Pregnancy and Childbirth: Symptoms, Complications, and Interventions | Exams Nursing | Docsity (2024)

Download Pregnancy and Childbirth: Symptoms, Complications, and Interventions and more Exams Nursing in PDF only on Docsity! ATI OB MATERNITY NURSING CARE (KEISER UNIVERSITY) DETAILED ANSWER KEY LATEST 2024 QUESTIONS AND ANSWER. 1. A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? A. Painless red vagin*l bleeding Rationale: Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagin*). Bright red, painless vagin*l bleeding occurs in the second and third trimester. B. Increasing abdominal pain with a nonrelaxed uterus Rationale: Abruptio placenta is separation of the placenta from the site of uterine implantation before delivery of the fetus. When the placenta separates prematurely, there is internal bleeding, which is painful, and the uterus is nonrelaxed or becomes rigid as the separation advances. C. Abdominal pain with scant red vagin*l bleeding Rationale: Placenta previa involves minimal to severe bright red vagin*l bleeding in the absence of abdominal pain. D. Intermittent abdominal pain following passage of bloody mucus Rationale: Intermittent abdominal pain following passage of bloody mucus is a description of normal labor. The passage of bloody mucus represents the loss of the cervical mucous plug, also referred to as the "bloody show." 2. A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? A. Document the findings and continue to monitor the client. Rationale: These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. Small clots are common. The nurse should document the findings and continue to monitor the client. B. Notify the client‟s provider. Rationale: These are expected findings, so there is no need to notify the provider. C. Increase the frequency of fundal massage. Rationale: These are expected findings and the fundus is already firm. Increasing the frequency of fundal massage is not indicated at this time. D. Encourage the client to empty her bladder. Rationale: These are expected findings, and the fundus is firm at the midline. If the fundus was deviated, this would be an indication of a distended bladder and the client should be encouraged to void to prevent uterine atony. Page 2 3. A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? A. Administer vitamin K. Rationale: Administration of vitamin K is important, but it can be delayed until the newborn is held by the mother and is breastfed. There is another, more important nursing action. B. Dry the skin. Rationale: The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother‟s abdomen, and a cap applied to the newborn‟s head to prevent cold stress. The newborn responds to the cooler environment by increasing his respiratory rate, which can lead to respiratory distress. Based on Maslow‟s hierarchy of needs, this is the most important nursing action after securing the airway. C. Administer eye prophylaxis. Rationale: Administration of eye prophylaxis should occur within the first hour after birth. There is another, more important nursing action. D. Place an identification bracelet. Rationale: Correct identification of the newborn is important, but it can be delayed, as long as it is completed prior to the mother and newborn leaving the delivery room. There is another, more important nursing action. 4. A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? A. "It's a minor inconvenience, which you should ignore." Rationale: This is a nontherapeutic response that disregards the client‟s concern and offers unwarranted reassurance. B. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." Rationale: The presence or absence of bladder tone has no bearing on urinary frequency during pregnancy. C. "There is no way to predict how long it will last in each individual client." Rationale: This is a nontherapeutic response that does not provide appropriate information to the client. D. "It occurs during the first trimester and near the end of the pregnancy." Rationale: Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the end of the pregnancy as the enlarging uterus places pressure on the bladder. Page 5 reliable methods of contraception. C. An oral contraceptive Rationale: This method of contraception has about 8 failures for every 100 users, due to failure to take pill consistently and decreased efficacy when taken with certain medications. D. A diaphragm with spermicide. Rationale: This method of contraception has about 16 failures for every 100 users during the first year of use. 10.A A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? A. The client is not experiencing a rubella infection at this time. Rationale: A negative rubella titer indicates the client is susceptible to the rubella virus. It does not indicate the presence or absence of a rubella infection. B. The client is immune to the rubella virus. Rationale: A negative rubella titer indicates the client is susceptible to the rubella virus. C. The client requires a rubella vaccination at this time. Rationale: Rubella vaccination during pregnancy is contraindicated because of possible injury to the developing fetus. D. The client requires a rubella immunization following delivery. Rationale: A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month. 11.A A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vagin*l bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action? A. Insert an indwelling urinary catheter. Rationale: An indwelling urinary catheter can be inserted in the delivery room just prior to delivery. This is not the priority nursing action. B. Initiate IV access. Rationale: Insertion of a large-bore IV catheter is the priority nursing action. The client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops. Page 6 C. Witness the signature for informed consent for surgery. Rationale: Rationale C. This is not the nurse's priority action at this time. A family member can sign the consent form if needed. D. Prepare the abdominal and perineal areas. Rationale: Skin preparation can be delayed until just prior to a cesarean delivery. This is no the priority nursing action. 12.A A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client? A. Rapid decline in human chorionic gonadotropin (hCG) levels Rationale: A client who has a hydatidiform mole usually has an elevated serum hCG level. B. Profuse, clear vagin*l discharge Rationale: A client who has a hydatidiform mole often has vagin*l bleeding later in the pregnancy. This discharge can be dark brown, bright red, scant, or profuse. C. Irregular fetal heart rate Rationale: When a client has a hydatidiform mole, fetal heart tones are not heard since there is no developing fetus. D. Excessive uterine enlargement Rationale: A hydatidiform mole is a rare tumor that forms inside the uterus at the beginning of a pregnancy and results in the over-production of tissue that would normally develop into the placenta. This tissue consists of fluid-filled vesicles. A rapidly enlarging uterus is a classic finding in clients who have a molar pregnancy. It is often accompanied by severe nausea and vomiting, elevated human chorionic gonadotropin levels, signs of hyperthyroidism, and early onset of preeclampsia. 13.A A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse? A. "I will call your primary care provider to report your concerns." Rationale: This is an inappropriate response by the nurse because it does not address the client's feelings of concern. B. "I will take your baby to the nursery for further examination." Rationale: It is not necessary for the nurse to complete additional examination of the newborn. This also does not address the client‟s concerns. C. "This occurs because newborns lack muscle control to regulate eye movement." Rationale: Page 7 This addresses the client‟s concerns because it provides information that addresses her concerns. The eyes of newborns are structurally incomplete and muscle control is not fully developed for 3 months. D. "This is a concern, but strabismus is easily treated with patching." Rationale: This is an inappropriate statement by the nurse because it offers unwarranted reassurance. The nurse is making an assumption that that should be addressed by the provider. 14. A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to 150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform? A. Immediately report the situation to the client's provider and prepare the client for induction of labor. Rationale: The fetus might not be moving because it is asleep, or there might be another benign reason. B. Encourage the client to walk around without the monitoring unit for 10 min, then resume monitoring. Rationale: Having the client walk is not likely to promote fetal movement. C. Offer the client a snack of orange juice and crackers. Rationale: A nonstress test depends upon fetal movement, and this fetus is most likely asleep. Most fetuses are more active after meals due to the increase in the mother's blood sugar. Giving the mother a snack will promote fetal movement. D. Turn the client onto her left side. Rationale: Turning the client onto her left side increases the placental perfusion of oxygen to the fetus, but the FHR of 130 to 150/min is not indicative of fetal distress. 15.A A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take? A. Notify the provider of the findings. Rationale: Calling the provider may be appropriate; however, this is not the priority intervention. B. Position the client with one hip elevated. Rationale: Based on Maslow‟s hierarchy of needs, the client's need for an adequate blood pressure to perfuse herself and her fetus is a physiological need that requires immediate intervention. Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By turning the client on her side and retaking her blood pressure, the nurse is attempting to correct the low blood pressure and reassess. C. Ask the client if she needs pain medication. Rationale: Page 10 D. Avoid foods containing aspartame. Rationale: Aspartame in the diet has no effect on the incidence of neural tube defects in a fetus. Clients who have phenylketonuria should be advised to avoid aspartame since it contains phenylalanine. 20. A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching? A. vagin*l intercourse can be resumed after 2 weeks. Rationale: The client should avoid vagin*l intercourse and the use of tampons for 2 weeks following discharge. B. Products of conception will be present in vagin*l bleeding. Rationale: The products of conception are surgically removed during a D&C. C. Increased intake of zinc-rich foods is recommended. Rationale: The client is encouraged to consume foods high in iron and protein to replace red blood cells and repair uterine tissue. D. Aspirin may be taken for cramps. Rationale: Aspirin for pain management of cramps should be avoided because of its anticoagulant property. NSAIDS, such as ibuprofen, are recommended as they are an antiprostaglandin agent and reduce the discomfort of cramping. 21.A A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia? A. 1+ pitting sacral edema Rationale: This finding is consistent with the diagnosis of preeclampsia. B. 3+ protein in the urine Rationale: This finding indicates proteinuria, a finding that is consistent with the diagnosis of preeclampsia. C. Blood pressure 148/98 mm Hg Rationale: This finding is consistent with the diagnosis of preeclampsia. D. Deep tendon reflexes of +1 Rationale: Deep tendon reflexes of +1 are decreased. In a client who has preeclampsia, the nurse should expect to find an increased, rather than a decreased, deep tendon reflex. Page 11 22. A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.) A. Cracked, peeling skin B. Positive Moro reflex C. Short, soft fingernails D. Abundant lanugo E. Vernix in the folds and creases Rationale: <b>Cracked, peeling skin is correct.</b> Physical findings that indicate postmaturity in a newborn (gestational age of greater than 42 weeks) include cracked, peeling skin.<br><br><b>Positive Moro reflex is correct.</b> Reflexes that are present in a postmature newborn are the same as those that are present in a mature newborn. These reflexes include a positive Moro reflex.<br><br><b>Short, soft fingernails is incorrect.</b> Short, soft fingernails are not characteristic of the postmature newborn. They appear long and are hard.<bR><br><b>Abundant lanugo is incorrect.</b> Abundant lanugo is seen in preterm (gestational age of less than 37 weeks) newborns.<Br><br><b>Vernix in folds and creases is incorrect</b> Vernix in the folds and creases is seen in mature, term newborns. 23.A A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate? A. "Exercising during pregnancy is not recommended." Rationale: Physical activity during pregnancy improves circulation, rest, and relieves boredom. However, risky activities that require precise balance and coordination should be avoided. B. "Daily jogging for up to 30 minutes is fine throughout the pregnancy." Rationale: While weight-bearing exercises might become uncomfortable in the last trimester, they are generally not contraindicated, providing the client stays hydrated and avoids becoming overheated for extended periods. C. "Activities that raise the body temperature, such as saunas and hot tubs, are safe until the third trimester." Rationale: Prolonged or repeated elevations of maternal and fetal temperature can result in birth defects, especially during the first trimester of pregnancy. D. "It is recommended that pregnant clients limit their exercise routine to stretching activities on a mat several times a week." Rationale: Daily moderate exercise throughout pregnancy is recommended. After the fourth month of pregnancy, clients should avoid exercising flat on their back due to the risk of vena cava syndrome. Page 12 24.A A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagin*. Which of the following actions should the nurse perform first? A. Cover the cord with a sterile, moist saline dressing. Rationale: While this is appropriate, it is not the first action the nurse should take. B. Prepare the client for an immediate birth. Rationale: Although an emergency vagin*l or cesarean birth might be necessary to deliver the fetus safely, this is not the first action the nurse should take. C. Place the client in knee-chest position. Rationale: Although this is appropriate, it is not the first action the nurse should take. D. Insert a gloved hand into the vagin* to relieve pressure on the cord. Rationale: This is the first nursing action because it is essential to prevent any pressure on the umbilical cord to promote oxygenation of the fetus. 