ATI MATERNAL NEWBORN PROCTORED EXAM, Exams of Nursing

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ATI MATERNAL NEWBORN PROCTORED EXAM

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ATI MATERNAL NEWBORN PROCTORED EXAM Anurse is planning care for a newborn who is receiving photother- apy for an elevated bilirubin level. Which of the following actions should the nurse take? A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the following findings should the nurse expect? A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the following actions should the nurse perform? A nurse is caring for a client who is in preterm labor and is re- ceiving magnesium sulfate. The client begins to show indications of magnesium sulfate toxicity. Which of the following medications should the nurse prepare to administer? A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. D. Use a photometer to monitor the lamp's energy The nurse should monitor the lamp's energy throughout the ther- apy to ensure the newborn is receiving the appropriate amount to be effective. Dark red vaginal bleeding The nurse should expect this client with a mild placental abruption to have minimal dark red vaginal bleeding. Correct Answer: B. Assess the newborn's blood glucose level Infants who become cold attempt to generate heat through in- creased muscular and metabolic activity. This process increas- es glucose consumption and puts the newborn at risk of hypo- glycemia. Incorrect Answers: A. The nurse should not obtain a rectal temperature from a new- born due to the risk of rectal perforation. Instead, the nurse should obtain an axillary temperature. C, Bathing a newborn will increase heat loss. The infant should not be bathed until the temperature has stabilized within the normal range. D. Placing the infant in front of a heater vent can incur heat loss through convection. Additionally, there is a potential fire risk from the bassinet linens and the vent. Correct Answer: C. Calcium gluconate The nurse should discontinue the magnesium sulfate infusion immediately and prepare to administer calcium gluconate IV to reverse the effects of magnesium sulfate and to prevent cardiac and respiratory arrest. Incorrect Answers: A. Protamine sulfate helps reverse the effects of heparin, not magnesium sulfate B. Naloxone is an opioid reversal agent. It does not reverse the effects of magnesium sulfate. D. Flumazenil reverses the effects of benzodiazepines such as lorazepam and alprazolam, not magnesium sulfate. Correct Answer: "Place fresh cabbage leaves on your breasts." After 3 days postpartum, the client's breasts can become swollen and distended because of congestion of the vascular structures of the breasts. Fresh cabbage leaves can be applied to engorged breasts to help relieve breast discomfort. The coolness of the leaves and the phytoestrogens exert a therapeutic effect on engorged breasts. Leaves should be replaced when they become wilted Which of the following pieces of information should the nurse include? A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and vomiting. Which of the following statements should the nurse include in the teaching? A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states, "I've heard that | can't use any birth control until | stop breastfeeding." Which of the following responses should the nurse make? Incorrect Answers A. The client should be instructed to wear a tight-fitting bra or breast binders to alleviate engorgement and swelling C. Application of warmth to the breasts should be avoided be- cause heat can stimulate milk production. An ice pack should be used to relieve engorged breasts. D. Milk should nat be expressed from the breasts. This intervention would increase milk production rather than decrease it. Correct Answer: D. "You shauld eat dry foods that are highin carbohydrates when you wake up." The nurse should instruct the client to eat foods that are high in carbohydrates such as dry toast or crackers upon waking or when nausea occurs. Incorrect Answers: A. The nurse should instruct the client to eat foods served at cool temperatures to decrease nausea and vomiting B. The nurse should instruct the client to avoid brushing her teeth immediately after eating to decrease vomiting. C. The nurse should instruct the client to eal sally and lart foods during periods of nausea Correct Answer: D. “A progestin-only pill or injection is available for use while you are breastfeeding.” Pragestin-only injections, implants, and birth control pills are ac- ceptable options for clients who are breastfeeding, although some experts recommend waiting until 6 weeks postpartum to initiate the medication Incorrect Answers: A. Breastfeeding can inhibit ovulation or prolong menstruation; however, it is not a reliable and effective means of birth control. The client may experience an unplanned pregnancy if she waits until her periods resume before cansidering birth control optians. B. Estrogen-containing birth control pills, implants, patches. and vaginal rings are not recommended for clients who are breast- feeding due to the risk of inhibiting breast milk production and supply. C. Condoms and other non-hormonal birth control methods are appropriate for clients who are breastfeeding; however, there are other methods that are