Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?

Swaddle the infant in a warm blanket

A multiparous client is involuntarily pushing while being wheeled into the labor triage area. The nurse observes the fetal head presenting at the perineum. Which action should the nurse take?

Apply suprapubic pressure

After two miscarriages, a client is Instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid

Strawberries

While assessing a 40-week gestation primigravida in active labor, the client's membranes rupture spontaneously and the nurse notes that the amniotic fluid is meconium stained. Which additional finding is most important for the nurse to report to the healthcare provider?

Fetal heart rate of 100 to 110 beats/minute

A client at 35 weeks gestation complains of a "pain whenever the baby moves." On assessment, the nurse notes the client's temperature to be 101.20 F (38.4° C), with severe abdominal or uterine tenderness on palpation. The nurse knows that these findings are indicative of which condition?

Chorioamnionitis

The nurse is caring for a client who is 10-weeks’ gestation and palpates the funds at 2 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

Obtain HCG levels

A gravida 3 para 3 who is Rh-negative delivers a full-term infant at home with the assistance of a nurse midwife. Two days later, the client calls the clinic to ask if it is necessary to see the healthcare provider since the infant is healthy, and she is not having any

complications. The woman's history indicates that both previously born infants were Rh-negative. Which

response should the nurse provide?

The newborn's blood type should be tested to determine the need for RhoGAM

The nurse is caring for a client who is 24-weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?

Oral glucose challenge test

At a prenatal visit, a primigravida client confides to the nurse that her partner is abusive. Which information should the nurse provide?

Safety plan to keep in a purse at all times

At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

Inform the anesthesia care provider

A primipara client at 42-weeks gestation is admitted for induction. Within one hour after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm dilated; contractions are occurring every 1 minute with a 75 second duration. The nurse stops the oxytocin and starts oxygen. After 30 minutes of uterine rest, the contractions are occurring every 5 minutes with 20 second duration. Which intervention should the nurse implement?

Restart oxytocin infusion rate per protocol

A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, *I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?" Which information should the nurse provide

Start a prenatal care plan as soon as possible

A client who is receiving oxytocin to augment early labor begins to experience tachy systolic or tetanic contractions with variable fetal heart deceleration. Which action should the nurse implement?

Turn off the oxytocin infusion

Which action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs. (3, 402 grams), weighs 7 lbs (3,175 grams) today?

Inform and assure the mother that this is a normal weight loss

The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?

Heart rate & blood pressure

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

Cries vigorously when stimulated

A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. Which information should the nurse provide this client?

Using alternative form of birth control until new diaphragm can be obtained

A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribes an oxytocin drip. Which data is most important for the nurse to monitor?

Intensity, interval, and length of contractions

A primiparous client delivered via cesarean section 24 hours ago. Which behavior should the nurse expect the client to exhibit?

Accepts the birth was not as expected.

The healthcare provider prescribes a maintenance dose of magnesium sulfate 1 gram per hour intravenously (IV) for client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.)

25 ml/hr

The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge teaching, which intervention is most important for the nurse to implement?

Evaluate infant feeding techniques prior to discharge

A client at 40-weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which actions should the nurse plan to perform? (Select all that apply.)

Give antiviral medication intravenously

Use standard precautions

A primipara at 20-weeks gestation is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?

Fetal growth and gestational age.

Following the vaginal delivery of a 10-pound (4536 gram) infant, the nurse assesses a new mother's vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. Which action should the nurse implement first?

Perform fundal massage until firm.

The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (2.2 kg), has a head circumference of 13 inches (33 cm), and a chest circumference of 10 inches (25.4 cm). Based on these physical findings, assessment for which condition has the highest priority?

Hypoglycemia

The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures. Which action is most important for the nurse to take?

Encourage the mother to hold and spend time with her baby.

A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

Ascertain the frequency of headaches

A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client?

Disseminated intravascular coagulation

A woman who delivered a 9 pound (4082 gram) baby boy by cesarean section under spinal anesthesia is recovering in the postanesthesia care unit. Her fundus is firm, at the umbilicus, and a continuous trickle of bright red blood with no clots from the vagina is observed by the nurse. Which action should the nurse implement?

Assess her blood pressure

An unlicensed assistive personnel (UP) reports to the charge nurse that a client who delivered a 7-pound(3,175 gram) infant 12 hours ago is reporting a severe headache. The client's blood pressure is 110/70 mm Hg, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6°F (37° C). The client's funds is firm and one fingerbreadth above the umbilicus. Which action should the charge nurse implement first?

