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VATI RN Maternal Newborn Assessment
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A |charge |nurse |is |teaching |a |newly |licensed |nurse |about |substance |use |disorders |during |pregnancy. | Which |of |the |following |statements |by |the |newly |licensed |nurse |indicates |an |understanding |of |the | teaching? |- |VERIFIED |ANSWERS |✔Encourage |client |who |are |prescribed |methadone |to |breastfeed. -The |nurse |should |encourage |clients |who |are |prescribed |methadone |during |pregnancy |to |breastfeed | their |newborns |to |help |with |withdrawal |symptoms. A |nurse |is |caring |for |a |client |who |received |terbutaline |subcutaneously. |Which |of |the |following | findings |is |an |indication |the |medication |was |effective? |- |VERIFIED |ANSWERS |✔Decreased |frequency |of |contractions. -Terbutaline |is |a |tocolytic |medication |that |is |used |to |halt |preterm |labor. |Terbutaline |cause |relaxation | of |smooth |muscle, |which |decrease |uterine |activity. |Therefore, |the |nurse |should |identify |that |a | decrease |in |frequency |of |contractions |is |an |indication |that |terbutaline |was |effective. A |charge |nurse |is |discussing |care |of |clients |who |are |in |labor |with |a |newly |licensed |nurse. |Which |of | the |following |actions |should |the |charge |nurse |include |in |the |teaching |regarding |situations |requiring | an |amniotomy? |- |VERIFIED |ANSWERS |✔Placing |a |fetal |scalp |electrode. -A |fetal |scalp |electrode |is |attached |to |the |presenting |part |of |the |fetus |in |order |to |provide |accurate | continuous |monitoring |of |the |fetal |heart |rate. |If |the |client's |membranes |are |intact, |the |amniotic |sac | must |be |artificially |ruptured |prior |to |attaching |the |electrode |to |enable |access |to |the |presenting |part. A |nurse |is |reviewing |the |medical |record |of |a |client |who |has |preeclampsia |prior |to |administering | labetalol. |For |which |of |the |following |findings |should |the |nurse |withhold |the |medication? |- |VERIFIED | ANSWERS |✔Heart |rate |54/min -The |nurse |should |identify |that |a |heart |rate |of |54/min |is |below |the |expected |reference |range |of | 60 |to |100/min. |During |pregnancy, |the |heart |rate |increases | 10 |to |15/min |due |to |increased |blood |volume | and |increase |tissue |demands |for |oxygen. |Bradycardia |is |a |contraindication |for |the |administration |of | labetalol, |an |antihypertensive |medication. |Therefore, |the |nurse |should |withhold |the |medication |and | notify |the |provider. A |nurse |is |caring |for |a |client |who |is |at | 30 |weeks |of |gestation |and |observes |the |client |choking |while | eating |lunch. |The |client |is |unable |to |speak |or |cough. |Identify |the |sequence |of |steps |the |nurse |should | take |to |clear |the |airway |obstruction. |- |VERIFIED |ANSWERS |**✔1. |Stand |posterior |to |the |client.
- |Position |arms |under |the |client's |axilla |and |across |the |client's |chest.
- |Place |thumb-side |of |a |clenched |fist |to |the |client's |mid-sternum |area.