also appropriate. Correct Answer: D. Urine output 20 mL/hr Opioid analgesics such as morphine can cause urinary retention. The client should have a urinary output of at least 30 mL/hr. The nurse should report this finding to the provicer. Incorrect Answers: 2/27 The parents of a child with phenylketonuria (PKU) ask the nurse if their second unborn child could have the same condition. The nurse should base the response on which of the following inher- itance patterns responsible for PKU? A nurse is teaching a client about physiological changes that can occur with menopause. Which of the following changes should the nurse include? A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? Incorrect Answers: A.PKU does not have an X-linked recessive pattern of inheritance. In X-linked recessive disorders, the abnarmal gene is carried on the X chromosome. In males, only 1 copy of the abnormal gene is required for the disorder to be expressed in males since the Y chromosome does not carry the disorder. Females must have 2 capies of the gene. Examples of this type of disorder are hemophilia and color blindness. B. PKU does not have an X-linked dominant pattern of inheritance. In X-linked dominant disorders, the abnormal gene is carried on the X chromosome. Only 1 copy of the abnormal gene is neces- sary for the disorder to occur. However, males are more likely to be severely affected due to the homozygous expression. There are only a few disorders that follow this pattern of inheritance. Examples include vitamin D-resistant rickets and Rett syndrome. D. PKU does not have an autosomal-dominant pattern of in- herilance. In these disorders, only 1 copy of the variant gene is necessary for the disorder to occur. Examples of this type of disorder are neurofibromatosis and Treacher Collins syndrome. Correct Answer: C. Stress incontinence The nurse should teach the client that stress incontinence can occur due to the shrinking of the uterus, vulva. and distal portion of the urethra Urinary incontinence and uterine displacement can occur be- cause of common age-related changes but are not necessarily a result of menopause-related changes. Incorrect Answers: A. The nurse should teach the client that urinary frequency, not hesitancy, can occur due to the shrinking of the uterus, vulva, and distal portion of the urethra B. The nurse should teach the client that hematuria is a mani- festation of irritation to the bladder mucosa and might indicate a urinary tract infection. Itis not an expected change associated with menopause. D. The nurse should teach the client that vaginal dryness can occur with menopause due to the vaginal walls becoming thinner and drier, delaying lubrication. This can lead to painful intercourse. Correct Answer’ B.Sponge balhe the newborn every olher day Daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The parents should sponge bathe the infant until the cord stump has detached and the area has healed Incorrect Answers: A. In uncircumcised males, the foreskin acheres to the glans of the penis. Parents should not attempt to retract the foreskin before the age of 3 years. Parents should wash the penis with soap and water. C. The parents should avoid using antimicrobial soaps and instead use soap with a neutral pH and no preservatives to protect the acid mantle of the newborn's skin. A postpartum nurse is caring for a client who is 4 hours postpar- tum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take? A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching? A nurse is caring for a newborn who is premature at 30 weeks gestation. Which of the following findings should the nurse ex- pect? D. The parents should maintain the bath water temperature be- tween 38° and 40°C (100° and 104°F). Correct Answer: Apply cald ice packs to the client's perineum A third-degree laceration extends from the perineum to the ex- ternal sphincter of the rectum. This can cause severe discomfort. Cold ice packs are used on the perineal area during the first 24 hours to decrease edema, pain, and discomfort. Incorrect Answers: A. Warm silz baths are appropriale afler the first 24 hours post- partum. A cool sitz bath is recommended within the first 24 hours to reduce edema and promote comfort B. The nurse should encourage the client to sit on firm surfaces, The client should avoid soft pillows and conut pillows because they separate the buttocks and decrease venous blood flow, re- sulting in more pain and discomfort to the perineal area D. The use of suppositories or enemas is contraindicated for a client who has a third-degree perineal laceration due to the severity of the laceration Correct Answer: “| will place my baby on his back when puiling him to sleep." Newborns should always sleep on the back ta prevent sudden infant death syndrome Incorrect Answers: B. The parents should not place the newborn's crib close to a heat source due to the risk of the crib linen catching on fire. C. The parents should always place the newborn in an approved car seat while driving with the newborn. Infant carriers are not approved safety seats for motor vehicles D. The parents should never tie any type of string or cord around the newborn's neck due lo the risk of strangulation. Correct Answer: Abundant lanugo Newborns who are premature have abundant lanugo (fine hair), especially over their back. A full-term newborn typically has min- imal lanugo present only on the shoulders, pinna, and forehead. Incorrect Answers: B. Newborns who are premature demonstrate hypotonia and a re- laxed posture. Full-term newborns demonstrate moderate flexion of the arms and legs. C. Newborns who are premature have few heel creases. Full-lerm newborns have heel creases that cover most of the battom of the feet. D. Newborns who are premature have abundant vernix caseosa, a thick whitish substance, covering and protecting their skin in utero. Past-mature newborns are likely to have dry, parchment-like skin Correct Answer: Assess the newborn for respiratory depression A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide? A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? A nurse is assessing a client who is at 12 weeks gestation and has a hydatidiform mole. Which of the following findings should the nurse expect? Show Explanation Prurilus gravidarum is a condition of pregnancy thal causes gen- eralized itching without the presence of a rash. This occurs due to the stretching of the skin. Exposure to sunlight can reduce itching Incorrect Answers: B, Prurilus gravidarum is a condilion of pregnancy thal causes generalized itching that occurs due to the stretching of the skin. It will resolve without extensive treatment after delivery. C. Pruritus gravidarum is a condition of pregnancy that will go away after delivery. It has no effect on the liver. Therefore. the client will not require weekly liver function studies. D. Isotretinoin cream is used to treat acne. It should nat be pre- scribed to a client who is pregnant due to its teratogenic effects on the fetus. Correct Answer: Pelvic inflammatory disease (PID) An ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and the placenta, and the fetus begin to develop in this area. The most common site is within a fallopian tube, bul ectopic pregnancies can occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery. Therefore, PID places the client at risk of an ectopic pregnancy Incorrect Answers A. Anemia does not place the client atincreased risk of an ectopic pregnancy. B. Frequent urinary tract infections do not increase the risk of ectopic pregnancy. C. Aprevious cesarean birth does not place the client atincreased risk of an ectopic pregnancy. Correct Answer: Dark brown vaginal discharge A hydatidiform mole (a molar pregnancy) is a benign proliferative growth of the chorionic villi that gives rise to multiple cysts. The products of conception transform into a large number of edematous, fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grape-like clusters. Incorrect Answers: A. The nurse should expecl the client's lemperalure lo be wilhin the expected reference range because a hydatidiform mole does not lead to hypothermia C. The nurse should expect the client to have increased urinary output due to the elevated maternal blood volume and pressure of the uterus on the maternal bladder. D. The nurse should not expect to hear fetal heart tones because a viable embryo or fetus is not present. Correct Answer: Frequent headaches A nurse in an antepartum clinic is caring for a client who is at 24 weeks gestation. Which of the following findings should the nurse report to the provider? Show Explanation A nurse is caring for a client who has oligohycramnias. Which of the following fetal anomalies should the nurse expect? Anurse is assessing a client on the first postpartum day. Findings include the following: fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following actions should the nurse take? Show Explanation A nurse is monitoring a client wha is receiving spinal anesthesia. The nurse should identify which of the following findings as a The nurse should report frequent headaches lo the provider. Frequent headaches, swelling of the face and fingers, visual dis- turbances, and epigastric pain are associated with preeclampsia. Incorrect Answers: B. Leukorrhea is a common discomfort of pregnancy and is an abdundant amount of vaginal mucus that may occur throughout pregnancy. C. Epistaxis is a common discomfort of pregnancy related to the increase of estragen D. Periodic numbness of the fingers is a common discomfort of pregnancy due to compression of the nerves and does not need to be reported to the provider. Carrect Answer: Renal agenesis Oligohydramnios is a volume of amniotic fluid that is <300 mL during the third trimester of pregnancy. This occurs when there is a renal system dysfunction or obstructive uropathy. The absence of fetal kidneys will cause aligohydramnios. Incorrect Answers: A. Fetal cardiac anomalies do not affect the volume of amniotic fluid. C. Fetal neural tube defects do not affect the volume of amniotic fluid, D. Fetal hydrocephalus does not affect the volume of amniotic fluid. Correct Answer: Ask the client when she last voided Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be firm at the midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void Incorrect Answers A. A slight maternal temperature increase is commonly seen in the first 6 to 10 days postpartum. A pulse of 52/minute is within the expected reference range. B. The nurse should massage the fundus when it is boggy. D. Administering an oxytocic agent