25. A nurse at a prenatal clinic is caring for a client who is in her first trimester of pregnancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in her life. Which of the following is an appropriate response by the nurse? A. "Ambivalent feelings are quite common for women early in pregnancy." Rationale: This response uses the therapeutic communication technique of providing information while addressing the client's concerns and feelings. This statement is true and gives the client the information she needs; many antepartum women experience similar feelings in early pregnancy. B. "Perhaps you should see a counselor to discuss these feelings further." Rationale: This nontherapeutic response puts the client's feelings on hold by referring her to another person. C. "Have you spoken to your mother about these feelings?" Rationale: This is a closed-ended response that is nontherapeutic because it anticipates a "yes" or "no" reply from the client and refers her to an inappropriate person. D. "Don't worry. You will be fine once the baby is born." Rationale: This nontherapeutic response devalues the client's feelings. 26.A A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider? A. Headaches Rationale: Page 15 C. Viability of the fetus Rationale: This is not the purpose of this examination. D. The biparietal diameter Rationale: This is not the purpose of this examination. 31.A A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make? A. "You might want to offer water supplements between feedings." Rationale: This is not an explanation for weight loss. Water supplements are not recommended at this time. The nurse should review the newborn‟s pattern of breast feeding, the mother‟s breast feeding technique, and factors that can influence decreased milk production. B. "It is due to the newborn‟s loss of the influence of the maternal hormones." Rationale: This is not an explanation for weight loss. Breastfed newborns typically lose 5% to 6% of body weight before gaining weight. A delayed period of weight gain might be due to a slower transition from early breast milk to mature milk. C. "This might be related to your baby having 3 stools a day." Rationale: This is not an explanation for weight loss. The newborn who is being breastfed typically has 3 or more stools per day during the first few weeks. D. "The cause might be too short or infrequent feedings." Rationale: Breastfed newborns typically lose 5% to 6% of body weight before gaining weight. Slow weight gain might be due to inadequate breastfeeding, incorrect feeding techniques, or maternal factors such as breasts not emptying, stress, and fatigue. 32. A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide? A. "The primary consideration is what type of incision was performed this time." Rationale: The most common type of incision during a cesarean birth is transverse, which is made across the lower, thinner part of the uterus. It is the primary criteria that permits a vagin*l birth after a cesarean (VBAC). Other types of incisions increase the risk of uterine rupture. Additional criteria for VBAC include an adequate maternal pelvis, no uterine scars or history of rupture, the availability of a provider to monitor labor, and personnel to perform a cesarean birth if needed. B. "There are so many variables that you'll have to ask your obstetrician." Rationale: This nontherapeutic reply avoids addressing the client's concerns. A nurse in the labor and Page 16 delivery suite or the postpartum unit should be able to provide the client with information that answers her question. C. "It's too soon for you to be worrying about this now." Rationale: This nontherapeutic reply devalues the client's concerns and avoids addressing them. A nurse in the labor and delivery suite or the postpartum unit should be able to provide the client with information that answers her question. D. "A repeat cesarean birth is safer for both you and your baby." Rationale: Research has shown that, a vagin*l birth after cesarean (VBAC) is safe for both the client and the fetus if specific criteria are met and labor is managed closely by nurses and health care providers. 33.A A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make? A. "This will occur during the last trimester of pregnancy." Rationale: A primigravida client should detect fetal movement earlier than the last weeks of pregnancy. B. "This will happen by the end of the first trimester of pregnancy." Rationale: This is too early in the pregnancy for a primigravida client to detect fetal movement. C. "This will occur between the fourth and fifth months of pregnancy." Rationale: Quickening is defined as the first time the client is able to feel her fetus move. In a primigravida client, this usually occurs at 18 weeks of gestation or later. In a multigravida client, this can occur as early as 14 to 16 weeks. D. "This will happen once the uterus begins to rise out of the pelvis." Rationale: The uterus rises out of the pelvis at 12 to 14 weeks of gestation, which is too early for a primigravida client to notice fetal movement. 34. A nurse is instructing a female client about how to check basal temperature in order to determine if the client is ovulating. The nurse should instruct the client to check her temperature at which of the following times? A. Every morning before arising Rationale: To measure basal temperature, the client must take her temperature every morning at the same exact time before getting out of bed. The client must try not to move too much, as any activity can raise the body temperature slightly. B. On days 13 to 17 of her menstrual cycle Rationale: The client should take her basal temperature every day of the month to accurately map the decrease in temperature that occurs at ovulation and the subsequent elevation in temperature that occurs until menses begin. Page 17 C. 1 hour following intercourse Rationale: Measuring the temperature after intercourse would not be accurate, as any activity can raise the body temperature slightly. D. Before going to bed every night Rationale: Measuring the temperature after a full day's activity would not be accurate, as any activity can raise the body temperature slightly. 35. A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take? A. Discontinue the medication infusion. Rationale: Magnesium toxicity is manifested by bradypnea (respiratory rate less than 12/min) and absent deep tendon reflexes. The magnesium sulfate infusion should be discontinued and calcium gluconate administered via IV. B. Prepare for an emergency cesarean birth. Rationale: There is no indication for a cesarean birth at this time. C. Assess maternal blood glucose. Rationale: This intervention is not indicated. D. Place the client in Trendelenburg position. Rationale: Trendelenburg position is used for clients in shock who are hypotensive. This position is not indicated for this client. 36. A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer? A. "You must be feeling scared and powerless." Rationale: This response illustrates the therapeutic communication technique of restatement. The nurse shows empathy for the client by recognizing that the client is concerned about the safety of the fetus and is powerless to do anything about the situation. This open-ended statement encourages further communication by the client. B. "Everyone worries about her baby when she‟s in labor." Rationale: This is a nontherapeutic response that is stereotypical as it oversimplifies and generalizes the client‟s concern. C. "Your pregnancy is advanced so your baby should be fine." Rationale: This nontherapeutic response offers false reassurance. The nurse is making a promise about Page 20 41.A A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should instruct the client to call the clinic if she experiences which of the following manifestations? A. Leukorrhea Rationale: Leukorrhea is a common discomfort in the first trimester and might be present throughout the pregnancy. The client is instructed to call the provider if she notices changes in the leukorrhea, such as presence of itching, foul odor, and altered characteristics or color. B. Urinary frequency Rationale: Urinary frequency, caused by pressure of the uterus on the bladder and changes in hormones, is a common discomfort of pregnancy in the first trimester. The client is instructed to call the provider if she notices burning or pain with urination. C. Nausea and vomiting Rationale: Nausea and vomiting is a common discomfort of pregnancy in the first trimester and occurs as a response to increased human chorionic gonadotropin (hCG) levels in pregnancy. The client is instructed to call the provider if vomiting becomes severe, as this can indicate hyperemesis gravidarum. D. Facial edema Rationale: Facial edema is a warning sign of a hypertensive condition or preeclampsia and should be reported immediately to the provider. 42.A A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis? A. Severe nausea and vomiting Rationale: Nausea and vomiting is a common discomfort during the first trimester of pregnancy. Severe vomiting is consistent with a diagnosis of hyperemesis gravidarum. B. Large amount of vagin*l bleeding Rationale: A large amount of vagin*l bleeding is usually not a finding in ectopic pregnancy. More commonly, the client might have a small amount of vagin*l spotting that occurs 6 to 8 weeks after the client‟s last normal menstrual period. C. Unilateral, cramp-like abdominal pain Rationale: An ectopic pregnancy is one in which the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop in this area. The most common site is within a fallopian tube; however, ectopic pregnancies can occur in the ovary, the abdomen, and in the cervix. D. Uterine enlargement greater than expected for gestational age Rationale: An ectopic pregnancy is rarely associated with uterine enlargement because the products of conception are outside of the uterus. 43.A A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching? A. Consume 40 to 50 g of protein daily. Rationale: The client who has mild preeclampsia is encouraged to consume 60 to 70 g of protein, 1200 mg of calcium, 400 mcg of folic acid, and 2 to 6 g of zinc and sodium in her daily diet. Protein is needed for tissue integrity and calories. B. Avoid salting of foods during cooking. Rationale: The client who has preeclampsia is instructed to salt foods to taste, and limit consumption of foods that are high in sodium, such as chips, pretzels, processed meats, and pickles. C. Drink 48 to 64 ounces of water daily. Rationale: The client who has preeclampsia is encouraged to drink six to eight 8-ounce glasses of water (48 to 64 ounces) per day. She should avoid alcohol and limit intake of caffeinated beverages. D. Limit intake of whole grains, raw fruits, and vegetables. Rationale: The client who has preeclampsia requires additional fiber in the diet, which should come from whole grain foods, raw fruits, and vegetables. 44. A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant? A. Maintain the integrity of the sac. Rationale: Myelomeningocele is a congenital disorder that causes the spine and spinal canal to not close prior to birth, which results in the spinal cord, meninges, and nerve roots protruding out of the child's back in a fluid-filled sac. Before surgery, the infant must be handled carefully to reduce damage to the exposed spinal cord and to maintain the integrity of the sac. B. Promote maternal-infant bonding. Rationale: Although promoting maternal-infant bonding is important, there is a higher priority during the preoperative phase of care. C. Educate the parents about the defect. Rationale: Although parental education is important, there is a higher priority during the preoperative phase of care. D. Provide age-appropriate stimulation. Rationale: Although providing age-appropriate stimulation is important, there is a higher priority during the preoperative phase of care. Page 22 45. A nurse in a college health clinic is speaking to a group of adolescents about toxic shock syndrome (TSS). Which of the following should the nurse include in the teaching as increasing the risk for contracting TSS? A. High-absorbency tampons Rationale: Toxic shock syndrome, a severe disease caused by a toxin made by Staphylococcus aureus, is characterized by shock and multiple organ dysfunction. Approximately 50% of all cases involve menstruating women using highly absorbent tampons. B. Mosquito bites Rationale: Mosquito bites are not associated with TSS. C. Travel to foreign countries Rationale: Travel to foreign countries is not associated with TSS. D. Multiple sexual partners Rationale: Multiple sexual partners is not associated with TSS. 46. A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on July 27. What is the client's EDB? (State the date in MMDD. For example, July 27 is 0727) 0504 Correct Rationale: Using Nägele's rule, the nurse subtracts three months from the date of the last menstrual period, then adds 7 days. July minus 3 months equals April. There are 30 days in April, so 27 + 7 = May 4. The client's EDB is May 4, which would be written as 0504 in the MMDD format. InCorrect Rationale: Using Nägele's rule, the nurse subtracts three months from the date of the last menstrual period, then adds 7 days. July minus 3 months equals April. There are 30 days in April, so 27 + 7 = May 4. The client's EDB is May 4, which would be written as 0504 in the MMDD format. 47.A A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, "How will I know if my baby gets enough breast milk?" Which of the following responses should the nurse make? A. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding." Rationale: Babies will typically sleep after a feeding, making this an unreliable indicator that the newborn is getting enough breast milk. B. "Your baby should wet 6 to 8 diapers per day." Rationale: Newborns should wet 6 to 8 diapers per day. This is an indication that the newborn is getting enough fluids. Page 25 forehead, nose, and cheeks and is an expected finding during pregnancy.<br><br><b>Striae gravidarum is correct.</b> Striae gravidarum, or stretch marks, occur because of the separation of underlying connective tissue on the breasts, thighs, and abdomen. They are an expected finding during pregnancy. 52.A A nurse is reviewing the health history of a client who has a new prescription for a combined oral contraceptive (COC). The nurse recognizes that which of the following client medications can interfere with the effectiveness of the COC? A. Antihypertensives Rationale: Antihypertensives do not interfere with the effectiveness of COCs when taken simultaneously. B. Anticonvulsants Rationale: Anticonvulsants when taken simultaneously with COCs can decrease their effectiveness. The anticonvulsants included are: phenytoin, phenobarbital, carbamazepine, oxcarbazepine, topiramate, and primidone. C. Antioxidants Rationale: Antioxidants do not interfere with the effectiveness of COCs when taken simultaneously. D. Antiemetics Rationale: Antiemetics do not interfere with the effectiveness of COCs when taken simultaneously. 53. A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect? (Select all that apply.) A. History of migraines B. Nulliparous C. Twin gestations D. History of gestational hypertension E. Oligohydramnios Rationale: <b>History of migraines is correct.</b> History of migraines is a risk factor for hyperemesis gravidarum, which typically occurs during the first 20 weeks of pregnancy.<br><br><b>Nulliparous is correct.</b> Hyperemesis gravidarum is more common in nulliparous women, beginning in the first trimester. Clinical manifestations can continue throughout the pregnancy in some women.<br><br><b>Twin gestations is correct.