The nurse is providing anticipatory guidance for an African- American who is at 24 weeks gestastion which prenatal laboratory assessment prescribed at28 weeks should the nurse include in the client teaching

one hour glucose screen

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

evaluation of feta

A term multigravida who is recieving oxytocin for labor augmentation is requesting pain medication review the of the clients records indicates that she was medicated 30 mins ago with butorphanol tartrate 2 mg and promethazine 25 mg IV push vaginal examination reveals that the clients cervical dilation is 3cm 70% effaced and at a 0 station which action should the nurse implement

instruct the client to use deep breathing during a contraction

The nurse is preparing to administer methylergonovine maleate to a postpartum client based on which assessment finding should the nurse withhold the drug

Blood pressure 140/90 mmHg

The nurse recieves change of shift report for four newborns the nurse should monitor closely which newborn for an increased risk for developing neonatal sepsis

reported prolonged rupture of membranes

A new mother asks the nurse why her infant son has a needle mark on his leg which response is best for the nurse to provide this mother

your baby was given an injection of vitamin K to prevent bleeding

during a routine prenatal visit a client at 32 weeks gestastion complains that urinary frequency has increased during the day as well as at night the nurse determines the client is having irregular uterine contactions what action should the nurse implement

obtain a midstream urine specimen for culture

In assessing a 1 - day old male newborn the nurse observes that the scrotal sac is large swollen smooth and taut what assessment technique should the nurse perform to determine if the newborn has a hydrocele

Perform transillumination of the scrotal sac to visualize a red glow of fluid around the testes

the nurse is reviewing the genetic test report for a pregnant client with a history of several spontaneous abortions the results show the client has a heterozygous x- linked dominant inheritance disorder how should the nurse explain the results to the client

there is a 50% chance of passing this gene on to all children

a primigravida client who is 33 weeks gestastion presents to the labor and delivery unit with complaints of a headache the initial assessment findings include blood pressure 144/96 mmHg facial edema and 3+ pitting edema in lower extremities which assessment should the nurse perform next

temperature pulse and respirations

a multiparous woman who us 2 months postpartum reports not feeling like herself not wanting to care for her children and not desiring to sleep all the time how should the nurse respond

join a local parent support group

A client with a history of substance abuse is attempting to breastfeed at 24- hours postpartum the nurse observes the infant is irritable with a high pitched cry exhibits nasal stuffiness and is having trouble latching which toxicology screening result would indicate these infant behaviors

opiods

a postpartum client who is Rh- negative refuses to recieve Rho(D) immune globulin after delivery of an infant who is Rh- positive which information should the nurse provide this client

The R- positive factor from the fetus threatens her blood cells

a client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control findings of the last vaginal exam performed 1 hour ago were 3cm cervical dilation 60% effacement and a -2 station which action should the nurse implement

determine current cervical dilation

a one week old full term infant is readmitted to the newborn nursery for hyperbilirubinemia which supplies should the nurse gather in preparation for this infants treatment plan

eye shield patches and an artificial light source for phototherapy

An oxytocin induction was started for a gravid client 6 hours ago when assessing the fetal heart rate on the electronic fetal monitor the nurse notes a U - shaped pattern occuring with the peak of the contraction which intervention should the nurse implement first

Change the position of the client

a client who is 12 weeks pregnant has type 1 diabetes mellitus which instruction should the nurse provide related to to insulin dosages

increases from 18 weeks to approxitmately 36 weeks of gestastion

A client at 40 weeks gestastion recieves an anticholinergic atropine 0.4mg IM as an adjunct to inhalation anesthesia for a scheduled cesarean delivery which finding should the nurse identify as a therapeutic response to the injection

increase pulse and reduced oral secretions

the nurse is caring for a client following an emergency cesarean delivery under general anesthesia which assessment finding occurring in the first 8 hours after delivery is most critical and requires immediate intervention

uterine atony

a client at 32 weeks gestastions presents with extreme abdominal tenderness and a small amount of bright red vaginal bleeding her blood pressure is 95/65 mmHg respiratory rate is 24 breaths/min and her heart rate is 116 breaths/min she is dizzy with cold clammy skin which prescription has the highest priority

lactated ringer at 200 ml/hr using an 18 gauge needle

in preparing a gravid client for a triple screen analysis which action should the nurse take

prepare to draw blood for analysis

a client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misopostol a synthetic prostaglandin E drug how should the nurse respond

you may be at higher risk for having a spontaneous miscarriage

a breastfeefding woman who delivered her infant two weeks ago develops mastitis in her left breast a cephalosporin anitbiotic is prescribed after consultation with the infants pediatrician which instruction regarding breastfeeding should the nurse provide