- |Initiate |chest |thrust |to |the |client |using |a |backward |motion. -If |the |client |becomes |unconscious, |the |nurse |should |perform |CPR |and |activate |emergency |medical | services. A |nurse |is |preparing |to |administer |an |opioid |analgesic |to |a |client |who |is |in |active |labor. |Which |of |the | following |assessments |should |the |nurse |perform? |(SATA) |- |VERIFIED |ANSWERS |✔Maternal |blood | pressure. | -Opioid |analgesic |can |cause |hypotension. |The |nurse |should |assess |the |clients |blood |pressure |before | and |after |administering |opioids. Pain |level. -The |nurse |should |assess |the |clients |baseline |pain |level |prior |to |administering |pain |medication |and | again |after |administering |pain |medication |to |determine |the |effectiveness |of |the |medication. |Opioid | analgesic |are |indicated |for |the |relief |of |moderate |to |sever |labor |pain. Fetal |heart |rate. -Opioid |analgesics |can |cause |fetal |bradycardia |and |changes |in |variability. |The |nurse |should |assess |the | fetal |heart |rate |prior |to |administering |an |opioid |analgesic |to |ensure |the |rate |is |within |the |expedited | reference |range |and |to |have |a |baseline |for |future |assessments. |The |nurse |should |provide |ongoing | assessments |of |fetal |heart |rate |throughout |labor |according |to |facility |protocol. A |nurse |is |reviewing |the |medical |records |of |a |client |who |is |at | 8 |wks. |of |gestation. |Which |of |the | following |findings |should |the |nurse |identify |as |a |risk |factor |for |developing |preeclampsia? |- |VERIFIED | ANSWERS |✔Rheumatoid |Arthritis. -The |presence |of |a |connective |tissue |disease, |such |as |rheumatoid |arthritis |or |systemic |lupus | erythematosus, |increase |a |clients |risk |for |developing |preeclampsia. A |nurse |is |reviewing |the |laboratory |results |for |a |postpartum |client |who |is |receiving |warfarin |for |deep- vein |thrombosis. |Which |of |the |following |laboratory |tests |should |the |nurse |monitor? |- |VERIFIED | ANSWERS |**✔International |normalized |ratio |(INR). -The |nurse |should |monitor |the |INR |of |a |client |who |is |taking |warfarin. |Prothrombin |time(PT) |is |also | measure |to |regulate |warfarin |therapy. |However, |PT |values |are |more |difficult |to |interpret. |INR | determined |by |multiplying |the |PT |by |a |correction |factor |based |on |the |specific |thromboplastin | preparation |used |for |the |test, |as |a |way |of |equalizing |laboratory |to |laboratory |variations.
A |nurse |is |reviewing |the |laboratory |results |for |a |client |who |is |at |29wks |of |gestation. |Which |of |the | following |results |should |the |nurse |identify |as |an |indication |of |a |prenatal |complication? |- |VERIFIED | ANSWERS |✔BUN | 30 |mg/dL -Above |the |expected |reference |range |of |10-20 |mg/dL |for |a |client |who |is |pregnant. |The |BUN |typically | decreases |during |pregnancy |due |to |the |increase |in |the |glomerular |filtration |rate. |The |nurse |should | identify |that |an |elevated |BUN |is |a |manifestation |of |preeclampsia |or |HELLP |syndrome, |potentially | serous |complications |of |pregnancy's. A |nurse |is |assessing |a |client |who |is |2hr |postpartum |and |has |saturated |a |perineal |pad |in |15min. |The | clients |skin |is |cool |and |clammy |to |touch. |Which |of |the |following |actions |should |the |nurse |take |first? |- |VERIFIED |ANSWERS |✔Firmly |massage |the |fundus. -The |greatest |risk |for |a |postpartum |client |who |is |experiencing |excessive |vaginal |bleeding |is |the | development |of |hypovolemic |shock, |which |can |lead |to |coma |and |death. |Uterine |atony |is |a |frequent | cause |of |excessive |vaginal |bleeding. |Therefore, |the |first |action |the |nurse |should |take |is |to |massage | the |clients |fundus |to |encourage |muscular |contractions, |which |will |decrease |bleeding. A |nurse |is |caring |for |a |client |who |is |at |28wks |of |gestation |and |has |received |two |doses |of |terbutaline | subcutaneously. |Which |of |the |following |adverse |effects |is |the |priority |for |the |nurse |to |report |to |the | provider? |- |VERIFIED |ANSWERS |✔Heart |rate: |132/min -The |nurse |should |notify |the |provider |of |tachycardia |greater |than |130/min; |therefore, |this |is |the | priority |finding. |The |client |might |also |report |chest |discomfort, |palpitations |and |have |arrhythmias. A |nurse |is |providing |teaching |for |a |client |who |is |2wks |postpartum |and |has |mastitis. |Which |of |the | following |instructions |should |the |nurse |include |in |the |teaching? |- |VERIFIED |ANSWERS |✔Apply |moist |heat |to |the |affected |breast. -The |application |of |warm |compresses |prior |to |feeding |or |pumping |promotes |the |flow |of |the |breast | milk |and |assists |to |ensure |complete |emptying |of |the |breast. |This |is |important |to |prevent |the | development |of |further |complications |such |as |the |formation |of |a |breast |abscess |or |chronic |mastitis. A |nurse |is |teaching |routine |prenatal |care |to |a |group |of |clients |who |are |pregnant. |Which |of |the | following |statements |by |a |client |indicates |an |understanding |of |the |teaching? |- |VERIFIED |ANSWERS | **✔I |will |have |monthly |prenatal |visits |for |the |first |28wks |of |pregnancy. -The |initial |visit |should |occur |in |the |first |trimester |with |monthly |visits |through |week |28, |and |every | 2 | weeks |until |week |36, |and |then |every |week |until |the |birth |of |the |newborn.