</b> Twin gestations are a risk factor for hyperemesis gravidarum and might be related to increasing hormone levels of estrogen, progesterone, and human chorionic gonadotropin (hCG).<br><br><b>History of gestational hypertension is incorrect.</b> A history of gestational hypertension is not a risk factor for hyperemesis gravidarum.<br><br><b>Oligohydramnios is incorrect.</b> Oligohydramnios is not a risk factor for hyperemesis gravidarum. Page 26 54. A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate? A. "The newborn might be actively shedding the virus." Rationale: Infants born to mothers who have rubella will continue to shed the rubella virus for up to 18 months postdelivery. B. "The newborn is at risk for developing a TORCH infection." Rationale: TORCH is an acronym for certain maternal viral infections that can cross the placenta and affect the developing fetus. While rubella is one of the TORCH infections, exposure to one viral infection does not increase the risk of developing an additional viral infection. C. "The child might develop encephalitis, a complication of rubella." Rationale: Newborns exposed to the rubella virus during gestation are at increased risk to develop hearing loss, congenital cataracts, and cardiac anomalies, but not encephalitis. D. "Exposure to rubella will suppress the newborn‟s immune response." Rationale: Exposure to rubella does not affect the infant‟s immune response. All newborns are at a high risk for infection during the first few months of life due to a lower concentration of immunoglobins and a delayed response from white blood cells. 55.A A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother‟s room. Which of the following is an appropriate response by the nurse? A. "You may carry your grandchild to the room." Rationale: This is not an appropriate response. Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting a newborn to leave the nursery. B. "You can push the baby to the room in a wheeled bassinet." Rationale: This is not an appropriate response. Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting a newborn to leave the nursery. C. "Have the mother call and I will take the baby to the room." Rationale: Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting an infant to remain in the mother‟s room. D. "If you show me your photo identification, you can take the infant." Rationale: This is not an appropriate response. Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting a newborn to leave the nursery. Page 27 56.A A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding? A. The fetal head is in the left occiput posterior position. Rationale: This describes a reference point of the fetal head in relation to the maternal pelvis, indicating a vertex presentation with the fetus in an attitude of general flexion. B. The largest fetal diameter has passed through the pelvic outlet. Rationale: The pelvic outlet is the lower border of the true pelvis. When the largest fetal diameter has passed through the outlet, the station is greater than zero. C. The posterior fontanel is palpable. Rationale: This is a clinical finding indicating that the fetal lie is longitudinal with the fetus in an attitude of general flexion. D. The lowermost portion of the fetus is at the level of the ischial spines. Rationale: The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client‟s ischial spines. Levels above the ischial spines are negative values: –1, –2, –3. Levels below the ischial spines are positive values: +1, +2, +3. 57. A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse‟s priority? A. Respiratory distress Rationale: Shortly before labor, there is a decreased production of fetal lung fluid and a catecholamine surge that promotes fluid clearance from the lungs. Newborns born by cesarean, in which labor did not occur, can experience lung fluid retention, which leads to respiratory distress. The priority assessment when using the airway, breathing, circulation (ABC) approach to client care is to monitor the newborn for respiratory distress. B. Hypothermia Rationale: Hypothermia in a newborn can lead to both respiratory distress and hypoglycemia. While it is important to monitor for this, there is another assessment that is the priority. C. Accidental lacerations Rationale: Accidental lacerations can be inflicted with the scalpel during a cesarean birth. They are typically superficial and rarely need sutures. While it is important to assess for the presence of these, there is another assessment that is the priority. D. Acrocyanosis. Rationale: Acrocyanosis is a bluish discoloration of the hands and feet and is an expected finding in the first 24 hours following delivery. There is another assessment that is the priority. including fetal intrauterine growth restriction, placental abruption, placenta previa, preterm delivery, and fetal death. C. Type 1 diabetes mellitus Rationale: A newborn‟s risk for development of type 1 diabetes mellitus is associated with a family history of diabetes and an autoimmune process. D. Congenital heart defects Rationale: Congenital alterations in the newborn, such as ventricular septal defects and central nervous system malfunctions, are associated with maternal alcohol abuse. 63.A A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as an indication of inhibition of parental attachment? A. "He‟s got my husband‟s nose, that‟s for sure." Rationale: Identification of family characteristics is a sign of healthy attachment. B. "I don‟t need a baby bath demonstration. I know how to do it." Rationale: The client might have experience bathing a newborn. The nurse should obtain additional information regarding the reason for the client not wanting this learning experience before assuming this is inhibited parental attachment. C. "I wish he had more hair. I will keep a hat on his head until he grows some." Rationale: This client statement expresses disappointment in the newborn‟s appearance and a need to hide what the client perceives as an undesirable feature. This is an indication of inhibited parental attachment. D. "Do you think you could keep him in the nursery for the next feeding so I can get some sleep?" Rationale: A client can experience fatigue and a need for sleep following labor and delivery. The nurse should validate the client‟s concerns before concluding that the client is manifesting inhibited parental attachment. 64.A A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make? A. "It would be best if you gained about 11 to 20 pounds." Rationale: Clients who are obese, having a BMI greater than 30, should be advised that the recommended weight gain is 5 to 9 kg (11 to 20 lb). This client is not obese. B. "The recommendation for you is about 15 to 25 pounds." Rationale: Clients who are overweight, having a BMI of 25 to 29.9, should be advised that the recommended weight gain is 7 to 11.5 kg (15 to 25 lb). The pattern of weight gain is also important, with minimal gain in the first trimester. Page 30 Page 31 C. "A gain of about 25 to 35 pounds is recommended for you." Rationale: Clients who have a single fetus and a BMI of 18 to 24.9, the normal range, should gain 11.5 to 16 kg (25 to 35 lb) during pregnancy. This client‟s BMI indicates that she is overweight. D. "A gain of about 1 pound per week is the best pattern for you." Rationale: Clients who are underweight, having a BMI less than 18.5, are advised that a weight gain of 0.5 kg (1.1 lb) per week during the second and third trimesters is appropriate. This client„s BMI indicates that she is overweight. 65.A A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make? A. The client is exhibiting early indications of mastitis. Rationale: Clinical manifestations of mastitis include chills, fever, malaise, and a localized area of breast tenderness. B. Additional interventions are not indicated at this time. Rationale: For this postpartum day, the client‟s fundal location and lochia characteristics are within the expected reference range. Breast engorgement is typical, as this is the time when the breasts begin producing milk. Frequent breastfeeding and routine care can help relieve engorgement. C. Application of a heating pad to the breasts is indicated. Rationale: Heat increases blood flow and can, therefore, increase congestion in breasts that are already engorged. A heating pad should not be offered. However, a warm shower before breastfeeding can help relieve engorgement. D. The client should be advised to remove her nursing bra. Rationale: Wearing a nursing bra helps reduce discomfort due to engorgement. 66.A A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn‟s head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make? to A. "You should go ahead and push to assist the delivery." Rationale: Pushing at this point could result in immediate delivery, increasing the risk of fetal intracranial injury, maternal muscle tears, and soft tissue injury. B. "You should try to pant as the delivery proceeds." Rationale: Panting allows uterine forces to expel the fetus and permits controlled muscle expansion to avoid rapid expulsion of the fetal head. C. "You should try to perform slow-paced breathing." Rationale: Page 32 Slow-paced breathing is used in the first stage of labor as the strength and duration of contractions increase. D. "You should take a deep, cleansing breath and breathe naturally." Rationale: A cleansing breath and breathing naturally at this point will not alleviate or reduce the urge to push. 67.A A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching? A. "I'll let my baby drain one breast at each feeding." Rationale: The client should have her newborn drain both breasts at each feeding to soften them. If the newborn can only drain one breast, the client should pump the other breast to soften it. B. "I‟ll try drinking an herbal tea to reduce the engorgement." Rationale: Herbal remedies should be reviewed with the provider to determine those that are safe to use when breastfeeding. C. "I‟ll apply cold compresses 20 minutes before each feeding." Rationale: There is no evidence to support the use of cold compresses to relieve breast engorgement. If a client prefers the application of cold compresses to manage the discomfort of engorgement, it should be applied after each feeding. D. "I‟ll feed my baby every 2 hours." Rationale: Breast engorgement is relieved by emptying both breasts. The client might be able to accomplish this with more frequent feedings. Otherwise, she can pump her breasts after breastfeeding to ensure optimal emptying. 68. A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? (Select all that apply.) A. Apply breast milk to the nipples before each feeding. B. Place breast pads inside the nursing bra. C. Massage the breasts and nipples prior to feeding. D. Start breastfeeding with the nipple that is less sore. E. Change the infant‟s position on the nipples. Rationale: <b>Apply breast milk to the nipples before each feeding is correct.</b>The application of colostrum and breast milk to the nipples moistens them and prepares them for breastfeeding. This can prevent and reduce nipple tenderness.<br><br><b>Place breast pads inside the nursing bra is incorrect. </b> Sore nipples should be exposed to the air as much as possible. The use of breast shells or cups inside the nursing bra is another option to reduce Page 35 A. "These exercises help prevent constipation." Rationale: Kegel exercises can help minimize or prevent urinary incontinence. B. "These exercises help pelvic muscles to stretch during birth." Rationale: Kegel exercises improve the strength of perineal muscles, facilitating stretching and contracting during childbirth. C. "They can help reduce back aches." Rationale: Kegel exercises have no effect on back aches, typical in late pregnancy due to the effects of musculoskeletal and hormonal changes and a shift in the pregnant client‟s center of gravity. D. "They can prevent further stretch marks." Rationale: Kegel exercises have no effect on striae gravidarum, or stretch marks, which are a result of separation of connective tissue beneath the skin. 74. A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding? A. Variable decelerations are due to umbilical cord compression. Rationale: Variable decelerations are decreases in the fetal heart rate with an abrupt onset, followed by a gradual return to baseline. Variable decelerations coincide with umbilical cord compression, which decreases the oxygen supply to the fetus. B. Variable decelerations are caused by uteroplacental insufficiency. Rationale: Uteroplacental insufficiency produces late decelerations, which indicate fetal hypoxemia. C. Variable decelerations are a result of the administration of IV narcotic analgesics. Rationale: The administration of narcotic analgesics can result in decreased variability, which is observed as irregular waves or fluctuations in the baseline fetal heart rate. D. Variable decelerations are related to fetal head compression. Rationale: Fetal head compression causes early decelerations, which are a gradual decrease in fetal heart rate with a return to baseline during a uterine contraction. 75.A A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch? A. Babinski Rationale: The Babinski reflex is elicited by stroking upward along the lateral edge of the sole of the newborn‟s foot. This reflex does not promote the newborn to latch. Page 36 B. Rooting Rationale: The rooting reflex is elicited when the client strokes the newborn‟s lips, cheek, or corner of the mouth with her nipple. The newborn will turn his head while making sucking motions with his mouth and latch onto the nipple. C. Moro Rationale: The Moro reflex is elicited by striking the surface next to the newborn to startle him. This reflex does not promote the newborn to latch. D. Stepping Rationale: The stepping reflex is elicited by holding the newborn vertically with one foot in contact with a surface. The newborn will make leg movements that look like walking. This reflex does not promote the newborn to latch. 76.A A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn‟s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make? A. "There is no need to worry about that. Most forms of hearing loss are not inherited." Rationale: The nurse is giving the client false reassurance, a nontherapeutic communication technique. One in 1,000 newborns has a significant hearing loss. B. "Look at how she looks as you when you speak. That‟s a good sign." Rationale: The nurse is giving the client false reassurance, a nontherapeutic communication technique, by equating what might be reflexive or unintentional behavior with hearing. One in 1,000 newborns has a significant hearing loss. C. "We do routine hearing screenings on newborns. You‟ll know the results before you leave the hospital." Rationale: Most states mandate hearing screening for all newborns. The two tests in use do not diagnose hearing loss, but determine whether or not a newborn requires further evaluation. D. "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles." Rationale: This is an unreliable way to test hearing. 