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Questions and Answers
What should the nurse explain as the primary purpose of amniocentesis requested by a 12-week pregnant client?
What should the nurse explain as the primary purpose of amniocentesis requested by a 12-week pregnant client?
- To identify potential complications during labor.
- To assess the mother's nutritional deficiencies.
- To confirm the fetal heartbeat.
- To determine if the baby has genetic or congenital disorders. (correct)
Which source of vitamin B should a nurse recommend for a vegan client during prenatal teaching?
Which source of vitamin B should a nurse recommend for a vegan client during prenatal teaching?
- Fortified soy milk (correct)
- Almonds
- Spinach
- Tofu
What potential complication should the nurse be vigilant for following a forceps-assisted birth?
What potential complication should the nurse be vigilant for following a forceps-assisted birth?
- Facial Palsy (correct)
- Umbilical hernia
- Respiratory distress
- Delayed developmental milestones
Which statement indicates that a parent understands the teaching about car seat safety for a newborn?
Which statement indicates that a parent understands the teaching about car seat safety for a newborn?
What should a nurse expect when assessing a newborn with neonatal abstinence syndrome?
What should a nurse expect when assessing a newborn with neonatal abstinence syndrome?
Which action should the nurse take when preparing a newborn with jaundice for phototherapy?
Which action should the nurse take when preparing a newborn with jaundice for phototherapy?
What instruction should a nurse give to a postpartum client seeking to continue using her diaphragm for contraception?
What instruction should a nurse give to a postpartum client seeking to continue using her diaphragm for contraception?
What question should a nurse ask to assess the dietary intake of a vegan client at 6 weeks of gestation?
What question should a nurse ask to assess the dietary intake of a vegan client at 6 weeks of gestation?
What should the nurse do immediately following the delivery of a stillborn fetus?
What should the nurse do immediately following the delivery of a stillborn fetus?
What isolation precautions should be taken for a client with methicillin-resistant Staphylococcus aureus?
What isolation precautions should be taken for a client with methicillin-resistant Staphylococcus aureus?
Which food should a nurse recommend to a client who follows a vegan diet and needs to increase vitamin B intake?
Which food should a nurse recommend to a client who follows a vegan diet and needs to increase vitamin B intake?
What question should the nurse ask to assess the effectiveness of a hands-and-knees position for a woman in labor?
What question should the nurse ask to assess the effectiveness of a hands-and-knees position for a woman in labor?
Which food selection should a nurse recommend to an antepartum client seeking to increase dietary fiber?
Which food selection should a nurse recommend to an antepartum client seeking to increase dietary fiber?
What instruction should a nurse include when providing discharge instructions to a breastfeeding client?
What instruction should a nurse include when providing discharge instructions to a breastfeeding client?
What is the first action a nurse should take when excessive vaginal bleeding is noted in a client 1 hour postpartum?
What is the first action a nurse should take when excessive vaginal bleeding is noted in a client 1 hour postpartum?
Which finding should a nurse expect when assessing a client with endometritis 6 hours postpartum?
Which finding should a nurse expect when assessing a client with endometritis 6 hours postpartum?
What should a nurse assess first when admitting a client for labor who is 8 cm dilated?
What should a nurse assess first when admitting a client for labor who is 8 cm dilated?
Which of the following findings in a client who had a vacuum-assisted delivery may indicate risk for postpartum hemorrhage?
Which of the following findings in a client who had a vacuum-assisted delivery may indicate risk for postpartum hemorrhage?
What action should a nurse take first for a client experiencing bladder distention after a vaginal birth?
What action should a nurse take first for a client experiencing bladder distention after a vaginal birth?
When should a nurse delay the instillation of antibiotic ophthalmic ointment in a newborn?
When should a nurse delay the instillation of antibiotic ophthalmic ointment in a newborn?
What should a nurse monitor for in a newborn who underwent a forceps-assisted birth?
What should a nurse monitor for in a newborn who underwent a forceps-assisted birth?
What is an appropriate non-pharmacological treatment option for clients undergoing fertility treatments?
What is an appropriate non-pharmacological treatment option for clients undergoing fertility treatments?
What does leukocytosis indicate about a client's condition?
What does leukocytosis indicate about a client's condition?
Which finding is associated with a sign of potential improvement in a client's postpartum condition?
Which finding is associated with a sign of potential improvement in a client's postpartum condition?
How should the nurse interpret a platelet count of 90,000/mm3 in a client with preeclampsia?
How should the nurse interpret a platelet count of 90,000/mm3 in a client with preeclampsia?
Which of the following findings in a postpartum client requires immediate follow-up?
Which of the following findings in a postpartum client requires immediate follow-up?