is not an appropriate inter- vention. Oxytocic agents are given to clients who have increased lochia rubra or a boggy fundus to promote uterine contractions Correct Answer: Maternal hypotension Maternal hypotension is a common adverse effect of a spinal block. To prevent supine hypotension, the client should lie on a side or lie supine with a wedge under a hip to displace the uterus. Incorrect Answers. B. Spinal anesthesia is more likely to cause fetal bradycardia than A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take? Show Explanation A nurse is caring for a client who is in labor and is reporting intense pain during contractions. The client has no previous knowledge of nonpharmacological comfort measures. Which of the following nursing interventions should the nurse implement? A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following medications should the nurse have available at the client's bedside? vasodilatation, which also promotes healing and comfort. Incorrect Answers: C. The nurse should instruct the client to perform Kegel exercises to strengthen perineal muscles following a vaginal delivery. How- ever, these exercises do not decrease episiotomy discomfort. D. The nurse should adminisler prescribed analgesics, including topical anesthetic cream. However, the cream should be applied no more than three to four times per day. Correct Answer: D. Slow-paced breathing Slow-paced breathing is an easy technique for the client to learn quickly and practice immediately. It provides distraction, which can help reduce the perception of pain. The pattern is In-2-3-4/Out-2-3-4/In-2-3-4/Out-2-3-4, Repeating this cycle slows the client's breathing to about half of its usual rate, which can help relax the client and improve oxygenation. Incorrect Answers: A. Self-hypnosis can help relieve labor pain, but clients might not be able to perform it if they haven't already learned from specially trained practitioners. B. Biofeedback can help relieve labor pain, bul clients might nol be able to implement it if they haven't already learned from specially trained practitioners. C. Specially trained practitioners perform acupuncture, so this is not something the nurse can initiate. Correct Answer: Calcium gluconate The nurse should have calcium gluconate available for a client who is receiving magnesium sulfate by continuous IV infusion in case of magnesium sulfate toxicity. The nurse should monitor the client for a respiratory rate of d12/min, muscle weakness, and depressed deep-tendon reflexes. Incorrect Answers: A.The nurse should have naloxone available for a client whois receiving opioid medication in case of respiratory depression. C. The nurse should have protamine sulfate available for a client who is receiving heparin in case of hemorrhage. D.The nurse should have atropine available for a client who is re- ceiving medications that can lead to asystole or sinus bradycardia, such as beta-adrenergic blockers. Correct Answer: Fetal asphyxia Oxytocin may cause tachysystole, which can lead to uteroplacen- tal insufficiency. Inadequate oxygen transfer to the placenta will result in fetal asphyxia. Incorrect Answers: A nurse is caring for a client wha is in labor and is receiving an infusion of oxytocin. The nurse should monitor the client for which of the following potential adverse effects? A nurse is caring for a client who is receiving magnesium sulfate IV. Which of the following medications should the nurse have available as an antidote ta magnesium sulfate? Show Explanation A nurse is teaching a client about breastfeeding. Which of the following client statements indicates an understanding of the teaching? Show Explanation Anurse is discussing contraceptive choices with a client who has a history of thrombophlebitis. Which of the following methods of contraception should the nurse recommend? Show Explanation A. Diarrhea is nol an adverse effect of oxylocin administration. Oxytocin can have adverse effects that include fetal asphyxia, water intoxication. hypotension, and abruptio placentae. B. Thromboembolism is not an adverse effect of oxytocin admin- istration. D. Oliguria is not a likely complication of oxytocin administration. Correct Answer: Calcium gluconate Calcium gluconate should be kept available as the antidote for magnesium sulfate toxicity. Incorrect Answers: A Betamethasone is administered to help mature the lungs of the premature fetus before delivery. It is not an antidote to magnesium sulfate. B. Terbutaline is a smooth muscle relaxer administered to inhibit uterine contractions in premature labor. It is not an antidote to magnesium sulfate. D. Indomethacin relaxes uterine smooth muscle and is adminis- tered to stop preterm labor. It is not an antidote to magnesium sulfate Correct Answer: "| may notice increased cramping when | am feeding my baby." The client may notice an increase in uterine cramping while breastfeeding due to the release of oxytocin, which causes uterine muscle contraction Incorrect Answers: A.A client who is breastfeeding requires an additional 500 calories per day to support lactogenesis. B. The client should not introduce an artificial nipple to the new- born until breastfeeding is well established (in approximately 3 or 4 weeks). D.The client should breastfeed on demand, not place