77.A A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make? A. Within 2 days Rationale: In this time frame, most clients who are breastfeeding are still producing colostrum. B. In 3 to 5 days Rationale: By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast Page 37 milk. C. In 6 to 8 days Rationale: Day 6 to 8 is not the usual time frame for the onset of breast milk production. D. In about 10 days Rationale: Breast milk transitions to mature milk in about 10 days, but clients do produce breast milk before that time. 78.A A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client‟s umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions? A. Cephalic Rationale: With a cephalic presentation, the fetal heart is generally below the level of the client's umbilicus. B. Transverse Rationale: With a transverse presentation, the fetal heart is generally below the level of the client's umbilicus. C. Posterior Rationale: With a posterior presentation, the fetal heart is generally below the level of the client‟s umbilicus. D. Frank breech Rationale: With a frank breech presentation, the fetal heart is generally above the level of the client's umbilicus. 79.A A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings should alert the nurse to the client‟s need to urinate? A. Moderate lochia rubra Rationale: Moderate lochia rubra is an expected finding 8 hr following delivery and does not correlate with a full bladder. B. Fundus three fingerbreadths above the umbilicus Rationale: A full bladder can raise the level of uterine fundus and possibly deviate it to the side. C. Moderate swelling of the labia Rationale: Swelling in the perineal area is an expected finding following a vagin*l delivery and does not correlate with a full bladder. Page 40 examination and gently pushes on the fetus with a fingertip. B. Lightening Rationale: Lightening is the beginning of fetal descent and engagement in the maternal pelvis during the final weeks of a term pregnancy. C. Quickening Rationale: Clients describe quickening as a fluttering sensation, which can be felt as early as the 14th week of gestation. It reflects fetal movement. D. Chloasma Rationale: Chloasma is the presence of a brown hyperpigmentation over the forehead, nose, and cheeks of a client who is pregnant. It is due to an increased level of melatonin, reflecting the hormonal changes of pregnancy. 85.A A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn‟s chest circumference? A. Sternal notch Rationale: Using this landmark can result in an incorrect measurement of chest circumference. B. Nipple line Rationale: The nurse should measure the newborn‟s chest circumference at the nipple line. C. Xiphoid process Rationale: Using this landmark can result in an incorrect measurement of chest circumference. D. Fifth intercostal space Rationale: Using this landmark can result in an incorrect measurement of chest circumference. 86. A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client‟s blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform? A. Prepare for a cesarean birth. Rationale: Unless late decelerations are noted during fetal monitoring, there is no need to prepare for a cesarean birth. B. Assist the client to an upright position. Rationale: Placing the client in an upright position is unlikely to improve her blood pressure significantly. C. Prepare for an immediate vagin*l delivery. Rationale: Page 41 Unless the fetus is exhibiting changes during fetal monitoring, indicating distress, there is no need to hasten delivery. D. Assist the client to turn onto her side. Rationale: Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena cava. Turning the client to her right side relieves this pressure and restores blood pressure to the expected reference range. 87.A A nurse in a provider‟s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption? A. Cocaine use Rationale: Use of cocaine is a risk factor for abruption, as it alters placental blood flow; however, it is not the most common risk factor. B. Hypertension Rationale: Maternal hypertension, either chronic or related to pregnancy, is the most common risk factor for placental abruption. C. Blunt force trauma Rationale: External trauma to the abdomen is a risk factor for placental abruption; however, it is not the most common risk factor. D. Cigarette smoking Rationale: Maternal cigarette smoking is a risk factor for placental abruption; however, it is not the most common risk factor. 88.A A nurse in a prenatal clinic is caring for a client. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client‟s right side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones? A. Left lower Rationale: This is an incorrect response. Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be above the maternal umbilicus. B. Right lower Rationale: This is an incorrect response. Fetal heart tones are best auscultated directly over the location of the fetal back which, in this breech presentation, would be above the maternal umbilicus. C. Left upper Rationale: This is an incorrect response. Fetal heart tones are best auscultated directly over the location of the fetal back. Page 42 D. Right upper Rationale: Fetal heart tones are best auscultated directly over the location of the fetal back, which, in this breech presentation, would be in the right upper quadrant. 89.A A nurse in a prenatal clinic is caring for a client who is at 12 weeks gestation. The client asks about the cause of her heartburn. Which of the following responses should the nurse make? A. Retained bile in the liver results in delayed digestion. Rationale: Retention of bile can result in its thickening, which can lead to gallstones during pregnancy. B. Increased estrogen production causes increased secretion of hydrochloric acid. Rationale: Increased estrogen production causes decreased secretion of hydrochloric acid. C. Pressure from the growing uterus displaces the stomach. Rationale: At 12 weeks of gestation, the uterus is not large enough to place pressure on the stomach. D. Increased progesterone production causes decreased motility of smooth muscle. Rationale: Increased progesterone production causes a relaxation of the cardiac sphincter of the stomach and delayed gastric emptying, which can result in heartburn. 90. A nurse in a prenatal clinic is reviewing the health record of a client who is at 28 weeks of gestation. The history includes one pregnancy, terminated by elective abortion at 9 weeks; the birth of twins at 36 weeks; and a spontaneous abortion at 15 weeks. According to the GTPAL system, which of the following describes the client‟s current status? A. 4-0-1-2-2 Rationale: This response correctly describes the client‟s current status: pregnant currently and had 3 prior pregnancies (G); no term births (T); one pregnancy resulted in the preterm birth (P) of twins; two pregnancies ended in abortion (A); and she has two living children (L). B. 3-0-2-0-2 Rationale: This identifies a client who is pregnant and who had two prior pregnancies (G), two preterm births (P), no miscarriages or abortions (A), and has two living children (L). C. 2-0-0-2-0 Rationale: This describes a client who had two pregnancies (G), no term births (T) or preterm births (P), two abortions or miscarriages (A), and has 0 living children (L). D. 4-2-0-2-2 Rationale: This indicates a client who has had four pregnancies (G), had two term births (T), had no preterm births (P), had two abortions or miscarriages (A), and has two living children (L). 8 Page 45 C. Elevate the client's legs. Rationale: This is a late deceleration and is associated with insufficient placental perfusion. Elevating the client‟s legs is an appropriate action; however, there is another action the nurse should take first. D. Administer oxygen using a nonrebreather mask. Rationale: This is a late deceleration and is associated with insufficient placental perfusion. Administering oxygen at 8 to 10 L/min by a nonrebreather mask is an appropriate action; however, there is another action the nurse should take first. 96.A A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain? A. Administer prescribed analgesic medication. Rationale: The gate control theory of pain is based on the concept of preventing the transmission of pain signals to the brain by using distraction techniques. Administering pain medication does not address this theory. B. Encourage the client to rest between contractions. Rationale: The gate control theory of pain is based on the concept of preventing the transmission of pain signals to the brain by using distraction techniques. Encouraging the client to rest between contractions does not address this theory. C. Massage the client's back. Rationale: The gate control theory of pain is based on the concept of blocking or preventing the transmission of pain signals to the brain by using distraction techniques such as massage. Massaging the client‟s back focuses on neuromuscular and cognitive changes. D. Turn the client onto her left side. Rationale: The gate control theory of pain is based on the concept of preventing the transmission of pain signals to the brain by using distraction techniques. Turning the client to her left side does not address this theory. 97. A nurse on the labor and delivery unit is caring for a client following a vagin*l examination by the provider which is documented as: –1. Which of the following interpretations of this finding should the nurse make? A. The presenting part is 1 cm above the ischial spines. Rationale: Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is minus (-) 1, then the presenting part is 1 cm above the ischial spines. B. The presenting part is 1 cm below the ischial spines. Rationale: Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is Rationale: Page 46 measured in centimeters above, below, or at the level of the spines. If the presenting part is 1 cm below the ischia spines it would be documented as plus (+) 1. C. The cervix is 1 cm dilated. Rationale: Rationale C. Dilation of the cervix is measured from closed to 10 cm. It is not documented in terms of minus 1. D. The cervix is effaced 1 cm. Rationale: Effacement or thinning and shortening of the cervix is measured from 0 to 100%. It is not documented in terms of minus 1. 98.A A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify? A. Fetal attitude is in general flexion. Rationale: Flexion permits the smallest part of the fetal head to present to the outlet. It is not a contributing cause of back labor. B. Fetal lie is longitudinal. Rationale: A longitudinal fetal lie is the most common position for vagin*l birth and is not a contributing cause of back labor. C. Maternal pelvis is gynecoid. Rationale: A gynecoid maternal pelvis is the most common type (50%) for women and is not a contributing cause of back labor. D. Fetal position is persistent occiput posterior. Rationale: The persistent occiput posterior position of the fetus is a common cause of prolonged, difficult labor with severe back pain as spinal nerves are being compressed. Counterpressure or a hands-and-knees position can offer pain relief. 99.A A nurse in is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure? A. Observe color and consistency of fluid. Rationale: The nurse should assess the color and consistency of the amniotic fluid for the presence of meconium or blood; however, this is not the priority action. B. Assess the fetal heart rate pattern. Rationale: Variable fetal heart rate decelerations and bradycardia can occur with an amniotomy as a result of umbilical cord prolapse or compression. Cord prolapse necessitates an emergent delivery. C. Assess the client's temperature. Rationale: Page 47 The client's temperature should be checked at least every 2 hr following an amniotomy. This is not the priority action. D. Evaluate client for the presence of chills and increased uterine tenderness using palpation. Rationale: Chills and increased uterine tenderness can be signs of an intraamniotic infection. Amniotomy increases the risk of uterine infection; however, this is not the priority action. 100.A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider‟s orders. Which of the following orders requires clarification? A. Assess deep tendon reflexes every hour. Rationale: Hyperactive deep tendon reflexes are a sign of increased central nervous system irritability. This is a potential neurological complication of worsening preeclampsia. B. Obtain a daily weight. Rationale: Increased vessel permeability and capillary leakage in preeclampsia leads to a fluid shift from intravascular to the interstitial tissues. This fluid shift can result in sudden significant weight gain in the client. C. Continuous fetal monitoring Rationale: Preeclampsia causes decreased placental perfusion. This can result in fetal hypoxia, restricted growth, and placental abruption D. Ambulate twice daily. Rationale: A provider‟s order to allow the client to ambulate requires clarification. The client who has severe preeclampsia should be placed on bedrest in a quiet, nonstimulating environment to prevent seizures and promote optimal placental blood flow. 101.A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vagin*l bleeding. The nurse should recognize this finding as an indication of which of the following conditions? A. Abruptio placentae Rationale: Abruptio placentae classically presents with vagin*l bleeding, abdominal pain, uterine tenderness, and contractions. In some cases the hemorrhage can remain concealed. B. Placenta previa Rationale: Painless, bright red vagin*l bleeding in the second or third trimester is a manifestation of placenta previa. C. Precipitous labor Rationale: Precipitous labor contractions are hypertonic and often tetanic in intensity. D. Threatened abortion Page 50 106.A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn? A. Placing the newborn on a warm surface Rationale: This action decreases the loss of heat from a warm body to a cooler surface in direct contact. This process is called conduction. B. Preventing air drafts Rationale: This action decreases the loss of heat from a warm body to a cooler solid surface in close proximity but not in direct contact. This process is called radiation. Air drafts increase the effect of radiation. C. Drying the newborn‟s skin thoroughly Rationale: Heat loss through evaporation occurs when moisture on the skin is converted to a vapor. This process is the most significant cause of heat loss in the first few days of life but is minimized by quickly and thoroughly drying the infant D. Maintaining ambient room temperature at 24° C (75° F) Rationale: This action decreases the loss of body heat to the cooler ambient air. This process is called convection. 