confusion, stress, or impact the mother's self-confidence.
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A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective?
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Changes in apical heart rate from the 180s to the 140s.
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Epogen
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given to prevent or treat anemia, stimulates erythropoietin production, resulting in an increase in RBCs. Since the body has not had to compensate for anemia with an increased heart rate, changes in heart rate from high to normal
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Epogen and RR
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Respiratory rate should decrease rather than increase
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Epogen and urinary output
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is not related to Epogen
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Epogen and bilirubin
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is usually related to resolution of hyperbilirubinemia, treated with phototherapy or increased oral intake in the infant.
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A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain?
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Date of last normal menstrual period. Evaluating the gestation of the pregnancy (C) takes priority. If the fetus is preterm and the fetal heart pattern is reassuring, the healthcare provider may attempt to prolong the pregnancy and administer corticosteroids to mature the lungs of the fetus.
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A 30-year-old multiparous woman who has a 3-year-old boy and an newborn girl ␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ manage both children when I get home." How should the nurse respond?
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Regression in behaviors in the older child is a typical reaction so he needs attention at this time.
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Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as
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a cephalhematoma, caused by forceps trauma and may last up to 8 weeks. Cephalhematoma (A), a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and the skull
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A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness?
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Correctly place the infant on the breast.
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The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.)
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A. Admission weight of 4 pounds, 15 ounces (2244 grams). B. Head to heel length of 17 inches (42.5 cm). C. Frontal occipital circumference of 12.5 inches (31.25 cm).
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appropriate for gestational age (AGA) newborn
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should fall between the measurement ranges of weight, 6-9 pounds (2700-4000 grams);; length, 19-21 inches (48-53 cm);; FOC, 13-14 inches (33-35 cm).
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SGA neonate's parameters
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Skin smooth with visible veins and abundant vernix. E. Anterior plantar crease and smooth heel surfaces.
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riteria for physical maturity score Ballard (Dubowitz) scale.
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Full flexion of all extremities in resting supine position.
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A pregnant client tells the nurse that the first day of her last menstrual period ␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ delivery?
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May 29, 2007. ␣␣␣␣␣␣␣␣ rule is used to calculate the expected date of delivery, and is obtained by subtracting 3 months and adding 7 days beginning from the first day of the last normal menstrual period.
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The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is recommended for which purpose?
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Screen for neural tube defects
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A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first?
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Obtain a specimen for urine analysis Obtaining a urine analysis (C) should be done first because preterm clients with uterine irritability and contractions are often suffering from a urinary tract infection, and this should be ruled out first.
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The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern?
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Edema, basilar rales, and an irregular pulse.
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The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside?
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A sterile glove An amnihook. Lubricant
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A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse perform first?
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Bathe the infant with an antimicrobial soap
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The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?
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Have the client breathe into her cupped hands.
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A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?
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Patellar reflex 4+. A 4+ reflex in a client with pregnancy-induced hypertension (A) indicates hyperreflexia, which is an indication of an impending seizure.
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A 4+ reflex in a client with pregnancy-induced hypertension (A) indicates hyperreflexia, which is an indication of an impending seizure.
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Check the infant's oxygen saturation rate.
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The nurse should encourage the laboring client to begin pushing when
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the cervix is completely dilated.
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The nurse is planning preconception care for a new female client. Which information should the nurse provide the client?
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Encourage healthy lifestyles for families desiring pregnancy. Planning for pregnancy begins with healthy lifestyles in the family (D) which is an intervention in preconception care that targets an overall goal for a client preparing for pregnancy.
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A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complaint indicates that the fallopian tubes are patent?
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Shoulder pain If the tubes are patent (open), pain is referred to the shoulder (C) from a subdiaphragmatic collection of peritoneal dye/gas.
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A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this client?
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Do you have a history of rheumatic fever? Clients with a history of rheumatic fever (D) may develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the increased blood volume that occurs during pregnancy, so obtaining information about this client's health history is a priority
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A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client?
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Take prescribed multivitamin and mineral supplements. A client who has had a spontaneous abortion or still birth in the last 11⁄2 years should take multivitamin and mineral supplements (D) and maintain a balanced diet because the previous pregnancy may have left her nutritionally depleted
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The nurse is assessing a client who is having a non-stress test (NST) at 41- weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take?
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Ask the client if she has felt any fetal movement. The client should be asked if she has felt the fetus move (D). An NST is used to determine fetal well-being, and is often implemented when postmaturity is suspected. A "reactive" NST occurs if the FHR accelerates 15 bpm for 15 seconds in response to the fetus' own movement, and is "nonreactive" if no FHR acceleration occurs in response to fetal movement. The client should empty her bladder before starting the test, but bladder distention does not impede fetal movement
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A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?
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Epigastric pain. Epigastric pain (C) is indicative of an edematous liver or pancreas which is an early warning sign of an impending convulsion (eclampsia) and requires immediate attention.
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A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client?
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Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
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When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation?