Notify the healthcare provider of the assessment findings (Quizlet temp. is 96.6 - read answer choices carefully)

The home health nurse visits a client who delivered a full term baby three days ago. The mother reports that the infant is waking up every 2 hours to bottle feed. The nurse notes white, curd-like patches on the newborn's oral mucous membranes. What action should the nurse implement?

Discuss the need for medication to treat curd-like oral patches

A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

Explain that a sonogram should be scheduled for definitive results

The nurse is caring for a 2-day-old neonate who has not passed meconium and has a swollen abdomen.The healthcare provider reviews the flat plate x-ray of the abdomen and makes a tentative diagnosis of Hirschsprung's disease. Which pathophysiological process is consistent with this neonate's clinical picture?

The congenital absence of parasympathetic ganglion cells to large intestine produces no peristalsis

Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

Pulse rate of 56 bpm

The healthcare provider prescribes magnesium sulfate 6 grams intravenously (IV) to be infused over 20minutes for client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)

4,500 mL/h

During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment.Which technique should the nurse implement to evaluate the leakage?

Test the fluid with a nitrazine strip

The nurse performs a routine assessment on a 12-hour-old infant. Which finding requires intervention?

No voiding or stooling since birth

The nurse is assessing a newborn who was precipitously delivered at 38- weeks gestation. The newborn is tremulous, tachycardia, and hypertensive. Which assessment action is most important for the nurse to implement ?

Obtain a drug screen for cocaine

A postpartum client who is giving her new baby formula feedings asks the nurse when she should expect to start menstruating again. What information should the nurse tell the client ?

6 to 8 weeks after birth

During a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement ?

Inform her that this is a normal physiological change

At 6-weeks gestation, the rubella titer for a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client?

Early postpartum, within 72 hours of delivery.

A client at 10- weeks gestation calls the clinic reporting a low-grade fever with moderate cramping and heavy bright -red bleeding. Which instruction should the nurse provide the client?

Come in for immediate evaluation

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eye. He asks the nurse what is the purpose of the ointment. The nurse would be correct in stating that the purpose for using the ointment is to ?

Prevent eye infection

Upon admission to the nursery, the nurse places a newborn supine under a radiant warmer, an external heat source. What intervention should the nurse implement first to ensure safe thermoregulation ?

Place temperature probe on the abdomen in the line with the radiant heat source

A new mother asks the nurse about an area of swelling on her baby's head near the posterior fontanel that lies across the suture line. How should the nurse respond?

That is called caput succedaneum. It will absorb and cause no problems.

An ambulatory client at 39-weeks gestation presents to the emergency center with an obvious injury to her arm that occured as the result of a fall. Which concurrent symptom is a priority for the nurse to address further?

Ecchymotic knees

The nurse is reviewing a women's health care records during her first prenatal visit. The client has a history of chickenpox as a child and syphilis as a teenager. Which action is most important for the nurse to take?

Explain common complications of pregnancy.

A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy?

Visualization of implantation by vaginal ultrasound

The nurse is caring for a postpartum client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit. Which action should the nurse perform?

Place procedure equipment at bedside

The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first?

Administer oxygen via facemask

The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7-pound 10-ounce (3220 gram) infant. Which information should the nurse provide the client about this finding?

Both the lower uterine segment and the fundus must be massaged.

.A new mother who is a lacto-ovo vegetarian, plans to breastfeed her infant. Which information should the nurse provide prior to discharge?

Continue prenatal vitamins with B12 while breast feeding.

Using the Ballard Gestational Age Assessment tool the nurse determines that a 15-minute old infant has a gestational age of 42 weeks. Based on this finding, which intervention is most important for the nurse to implement?

Obtain a capillary blood glucose

.A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7-pound infant four hours ago by caesarean delivery. Which nursing problem has highest priority?

Risk for injury related to uterine atony

A multiparous client at 38-weeks’ gestation is admitted to labor and delivery with a compliant of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears a baby crying. Which action should the nurse take first?

Push the call light for help

The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse observes red marks on the head with swelling that does not cross the suture lines. Which condition should the nurse document in the medical record?

Cephalhematoma

A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that began one hour ago. The nurse’s assessment reveals approximately 30 ml of bright red vaginal bleeding, Fetal Heart Rate of 130 to 140 beats/min, no contractions, and no complaints of pain. What is the most likely cause of this client’s bleeding?