107.A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions? A. Perform a sharp hand clap near the infant. Rationale: To elicit the Moro reflex, the nurse performs a sharp hand clap near the newborn and observes symmetric abduction and extension of the arms, fanning of the fingers with the thumb and forefinger to form a C, and then a return to a relaxed flexion position. B. Hold the newborn vertically allowing one foot to touch the table surface. Rationale: This position is used to elicit the stepping reflex. The newborn should respond by alternating flexion and extension of his feet, as if he was walking. C. Place a finger at the base of the newborn's toes. Rationale: This action elicits the plantar grasp reflex. The expected response is that the newborn‟s toes will curl downward. D. Turn the newborn‟s head quickly to one side. Rationale: This action elicits the tonic neck reflex. The expected response is that the newborn will extend the arm and leg on the side where the head was turned, while the opposite arm and leg will flex. Page 51 108.A nurse is caring for a newborn delivered by vagin*l birth with a vacuum assist. The newborn‟s mother asks about the swollen area on her son‟s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse? A. "Mongolian spots can be found on the skin of many newborns." Rationale: Mongolian spots are bluish-black areas of pigmentation more commonly noted on the back and buttocks. B. "A caput succedaneum occurs due to compression of blood vessels." Rationale: A caput succedaneum is an area of edema on the newborn‟s occiput, often seen where the cup of the vacuum was applied. It is present at birth and will disappear within 3 to 4 days. C. "This is a cephalhematoma, which can occur spontaneously." Rationale: A cephalohematoma is a collection of blood between the skull and periosteum and does not cross the suture line. It appears after the birth and will take 3 to 6 weeks to resolve. D. "This is erythema toxicum, which is a transient condition." Rationale: Erythema toxicum is a transient skin rash that can occur during the first 3 weeks of life. It is thought to be an inflammatory response and no treatment is required. 109.A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn? A. Cold stress Rationale: When an infant is stressed by cold exposure, oxygen consumption increases and pulmonary and peripheral vasoconstriction occurs. Metabolic demands for glucose increase. If the cold stress continues, hypoglycemia and metabolic acidosis can result. B. Shivering Rationale: The shivering mechanism in newborns is rarely operable. Newborns respond to cold by increasing muscle and metabolic activity and through metabolizing brown fat. C. Basal metabolic rate reduction Rationale: If the newborn becomes chilled, he will increase his basal metabolic rate in an attempt to generate heat. This results in an increased consumption of oxygen and blood glucose. D. Brown fat production Rationale: Infants are born with stores of brown fat, which they utilize during the first few weeks of life to produce heat. Brown fat is unique to the newborn and can increase heat production by 100%. 110.A nurse is caring for a client who is 6 hr postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse? Page 52 A. "It determines if kernicterus will occur in the newborn." Rationale: Kernicterus is the irreversible chronic result of acute bilirubin encephalopathy. While the presence of Rh antibodies in the client‟s blood increases the risk of jaundice and acute bilirubin encephalopathy in the newborn, it does not determine if these disorders will occur. B. "It detects Rh-negative antibodies in the newborn‟s blood." Rationale: If the client is Rh-negative, her blood is lacking Rh factor. Rh antibodies are only produced in response to the unexpected presence of Rh factor, not its absence. A newborn who has Rh positive blood has Rh factor so would not produce antibodies against it. C. "It detects Rh-positive antibodies in the mother‟s blood." Rationale: An indirect Coombs test determines the presence of Rh antibodies. If the client has Rh-negative blood, she does not produce Rh factor. Exposure to Rh positive blood, such as from an Rh factor positive fetus, could trigger the client to begin producing antibodies against Rh factor. These antibodies can cross the placenta and harm an Rh-positive fetus. D. "It determines the presence of maternal antibodies in the newborn‟s blood." Rationale: A direct Coombs test measures the present of maternal antibodies in the newborn's blood. 111.A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention? A. A newborn who is 24 hr post-delivery and has not voided Rationale: First voiding usually occurs within 24 to 48 hr following delivery. B. A newborn who is 18 hr post-delivery and has acrocyanosis Rationale: Acrocyanosis, a bluish discoloration of the hands and feet, can persist for 24 hr following delivery. C. A newborn who is 24-hr post-delivery and has not passed meconium Rationale: Passage of meconium usually occurs within 12 to 48 hr post-delivery. D. A newborn who is 12 hr post-delivery and has a temperature of 37.5° C (99.5° F) Rationale: Hyperthermia in the newborn requires immediately intervention. Hyperthermia is typically caused by increased heat production related to sepsis or decreased heat loss. 112.A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn‟s Apgar score. 6 points Correct Rationale: The Apgar score is 6 out of a possible 10. It is based on 5 signs evaluated at 1 and 5 Page 55 If manual massage of the uterine fundus does not increase contractility and slow bleeding, it would then be appropriate to empty the bladder and administer a continuous IV infusion of oxytocin. 117.A nurse in a prenatal clinic is teaching a group of clients about nutrition requirements during lactation. Which of the following statements should the nurse make? A. "Calcium intake should be at least 2,000 mg per day." Rationale: The calcium requirement during lactation for women over age 19 is 1,000 mg, which is the same as during pregnancy and for nonpregnant female clients of the same age. B. "Zinc intake should be at least 12 mg per day." Rationale: Zinc intake should be increased to 12 mg per day during lactation, which is above the recommended levels for pregnancy and nonpregnant female clients over age 19. C. "The recommended intake of folic acid remains the same as for pregnant women." Rationale: Folic acid requirements are 500 mcg per day during lactation, as compared to a recommended intake of 600 mcg during pregnancy. D. "The recommended intake of iron increases." Rationale: Iron requirements do not increase during lactation. They remain 9 mg per day for female clients over age 19. 118.A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications? A. Anaphylactoid syndrome of pregnancy Rationale: Anaphylactoid syndrome of pregnancy, due to an amniotic fluid embolism, typically occurs within 30 min after birth and is manifested by sudden, acute onset of hypoxia, hypotension, cardiac arrest, and coagulopathy. B. Disseminated intravascular coagulation Rationale: Clinical manifestations of disseminated intravascular coagulation (DIC) include oozing from intravenous access and venipuncture sites; petechiae, especially under the site of the blood pressure cuff; spontaneous bleeding from the gums and nose; other signs of bruising; and hematuria. C. Preeclampsia Rationale: Preeclampsia is typically seen in the antepartum period and is manifested by elevated blood pressure, hyperactive reflexes, proteinuria, and edema. D. Puerperal infection Rationale: Page 56 Puerperal or postpartum infection is identified by the presence of a fever of 380 C (100.40 F) or higher on 2 consecutive days of the first 10 postpartum days and can include endometritis, wound infections, urinary tract infections, and mastitis. 119.A nurse is caring for a client who is postpartum and is breastfeeding. The client states that she is concerned about dietary precautions since she has a family history of food allergies .The nurse offers which of the following responses? A. "You might want to avoid eating peanuts." Rationale: There are no standard foods that are contraindicated during breastfeeding. With a family history of food allergies, it is important to avoid eating highly allergenic foods, such as peanuts, as well as other foods to which the client has a known allergy. B. "Rice cereals can be a problem during lactation." Rationale: Common food allergies include wheat products, such as wheat cereal. C. "Foods you eat do not affect breast milk." Rationale: The flavor of breast milk can be altered by foods and spices in the diet. D. "The infant needing more sleep can indicate a food allergy." Rationale: Colic-like symptoms occur in infants with a family history of milk protein intolerance. Infants who are breastfed can exhibit fussiness and gastrointestinal distress as a response to foods and spices consumed by mothers. 120.A nurse is caring for a client who is breastfeeding and states that her nipples are sore. Which of the following interventions should the nurse suggest? A. Apply mineral oil to the nipples between feedings. Rationale: The client should apply purified lanolin to the nipples after feedings. B. Keep the nipples covered between breastfeeding sessions. Rationale: The client should expose sore nipples to the air as much as possible. C. Increase the length of time between feedings. Rationale: Decreasing the frequency of feedings does not prevent sore nipples or allow time for healing. D. Change the newborn‟s position on the nipples with each feeding. Rationale: When the client‟s nipple is sore due to breastfeeding, the client should break the suction with her finger, remove the newborn from the breast, and try a different position. The newborn‟s mouth should be open wide before connecting with the nipple. Page 57 121.A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding? A. Caput succedaneum Rationale: Caput succedaneum is edema of the presenting part of the newborn‟s head due to pressure during labor. The edema extends across the suture lines of the skull. B. Cephalhematoma Rationale: A cephalhematoma is a swelling, indicating bleeding under the subcutaneous tissues of the newborn‟s scalp. The collection of blood is beneath the periosteum of the cranial bone and therefore does not cross the suture line. C. Molding Rationale: Molding is a temporary misshaping of the fetal head due to overlapping cranial bones at the suture lines to accommodate the passage of the fetal head through the birth canal. D. Pilonidal dimple Rationale: Pilonidal dimple can be observed when assessing the vertebral column and can be associated with spina bifida. 122.A nurse observes that a newborn has a pink trunk and head, bluish hands and feet, and flexed extremities 5 min after delivery. He has a weak and slow cry, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant? 8 Correct Rationale: Apgar scoring is an assessment of five areas of newborn well-being: respiratory effort, heart rate, muscle tone, reflex irritability, and color. This newborn scores 2 each for heart rate, muscle tone, and reflex irritability. The weak cry and acrocyanosis of the hands and feet score 1 each, for a total of 8. InCorrect Rationale: Apgar scoring is an assessment of five areas of newborn well-being: respiratory effort, heart rate, muscle tone, reflex irritability, and color. This newborn scores 2 each for heart rate, muscle tone, and reflex irritability. The weak cry and acrocyanosis of the hands and feet score 1 each, for a total of 8. 123.A nurse is teaching a client who is breastfeeding about dietary recommendations. Which of the following statements by the client indicates understanding of the teaching? A. "I will decrease my daily fiber intake." Rationale: During lactation, clients should consume about 4 g more of fiber per day than nonpregnant, nonlactating women. B. "I‟ll make sure I reduce salt in my diet." Rationale: Unless the client has an underlying disorder that requires sodium restriction, this is not Page 60 Panting is rapid, continuous, shallow breathing. It helps a client in labor refrain from pushing before her cervix reaches full dilation. Observe for hyperventilation and have the client exhale slowly through pursed lips. D. Help the client to the bathroom to void. Rationale: Emptying the bladder does not alter the client‟s urge to push. 128.A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take? A. Ask another nurse to verify the heart rate. Rationale: Unless the nurse has doubts about measuring the newborn‟s apical heart rate, there is no need to ask another nurse to verify this finding. B. Document this as an expected finding. Rationale: The expected reference range for an apical pulse in a newborn who is awake is 120 to 160/min. The nurse should document this as an expected finding. C. Call the provider to further assess the newborn. Rationale: Based on this finding, there is no need to call the provider to assess the newborn. D. Prepare the newborn for transport to the NICU. Rationale: Based on this finding, there is no need to prepare the newborn for transport to the NICU. 129.A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor? A. Cervical dilation Rationale: Cervical dilation and effacement are indications of true labor. B. Report of pain above the umbilicus Rationale: The pain of true labor is generally in the back or lower abdomen. C. Brownish vagin*l discharge Rationale: Brownish to bloody discharge can be the result of recent sexual intercourse or trauma following a vagin*l examination and does not indicate true labor. D. Amniotic fluid in the vagin*l vault Rationale: This indicates ruptured membranes, not necessarily true labor. Page 61 130.A nurse is caring for a client 2 hr after a spontaneous vagin*l birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time? A. Palpate the client‟s uterine fundus. Rationale: Although the expectation is moderate bleeding in the first 2 hr after delivery, saturating a perineal pad in 15 min or less indicates excessive blood loss. The priority nursing intervention is to palpate the client‟s fundus to determine the presence of uterine atony, followed by fundal massage to stimulate uterine muscle tone. B. Assist the client on a bedpan to urinate. Rationale: Assisting the client to urinate reduces bladder distention, which displaces the uterus. A midline position allows the uterus to contract normally and reduces bleeding; however, this is not the priority nursing intervention. C. Prepare to administer oxytocic medication. Rationale: Oxytocic medication might be necessary if excessive bleeding persists; however, this is not the priority nursing intervention. D. Increase the client‟s fluid intake. Rationale: Increasing fluids, IV and PO, is essential for restoring fluid volume, but it is not the priority nursing intervention. 