What does a blood pressure of 80/50 mm Hg indicate in a postpartum hemorrhage case?
What does a blood pressure of 80/50 mm Hg indicate in a postpartum hemorrhage case?
In the evaluation of a 48-hour old term newborn, which sign indicates worsening condition?
In the evaluation of a 48-hour old term newborn, which sign indicates worsening condition?
Which of the following findings would suggest improvement in a postpartum assessment?
Which of the following findings would suggest improvement in a postpartum assessment?
What does a finding of cloudy urine indicate in a postpartum client?
What does a finding of cloudy urine indicate in a postpartum client?
What does increased muscle tone in a newborn suggest?
What does increased muscle tone in a newborn suggest?
Which of these findings in a postpartum assessment is an indication of worsening condition?
Which of these findings in a postpartum assessment is an indication of worsening condition?
Which finding should the nurse identify as an adverse effect of the medication?
Which finding should the nurse identify as an adverse effect of the medication?
What action should the nurse take when caring for a client who is 1 hour postpartum with peripartum cardiomyopathy?
What action should the nurse take when caring for a client who is 1 hour postpartum with peripartum cardiomyopathy?
Which laboratory finding in a client at 20 weeks of gestation should the nurse report to the provider?
Which laboratory finding in a client at 20 weeks of gestation should the nurse report to the provider?
What finding should the nurse identify as a manifestation of pyelonephritis in a client at 30 weeks of gestation?
What finding should the nurse identify as a manifestation of pyelonephritis in a client at 30 weeks of gestation?
What should the nurse do after observing fetal bradycardia and a protruding umbilical cord following the spontaneous rupture of membranes?
What should the nurse do after observing fetal bradycardia and a protruding umbilical cord following the spontaneous rupture of membranes?
What should the nurse include in the care plan for a newborn with a leaking myelomeningocele?
What should the nurse include in the care plan for a newborn with a leaking myelomeningocele?
What finding indicates a decline in the status of a newborn who is 2 hours old?
What finding indicates a decline in the status of a newborn who is 2 hours old?
What information should the nurse provide to the parents regarding the Plastibell circumcision technique?
What information should the nurse provide to the parents regarding the Plastibell circumcision technique?
What action should the nurse take when administering a hepatitis B vaccine to a newborn?
What action should the nurse take when administering a hepatitis B vaccine to a newborn?
What should the nurse assess in a breastfeeding client who reports sore nipples 1 day postpartum?
What should the nurse assess in a breastfeeding client who reports sore nipples 1 day postpartum?
What indicates understanding of discharge teaching following tubal ligation?
What indicates understanding of discharge teaching following tubal ligation?
What safety instruction should the nurse give to a client who is 2 days postpartum?
What safety instruction should the nurse give to a client who is 2 days postpartum?
What finding should the nurse report for a client who is 3 days postpartum?
What finding should the nurse report for a client who is 3 days postpartum?
What is the first action the nurse should take when instructed to perform the McRoberts maneuver during a shoulder dystocia?
What is the first action the nurse should take when instructed to perform the McRoberts maneuver during a shoulder dystocia?
What should the nurse do for a client who is hypotensive following epidural anesthesia?
What should the nurse do for a client who is hypotensive following epidural anesthesia?
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Study Notes
Amniocentesis
- Amniocentesis determines genetic and congenital disorders, not sex
Vegan Diet
- Fortified soy milk is a recommended food source for B vitamins
Forceps Assisted Birth
- Facial palsy can be a clinical manifestation
Car Seat Safety
- A newborn who has been born at 38 weeks of gestation needs a car seat challenge test before discharge
Neonatal Abstinence Syndrome
- Excessive crying is a finding for newborns with neonatal abstinence syndrome
Phototherapy
- Close the newborn’s eyes before applying eyepatches for phototherapy
Diaphragm Contraception
- A new diaphragm fitting is needed postpartum
Clomiphene Citrate
- Breast tenderness is an adverse effect of clomiphene citrate
Vegan Diet
- Assessing a client’s protein intake is important to understand a vegan diet
Stillbirth
- The nurse should tell the client an autopsy can be performed within 24 hours
- The nurse should provide photos of the fetus
Methicillin-resistant Staphylococcus Aureus
- Contact isolation precautions are required for Methicillin-resistant Staphylococcus Aureus
Constipation During Pregnancy
- Lentils are a high fiber food
Breastfeeding