A |nurse |is |providing |client |teaching |regarding |an |intrauterine |device |(IUD). |Which |of |the |following | statements |should |the |nurse |include |in |the |teaching? |(SATA) |- |VERIFIED |ANSWERS |**✔1. |You |might | have |to |have |cultures |for |sexually |transmitted |infections |prior |to |placement |of |the |device. -If |the |provider |determines |the |client |is |at |risk |of |STI |they |might |require |the |collection |of |cultures |for | STI |prior |to |the |placement |of |the |IUD.
- |You |might |experience |irregular |spotting |the |first |few |months |after |placement |of |the |device.
- |You |will |need |to |sign |informed |consent |prior |to |the |procedure. A |nurse |is |assessing |a |client |who |is |at |33wks |of |gestation. |Which |of |the |following |findings |should |the | nurse |report |to |the |provider? |- |VERIFIED |ANSWERS |✔Epigastric |pain. -This |is |a |manifestation |of |preeclampsia. |Other |findings |the |nurse |should |report |include |severe |HA, | Blurred |vision, |confusion, |N&V, |and |decrease |urinary |output. A |nurse |is |assessing |a |client |who |is |6hrs |postpartum, |tachycardia, |and |has |cool |skin. |The |client | reports |that |they |have |been |bleeding |excessively. |Which |of |the |following |actions |should |the |nurse | take? |- |VERIFIED |ANSWERS |✔Initiate |and |infusion |of |oxytocin. -The |nurse |should |identify |that |the |client |is |exhibiting |manifestations |of |hypovolemic |shock, |which | can |be |caused |by |uterine |atony |and |is |a |medical |emergency. |The |nurse |should |initiate |an |infusion |of | 10-20 |units |of |oxytocin, |which |is |an |oxytocic |medication. |This |will |cause |the |uterus |to |contract |and | decrease |bleeding. A |nurse |is |monitoring |a |client |who |is |in |active |labor |and |observes |a |pattern |of |late |decelerations |on | the |fetal |monitor |tracing. |Which |of |the |following |findings |should |the |nurse |recognize |as |the |potential | cause |of |the |deceleration? |- |VERIFIED |ANSWERS |✔Fetal |hypoxia -Late |decelerations |are |caused |by |uteroplacental |insufficiency |or |a |decreased |blood |flow |from |the | uterus |to |the |placenta |during |contractions. |This |results |in |a |decreased |supply |of |oxygen |to |the |fetus | during |the |contraction. |This |pattern |can |be |cause |by |a |wide |variety |of |reasons |including |uterine |tone, |maternal |hypotension, |and |disorders |that |affect |the |placenta |such |as |maternal |diabetes, | preeclampsia |and |post |maturity. A |nurse |is |teaching |a |prenatal |class |to |a |group |of |parents |and |is |discussing |facilitation |of |sibling | acceptance |of |the |newborn. |Which |of |the |following |instructions |should |the |nurse |include |in |the | teaching? |- |VERIFIED |ANSWERS |✔The |patent |should |plan |to |spend |individual |time |with |the |older | sibling. -To |enhance |and |facilitate |sibling |acceptance |of |the |newborn.