131.A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and undergoing a contraction stress test. The test results are negative. Which of the following interpretations of this finding should the nurse make? A. There is evidence of cervical incompetence. Rationale: A contraction stress test is used to evaluate how well the fetus tolerates the stress of uterine contractions. It does not evaluate the status of the cervix. Cervical incompetence is a contraindication for a contraction stress test. B. There is no evidence of two or more accelerations in fetal heart rate in 20 min. Rationale: This finding is an interpretation of a nonreactive nonstress test. C. There is no evidence of uteroplacental insufficiency. Rationale: A contraction stress test determines how well the fetus tolerates the stress of uterine contractions. A test is negative when there are at least 3 uterine contractions in a 10-min period with no late or significant variable decelerations during electronic fetal monitoring. Uteroplacental insufficiency produces late decelerations. D. There are less than 3 uterine contractions in a 10-min period. Rationale: This finding is an interpretation of an unsatisfactory contraction stress test. Page 62 132.A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching? A. "Refrain from exercises that include stretching." Rationale: Stretching exercises help prepare the joints for more strenuous exercises and also lessens the risk for injury. B. "Moderate exercise improves circulation." Rationale: Improving circulation is just one of the many benefits of moderate exercise during pregnancy. It enhances well-being, promotes rest and relaxation, and improves muscle tone. C. "It is recommended to increase your weight-bearing exercises." Rationale: The usual recommendation is to reduce weight-bearing exercise and choose swimming, cycling, or stretching instead. D. "It is recommended to rest for 30 minutes before each new exercise." Rationale: The usual recommendation is to rest in a side-lying position for 10 min after exercising. This position promotes optimal circulation in the later stages of pregnancy. 133.A nurse is caring for a client who experienced a vagin*l birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time? A. Massage the fundus. Rationale: The client‟s fundus is firm, so there is no indication for massage. B. Insert a urinary catheter. Rationale: Catheterization might be necessary if the client is unable to void after implementing additional measures to promote urination. C. Have the client urinate. Rationale: A full bladder displaces the uterine fundus and elevates it above the level of the umbilicus. This can lead to uterine atony and excessive bleeding. Having the client urinate allows the uterus to return to midline and remain below the umbilicus. D. Administer an analgesic. Rationale: Unless the client reports pain, there is no indication to administer an analgesic. 134.A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client‟s tolerance of the procedure, which of the following assessments should the nurse perform? A. Bladder distention Rationale: Page 65 139.A nurse is completing a newborn gestational age assessment. Which of the following findings should be recorded as part of this assessment on the newborn? A. Acrocyanosis of hands and feet Rationale: Acrocyanosis is monitored as part of the Apgar and newborn physical assessment but is not a component of gestational age assessment. B. Anterior fontanel soft and level Rationale: The anterior fontanel is palpated as part of newborn physical assessment but is not a component of gestational age assessment. C. Plantar creases cover 2/3 of sole Rationale: Observing the presence of creases on the plantar surface is one of the components of a gestational age assessment. D. Vernix caseosa in inguinal creases Rationale: Vernix caseosa in inguinal creases is a normal newborn finding but not a component of gestational age assessment. 140.A nurse is caring for a client who experienced a vagin*l birth 12 hr ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase? A. Expressions of excitement Rationale: Expressing excitement and being talkative are characteristic of this phase. B. Lack of appetite Rationale: A lack of appetite is not a characteristic of maternal postpartum adjustment. C. Focus on the family unit and its members Rationale: A focus on the family unit and its members is a finding in the interdependent, letting go phase of maternal postpartum adjustment. D. Eagerness to learn newborn care skills Rationale: A desire to learn newborn care is a finding in the dependent-independent, taking hold phase of maternal postpartum adjustment. 141.A nurse is planning care for a newborn who has a new diagnosis of phenylketonuria (PKU). Which of the following actions should be included in the plan of care? A. Initiate a controlled low-protein diet. Rationale: Page 66 PKU is managed by eliminating phenylalanine from the diet. It is found in most natural food proteins, such as milk and infant formulas. A special low-protein, amino-acid formula that is low in phenylalanine is initiated and included in the plan of care. B. Educate parents on blood glucose monitoring. Rationale: Blood glucose monitoring is needed for the client who has a new diagnosis of diabetes. Therefore, educating parents on blood glucose monitoring is not an appropriate action to include in the plan of care. C. Administer thyroid hormone replacement. Rationale: Thyroid hormone replacement is necessary for the client who has a new diagnosis of hypothyroidism. Therefore, administering thyroid hormone replacement is not an appropriate action to include in the plan of care. D. Obtain a blood sample for blood type. Rationale: Obtaining a blood sample for blood type is not indicated for newborns who have PKU. Therefore, it is not an appropriate action to include in the plan of care. 142.A nurse in a clinic is teaching the mother of a 4-month-old infant who has been breastfed. The mother plans to switch her infant to an iron-fortified formula. Which of the following should be included in the teaching? A. Iron facilitates development of vision in infants. Rationale: Vitamin A is important for development of vision. B. Iron facilitates growth of bones in infants. Rationale: Calcium facilitates bone mineralization and growth. C. Iron stores in infants begin to deplete. Rationale: Iron stores in infants are adequate until about 6 months of age. Infants who are weaned before 6 months of age should be given iron-fortified formula until 12 months of age. Iron stores will also be supplemented with the addition of iron-fortified cereals and iron-rich foods to the infant‟s diet at 6 months of age. D. Iron is poorly absorbed in infants. Rationale: The whey proteins in human milk and infant formulas have iron-binding capacities that allow for adequate absorption and storage of iron. 143.A nurse is teaching about nutrition guidelines to a parent of a newborn. Which of the following statements by the parent indicates understanding of the teaching? A. "I should start solid foods when my baby is 3 months old." Rationale: The American Academy of Pediatrics recommends that the introduction of solid foods should not begin until after 4 months of age, and preferably not until 6 months of age. Page 67 B. "I should introduce cow‟s milk when my baby is 9 months old." Rationale: Cow‟s milk lacks adequate nutrients an infant needs to grow. Therefore, it is recommended that cow‟s milk should not be introduced until the infant is 12 months old. C. "I should wait to give fruit juice until my baby is 6 months of age." Rationale: Fruit juice provides minimal nutritional value to the infant‟s diet. Therefore, fruit juices should be limited and not offered until the infant is 6 months of age. D. "I should wait to begin fluoride supplements until my baby is 4 months of age." Rationale: Commercial iron-fortified formula has all the fluoride an infant needs for the first 6 months of life. Fluoride supplements should not begin until 6 months of age and only for infants if the local water supply is not fluoridated. 144.A nurse is completing an assessment of a 1-month-old newborn. Which of the following developmental skills is an expected finding? A. Displays a social smile Rationale: An infant that is 2 months old is able to display a social smile. B. Follows movements of objects with eyes Rationale: A 1-month-old infant is able to follow movements with their eyes. C. Reacts to sounds by turning head Rationale: An infant that is 3 months old is able to turn their head to locate sounds. D. Makes babbling sounds Rationale: An infant that is 3 months old is able to make a babbling sound. 145.A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse? A. Assist the family to identify prior use of positive coping skills in family crises. Rationale: Assisting the family to identify the use of coping mechanisms at a time of family crisis is important, but it is not the first action the nurse should consider. B. Ask the client if she has considered harming her newborn. Rationale: When using the nursing process in caring for a client, the first action should focus on assessment of the client‟s mood, ability to concentrate, thought processes, and if the client has had thoughts of self-harm or of injuring her newborn. C. Anticipate a prescription by the provider for an antidepressant. Rationale: Page 70 150.A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction? A. "I will keep my baby‟s head elevated while he is feeding." Rationale: A semi-reclining position is appropriate for bottle feeding. B. "I will allow my baby to burp several times during each feeding." Rationale: Newborns swallow air during feeding and should be offered the opportunity to burp several times during each feeding. C. "I will tip the nipple so air is present as my baby sucks." Rationale: The nipple should be held so it fills only with formula. The infant should not be permitted to suck air. D. "My baby will have soft, formed yellow stools." Rationale: A newborn who is bottle-fed typically has soft, formed yellow stools and they can occur with each feeding. The frequency of stools will decline as the newborn adapts to feeding. 151.A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion? A. Diminished deep-tendon reflexes Rationale: Diminished or absent deep-tendon reflexes is a manifestation of magnesium toxicity. The nurse should stop the infusion immediately. B. Respiratory rate of 16/min Rationale: The client‟s respiratory rate should be at least 12/min to maintain adequate respiratory function. Magnesium toxicity causes bradypnea. Based on this finding, the nurse may continue the infusion. C. Urine output of 50 mL in 4hr Rationale: The client‟s urine output should be at least 25 to 30 mL/hr to promote adequate excretion of magnesium. The nurse should stop the infusion. D. Heart rate of 56/min Rationale: Bradycardia is a manifestation of magnesium toxicity. The nurse should stop the infusion immediately. 152.A nurse is caring for a client who is postpartum and has a prescription for Rho (D) immunoglobulin. The nurse should verify which of the following prior to administration? Page 71 A. Client is Rh positive and the newborn is Rh positive. Rationale: Rho (D) immunoglobulin is unnecessary in this situation. B. Client is Rh negative and the newborn is Rh negative. Rationale: Rho (D) immunoglobulin is not necessary if the newborn is Rh negative. C. Client is Rh negative and the newborn is Rh positive. Rationale: Rho (D) immunoglobulin contains antibodies to Rho (D). Administering it prevents antibody formation in women who are Rh negative following exposure to Rh positive blood, such as from a fetus who is Rh positive. D. Client is Rh positive and the newborn is Rh negative. Rationale: Rho (D) immunoglobulin is unnecessary in this situation. 153.A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles? A. Vastus lateralis Rationale: The nurse should administer vitamin K, or phytonadione, into the vastus lateralis muscle in the thigh. This medication prevents and treats hemorrhagic disease of the newborn, as newborns are born with vitamin K deficiency. B. Ventrogluteal Rationale: The ventrogluteal muscle is used for some IM injections, but it is not the preferred site for injecting vitamin K into a newborn. C. Dorsogluteal Rationale: The dorsogluteal muscle in newborns is too small to receive an IM medication, and it is near the sciatic nerve. It is not recommended as an injection site in small children. D. Deltoid Rationale: The deltoid muscle in newborns is too small to receive an IM medication. It is not recommended as an injection site in small children. 154.A nurse is assessing a client who received magnesium sulfate to treat preterm labor. Which of the following clinical findings should the nurse identify as an indication of toxicity of magnesium sulfate therapy and report to the provider? A. Respiratory depression Rationale: Magnesium sulfate toxicity can cause life-threatening adverse effects, including respiratory and CNS depression. The nurse should report a respiratory rate slower than 12/min immediately to the provider and stop the infusion. Page 72 B. Facial flushing Rationale: Facial flushing and sedation are expected reactions to magnesium sulfate administration. They do not require reporting to the provider. C. Nausea Rationale: Nausea and burning at the IV access site are expected reactions to magnesium sulfate administration. They do not require reporting to the provider. D. Drowsiness Rationale: Drowsiness and dizziness expected reactions to magnesium sulfate administration. They do not require reporting to the provider. 155.A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block? A. Vomiting Rationale: Vomiting is not an adverse effect of epidural anesthesia. It is an adverse effect of opioids and opioid agonist analgesics, both of which can help minimize labor pain. B. Tachycardia Rationale: Tachycardia is not an adverse effect of epidural anesthesia. It is an adverse effect of opioid agonist-antagonist analgesics, such as butorphanol. C. Respiratory depression Rationale: Respiratory depression is not an adverse effect of epidural anesthesia. It is a risk for clients receiving magnesium sulfate for pre-eclampsia or premature labor. D. Hypotension Rationale: Maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of the epidural catheter to decrease the likelihood of this complication. 156.A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take? A. Decrease the rate of infusion of the maintenance IV solution. Rationale: Increasing the rate of infusion of the maintenance IV solution is an appropriate action to take when late decelerations occur. B. Discontinue the infusion of the IV oxytocin. Rationale: Page 75 nurse‟s priority focus of care. D. Hypocalcemia Rationale: Newborns of mothers who have diabetes are at risk for hypocalcemia, but this is not the nurse‟s priority focus of care. 161.A nurse is caring for a client who is gravida 3, para 2, and is in active labor. The fetal head is at 3+ station after a vagin*l examination. Which of the following actions should the nurse take? A. Apply fundal pressure. Rationale: Fundal pressure is not advised because there is no evidence to support that this action facilitates a safe vagin*l birth. B. Observe for the presence of a nuchal cord. Rationale: An umbilical cord that is wrapped around the neck of the fetus cannot be seen until after the fetal head is delivered. A +3 station indicates that the fetal head is still in the birth canal, crowning may be observed, and delivery of the fetal head is imminent. C. Observe for crowning. Rationale: In the descent phase of the second stage of labor, crowning occurs when the fetal head is at +2 to +4 station. Because this is the client‟s third childbirth experience, it is reasonable to assume that delivery is imminent. D. Prepare to administer oxytocin. Rationale: There are no data to suggest that labor is delayed or ineffective. Preparing to administer oxytocin is not an appropriate action at this time. 162.A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching? A. "The test will be performed if your baby‟s heart beat is heard." Rationale: The presence of fetal heart tones is not a determining factor for an amniocentesis. The uterus must be palpable in the abdomen and amniotic fluid needs to be present. B. "This test will determine if your baby‟s lungs are mature." Rationale: An amniocentesis in early pregnancy is used to identify congenital disorders of the fetus, such as neural tube defects, genetic disorders, and inborn errors of metabolism. In late pregnancy, it is used to identify fetal lung maturity and fetal hemolytic disease. C. "This test requires the presence of amniotic fluid." Rationale: Amniocentesis requires adequate amniotic fluid for testing, which is not available until after 14 weeks of gestation. Page 76 D. "After the test, you will be given Rho immune globulin since you are Rh positive." Rationale: After an amniocentesis, Rho immune globulin is administered to clients who are Rh negative due to the risk of fetomaternal hemorrhage. 