the newborn on a strict feeding schedule. Forcing a newborn to wait for a feeding can lead to weight loss and failure lo thrive. orrect Answer: Copper intrauterine device A history of thrombophlebilis is a contraindication for the use of hormonal contraceptive methods such as oral combinations of estragen and pragesterone in pill form, vaginal inserts that release hormones continuously, and injectable progestins. A copper in- trauterine device that does not contain hormones is a safer choice for this client. Other options for this client include barrier mathads and spermicides. Incorrect Answers: B. A hislory of thrombophlebilis is a contraindication for laking oral contraceptives. Safer methods of contraception for this client include barrier methods and spermicides. A nurse is assessing a client who has placenta previa. Which of the following findings should the nurse expect? Anurse is calculating a pregnant client's estimated dale of deliv- ery using Naegele's rule. The client's last menstrual period started on January 20. Which of the following is the client's expected date of delivery? Show Explanation A nurse is reviewing the laboratory findings for 4 clients. Which of the following infections should be reported to the public health department? Show Explanation A client at a routine prenatal care visit asks the nurse if developing vaginal yeast infections is common during pregnancy. Which of the following responses should the nurse make? Correct Answer: A. Painless, bright red bleeding Placenta previa is the placement of the placenta low in the ulerus. Depending on the severity. manifestations include bright red vagi- nal bleeding and a fundal height higher than expected for the geslalional age. The presenting parl is higher due lo the placenta taking up space inside the lower part of the uterus. Incorrect Answers:B. Uterine hypertonicity is a manifestation of placental abruplion, nol placenta previa C. Uterine tonicity is normal with placenta previa; it does not cause contractions. D. Abdominal tenderness or pain is a manifestation of placental abruption, not placenta previa. Correct Answer: C. October 27 Nagegele's rule involves subtracting 3 months from the first day of the last menstrual period and adding 7 days. Incorrect Answers:A. An expected date of delivery of October 13 would follow a last menstrual period date of January 6. B. An expected date of delivery of November 13 would follow a last menstrual period date of February 6. D. An expected date of delivery of November 27 would follow a last menstrual period date of February 20. Carrect Answer: D. Gonorrhea Gonorrhea is often asymptomatic. The client might have purulent endocervical discharge. Gonorrhea is one of the infectious con- ditions on the Nationally Notifiable Infections list and should be reported by the nurse to the community health department, which will report the infection to the CDC. Incorrect Answers:A. Bacterial vaginosis, also known as vagini- tis, is the most common vaginal infection. Manifestations include client report of a “fishy odor" and vaginal discharge that appears thin, watery, gray, white, or milky. The client might also report pru- ritus. This vaginal infection does not require reporting; however, it should be treated with metronicazole or clindamycin cream. B. Trichomoniasis can be asymptomatic. Manifestations include greenish to yellowish mucopurulent, frothy, malodorous discharge. This vaginal infection does not require reporting. C. Candidiasis, also known as a yeast infection, is the sec- ond-most common vaginal infection. Manifestations include a client report of thick, cottage cheese-like discharge and vaginal itching. This vaginal infection does not require reporting Correct Answer: B. "The hormonal changes of pregnancy alter the acidity of the vagina, making yeast infections more common." This is an information-seeking question; therefore, the therapeutic response is an answer that provides the client with the information she requested Incorrect Answers:A. This is a close-ended response that discour- ages further communication C. This is a close-ended response that discourages further com- munication and is both nontherapeutic and inaccurate. D. Asking "why" questions typically makes clients feel defensive. A nurse is planning care for a client in labor who is positive for HIV. Which of the following actions should the nurse take after the baby is born? Show Explanation A nurse is assessing a client who is at 36 weeks of gestation. Which of the fallowing manifestations should the nurse recognize as a potential prenatal complication and report to the provider? A nurse is caring far a client who had a precipitous delivery. Which of the following assessments is the priority during the fourth stage of labor? A nurse is caring for a client who has eclampsia and just had a tonic-clonic seizure. After turning the client's head to the side, Correct Answer: B. Administer the hepatitis B vaccine prior to discharge Infants who are exposed to HIV should receive all routine vaccina- tions. Infants who are infected with HIV can receive all inactivated vaccinations. Incorrect Answers:A. In the United States and Canada, breast- feeding should be avoided by mothers who are HIV-positive. C. The nurse should use standard precautions when caring