A |nurse |is |preparing |to |administer |methotrexate |to |a |client |who |is |experiencing |an |ectopic | pregnancy. |Which |of |the |following |actions |should |the |nurse |take? |- |VERIFIED |ANSWERS |✔Wear | two |pairs |of |gloves |when |handling |the |medication. -Methotrexate |is |an |antineoplastic |agent |that |a |pharmacist |must |prepare |in |a |syringe |under |a |biologic |safety |cabinet |and |place |in |a |sealed |plastic |bag. |The |nurse |should |wear |two |pairs |of |gloves |when | removing |the |syringe |from |the |bag, |administering |the |medication, |and |disposing |of |the |syringe. A |nurse |is |completing |a |health |history |and |assessment |for |a |client |who |reports |they |are |pregnant. | Which |of |the |following |findings |is |a |presumptive |sign |of |pregnancy? |- |VERIFIED |ANSWERS | ✔Amenorrhea. -A |client |can |present |with |amenorrhea |for |a |variety |of |reasons |besides |pregnancy. A |nurse |is |caring |for |a |client |who |is |in |active |labor |and |is |scheduled |to |receive |epidural |anesthesia. | Which |of |the |following |actions |should |the |nurse |take? |- |VERIFIED |ANSWERS |✔Administer |lactated | Ringer's | 500 |mL |bolus |via |intermittent |IV |infusion |prior |to |epidural |placement. -To |prevent |hypotension. A |nurse |is |admitting |a |client |who |is |at |39wks |of |gestation |and |in |active |labor. |The |client |reports |being |positive |for |group |B |streptococcus |(GBS) |when |screened |at |36wks |of |gestation. |Which |of |the | following |actions |should |the |nurse |expect |to |take? |- |VERIFIED |ANSWERS |✔Administer |IV |antibiotic | prophylaxis. -To |decrease |the |risk |of |the |neonate |contracting |a |GBS |infection, |it |is |recommended |that |pregnant | clients |who |test |positive |for |GBS |receive |antibiotics |during |labor. A |nurse |is |reviewing |the |results |of |a |nonstress |test |for |a |client |who |is |at |37wks |of |gestation. |Which | of |the |following |findings |indicates |a |reactive |nonstress |test? |- |VERIFIED |ANSWERS |✔Fetal |heart | rate |(FHR) |accelerations |occur |with |fetal |movement. -A |nonstress |test |measures |the |response |of |the |FHR |to |fetal |movement. |Accelerations |of |the |FHR | with |fetal |movement |are |a |reassuring |sign |of |fetal |well |being. A |nurse |is |providing |teaching |about |nifedipine |for |a |client |who |is |at |34wks |of |gestation |and |has | gestational |HTN. |For |which |of |the |following |adverse |effects |should |the |nurse |instruct |the |client |to | notify |the |provider? |- |VERIFIED |ANSWERS |✔Irregular |heartbeat. -Cardiac |arrhythmia |is |a |potential |life-threatening |adverse |effect |of |nifedipine. |Therefore, |the |client | should |report |an |irregular |heartbeat |to |the |provider.