Placenta previa (painless bright red)

A newborn’s head circumference is 12 inches, and his chest measurement is 13 inches. The nurse notes that this infant has no molding and was a breech presentation delivered by Caesarean section. What action should the nurse take based on these data

Record the findings on the chart. They are within normal limits

What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?

Assisting her to maintain control

A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. The
nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute, and the contractions are occurring irregularly every 10 to 15 minutes. What assessment finding confirms to the nurse that the client is not in labor at this time?

Contractions decrease with walking.

A client at 31 weeks gestation with a fundal height measurement of 25 cm is scheduled for a series of ultrasounds to be performed every two weeks. Which explanation should the nurse provide to the client for the ultrasounds?

Evaluation of fetal growth

The nurse is caring for a multiparous client who is 8 cm dilated, 100% effaced, and the fetal head is at 0 station. The client is shivering and states extreme discomfort with the urge to bear down. Which intervention should the nurse implement?

Reposition to side-lying

The health care provider prescribes a maintenance dose of magnesium sulfate 2 grams per hour intravenously (IV) for client with preeclampsia. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hr should the nurse program the infusion pump?

50

An UAP reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is reporting a severe headache. The clients' blood pressure is 110/70 mm Hg, respiratory rate is 18 breaths/minute, heart rate is 74 bpm, and temperature is 98.6 F. The client’s fundus is firm and one fingerbreadth above the umbilicus. Which action should the charge nurse implement first?

Assign a practical nurse to reassess the client’s vital signs

A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. What action should the nurse implement?

Inform her that a decreased need for insulin occurs while breastfeeding

The newborn nursery protocol includes a prescription for ophthalmic erythromycin 5% ointment to both eyes upon a newborn admission. What action should the nurse take to ensure adequate instillation of the ophthalmic ointment?

Instill a thin ribbon into each lower conjunctival sac

A newborn with a respiratory rate of 40 breaths/minute at one minute after birth is demonstrating cyanosis of the hands and feet. What action should the nurse take?

Continue to monitor

A primigravida at 36-weeks’ gestation, who is Rh negative, experienced abdominal trauma in a motor vehicle collision. Which assessment finding is most important for the nurse to report to the health care provider?

Positive fetal hemoglobin test

A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours. Concerned, she arrives in a panic at the obstetric clinic where she is immediately sent to the hospital. Which assessment finding warrants immediate intervention by the nurse?

Fetal heart rate 60 beats/min

The healthcare provider prescribes 10 units/l of oxytocin via iv drip to augment a client’s labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?

Contraction duration of 100 seconds contractions are only 60-90 sec anything more stop oxytocin

Four clients at full term present to the labor and delivery at the same time. Which client should the nurse asses first?

Multipara with contractions occurring every 3 minutes

A client tells the nurse that she thinks she is pregnant. Which sign or symptom provides the best indication that the client is pregnant

Amenorrhea (an abnormal absence of menstruation).

A 3-hour old male infant’s hands and feet are cyanotic, and he has an axillary temperature of 96.5, a respiratory rate of 40 breaths/minute, and a heart rate of 165 bpm. What nursing intervention is best for the nurse to implement?

Gradually warm the infant under a radiant heat source

The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first? A. Administer oxygen via facemask

Change the client’s position

A client who delivered a healthy newborn an hour ago asks the nurse when can she go home. Which information is most important for the nurse to provide the client?

When there is no significant vaginal bleeding

The nurse is receiving report for a laboring client who arrived in the emergency center with ruptured membranes that the client did not recognize. Which is the priority nursing action to implement when the client is admitted to the labor and delivery suite?

Prepare to start an IV

A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?

Keep an airway at the bedside.

The nurse is scheduling a client with gestational diabetes for an amniocentesis because the fetus has an estimated weight of 8 pounds at 36- weeks’ gestation. This amniocentesis is being performed to obtain which information?

Fetal lung maturity

A client arrives to the clinic reporting she is unable to conceive for the last year. The obstetrical history includes: a live birth at 28 weeks and one at 22 weeks who lived to 2 days, and 3 miscarriages in the first trimester. Which GTPAL should the nurse document?

G5 P0231

A 17-year-old client gave birth 12 hours ago. She states that she doesn’t know how to care for her baby. To promote parent-infant attachment behaviors, which intervention should the nurse implement?

Encourage rooming-in while in the hospital

Twelve hours after birth of a healthy infant the mother complains of feeling constant vaginal pressure. The nurse determines the fundus is firm and at midline with moderate rubra lochia. Which action should the nurse take?