- Allow baby to feed at least every 3 hours
Dinoprostone
- Informed consent is required prior to administration
Fertility Treatment Options
- Maintaining a healthy weight is a nonpharmacological treatment option
Labor Contractions
- 80% effaced and 8 cm dilated is at risk for postpartum hemorrhage
Full-term Newborn
- A subconjunctival hemorrhage should be reported to the provider
Oxytocin Infusion
- Administer oxygen at 10 L/min via nonrebreather facemask after discontinuing oxytocin infusion
Maternal Cytomegalovirus
- Transmission can occur via the saliva and urine of the newborn
Postpartum Hemorrhage
- Massage the client's fundus to stop bleeding
Endometritis
- Uterine tenderness is a finding
Contraindication for Contraction Stress Test
- A client who has a previous classical incision
Third-degree Perineal Laceration
- A third-degree perineal laceration contraindicates suppository use
Severe Vomiting During Pregnancy
- A client who is 8 weeks pregnant and reports severe vomiting should be assessed first
Digoxin
- Ask the client if they are taking the medication as prescribed to assess adherence
Nagele's Rule
- The estimated date of delivery is May 17
Bladder Distention
- Assist the client to the bathroom
Antibiotic Ophthalmic Ointment
- Delay installation to allow for observation of infection
Cesarean Birth
- Evaluate urinary output for a steady trickle of vaginal bleeding that does not stop with fundal massage
Postpartum Hemorrhage Risk Factors
- Vacuum-assisted delivery
- History of uterine atony
- Labor induction with oxytocin
Trichomoniasis During Pregnancy
- A malodorous discharge is expected
Epidural Block
- Hypotension is an adverse effect of epidural anesthesia
Peripartum Cardiomyopathy
- Assess blood pressure twice daily
Fasting Blood Glucose
- A fasting blood glucose of 180 mg/dL should be reported
Pyelonephritis
- Flank pain is a manifestation
Spontaneous Rupture of Membranes (PROM)
- Call for assistance and notify the provider
- Cover the umbilical cord with a sterile saline-saturated towel
Myelomeningocele
- Cleanse the site with povidone-iodine
Newborn Decline
- An oxygen saturation of 89% indicates a decline in status
Plastibell Circumcision
- Notify the provider if the end of the baby’s penis appears dark red
Hepatitis B Vaccine
- Administer the injection into the vastus lateralis muscle
Breastfeeding Sore Nipples
- Assess the newborn’s latch
Tubal Ligation
- Ovulation will remain the same
Home Safety - Newborn
- Wash the baby’s face with plain water
Postpartum Assessment
- Cool/clammy skin should be reported to the provider
McRoberts Maneuver
- Assist the client in pulling their knees toward their abdomen
Hypotension Following Epidural Anesthesia
- Turn the client to a side-lying position
Fourth-degree Laceration
- Provide the client with a cool sitz bath
Uterine Atony
- Anticipate a prescription for misoprostol
Neonatal Abstinence Syndrome - Nursing Actions
- Maintain a low-stimulation environment
- Instruct the parent to avoid breastfeeding
- Perform Ballard newborn screening each shift
- Weigh the newborn daily
- Swaddle the newborn with flexed extremities
Leopold Maneuvers
- Instruct the client to empty their bladder
- Position the client supine with knees flexed and place a small rolled towel under one of their hips
- Palpate the fetal part positioned in the fundus
- Palpate the fetal parts along both sides of the uterus
- Palpate the fetal part positioned above the symphysis pubis
Deep Vein Thrombosis (DVT)
- Leukocytosis is a sign that the client's condition is worsening
- Redness in the extremity is a sign that the client's condition is worsening
- Scant lochia rubra is a sign that the client's condition is improving
- Increased warmth of the extremity is a sign that the client's condition is worsening
- Tachycardia is a sign that the client's condition is worsening
- Decreased extremity edema is a sign that the client's condition is improving
Preeclampsia
- A platelet count of 90,000/mm³ is a sign of potential worsening
- Hematuria is a sign of potential worsening
- Positive clonus is a sign of potential worsening
- Proteinuria (2+) is a sign of potential worsening
- Leukorrhea is a sign of potential improvement
- BUN of 40 mg/dL is a sign of potential worsening
Postpartum Assessment
- Lateral deviation of the uterus
- Large amount of lochia rubra
- Uterine tone (firmness or softness)
Postpartum Hemorrhage
- Blood pressure of 80/50 mm Hg is a sign of potential worsening
- Cloudy urine is a sign of potential worsening
- Moderate lochia rubra is a sign of potential worsening
- Fundus firm to palpation is a sign of potential improvement
- Fundus at level of umbilicus is a sign of potential worsening
Neonatal Abstinence Syndrome
- Regurgitation is a sign of potential worsening
- Mottling is a sign of potential worsening
- Transient strabismus is a sign of potential improvement
- Continuous high-pitched cry is a sign of potential worsening
- Respiratory rate of 70/min is a sign of potential worsening
- Loose stools are a sign of potential worsening
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