A |nurse |is |assessing |a |client |who |is |in |labor, |Which |of |the |following |findings |should |the |nurse |expect? |- |VERIFIED |ANSWERS |✔Decrease |in |blood |glucose |level. -Maternal |metabolism, |physical |exertion, |and |delivery |of |the |placenta |can |lead |to |a |decreased |blood | glucose |level. A |nurse |is |assessing |a |newborn |following |a |circumcision |48hrs |ago. |The |nurse |should |identify |that | yellow |exudate |covering |the |newborn's |glans |penis |indicates |which |of |the |following? |- |VERIFIED | ANSWERS |✔Healing. -After |24hrs, |yellow |exudate |usually |forms |over |the |glans |penis |and |remains |for |the |next |2-3 |days. |It | sometimes |forms |a |crust, |which |is |expected. |The |nurse |should |explain |that |the |yellow |film |the | guardians |will |see |is |granulation |tissue |as |the |circumcision |heals. |The |guardians |should |not |remove | this |tissue. A |nurse |is |performing |an |initial |assessment |during |a |client's |first |prenatal |visit. |The |client |states |that | her |last |menstrual |period |began |April |22. |Use |Nagele's |rule |to |calculate |the |expected |date |of |birth | (EDB). |- |VERIFIED |ANSWERS |✔ 0129 -Begin |with |the |first |day |of |the |clients |last |menstrual |period, |subtract | 3 |months, |and |add | 7 |days. A |nurse |is |assessing |a |newborn. |Which |of |the |following |findings |indicates |a |need |to |check |the | newborn's |blood |glucose |level |for |hypoglycemia? |- |VERIFIED |ANSWERS |✔Hypotonia -CNS |findings |of |hypoglycemia |include |lethargy |and |hypotonia, |as |well |as |jitteriness, |twitching, |poor | feeding, |temperature |instability, |apnea, |respiratory |distress, |and |seizures. A |nurse |is |teaching |a |class |to |clients |who |are |pregnant. |Which |of |the |following |topics |should |the | nurse |include |in |the |discussion |about |cesarean |birth? |(SATA) |- |VERIFIED |ANSWERS |**✔1. | Management |of |postpartum |pain -The |nurse |should |discuss |with |clients |that |they |will |have |incisional |pain |associated |with |uterine | involution.
- |Advantage |of |early |ambulation |post-surgical |procedure. -Early |ambulation |following |a |cesarean |birth |facilitates |circulation |in |the |lower |extremities, |preventing |stasis, |and |assists |with |relieving |gas |pains.
- |The |need |for |an |indwelling |urinary |catheter |during |delivery.
A |nurse |is |teaching |a |new |guardian |how |to |correctly |use |a |car |seat. |Which |of |the |following | statements |by |the |guardian |indicates |an |understanding |of |the |teaching? |- |VERIFIED |ANSWERS |✔I | should |keep |my |baby |in |a |rear-facing |car |seat |until |he |is |2yrs |old. | -Or |until |the |child |reaches |the |maximum |height |and |weight |for |the |seat. A |nurse |is |planning |to |obtain |a |blood |specimen |from |a |newborn |via |a |heel |stick. |Which |of |the | following |actions |should |the |nurse |take? |- |VERIFIED |ANSWERS |✔Cleanse |the |puncture |site |with | alcohol |gauze |prior |to |the |procedure. -Or |a |facility-approved |skin |cleanser |prior |to |the |procedure |to |minimize |the |risk |of |infection. A |nurse |is |teaching |a |client |who |has |hyperemesis |gravidarum |about |dietary |modifications. |Which |of | the |following |client |statements |indicates |an |understanding |of |the |teaching? |- |VERIFIED |ANSWERS | ✔I |will |eat |small, |frequent |meals |throughout |the |day. -The |client |should |focus |on |eating |small, |frequent |meals |throughout |the |day |and |consuming |foods | that |are |appealing. A |nurse |is |caring |for |a |group |of |clients |who |are |postpartum. |Which |of |the |following |clients |is |at |an | increased |risk |for |a |fall? |- |VERIFIED |ANSWERS |✔A |client |who |has |an |indwelling |urinary |catheter. -The |client's |required |medical |interventions, |such |as |IVs |and |urinary |catheters, |increase |the |risk |for | falls |from |tripping |over |tubing. |The |nurse |should |assist |the |client |when |getting |out |of |bed |and | ambulating |to |prevent |an |injury |from |a |fall. A |nurse |is |caring |for |a |client |who |is | 3 |days |postpartum. |Which |of |the |following |actions |should |the | nurse |take? |- |VERIFIED |ANSWERS |✔Obtain |a |vaginal |culture. -Fever |for | 2 |consecutive |days, |chills, |foul-smelling |lochia, |and |abdominal |tenderness |are | manifestations |of |endometritis, |an |infection |of |the |lining |of |the |uterus. |The |nurse |should |obtain |a | vaginal |culture |using |a |sterile |swab |to |collect |the |fluid |from |the |client's |vaginal |cavity |to |identify |the | organism. A |nurse |is |caring |for |a |client |who |is |in |active |labor |and |receiving |epidural |anesthesia. |The |client | reports |feeling |nauseated |and |experiences |a |blood |pressure |drop |from |125/70 |mm |Hg |to |90/50 |mm | Hg. |Which |of |the |following |actions |should |the |nurse |take |first? |- |VERIFIED |ANSWERS |✔Turn |the | client |to |a |lateral |position.