for a newborn who has been exposed to HIV. D. To test a newborn for the presence of HIV, a sample of the newborn's blood must be obtained. Maternal antibodies will be present in the cord blood and can affect the test results. Correct Answer: B. Double vision Double vision, blurred vision, or visual disturbances are signs of potential complications associated with preeclampsia. The nurse should report this finding to the provider. Incorrect Answers:A. Varicose veins are a common manifestation associated with pregnancy. They are caused by the relaxation of the smooth muscle walls of the veins and pelvic vasacongestion. C. Leukorrhea is a hormonal production of an abundant amount of mucus. It is a common manifestation associated with pregnancy. D. Flatulence is a common manifestation associated with preg- nancy. Progesterone causes reduced gastrointestinal motility. Correct Answer: Cc. Palpating the client's fundus The nurse should apply the safety and risk-reduction priorily-set- ting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safely, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. A precipitous delivery follows a labor of <3 hours. Regardless of the cause of the rapid delivery, uterine atony can result, causing postpartum hemorrhage. The nurse should palpate the fundus and massage as needed to monitor for and reduce the risk of hemorrhage Incorrect Answers:A. The nurse should monitor the client's tem- perature during the fourth stage of labor; however, another as- sessment is the priority. B. The nurse should assess the client's perineum, especially if an episiotomy or laceration is present; however, anather assessment is the priority. D. The nurse should check the client for hemorrhoids during the fourth stage of labor: however, another assessment is the priority. Correct Answer: ion Give oxygen at 10 L/min via face mask The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to administer oxygen to help stabilize the client's respiratory status. Incorrect Answers:A. The nurse should administer magnesium sulfate to prevent further seizure activity; however, there is anather 27 A nurse is caring for a newborn immediately following birth. Which of the following actions should the nurse take first? A nurse is performing a physical assessment of a newborn. Which of the following actions should the nurse take? A nurse is caring for a client who recently gave birth and plans to breastfeed. Which of the following actions should the nurse take? A nurse is caring for a client at 34 weeks gestation who presents with vaginal bleeding. Which of the following assessments will indicate whether the dleeding is caused by placenta previa or an abruptio placenta? Show Explanation Correct Answer: D. Dry the newborn The greatest risk to (he newborn immediately afler birth is heal loss, which can cause cold stress, respiratory distress, and hypo- glycemia. Therefore, the first action the nurse should take is to dry the newborn to prevent heal loss from evaporalicn. Incorrect Answers:A. The nurse should obtain the newborn's weight within 1 to 2 hours after birth. However, there is another action the nurse should take first. B. The nurse should instill erythromycin ophthalmic ointment in the newborn's eyes afler the first breastfeeding lo prevent infection However, there is another action the nurse should take first. C. The nurse should administer vitamin K to the newborn within 1 to 2 hours after birth to prevent bleeding. However, there is another action the nurse should take first. Correct Answer: Cc. Measure the circumference of the newborn's head with a tape measure just adove the eyebrows Shortly after birth, the nurse should measure the circumference of the newborn's head at its largest diameter, which is around the occipitofrontal area. Incorrect Answers:A. The nurse should measure the newborn's length from the top of the head to the heel. B. The nurse should remove the newborn's diaper and clothing to measure weight. D. The nurse should measure the newborn's chest circumference at the nipple line, not below it. Correct Answer: A. Place the unwrapped newborn on the mother's bare chest. Skin-lo-skin contact will maintain the newborn's temperature and illicit instinctive newborn feeding behaviors. Incarrect Answers:B. Breastfed infants should not be fed anything except breast milk unless deemed medically necessary. C. Newborns should never be bathed under running water. The temperature of the water could change and cause burns or cold stress in the newborn. Adcitionally, bathing shauld be delayed until the completion of the first breastfeeding. D. Routine care such as bathing, weighing, eye prophylaxis, and a vitamin K injection should all be delayed until after the infant has completed the first feeding. Correct Answer: A. Uterine tone The uterus will be relaxed, soft. and painless if the bleeding is caused by placenta previa. With abruptio placenta, the uterus will be firm and board-like, and the client will complain of pain. Incorrect Answers:B. Fetal distress may be present in both abrup- tio placenta and placenta previa C. Hypotension may be present in both conditions. D. The amount cf blood loss is not diagnostic of the cause of the bleeding Correct Answer A. “Apply ice packs to your breasts." A nurse is teaching about