Maternity Latest Exam Solution Guide Graded A+

Following delivery of the placenta a nurse examines umbilical cord. which vessels should nurse expect to observe?ANSWERS-Two arteries, one vein Reinforcing teaching about reducing perineal infection after vaginal delivery. Include what in the teachingANSWERS-blot perineal area dry after cleansing Clean perineal area from front to back Perform hand hygiene before and after voiding Apply ice packs to perineal area several times daily Wash perineal area using squeeze bottle of warm water after each void Prenatal clinic is caring for a client with suspected hydatiform mole. What should nurse expect to observe?ANSWERS-Excessive uterine enlargement A nurse is caring for a client who is in labor and has an epidural anesthesia block. The clients good pressure is 80/40 mm Hg and the fetal heart rate is 140/min. Which of the following is the priority action?ANSWERS-Place client in lateral position Nurse is caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which is priority?ANSWERS-Position the client on her side 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?ANSWERS-Dyspnea A nurse is assessing a newborn who has developmental dysplasia of the hip. Which of the following findings should the nurse expect?ANSWERS-Assymetric thigh folds A nurse is caring for a client who reports unrelieved episiotomy pain 8 hr following vaginal birth. Which of the following actions should the nurse take?ANSWERS-apply an ice pack to the affected area A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborns nose and mouth. Which of the following actions is the nurses priority?ANSWERS-Suction the mouth with a bulb syringe A nurse is reviewing a newborns lab results. which is the nurses priorityANSWERS-Billirubin 19mg jaundice is greater than 15mg A nurse is caring for a newborn who has myelomeningocele. Which of the follwowing nursing goals has the priority in the care of this infant?ANSWERS-maintain the integrity of the Sac 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, HR 130 and cries in response to suctioning. The nurse should document what APGAR score for this infantANSWERS-8 A nurse is completing a newborn age assessment. which of the following findings should be recorded as part of this assessment on the newbornANSWERS-plantar creases cover 2/3 of sole A nurse is caring for a client who is 16 hr postpartum and states my baby has been breathing funny, fast and slow, off and on. which of the following responses should the nurse provide?ANSWERS-Lets sit here together and observe your baby while you feed him A nurse admits a woman who is 38 weeks gestation and in early labor with ruptured membranes. The nurse determines that the clients temperature is 38.9C 102F. Besides notifying the provider, which of the following is an appropriate action?ANSWERS-Assess the odor of amniotic fluid A nurse is caring for a client who is in preterm labor with a current L/S ratio of 1:1. which of the following actions should the nurse take?ANSWERS-Administer betamethasone 12 mg IM 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?ANSWERS-Your baby should wet 6-8 diapers per day A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as an indicator of inhibition of parental attachment?ANSWERS-I wish he had more hair. I will keep a hat on his head until he grows some 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?ANSWERS-I will feed my baby every 2 hours A nurse is planning care for a newborn who is SGA. Which of the following is the priority intervention the nurse should include in the newborns plan of care?ANSWERS-Monitor blood glucose levels A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch?ANSWERS-Rooting 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 clients BP reading as 82/52. Which of the following nursing interventions should the nurse perform?ANSWERS-Assist the client to turn onto her side 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?ANSWERS-I will tip the nipple so air is present as my baby sucks A nurse is caring for a client who is in labor at 40 weeks and reports that she has saturated 2 perineal pads in the past 30 minutes. The nurse caring for her suspects placenta previa. Which of the following is an appropriate action?ANSWERS-Prepare for c section A A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?ANSWERS-Change clients position A nurse is caring for a client during a NST. At the end of a 30 minute period of observation, the nurse notes the following findings. FHR baseline is 120 with minimal variability and no accelerations. There are 2 decelerations of 15/min in the FHR during a period of fetal movement each lasting 20 seconds. Which of the following interpretations of these findings should the nurse make?ANSWERS-A nonreactive test A nurse on the l&d 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 minutes, last 90 seconds and are strong to palpation. The baseline FHR is 150/min, with uniform decelerations at the peak the contraction and a return to baseline after the contraction is over? Which action?ANSWERS-Discontinue the infusion of IV oxytocin A nurse in a clinic is caring for a client who is at 11 weeks gestation and reports that she has had slight occasional vaginal bleeding over the past 2 weeks. Following an examination by the Dr. the client is told that the fetus has died and that the placenta fetus and tissues remain in the uterus. How should the nurse document these findings?ANSWERS-Missed miscarriage A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?ANSWERS-Dry the skin A nurse in the newborn nursery is caring for a group of newborns. which of the following newborns requires immediate interventionANSWERS-A newborn who is 12 hr post delivery and has a temp of 375.C 99.5F A nurse is assessing a client who is 12 hr postpartum and received spinal anesthesia for a c section. Which of the following findings require immediate intervention by the nurse?ANSWERS-RR 10/min A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates hyperbilliruinenemia due to Rh incompatibility. The nurse should understand that hyperbillirubinemia occurs with Rh incompatibility for which reason?ANSWERS-The clients blood does not contain the Rh factor, she produces anti Rh antibodies that cross the placental barrier and cause hemolysis of RBC in newborns A nurse is teaching a newborns parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?ANSWERS-Give a sponge bath until the cord stump falls A nurse is caring for a client who is postpartum. The client tells the nurse that the newborns maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which statements should the nurse make?ANSWERS-We do routine hearing screenings on newborns. You'll know the results before you leave the hospital A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, I dont want to take anything for pain because I am breastfeeding. Which statement should the nurse make?ANSWERS-We can time your pain meds so that you have an hour or 2 before the next feeding 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 response should the nurse make?ANSWERS-Your baby should wet 6-8 diapers per day A nurse is caring for a client who had a vaginal delivery 2 hr ago. which of the following actions should the nurse anticipate in the care of this pt?ANSWERS-document fundal height observe the loch during palpation of fundus