-The |greatest |risk |to |this |client |is |injury |from |maternal |hypotension |and |decreased |placental | perfusion; |therefore, |the |first |action |the |nurse |should |take |is |to |place |the |client |in |a |lateral |position | to |relieve |the |pressure |on |the |vena |cava |and |restore |venous |return. A |client |who |is |in |active |labor |is |admitted |to |a |labor |and |delivery |unit |and |reports, |"My |water |just | broke |and |my |baby |is |breech." |Which |of |the |following |actions |should |the |nurse |take |first? |- |VERIFIED | ANSWERS |✔Check |fetal |heart |tones. -A |variation |in |fetal |heart |tones |can |occur |due |to |a |prolapsed |umbilical |cord. |The |risk |of |a |prolapsed | cord |is |increased |with |noncephalic |presentations |when |the |membranes |are |ruptured. |Prolapse |of |the | cord |compromises |circulation |to |the |fetus. A |nurse |is |assessing |a |client |who |is |in |active |labor. |The |client |reports |back |labor |pains. |Which |of |the | following |nonpharmacological |interventions |should |the |nurse |provide |to |manage |the |clients |pain? |- | VERIFIED |ANSWERS |✔Encourage |the |support |person |to |apply |sacral |counterpressure. -Consistent |pressure |applied |by |the |support |person |using |the |heel |of |the |hand |or |fist |against |the | client's |sacral |area |will |lift |the |fetal |head |off |the |spinal |nerves |and |provide |relief |of |the |pain |in |the | lower |back. A |nurse |is |caring |for |a |client |who |had |a |vaginal |delivery |2hrs |ago |and |is |reporting |increasing |perineal | pain |and |pressure. |The |nurse |examines |the |clients |perineum |and |sees |a |4cm |(1.6in) |area |of |purplish | discoloration |with |swelling. |The |nurse |should |interpret |these |findings |as |which |of |the |following? |- | VERIFIED |ANSWERS |✔A |hematoma -A |hematoma |is |a |collection |of |blood |in |the |connective |tissue |while |the |overlying |skin |or |mucous | membranes |remain |intact. |Hematomas |develop |from |injury |to |soft |tissue |in |spontaneous |deliveries, | as |well |as |forceps-and-vacuum-assisted |deliveries. |Small |hematomas |usually |reabsorb |on |their |own, | but |large |ones |might |require |incision |and |ligation |of |bleeding |vessels. A |nurse |is |providing |discharge |teaching |to |a |postpartum |client |who |had |no |immunity |to |rubella |and | received |the |rubella |immunization. |Which |of |the |following |statements |by |the |client |indicates |an | understanding |of |the |teaching? |- |VERIFIED |ANSWERS |✔I |can |breastfeed |my |baby |even |though |I | received |this |immunization. -According |to |the |CDC, |breastfeeding |should |not |delay |a |client |from |receiving |the |rubella | immunization. A |nurse |is |assessing |a |1-hr-old |newborn. |Which |of |the |following |findings |should |the |nurse |report |to | the |provider? |- |VERIFIED |ANSWERS |**✔Generalized |petechiae