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Vernix is a white, cheesy substance, predominantly located in the skin folds.
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When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?
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At 30-weeks gestation.
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A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement?
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Describe diet changes that can improve the management of her diabetes.
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During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions? (Arrange in order.) A. Reposition the client. B. Call the healthcare provider. C. Increase IV fluid. D. Provide oxygen via face mask.
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To stabilize the fetus, intrauterine resuscitation is the first priority, and to enhance fetal blood supply, the laboring client should be repositioned (1) to displace the gravid uterus and improve fetal perfusion. Secondly, the IV fluids should be increased (2) to expand the maternal circulating blood volume. Next, to optimize oxygenation of the circulatory blood volume, oxygen via face mask (3) should be applied to the mother. Then, the primary healthcare provider should be notified (4) for additional interventions to resolve the fetal stress.
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On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) is
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November 22. Nagele's ␣␣␣␣␣␣ rule for estimating the due date by counting back 3 months from the first day of the last menstrual period (January, December, November) and adding 7 days (15+7=22).
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Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?
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Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?
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A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?
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Meet the mother's physical needs and demonstrate warmth toward the infant. It is most important to meet the mother's requirement for attention to her needs so that she can begin infant care-taking (D). Nurse theorist Reva Rubin describes the initial postpartal period as the "taking-in phase," which is characterized by maternal reliance on others to satisfy the needs for comfort, rest, nourishment, and closeness to families and the newborn
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The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?
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Observe for an asymmetrical Moro (startle) reflex. The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fractured clavicle should be suspected if an infant has limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex (B), crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.
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A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn?
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Infant's condition at birth and treatment received. Immediate care is most dependent on the infant's current status (i.e., Apgar scores at 1 and 5 minutes) and any treatment or resuscitation that was indicated. The transitional care nurse needs the information listed in the choices
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Immediate care is most dependent on the infant's current status (i.e., Apgar scores at 1 and 5 minutes) and any treatment or resuscitation that was indicated. The transitional care nurse needs the information listed in the choices
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Increase the rate of IV fluids.
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Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take?
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Place the woman in a lateral position
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A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation should the nurse provide?
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Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day.
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One hour after giving birth to an 8-␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣␣ has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse take immediately?
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Call the healthcare provider to question the prescription. Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription
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A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?
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Move about every hour
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The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception?
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Between the time the temperature falls and rises.
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The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do?
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Reduce activity level and notify the healthcare provider.
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A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse implement?
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Extend the leg and dorsiflex the foot.
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Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client?
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The client's readiness to learn.
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The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant?
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Gonorrhea. chlamydia
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The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention?
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chlamydia
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The nurse is calculating the estimated date of confinement (EDC) using ␣␣␣␣␣␣␣␣ rule for a client whose last menstrual period started on December 1. Which date is most accurate?
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September 8.
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A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is:
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a persistent cold.
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A client in active labor complains of cramps in her leg. What intervention should the nurse implement?
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Extend the leg and dorsiflex the foot.
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A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement?
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Document the finding in the infant's record.
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While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother?
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The scalp edema will subside in a few days after birth. Caput succedaneum is edema of the fetal scalp that crosses over the suture lines and is caused by pressure on the fetal head against the cervix during labor;; it subside in a few days after birth without treatment
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A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge?
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It is difficult to consume 18 mg of additional iron by diet alone.
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A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best?
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That is normal;; the head will return to a round shape within 7 to 10 days.
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An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father?
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Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement. These behaviors are positive signs of maternal/fetal bonding
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A client at 32-weeks gestation is hospitalized with severe pregnancy- induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?
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A decrease in respiratory rate from 24 to 16. Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory rate (C) indicates that the drug is effective. (Respiratory rate below 12 indicates toxic effects.)
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A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?
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Urine output 90 ml/4 hours. Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.
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The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate?
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Grief related to her perceptions about the loss of this child.
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The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding?
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Three vessels: two arteries and one vein
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A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child?
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They use lubricants with each sexual encounter to decrease friction. The use of lubricants (D) has the potential to affect fertility because some lubricants interfere with sperm motility.
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Which action should the nurse implement when preparing to measure the fundal height of a pregnant client?
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Have the client empty her bladder.
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Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse perform next?
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Initiate positive pressure ventilation. The nurse should immediately begin positive pressure ventilation (A) because this infant's vital signs are not within the normal range, and oxygen deprivation leads to cardiac depression in infants. (The normal newborn pulse is 100 to 160 beats/minute and respirations are 40 to 60 breaths/minute.) Waiting until the infant is 1 minute old to intervene may worsen the infant's condition. According to neonatal resuscitation guidelines, CPR is not begun until the heart rate is 60 or below or between 60 and 80 and not increasing after 20 to 30 seconds of PPV. (D) can be checked after treating the respiratory rate.
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The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement?
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Encourage the mother to breastfeed frequently.
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The nurse is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?