163.A nurse is planning care for a client who is 2 hours postpartum following a cesarean birth. The client has a history of thromboembolic disease. Which of the following nursing interventions should be included in the plan of care? A. Apply warm, moist heat to the client‟s lower extremities. Rationale: Warm, moist heat helps relieve the discomfort of thrombophlebitis, but it does not prevent it. B. Massage the client‟s posterior lower legs. Rationale: Massage of the legs does not prevent blood clot formation, and can dislodge a clot that is present and undetected. C. Place pillows under the client‟s knees when resting in bed. Rationale: Flexing the client‟s knees by placing pillows under them causes blood to pool in the lower extremities and increases the risk of thrombophlebitis. D. Have the client ambulate. Rationale: Venous stasis is a major cause of thrombophlebitis. To prevent clot formation, have the client ambulate as soon as she can after delivery and as often as possible. 164.A nurse is teaching a client who is at 15 weeks of gestation and is to undergo an amniocentesis. The nurse should explain that the purpose of this test is to identify which of the following conditions? (Select all that apply.) A. Rh incompatibility B. Cephalopelvic disproportion C. Anomalies in fetal chromosomes D. Neural tube defects E. Fetal gender Rationale: <b>Rh incompatibility is incorrect.</b> An indirect Coombs test is a screening tool for Rh incompatibility.<br><br><b>Cephalopelvic disproportion is incorrect.</b> Abdominal ultrasonography is used to identify cephalopelvic disproportion later in pregnancy.<br><br><b>Anomalies in fetal chromosomes is correct.</b> Examination of amniotic fluid yields data about genetic anomalies, such as hemophilia and inborn metabolic disorders.<Br><br><b>Neural tube defects is correct.</b> Examination of alpha fetoprotein levels in amniotic fluid confirms the presence of a neural tube defect, such as spina bifida.<Br><br><b>Fetal gender is correct.</b> Karyotyping of fetal cells obtained from amniotic fluid permits the identification of fetal gender, which is important if an X-linked disorder is suspected in a male fetus. Page 77 165.A nurse is admitting a client who is at 33 weeks of gestation and has a diagnosis of placenta previa. Which of the following is the priority nursing action? A. Monitor vagin*l bleeding. Rationale: The quantity of vagin*l bleeding and any associated pain should be monitored, but this is not the priority action by the nurse. B. Administer glucocorticoids. Rationale: Glucocorticoids should be administered to the client who is at less than 34 weeks of gestation to promote fetal lung maturity, but this is not the priority action by the nurse. C. Insert an IV catheter. Rationale: IV access should be established, but this is not the priority action by the nurse. D. Apply an external fetal monitor. Rationale: Based on Maslow‟s hierarchy of needs, the nurse should immediately apply the fetal monitor to determine if the fetus is in distress. 166.A nurse is caring for a client who is in labor and has an epidural anesthesia block. The client‟s blood pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority nursing action? A. Elevate the client‟s legs. Rationale: The nurse should elevate the client‟s legs if there is no improvement in the blood pressure with the client in a lateral position, but this is not the priority nursing action. B. Monitor vital signs every 5 min. Rationale: The client‟s vital signs should be monitored every 5 min, but this is not the priority nursing action. C. Notify the provider. Rationale: The provider should be notified, but this is not the priority nursing action. D. Place the client in a lateral position Rationale: Based on Maslow‟s hierarchy of needs, the client should be moved to a lateral position or a pillow placed under one of the client‟s hips to relieve pressure on the inferior vena cava and improve the blood pressure. 167.A nurse is preparing to administer an injection of Rho (D) immunoglobulin. The nurse should understand that the purpose of this injection is to prevent which of the following newborn complications? A. Hydrops fetalis Rationale: Page 80 Initial nursing assessment of the perineal pad of a client following delivery cannot be delegated to the AP because this requires professional nursing knowledge. 172.A nurse is caring for a client who is in labor and assists the provider who performs an amniotomy. Which of the following is the priority action by the nurse following the procedure? A. Monitor the client‟s temperature. Rationale: The client‟s temperature should be checked at least every 2 hr following the rupture of the membranes, but this is not the priority action by the nurse. B. Assess the fetal heart rate. Rationale: The fetal heart rate should be assessed before and immediately after the amniotomy to detect any changes. C. Assess the odor of the amniotic fluid. Rationale: The nurse should assess the odor, color, and consistency of the amniotic fluid, but this is not the priority action by the nurse. D. Provide clean, dry underpads. Rationale: The nurse should provide clean, dry underpads following the amniotomy, but this is not the priority action by the nurse. 173.A nurse is instructing a male client about a sem*n analysis to be done for suspected infertility. Which of the following should be included in the teaching? A. Abstain from ejacul*tion for at least 2 to 5 days prior to the test. Rationale: The client should be instructed to abstain from ejacul*tion for at least 2 to 5 days prior to the test. B. Refrigerate the specimen after collection. Rationale: The specimen should be protected from excessive cold after collection. C. Leave the specimen at room temperature for 3 to 4 hr prior to transport to the laboratory. Rationale: The specimen should be transported to the laboratory within 2 hr of ejacul*tion. D. Collect the specimen using a condom with spermicidal lubricant. Rationale: A plastic sheath for sem*n collection should not contain a spermicidal agent. 174.A nurse is assessing a newborn who has Trisomy 21 (Down‟s Syndrome). Which of the following are common characteristics? (Select all that apply.) Page 81 A. Transverse palmar creases B. Large ears C. Muscular hypertonicity D. Protruding tongue E. Low birth weight Rationale: <b>Transverse palmar creases is correct.</b> A common characteristic of newborns who have Trisomy 21 is transverse palmar creases.<br><br><b>Large ears is incorrect.</b> A common characteristic of newborns who have Trisomy 21 is small ears.<br><br><b>Muscular hypertonicity is incorrect.</b> A common characteristic of newborns who have Trisomy 21 is muscular hypotonicity.<br><br><b>Protruding tongue is correct.</b> A common characteristic of newborns who have Trisomy 21 is protruding tongue.<Br><br><b>Low birth weight is incorrect.</b> Newborns who have Trisomy 21 do not demonstrate the common characteristic of low birth weight. 175.A nurse is assessing a newborn who has a coarctation of the aorta. Which of the following should the nurse recognize is a clinical manifestation of coarctation of the aorta? A. Increased blood pressure in the arms with decreased blood pressure in the legs Rationale: There is a narrowing next to the ductus arteriosus that results in an increased pressure proximal to the defect, with a decreased pressure distal to the obstruction. Therefore, an increased blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta. B. Decreased blood pressure in the arms with increased blood pressure in the legs Rationale: There is a narrowing next to the ductus arteriosus that results in an increased pressure proximal to the defect, with a decreased pressure distal to the obstruction. Therefore, an increased blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta. C. Increased blood pressure in both the arms and the legs Rationale: There is a narrowing next to the ductus arteriosus that results in an increased pressure proximal to the defect, with a decreased pressure distal to the obstruction. Therefore, an increased blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta. D. Decreased blood pressure in both the arms and the legs Rationale: There is a narrowing next to the ductus arteriosus that results in an increased pressure proximal to the defect, with a decreased pressure distal to the obstruction. Therefore, an increased blood pressure in the arms with a decreased blood pressure in the legs would be a clinical manifestation of a coarctation of the aorta. 176.A nurse is assessing a newborn for manifestations of a large patent ductus arteriosus. Which of the following Page 82 findings should the nurse expect? A. Cyanosis with crying Rationale: A patent ductus arteriosus is failure of the artery connecting the aorta and pulmonary artery to close after birth, causing a left-to-right shunt. Therefore, cyanosis is not a clinical manifestation of a large patent ductus arteriosus. B. Systolic murmur Rationale: A patent ductus arteriosus is failure of the artery connecting the aorta and pulmonary artery to close after birth, causing a left-to-right shunt. A systolic murmur is a clinical manifestation found in newborns who have a large patent ductus arteriosus. C. Weak pulses Rationale: A patent ductus arteriosus is failure of the artery connecting the aorta and pulmonary artery to close after birth, causing a left-to-right shunt. Therefore, bounding pulses is a clinical manifestation of a large patent ductus arteriosus. D. Chronic hypoxemia Rationale: A patent ductus arteriosus is failure of the artery connecting the aorta and pulmonary artery to close after birth, causing a left-to-right shunt. Therefore, chronic hypoxemia is not a clinical manifestation of a large patent ductus arteriosus. 177.A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis? A. Absent bowel sounds Rationale: Visible gastric peristaltic waves moving from the left to the right are a clinical manifestation of pyloric stenosis. B. Increased sodium levels Rationale: Vomiting causes a depletion of fluid and electrolytes; therefore, a decrease in serum sodium levels is a clinical manifestation of pyloric stenosis. C. Projectile vomiting after feedings Rationale: Pyloric stenosis is a narrowing and thickening of the pyloric canal between the stomach and the duodenum, resulting in projectile vomiting. D. Golf ball-sized mass over the left quadrant Rationale: An olive-shaped mass palpable right of the umbilicus is a clinical manifestation of pyloric stenosis. 178.A nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action? Page 85 B. Accelerations Rationale: Accelerations are caused by fetal movement, vagin*l examination, electrode application, and fetal scalp stimulation. C. Late decelerations Rationale: Late decelerations are caused by insufficient placental perfusion during contractions. This results in a disruption of the flow of oxygen to the fetus. D. Variable decelerations Rationale: Variable decelerations occur when the umbilical cord becomes compressed and disrupts the flow of oxygen to the fetus. 183.A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect? A. Absent plantar reflexes Rationale: Absence of any newborn reflexes indicate a neurological problem, not a musculoskeletal one. B. Lengthened thigh on the affected side Rationale: With DDH, the thigh on the affected side is shorter than the thigh on the unaffected side. This is known as Galeazzi sign. C. Inwardly turned foot on the affected side Rationale: A foot that turns inward can be the result of fetal positioning or due to a congenital condition known as talipes equinovarus or club foot. D. Asymmetric thigh folds Rationale: Gluteal and thigh skin folds that are not equal and symmetric is a sign of DDH. 184.A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilirubinemia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia occurs with Rh incompatibility for which of the following reasons? A. The client‟s blood does not contain the Rh factor, so she produces anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns. Rationale: If the Rh-negative client has been exposed to Rh-positive fetal blood, she will produce antibodies against Rh factor. These antibodies can cross the placenta and destroy the red blood cells of the Rh-positive fetus. This accelerated rate of red blood cell destruction results in the increased release of bilirubin. The newborn‟s serum bilirubin level can rise quickly. B. The client‟s blood contains the Rh factor and the newborn‟s does not, and antibodies that destroy red blood cells are formed in the fetus. Rationale: Page 86 Rh incompatibility only occurs when the client's blood does not contain Rh factor (Rh negative) but the fetal blood does contain Rh factor (Rh positive). C. The client has a history of receiving a transfusion with Rh-negative blood. Rationale: Receiving a transfusion of Rh-negative blood would not cause sensitization of the client's blood against Rh factor. D. The client‟s anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal red blood cells. Rationale: Anti-A and anti-B antibodies can cause fetal blood cell destruction when there is an ABO incompatibility. This type of incompatibility is related to the client/fetal blood type, not the presence of Rh factor. 