A |nurse |is |providing |discharge |instructions |to |the |parents |of |a |newborn |about |bathing. |Which |of |the | following |statements |by |the |parent |indicates |an |understanding |of |the |instructions? |- |VERIFIED | ANSWERS |✔We |will |wash |out |newborn's |face |first. -Bathing |should |proceed |from |the |cleanest |part |of |the |body |to |the |most |soiled |areas. |First, |from |the | eyes |and |face, |then |to |the |trunk |and |extremities, |and |then |to |the |diaper |area |to |prevent |the |spread | of |infection |or |cross |contamination. A |nurse |is |interviewing |a |client |who |is |at |10wks |of |gestation. |Which |of |the |following |statements |by | the |client |should |the |nurse |investigate |further? |- |VERIFIED |ANSWERS |✔I |just |want |to |stay |in |bed |all |day |because |nothing |interest |me |anymore. -Feelings |of |sadness |marked |by |loss |of |interest |in |usual |activities |can |indicate |depression, |which |is | not |a |normal |adaptation |to |pregnancy. A |nurse |is |planning |to |use |a |Doppler |device |to |auscultate |fetal |heart |tones |(FHTs) |for |a |client |who |is | at |12wks |of |gestation. |Which |of |the |following |actions |should |the |nurse |plan |to |take? |- |VERIFIED | ANSWERS |✔Count |the |radial |pulse |of |the |client |while |auscultating |FHTs. -The |nurse |should |count |the |client's |radial |pulse |while |auscultating |FHTs |to |differentiate |it |from |the | fetal |heart |rate. A |nurse |is |providing |teaching |for |a |guardian |regarding |newborn |care. |Which |of |the |following | statements |by |the |guardian |indicates |understanding |of |the |teaching? |- |VERIFIED |ANSWERS |✔I |will | use |a |rear-facing |car |seat |for |my |baby |for |the |first | 2 |years. -Infants |should |travel |in |rear-facing |car |seats |until |the |age |of | 2 |years |old |or |until |the |child |reaches | the |height |or |weight |requirements |that |are |recommended |by |the |manufacturer |of |the |care |seat. A |nurse |is |providing |prenatal |education |to |a |client |who |is |at |16wks |of |gestation. |Which |of |the | following |statements |by |the |client |indicated |an |understanding |of |anticipated |body |changes |during |the |second |trimester? |- |VERIFIED |ANSWERS |✔I |might |notice |a |change |in |my |skin |coloring. -Skin |pigmentation |deepens |during |the |second |trimester |of |pregnancy |due |to |actions |of |the | melanocyte-stimulating |hormone. A |nurse |is |providing |teaching |to |a |client |who |is |at |8wks |of |gestation |about |vaccines |that |are | administered |during |pregnancy. |Which |of |the |following |vaccines |should |the |nurse |discuss |with |the | client? |- |VERIFIED |ANSWERS |✔Tetanus-diphtheira-acellular |pertussis |(Tdap) |vaccine.