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A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged. When the presenting part is ballottable (D), it is floating out of the pelvis. In such a situation, the cord can descend before the fetus causing a prolapsed cord, which is an emergency situation.
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A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurse's response should be based on what information?
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Each pregnancy carries a 50% chance of inheriting the disorder.
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The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period is
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January 30-31
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A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client?
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There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair. (D) provides correct information and attempts to alleviate anxiety related to knowledge deficit. The anterior fontanel or "large soft spot" has a strong epidermal membrane present, which can be touched
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The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the nurse to assess the client for which condition?
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Gestational diabetes.
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An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?
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Put the newborn to breast. Putting the newborn to breast (D) will help contract the uterus and prevent a postpartum hemorrhage--this intervention has the highest priority. It is not necessary to tie off the umbilical cord
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During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have
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weights.
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When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.) A. Mood swings. B. Panic attacks. C. Tearfulness. D. Decreased need for sleep. E. Disinterest in the infant.
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Mood swings. Tearfulness.
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Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?"
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Lying prone with a pillow on the abdomen. Lying prone (A) keeps the fundus contracted and is especially useful with multiparas, who commonly experience afterpains due to lack of uterine tone.
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A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited?
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Choking, coughing, and cyanosis. includes the "3 Cs" of esophageal atresia caused by the overflow of secretions into the trachea.
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pyloric stenosis in the infant.
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Projectile vomiting and cyanosis.
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characteristic of diaphragmatic hernia.
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Scaphoid abdomen and anorexia
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Which nursing intervention is helpful in relieving "afterpains" (postpartum uterine contractions)?
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Using relaxation breathing techniques.
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A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the nurse take?
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Apply cold compresses to both breasts for comfort.
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A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?
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Raise the foot of the bed.
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The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class?
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Feed your baby every 2 to 3 hours or on demand, whichever comes first.
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A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best?
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A home pregnancy test can be used right after your first missed period.
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The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
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Monitor bleeding from IV sites Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruptio, characterized by abnormal bleeding. Invasive vaginal procedures (A and B) or (D) can increase the abruption and bleeding, so these interventions are contraindicated.
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Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is presenting with signs of placental abruption. Disseminated intravascular coagulation (DIC) is a complication of placental abruptio, characterized by abnormal bleeding. Invasive vaginal procedures (A and B) or (D) can increase the abruption and bleeding, so these interventions are contraindicated.
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Places the infant prone in the bassinet.
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client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide?
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It is important that you want to take part in your care. The emphasis of alternative and complementary therapies, such as herbal therapy, is that the client is viewed as a whole being, capable of decision-making and an integral part of the health care team, so (D) recognizes the client's request
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In evaluating the respiratory effort of a one-hour-old infant using the Silverman-Anderson Index, the nurse determines the infant has synchronized chest and abdominal movement, just visible lower chest retractions, just visible xiphoid retractions, minimal and transient nasal flaring, and an expiratory grunt heard only on auscultation. What Silverman-Anderson score should the nurse assign to this infant? (Enter numeral value only.)
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A Silverman-Anderson Index has five categories with scores of 0, 1, or 2. The total score ranges from 0 to 10. Four of the these assessment findings should receive a score of 1, and the 5th finding (synchronized chest and abdominal movement) receives a score of 0. Therefore, the total score is 4. A total score of 0 means the infant has no dyspnea, a total score of 10 indicates maximum respiratory distress.
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A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26- weeks gestation in preterm labor. She is started on an IV of ritodrine hydrochloride (Yutopar). What are the highest priority readings that the nurse should monitor frequently during the administration of this drug?
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Maternal and fetal heart rates. Monitoring the maternal and fetal heart rates (B) is most important when ritodrine is being administered. Ritodrine is a sympathomimetic agent that stimulates both beta 1 and beta 2 receptors. Stimulation of beta 1 receptors causes tachycardia (side effect of the drug) and stimulation of beta 2 receptors causes uterine relaxation (desired effect of the drug)
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A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the nurse document in this client's record
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3-1-1-0-3. describes the correct GTPAL. The client has been pregnant 3 times including the current pregnancy (G-3). She had one full-term infant (T-1). She also had a preterm (P-1) twin pregnancy (a multifetal gestation is considered one birth when calculating parity). There were no abortions (A-0), so this client has a total of 3 living children
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A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin?
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Hyperstimulation. Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the client is at risk for hyperstimulation (B) which can lead to tetanic contractions, uterine rupture, and fetal distress or demise
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The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs
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two weeks before menstruation
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A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide?
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Come to the clinic today for an ultrasound. Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound (A). Bleeding that has a sudden onset and is accompanied by intense uterine pain indicates abruptio placenta, which IS life- threatening to the mother and fetus--then (B) would be appropriate.
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In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal newborn, the
answer
anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.
question
Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the nurse to implement first?
answer
Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
question
After feeding a newborn, how should the nurse position the infant in the crib?
answer
On the right side.
question
A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider?
answer
A platelet count of 67,000/mm3.