185.A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn‟s nose and mouth. Which of the following actions is the nurse‟s priority? A. Suction the nose with a bulb syringe. Rationale: Suctioning the secretions from the nose is important, but it is not the first action the nurse should take. Touching the nares with the tip of the bulb syringe might make the newborn gasp and inhale secretions from the mouth. B. Suction the mouth with a bulb syringe. Rationale: The greatest risk to the newborn is aspiration of secretions. Removing the secretions from the mouth first is the priority action. C. Use a suction catheter with low negative pressure. Rationale: It might become necessary to remove secretions that interfere with respiratory effort using a mechanical suction system, but this is not the first action the nurse should take. D. Turn the newborn on his side. Rationale: Positioning a newborn with excessive secretions on the side with a rolled blanket supporting the back is important to help prevent aspiration, but it is not the first action the nurse should take. 186.A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis? A. Moderate amount of dark red lochia with a bloody odor Rationale: Foul-smelling, profuse lochia indicates endometritis. B. A localized area of breast tenderness Rationale: Localized breast tenderness along with fever and malaise are symptoms of mastitis. Page 87 C. Pelvic pain Rationale: Indications of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain. D. Hematuria Rationale: Hematuria is an indication of a urinary tract infection. 187.A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client‟s oral temperature is 38.9° C (102° F). Besides notifying the provider, which of the following is an appropriate nursing action? A. Recheck the client‟s temperature in 4 hr. Rationale: The client‟s temperature should be checked at least every 2 hours after rupture of membranes. B. Administer glucocorticoids intramuscularly. Rationale: Antenatal glucocorticoids are indicated for all women between 24 and 34 weeks of gestation when preterm birth is threatened. C. Assess the odor of the amniotic fluid. Rationale: Chorioamnionitis is an infection of the amniotic cavity that presents with maternal fever, tachycardia, increased uterine tenderness, and foul-smelling amniotic fluid. D. Prepare the client for emergency cesarean section. Rationale: While clients who have chorioamnionitis are more likely to have a dysfunctional labor, it is not an indication for an emergent cesarean section. 188.A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find? A. Over-riding suture lines Rationale: Newborns who have hydrocephalus will have widened suture lines and full or bulging fontanels due to pressure from the increased amount of cerebral spinal fluid. B. Dilated scalp veins Rationale: Manifestations of hydrocephalus in newborns include dilated scalp veins, separated sutures, and, in late infancy, frontal enlargement. C. Hypertension Rationale: Hydrocephalus increases pressure within the central nervous system, not within the cardiovascular system. Signs of increased pressure in the CNS include irritability, lethargy, and vomiting. Page 90 A pregnancy that involves more than one fetus is referred to as a multifetal pregnancy. B. There is an elevated level of alpha-fetoprotein (AFP) in the amniotic fluid. Rationale: AFP is produced by the fetal liver and can be detected in both maternal serum and amniotic fluid. Increasing amounts of AFP are associated with neural tube defects C. An excessive amount of amniotic fluid is present. Rationale: An excess of amniotic fluid is defined as amniotic fluid pockets of >8 cm or an amniotic fluid index of greater than 25. Polyhydramnios or hydramnios is associated with neural tube defects, obstructions of the fetal gastrointestinal tract, multiple fetuses, and fetal hydrops. D. The fetus is likely to have a congenital anomaly, be growth restricted, or demonstrate fetal distress during labor. Rationale: These findings are associated with oligohydramnios, which is a decreased amount of amniotic fluid. 194.A nurse is preparing to administer oxygen via hood therapy to a newborn who was born at 30 weeks of gestation. Which of the following is an appropriate nursing action when providing care to this infant? A. Remove the hood every hour for 10 min to facilitate bonding. Rationale: Supplemental oxygen must be provided if the hood is removed to minimize significant fluctuations in oxygenation. B. Insert an orogastric tube for decompression of the stomach. Rationale: Insertion of an orogastric tube is indicated with the use of continuous positive airway pressure therapy. C. Place the newborn in Trendelenburg position. Rationale: Trendelenburg position should be avoided because it increases intracranial pressure and reduces lung capacity. D. Maintain oxygen saturations between 93% to 95%. Rationale: Rates of retinopathy of prematurity and bronchopulmonary dysplasia in preterm newborns are reduced if oxygen saturations are maintained between 93% and 95%. 195.A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following? A. Hyperinsulinemia Rationale: High levels of maternal glucose increase the production of fetal insulin. High fetal insulin levels interfere with the production of surfactant. Page 91 B. Increased deposits of fat in the chest and shoulder area Rationale: Increased fat deposits in the chest and shoulder area increase the risk of shoulder dystocia at delivery. C. Brachial plexus injury Rationale: A brachial plexus injury causes the arm to hang limply at the newborn‟s side. It is typically the result of a difficulty delivery. D. Increased blood viscosity Rationale: Increased blood viscosity is due to polycythemia, which increases the risk of developing hyperbilirubinemia. 196.A nurse is providing teaching to the mother of a newborn born small for gestational age. Which of the following should the nurse include as a possible cause of this condition? A. Placental insufficiency Rationale: Placental insufficiency is a cause of small for gestational age. It can result from maternal infections, embryonic placental deficiency, teratogens, or chromosomal abnormalities. B. Preterm delivery Rationale: A preterm newborn is defined as one born prior to the completion of 37 weeks of gestation, regardless of the birth weight. Small for gestational age refers to newborns whose weight falls below the 10th percentile on intrauterine growth curves. C. Fetal hyperinsulinemia Rationale: Fetal hyperinsulinemia is the result of high levels of maternal glucose crossing the placenta. This would result in increased growth and fat deposits in the fetus. D. Perinatal asphyxia Rationale: Newborns who are small for gestational age are at risk for perinatal asphyxia due to chronic hypoxia, but this is not a cause of the condition. 197.A nurse is caring for a newborn who is small for gestational age (SGA). Which of the following findings is associated with this condition? A. Moist skin Rationale: Newborns who are SGA have loose, dry skin. B. Protruded abdomen Rationale: Newborns who are SGA have a sunken abdomen. C. Gray umbilical cord Rationale: Page 92 Newborns who are SGA have a thin, yellowish umbilical cord that appears dull and is dry. D. Wide skull sutures Rationale: Newborns who are SGA have wide skull sutures due to inadequate bone growth. Head circumference is smaller than in a normal newborn and there is reduced brain capacity. 198.A nurse is caring for a client who is 2 hr postpartum following a vagin*l birth. Which of the following findings indicates the client‟s bladder is distended? A. Client report of frequent uterine contractions Rationale: Bladder distention can cause uterine atony, which is failure of the uterine muscles to contract. The client would not report experiencing frequent uterine contractions; the fundus would feel boggy to palpation. B. Less than 2.5 cm of rubra lochia on perineal pad Rationale: Bladder distention can cause excessive bleeding, which is due to uterine atony. Scant (< 2.5 cm) rubra lochia on the clients perineal pad is consistent with a finding of a firm, contracted uterus and absence of bladder distention. C. Fundus palpable to right of midline Rationale: Bladder distention results in uterine displacement, pushing the fundus above the umbilicus and away from the midline. The fundus might feel boggy to palpation and does not contract normally. D. Client report of increased thirst Rationale: Fluid shifts due to decreased estrogen levels, changes in body structure, and blood volume, as well as the length of labor, can result in diaphoresis and increased thirst. They are not associated with bladder distention. 199.A nurse is caring for a client who is in the active phase of the first stage of labor. When monitoring the uterine contractions, which of the following findings should the nurse report to the provider? A. Contractions lasting longer than 90 seconds Rationale: A pattern of prolonged uterine contractions lasting more than 90 seconds is an indication that there is inadequate uterine relaxation and should be reported to the provider. B. Contractions occurring every 3 to 5 min Rationale: In the active phase of the first stage of labor, contractions are more regular and occur at 3 to 5 min intervals. This is an expected finding. C. Contractions are strong in intensity Rationale: This is an expected finding in a client who is moving from the active to transition phase of the first stage of labor. It does not need to be reported to the provider. Page 95 Manifestations of severe preeclampsia include severe (usually frontal) headache, blurred vision, photophobia, scotomas, right upper quadrant pain, irritability, presence of clonus and brisk deep tendon reflexes, nausea, vomiting, hypertension, oliguria, and proteinuria. 204.A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vagin*l bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care? A. Administer oxygen via nasal cannula. Rationale: Unless the client exhibits signs of respiratory distress, there is no need for supplemental oxygen administration. B. Offer option to view products of conception. Rationale: Providing support for pregnancy loss includes offering the client and her partner the options of viewing the products of conception and making arrangements for handling of the fetal remains. The client should be instructed on possible grief responses, how to manage these, and provided a referral to a support group. C. Instruct the client to increase potassium-rich foods in the diet. Rationale: Due to the blood loss and the need for tissue repair, the client should be instructed to eat foods high in iron and protein. D. Maintain the client on bed rest. Rationale: There is no evidence to indicate that bed rest can prevent miscarriage, and a diagnosis of inevitable abortion suggests that the miscarriage will proceed. 205.A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication? A. Orthostatic hypotension Rationale: A client report of dizziness or feeling faint upon standing is an expected finding in the first 48 hr postpartum. This is the result of large fluid shifts and altered hormone levels. B. Fundus palpable at the umbilicus Rationale: At 12 hr after delivery, the fundus should be at the level of the umbilicus, and then it should descend about 1 to 2 cm every 24 hr. C. Urine output of 3,000 mL in 12 hr Rationale: Profound diuresis is common after delivery due to the decrease in estrogen and the body getting rid of excess fluid volume. D. Heart rate 110/min Rationale: A rapid or increasing heart rate can be a manifestation of fluid volume depletion related to Page 96 hemorrhage. The nurse should further evaluate the client for evidence of postpartum hemorrhage. 206.A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations? A. "It is used to stop preterm labor contractions." Rationale: Magnesium sulfate, not betamethasone, is an example of a tocolytic medication that helps stop preterm labor B. "It halts cervical dilation." Rationale: A tocolytic medication relaxes the smooth muscles of the uterus to stop preterm labor, and if effective, will also halt cervical dilation. C. "It promotes fetal lung maturity." Rationale: Betamethasone is a glucocorticoid that enhances fetal lung maturity by promoting the release of certain enzymes that help produce surfactant. D. "It increases the fetal heart rate." Rationale: Betamethasone does not affect the fetal heart rate. Terbutaline is an example of a tocolytic medication that can cause fetal tachycardia. 207.A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following? A. Maternal/newborn blood group incompatibility Rationale: Maternal/newborn blood group incompatibility is the most common form of pathologic jaundice and the jaundice appears within the first 24 hr of life. B. Absence of vitamin K Rationale: The absence of vitamin K results in increased bleeding and hemorrhagic disease of the newborn. C. Physiologic jaundice Rationale: Physiologic jaundice in the term newborn appears after 24 hr. D. Maternal cocaine abuse Rationale: The newborn exposed to maternal cocaine abuse is often small for gestational age, exhibits tremors, irritability, hyperactivity to stimuli, and poor feeding. Page 97 208.A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care? A. Keep four side rails up while the client is in bed. Rationale: Raising side rails is not usually necessary during labor unless clients have received opioid or sedative medications. Many clients in labor prefer to walk to help their labor progress. Raising four rails restrains the client. B. Check the cervix prior to analgesic administration Rationale: Prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix has dilated. Administration too close to the time of delivery could cause respiratory depression in the newborn. C. Monitor the fetal heart rate (FHR) every hour. Rationale: Monitoring the FHR every hour is not frequent enough. Even for low-risk clients, most facilities‟ protocols require monitoring the FHR every 15 to 30 min while the client is in the first stage of labor and every 5 to 15 min in the second stage (as long as the FHR has reassuring characteristics). High-risk clients require more frequent monitoring. D. Insert an indwelling urinary catheter. Rationale: Inserting an indwelling urinary catheter is not generally necessary. The nurse should assess for bladder fullness, especially if the client has had epidural anesthesia. If the client is unable to urinate, a straight catheter will suffice in most instances. 209.A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record? A. Vertex Rationale: Fetal position is indicated by a three letter abbreviation. The first letter indicates the side of the maternal pelvis that the presenting part of the fetus is located. The second letter indicates the part of the fetus that is closest to the cervix. The third letter indicates whether the fetal presenting part is located in the anterior, posterior, or transverse portion of the maternal pelvis. A vertex presentation indicates that the fetal head is the closest fetal part to the cervix. A letter "O" as the second letter in the abbreviation would indicate the fetal occiput was the presenting part. B. Shoulder Rationale: Fetal position is indicated by a three letter abbreviation. The first letter indicates the side of the maternal pelvis that the presenting part of the fetus is located. The second letter indicates the part of the fetus that is closest to the cervix. The third letter indicates whether the fetal presenting part is located in the anterior, posterior, or transverse portion of the maternal pelvis. A shoulder as the presenting part is denoted as an "A" for the acromion process. C. Breech Rationale: An RSA position indicates that the body part of the fetus that is closest to the cervix is the sacrum. Therefore, the buttocks or feet are the presenting part, which is classified as a breech presentation.