preventing engorgement to a client who is planning to use formula to feed her newborn. Which of the following instructions should the nurse include? A nurse is providing teaching to a client who is at 8 weeks gestation about manifestations to report to the provider during pregnancy. Which of the following pieces of information should the nurse include in the teaching? A nurse is caring for a client who experienced a fetal loss. When initiating communication with this client, which of the following statements should the nurse make? A nurse is assisting with an amniocentesis for a client who is Rh-negative. Which of the following actions should the nurse take following the procedure? Show Explanation Applying ice packs to the breasts can assist in reducing the discomforts of engorgement. Incorrect Answers:B. Pumping or hand expressing can cause breast stimulation and continued milk production. C. The client should wear a well-fitted and supportive bra for the first 72 hours after delivery ta assist with suppression of lactation. D. No medications are indicated for lactation suppression. Correct Answer: D. Blurred or double vision Acient who is pregnant should report experiencing blurred or double vision, as these could be a manifestation of gestational hypertension or preeclampsia Incorrect Answers:A. A client who is pregnant can have nausea upon awakening due to changes in hormone levels. B. A client who is pregnant can experience leg cramps while sleeping due to the compression of the pelvic nerves by the enlarged uterus. C. A client who is pregnant can have an increase in vaginal discharge due to hyperstimulation of the cervix from an increase in hormones. Correct Answer: B. “I'm here for you if you would like to talk.” This is a therapeutic statement because it acknowledges the client's loss and invites her to share her thoughts anc feelings. Incorrect Answers:A. This is a nontherapeutic statement because the nurse should not presume to know how the client feels after a fetal loss. C. This is a nontherapeutic statement because it gives common advice. Furthermore, the nurse should never deny the bond that many pregnant women feel with the fetus throughout pregnancy. D. This is a nontherapeutic statement because it gives unwanted reassurance that has no basis in fact. Furthermore, the nurse should never assume that any other chile could take the place af the lost child. Correct Answer: Cc Administer immune globulin to the client to prevent fetal isoimmu- nization Because the client is Rh-negative, Rh immune globulin is admin- istered after the procedure to prevent fetal isoimmunization or help ensure maternal antibodies will not form against any placental red blood cells that might have accidentally been released into the maternal bloodstream during the procedure. Incorrect Answers:A. The provider screens the client for chlamydia during a pelvic examination rather than through an amniocentesis. B. Testing the client's blood for Rh antibodies is done at the beginning of pregnancy and repealed at 28 weeks. This diagnostic test is performed an the client's 5load rather than amniotic fluid D. The provider performs the amniocentesis with sterile technique; although infection is a risk with any invasive procedure, the routine administration of prophylactic antibiotics is not indicated. Correct Answer: A "Crib slats should be less than 2.25 inches apart.” A nurse is providing teaching about the rubella immunization to a client who is 24 hours postpartum. Which of the following client statements indicates an understanding of the teaching? Show Explanation Anurse is assessing a postpartum client who has preeclampsia and notes a boggy ulerus and excessive ulerine bleeding. The nurse should plan to administer which of the following medica- tions? Show Explanation Anurse is caring for a client in the third trimester of pregnancy who is scheduled to undergo a non-stress test. Which of the following actions should the nurse take prior to the test? Show Explanation A nurse is providing education to a client who is 4 weeks postpar- lum and is breastfeeding. The client asks aboul expecled weight loss. Which of the following responses should the nurse make? Show Explanation While the chances of ferlilily in the first 4 weeks postpartum are low, clients who receive a rubella immunization must be acdi- tionally careful to avoid pregnancy either through maintaining ab- stinence or through using an effective contraceptive. The rubella vaccine is @ live virus vaccine and can cause birth defects. Incorrect Answers:A. The rubella vaccine is a live virus vaccine, but the live attenuated rubella virus is not passed via breastmilk. However, it can be spread via other bodily fluids such as urine. If there are other family members who are immunocompromised, the vaccine should not be administered to the client B. A single rubella vaccine postpartum is adequate for most non-immune clients. If a client also receives RhoGAM postpar- tum, the client should be tested 3 months postpartum to verify immunity. D. The rubella vaccine is administered as the MMR (measles, mumps, and rubella) vaccine subcutaneously. orrect Answer: Cc. Oxytocin Oxytocin is a ulerolonic medication thal causes the ulerus lo contract and reduces excessive uterine bleeding. Incorrect