Check the suprapubic area for distention

A 38-week primigravida is admitted to labor and delivery after a non-reactive result on a non-stress test (NST). The nurse begins a contraction stress test (CST) with an oxytocin (Pitocin) infusion. Which finding is most important for the nurse to report to the health care provider?

A pattern of late fetal decelerations

A primipara woman presents in labor with the following labs hemoglobin 10.9 g/dL, hematocrit 29%, hepatitis surface antigen positive, group B streptococcus positive, and rubella non-immune. Which intervention should the nurse implement?

Administer ampicillin 2 grams intravenously

On the first postpartum day, the nurse examines the breasts of the new mother. Which condition is the nurse most likely to find?

Filling and secreting colostrum

The nurse is planning care for a client at 30-weeks’ gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome?

Betamethasone (Celestone) 12 mg deep IM.

A newborn’s assessment reveals spina bifida occulta. Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication?

Folic acid deficiency

The healthcare provider prescribes amiodarone 100 mg by mouth five times daily for a pregnant woman who is HIV positive. The drug is available in a 240 ml bottle labeled “50 mg/5 ml”. How many ml should the nurse administer?

10

A multigravida client in labor is receiving oxytocin 4 mu/minute to help promote an effective contraction pattern. The available solution is Lactated Ringer’s 1000 ml with oxytocin 20 units. The nurse should program the pump to deliver how many ml/hr?

12 4 x 60 =240 (240/20=12)

Vaginal examinations reveal that a laboring client cervix is dilated 2cm, 70% effaced, with presenting part at -2 station. The client tells the nurse " I need my epidural now! This hurts!" The nurse response to the client should be based on which information?

Administering an epidural at this point would slow the labor process.

Which fetal heart pattern requires immediate nursing intervention?

A decreased in fetal heart rate that occurs after the peak of a contraction

Following a traumatic delivery, an infant receives an initial Apgar score of 3. Which intervention is most important for the nurse to implement?

Continue resuscitative efforts

A woman who is 38-weeks’ gestation is receiving magnesium sulfate for severe preeclampsia. Which assessment finding warrants immediate intervention by the nurse?

Absent patellar reflexes

A client at 37-weeks’ gestation presents to labor and delivery with contractions every 2 minutes. The nurse observes several shallow, small vesicles on her pubis, labia, and perineum. The nurse should recognize the client is exhibiting symptoms of which condition?

Herpes simplex virus

A 30-year-old primigravida delivers a 9-pound infant vaginally after a 30-hour labor. What is the priority nursing action for this client?

Observe for signs of uterine hemorrhage

A multipara client at 38-hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 cm above the umbilicus. Which action should the nurse take first?

Encourage the client to void

A pregnant client mentions in her history that she changes a cat's litter box daily. Which test should the nurse anticipate the healthcare provider to prescribe?

TORCH screening

In determining the one-minute Apgar score of a male infant, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. He has a loud cry with stimulation, good muscle tone, and his color is acrocyanotic. What Apgar score should the nurse assign?

10

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?

Prevent hemorrhagic disorders

The nurse is planning discharge teaching for 4 mothers. Which postpartum client is at highest risk for psychological difficulties during the postpartum period?

A primiparous woman who has recently immigrated to the U.S. with her spouse

a client in the first trimester of pregnancy calls the prenatal clinic to report she is nauseated, and her stools are black and thick since she started taking iron supplements last week. how should the nurse respond? (Select all that apply)

Take the iron supplement at bedtime

Changes in color and consistency of stool are normal

A client who is 24-week’ arrives to the clinic reporting swollen hands. On examination, the nurse notes the client has had weight gain over six weeks. Which action should the nurse implement next?

Examine the client for pedal edema

A mother spontaneously delivers her newborn in a taxicab on the way to the hospital. The emergency room nurse reports that the mother has active herpes (HSVII) lesions on the vulva. Which intervention should the nurse implement first when admitting the neonate to the nursery?

Place the newborn in the isolation area of the nursery

The nurse working in an antepartal clinic measures a 38 cm fundal height on a client who is at 30-weeks’ gestation by dates. Which action is most important for the nurse to take?

Obtain a prescription for an ultrasound and schedule it as soon as possible

The mother of a breastfeeding 24-hour-old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is "doing it right." She tells the nurse, "I just know my daughter is not getting enough to eat." What response would be best for the nurse to make?

If your baby's urine is straw-colored, she is getting enough milk

A client at 18-weeks’ gestation was informed this morning that she has an elevated alpha fetoprotein level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

Explain that a sonogram should be scheduled for definitive results