-The |CDC |recommends |that |clients |who |are |pregnant |should |receive |the |Tdap |and |seasonal | inactivated |influenza |vaccine |with |each |pregnancy. |Clients |who |are |pregnant |should |avoid |all |live |or | live |attenuated |immunizations |due |to |potential |for |teratogenic |effects |in |the |fetus. A |nurse |is |collecting |information |about |a |health |history |for |a |client |who |requests |a |prescription |for |a | combined |oral |contraceptive |(COC). |Which |of |the |following |information |should |the |nurse |identify |as |a |contraindication |for |the |use |of |a |COC? |- |VERIFIED |ANSWERS |✔History |of |migraine |with |aura. -Contain |both |estrogen |and |progestin. |These |hormones |can |cause |an |increase |in |the |risk |for | thrombotic |stroke |for |clients |who |have |migraine |w/aura. |Safe |for |client |to |have |migraines |without | aura |to |use |a |COC |if |they |have |no |other |contraindications, |such |as |a |history |of |estrogen-dependent | tumors |or |coronary |artery |disease. A |nurse |is |caring |for |a |client |who |is |in |the |second |stage |of |labor |and |is |experiencing |shoulder | dystocia. |Which |of |the |following |actions |should |the |nurse |take? |- |VERIFIED |ANSWERS |✔Position | the |client |using |the |McRoberts |maneuver. -Decreases |shoulder |dystocia. |The |nurse |should |flex |the |client's |thighs |sharply |against |their |abdomen, |with |their |legs |apart, |to |straighten |the |sacral |area |and |rotate |the |symphysis |pubis |toward |the |client's |head. A |nurse |is |assessing |a |client |who |is |at |32wks |of |gestation. |Which |of |the |following |findings |is |an | indication |of |a |potential |prenatal |complication? |- |VERIFIED |ANSWERS |**✔Epigastric |pain. -Indication |of |preeclampsia. |Other |indications |of |preeclampsia |include |abdominal |pain, |severe |HA, | HTN, |polyuria, |and |proteinuria. A |nurse |is |caring |for |a |newborn |who |has |hyperbilirubinemia |and |a |new |prescription |for | phototherapy. |Which |of |the |following |actions |should |the |nurse |plan |to |take? |- |VERIFIED |ANSWERS | ✔Change |the |newborn's |position |every |2hrs. -Reposition |the |newborn |every |2-3hrs |during |phototherapy. |This |will |maximize |exposure |of |the |skin | to |the |light, |enhancing |the |effectiveness |of |phototherapy. A |nurse |is |creating |a |plan |of |care |for |a |client |who |is |at |35wks |of |gestation |and |is |experiencing |mild | vaginal |bleeding |due |to |placenta |previa. |Which |of |the |following |interventions |should |the |nurse | include? |- |VERIFIED |ANSWERS |✔Initiate |continuous |monitoring |of |the |FHR. -Initiate |continuous |monitoring |of |the |FHR |and |uterine |activity |using |an |external |fetal |monitor.
-Warm |heel |for |5-10mins |prior |to |puncture. |Warming |the |heel |causes |vasodilation |which |enhances | blood |flow |to |the |puncture |site. A |nurse |is |reviewing |the |laboratory |report |of |a |client |who |is |at |31wks |of |gestation |and |has |gestation | hypertension. |Which |of |the |following |laboratory |results |should |the |nurse |report |to |the |provider? |- | VERIFIED |ANSWERS |✔Platelet |count |99,000/mm3. -A |platelet |count |of |99,000/mm3, |or |thrombocytopenia, |is |an |indication |of |HELLP |syndrome, |a |serious |complication |of |gestational |HTN. A |nurse |is |reviewing |the |laboratory |report |of |a |term |newborn |who |is |24hrs |old. |Which |of |the | following |laboratory |results |should |the |nurse |report |to |the |provider? |- |VERIFIED |ANSWERS | ✔Glucose | 35 |mg/dL. -Reference |range |is |40-45 |mg/dL |for |a |newborn |who |is |24hrs |old. A |nurse |is |assessing |a |newborn |who |was |born |15mins |ago. |Which |of |the |following |actions |should |the |nurse |take? |- |VERIFIED |ANSWERS |✔Count |the |respiratory |rate |for | 60 |seconds. -Newborn |often |have |an |irregular |respiratory |rate. |Short |periods |of |apnea, |and |shallow |respirations | are |expected |findings |for |a |newborn. |The |nurse |should |also |assess |for |symmetry |of |chest |and | abdominal |movements |during |inhalation |and |exhalation. A |nurse |is |assessing |a |client |who |has |genital |herpes. |Which |of |the |following |findings |should |the |nurse |expect? |- |VERIFIED |ANSWERS |✔Ulcerated |lesions |on |the |labia. -The |nurse |should |identify |that |ulcerated |lesions |on |the |labia |are |an |expected |findings |for |a |client | who |has |genital |herpes |simplex |virus. |Other |manifestations |may |include |lymphadenopathy, |itching, | and |dysuria.