initiate feeding on the unaffected breast first

a woman is brought and delivery unit after delivering a term infant and the placenta in the the hospital parking lot 10 mins ago which action should the nurse perform first

massage the fundus and give an oxytoxic agent

a single woman is scheduled for a thyroid scan using radioactive iodine she confides in the nurse that she may be pregnant and plans to have an abortion right away if the pregnancy is confirmed she insists that the nurse keep the information confidential which action should the nurse take

explain to the client that the procedure will need to be canceled until confirmation is obtained that the client is not pregnant

prior to performing a postpartum assessment the client tells the nurse i have pain in my stitches the nurse knows that the client has a mid line episiotomy which action should the nurse take

visualize the perineum and check the eposiotomy

a primigravida client is in the fourth stage of labor after the delivery of a newborn male infant which information should the nurse provide

techniques to breastfeed

the nurse is assessing a pregnant client who reports that she smokes one pack of cigarettes per day the client believes she is six months pregnant but is unsure of the date of her last menstrual period which method of assessment provides the best estimate of gestastional age

ultrasonography

while on the delivery table a primipara tells the nurse that she wishes to breastfeed her infant to assist the new mother with her goal which intervention is best for the nurse to implement

evaluate the infants sucking reflex then give the infant to the mother

after placing a 36 week gestation newborn in an isolette and drying the infant with several blankets what should the nurse implement next

place erythromycin ophthalmic ointment in both eyes

which content should the nurse plan to include in a nutrition class for pregnent asolescents SATA

take folic acid supplements daily

increase food intake by 300 to 400 calories/day

take iron and calcium supplements

the current vital signs for a primipara who delivered vaginally during the previous shift are temp 100.4 heart rate 58 beats/min respiratory rate 16 breaths/min and blood pressure 130/74 mmHg what action should the nurse implement

document the vital signs in the record

a client who is positive for neisseria gonorhoea vaginally delivered a newborn which medication should the nurse administer

erythromycin ointment

following an amniocentesis a client verbalizes several complaints what reported finding indicates to the nurse the client is experiencing a complication from the amniocentesis

low back pain with pelvic cramping

a client who is 14 days postpartum arrives to the clinic for a follow up examination the nurse is unable to palpate the uterine fundus which action should the nurse take

document the normal finding

a client states I think my water just broke the nurse notes that the umblical cord is on the perineum what action should the nurse perform first

place the client in trendelenburg

the nurse is assessing a client is 29 weeks gestastion which assessment method would provide the most determination of fetal position

Ultrasound

in assessing a client diagnosed with preeclampsia who is receiving magnesuim sulfate the nurse dtermines that her deep tendon reflexes are 1+ respiratory rate is 12 breaths/ min urinary output is 90mL in 4 hours magnesium sulfate level 9 mEg/L based on these findings what intervention should the nurse implement

stop the magnesuim sulfate infusion immediately

the nurse is preparing to draw blood from a newborn to obtain hemoglobin and hematocrit levels what is best method to obtain this blood sample

use lancet to puncture the outer lateral aspect of the heel

a client who is human immunodeficiency virus positive (HIV+) is receiving zidovudine during labor which information should the nurse provide to the client

the treatment helps prevent transmission of the virus to the fetus

a community health nurse visits a family in which a 16 year old unmarried daughter is pregnant with her first child and is 32 weeks gestastion the client tells the nurse that she has been having intermittent back pain since the night before what is the priority nursing intervention

ask the client if she has experienced any recent changes in vaginal discharge

a client delivers a viable infant but begins to have excessive uncontrolled vaginal bleeding after the IV oxytocin is infused when notifying the healthcare provider of the clients condition which information is most important for the nurse to provide

maternal blood pressure

following a minor vehicle collision a client at 36 weeks gestation is brought to the emergency center she is lying supine on a backboard is awake and denies any complaints her blood pressure is 80/50 mmHg heart rate is 130beats/min which action should the nurse implement first

infuse 1000 ml normal saline using a large bore IV

a primigravida client with gestastional hypertension and a bishop score of 3 is scheduled for induction of labor the nurse administers misoprostol at 0700 then observes regular contractions with cervical changes at 0900 which action should the nurse take

Start oxytocin infusion immediately

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

Intensity, interval, and length of contractions

A newborn's head circumference is 12 inches (30.5cm), and his chest measurement is 13 inches (33cm). The nurse notes that this infant has no molding, and was at breech presentation delivery by c section. What action should the nurse take based on these data?

Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal

A gravida 3 para 3 who is Rh-negative delivers a full-term infant at home with the assistance of a nurse-midwife. Two days later, the client calls the clinic to ask if it is necessary to see the healthcare provider since the infant is healthy, and she is not having any complications. The woman's history indicates that both previously born infants were Rh-negative. Which response should the nurse provide?

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

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

Inform her that a decreased need for insulin occurs while breastfeeding

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

A primiparous woman who has recently immigrated with her spouse

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

Visualization of implantation by vaginal ultrasound

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

Early postpartum, within 72 hours of delivery.

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

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

a newborn's assessment reveals spina bifida occulta which maternal factor should the nurse identify as having the greatest impact on the development of this

Folic Acid Deficiency

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

Ecchymotic Knees

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

Change the clients position

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

Sinus Tachycardia

a pregnant client presents to the antepartal clinic complaining of brownish vaginal bleeding. the nurse notes a greatly enlarged uterus and is complaining of severe nausea. the client reports that period was about 2 and a half months ago vital signs are temperature 98.7 based on these findings what laboratory value should the nurse review?

HcG values

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

Keep an airway at the bedside

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

Prevent Hemorrhagic disorders

An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is reporting a severe headache.The client's blood pressure is 110/70 mm hg, respiratory rate is 18 breaths/minute,heart rate is 74 bpm, and temperature is 96.6F (37C). The client's fundus is firm and one fingerbreadth above the umbilicus. Which action should the charge nurse implement first

Notify the healthcare provider of the assessment findings

A client at 35 weeks gestation complains of a "pain whenever the baby moves."On assessment, the nurse notes the client's temperature to be 101.2 F, with severe abdominal or uterine tenderness on palpation. The nurse knows that these findings are indicative of what condition?

Chorioamnionitis

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

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

Following a minor vehicle collision, a client 36 weeks gestation is brought to the emergency center. She is lying supine on a backboard , is awake , denies any complaints. Her blood pressure is 80/50 mm Hg and heart rate is 130 beats per min. What action should the nurse implement first?

Turn the board sideways to displace the uterus lateral

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

Encourage the mother to hold and spend time with her baby

A multigravida client in labor is receiving oxytocin Pitocin 4mu/minute to help promote an effective contraction pattern. The available solution is Lactated Ringers 1,000 ml with Pitocin 20 units. The nurse should program the infusion pump to deliver how many ml/hr?

12

A primigravida client with gestational hypertension and bishop score of 3 is scheduled for induction of labor. the nurse administers misoprostol at 0700 then observes regular contractions with cervical changes at 0900 which action should the nurse take?

Administer oxytocin 4 hours later

A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. the nurse applies the external fetal heart monitor and determines she is not in labor. What makes the nurse realize she is not in labor?

Contractions stop when the client is walking

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

Restart the oxytocin per oxytocin protocol

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

Hypoglycemia

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

Place procedure equipment at bedside

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

Inform the anesthesia care provider

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

Massage the fundus Q 4 hours

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

Use alternative form of birth control until new diaphragm can be obtained.

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

herpes simplex virus

the nurse is assessing a newborn who has precipitously delivered at 38 weeks gestation period the newborn is tremulous,tachycardia and ...assessment action in most important for the nurse to implement

obtain a drug screen for cocaine

the nurse knows that a newborn at 24 hours of age has a large cephalohematoma which intervention has the highest priority

Assess the infant for jaundice every eight hours

after two miscarriages client is instructed to increase her daily intake of foods and include folic acid the client does not like .. is allergic to soy which food should the nurse suggest that the client eat to obtain folic acid

strawberries

the nurse providing anti separatory guidance for an african american client who was at 24 weeks gestastion period which prenatal laboratory assessment prescribes weeks should the nurse include in client teaching

one hour glucose screen

while caring for a laboring client on continuous fetal monitoring the nurse notes of fetal heart rate pattern that falls and rises abruptly which action should the nurse takr first

change the maternal position

a young ashkenazi jewish woman is planning to become pregnant and asked the nurse if she should be tested for any genetic disorders what action should the nurse implement

explain the risks of carrying genes for tay sachs disease

the nurse is caring for a client who was 10 weeks gestation and palpation the fundus at 2 fingerbreaths above the oubic symphysis the client has scant and dark brown vaginal discharge which action should he nurse take

measure vital signs

when assessing a pregnant woman at 39 weeks gestations who is admitted to labor and delivery which finding is most important to report

101.2 F. oral temp

The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?

Encourage voiding