Answers:A. Terbutaline is a tocolytic medication that causes ulerine relaxation and is used to treat preterm labor. Itis not an appropriate medication to treat uterine atony. B. Magnesium sulfate is a tocolytic medication used to treat preterm labor and decrease the risk of eclamptic seizures. It is not an appropriate medication to treat uterine atony. D. Methylergonovine is a uterotonic medication that has an ad- verse effect of hypertension. Therefore, this medication is con- traindicated for a client who has preeclampsia. Correct Answer: A Ask the client to drink a glass of orange juice The nurse should give the client orange juice or a glucose prepa- ration prior to this test. This should raise the client's blood glucose level and help promote fetal movement. Incorrect Answers:B. A non-stress test involves the application of a fetal heart monitor and a tocodynamometer to track uterine contractions and fetal movement. There is no vaginal examination with this procedure. C. Anon-stress test evaluates the fetal heart rate's response to uterine contractions and fetal movement. It does not involve the client's hemoglobin level. D. Anon-stress test evaluates the fetal heart rate's response to uterine contractions anc fetal movement. It does not involve identifying indications of a urinary tract infection in the client. Correct Answer: A. "Losing 2.2 pounds each month would be acceptable." An important postpartum goal is for the client to lose the weight gained during pregnancy. An acceptable amount of weight loss for a client who is lactating is 1 kg (2.2 Ib) per month. Incorrect Answers:B. C. D.. Clients who are not lactating should lose approximately 0.5 to 0.9 kg (1.1 to 2 Ib) per week. orrect Answer: Cc. Infection Anurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn? Show Explanation A nurse is caring for a client who is in labor and has received epidural analgesia. The client's blood pressure is 88/50 mmHg, and the fetal heart tracing shows late decelerations. Which of the following actions should the nurse take? Show Explanation A nurse is caring for a primigravid client who is al 8 weeks ges- tation with twins. The client states that even though she and her husband planned this pregnancy, she is experiencing ambivalent feelings about it. Which of the following responses should the nurse make? Show Explanation A nurse is caring for a client at 37 weeks gestation who is un- dergoing a nonsiress test. The fetal heart rate (FHR) is 130/min without accelerations for the past 10 min. Which of the following actions should the nurse take? Show Explanation 20 Blood group incompalibililies, maternal infection, malernal dia- betes, and the administration of oxytocin during labor are potential risk factors for the development of hyperbilirubinemia in newbarns. Incorrect Answers:A. Placenta previa is not a potential risk factor for hyperbilirubinemia in newborns. B. Multiple gestation is not a potential risk factor for hyperbiliru- binemia in newborns. D. Anemia is not a potential risk factar for hyperbilirubinemia in newborns. Correct Answer: B. Increase the rate of the primary IV infusion Late decelerations can be caused by uteroplacental insufficiency. The fetal heart tracing shows a gracual decrease in fetal heart rate with a return to baseline on uterine contractions. This could be related to maternal hypotension, which can be corrected with increased IV fluids to increase maternal bload volume. This im- proves uterine and cardiac perfusion as well Incorrect Answers:A. A client who has received epidural analgesia should not be assisted out of bed to the toilet or a bedside commode due to inhibited muscle control and the increased risk of falling. C. Maternal position influences both maternal hypotension and the fetal response to low blood pressure. Positioning the client in a lateral or Trendelenburg position impraves maternal circulation D. Hypotension is a function of low blood pressure rather than low blood glucose. The nurse should address low blood pressure through positianing and bolus IV fluids. Correct Answer: B. "These feelings are quite normal at the beginning of pregnancy." This client needs reassurance that these feelings are normal and that there is no reason for concern. Incorrect Answers:A. C. This nontherapeutic response puts the client's feelings on hold and insinuates that there is a problem that needs to be resolved D. This is an inappropriate response because the client's feelings are normal, and there is no reason for cancern. Correct Answer, A. Use vibroacoustic stimulation on the client's abdomen for 3 sec The nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity because the fetus is most likely sleeping. Fetal movement should cause accelerations in the FHR. Incorrect Answers:B. The nurse will determine a nonstress test to be nonreaclive afler 40 minules of conlinuous monitoring without accelerations in the FHR despite vibroacoustic stimulation C. The client should have an internal fetal scalp electrode during labor to monitor the FHR. D. The external fetal monitor is recording the FHR. Therefore, it is not necessary for the nurse to auscultate the FHR with a Doppler. Correct Answer: 0.25 To solve using the ratio and proportion method: Step 1: What is the unit of measurement the nurse should calcu- late? mg 27