Maternal Exam 2

A client experiences a large gush of fluid from her vagina while walking in the Hallway of the birthing unit. the nurse established the fluid is amniotic fluid. what should be the nurses first action? - A. Monitor the fetal heart rate for distress. A nurse is assessing a client breastfeeding. The nurse recognizes that what reflex will promote the newborn to latch? - B. Rooting Three hours after a vaginal delivery, the client reports increase perineal pain. What should the nurse do first? - A. Assess the perineum. A client is admitted in labor. her cervix is 100% effaced and 5 cm dilated. her fetus is in cephalic position and is at +1 station. what does the nurse know about the position of the fetus head? - A. It is below the ischial of spine. A client at 38 weeks gestation tells the nurse that it feels like her baby is sitting on her bladder causing her to urinate more frequently. However, the client states it has made it easier for her to breathe. What does the nurse recognize this is a sign of? - A. lightening The prenatal nurse providing care to a laboring woman recognize variable deceleration. what is the appropriate initial nursing action? - A. Assist the woman to a left-lateral position Through a vaginal examination the nurse determines that a client is 6 cm dilated and the fetus is at 0 station. The external monitor shows uterine contractions are 3- 4 minutes apart. Which of the following stages and phases of labor is this client? - C. first stage, active phase. Medications that are used to manage postpartum hemorrhage include which of the following? (select all apply) - B. Methylergonovine D. Misoprostol A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients? - A client who is experiencing preterm labor at 26 weeks of gestation. A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is not really sure if she is in labor or not. Which of the following should the nurse recognize as a sign of true labor? (Look up) - Contractions occurring every 5 minutes ) The nurse has received a report about a woman in labor. The woman's last vaginal examination was recorded as 1 cm, 30%, and -2. What is the nurse's interpretation of this report? - The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 2 cm above the ischial spines. The nurse is caring for a client who has just delivered vaginally. After assuring there is a patent airway, which of the following action should the nurse's next priority in the care of the neonate? - Dry the infant and place the infant skin to skin with mom. A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. what signs and symptoms should the nurse include in her discussion? (select all apply) - B. Warm to the touch. C. Redness D. Breast tenderness A laboring woman received butorphanol in opioid, IVP 30 minutes before she gave birth. which medication should be available to reduce the effect of the butorphanol on the neonate? - A. Naloxone A nurse is assessing the newborn of a mother with a drug addiction. which assessment finding would the nurse expect to note during the assessment of this newborn? - A. Excessive crying A newborn is placed under a radiant warmer, and the nurse evaluates the infant body temperature every hour. maintaining the newborn body temperature is important for preventing what risk? - . Cold stress A new mother calls the clinic 4 days after deliver. She is breastfeeding her infant and is concerned that her baby is not getting enough milk. what is the most important question for the nurse to ask the mother? - . How many wet diapers has your baby had in the last 24 hours? A nurse has provided discharge instruction to a client who delivered a healthy infant by cesarean section. Which statement made by the client indicates a need for further instruction? - I will begin abdominal exercise immediately. The nurse expects to administer oxytocin to a woman after expulsion of her placenta. what affect will this medication have on the client? - C. Stimulate uterine contraction. A client states that her newborn must be cold because his hands and feet are blue. The nurse explains that this is which common and temporary condition - A. Acrocyanosis A nurse is assessing a newborn for congenital hip dysplasia. Which signs and symptoms should be brought to the health care provider for further evaluation? - A. Newborn who has a click in the hip joint when one hip is maneuvered D. Newborn has one leg that appears longer than the other E. Newborn who has extra skin folds on the inner thigh of one leg A G2 T2 P0 a L2 client experienced a precipitous birth 90 minutes ago. her in front weight 4200 grams and a repair of a second-degree laceration was needed following the birth. as part of the nursing assessment, the nurse discovers that the patient's uterus is buggy. Furthermore, it is noted that the patient's vaginal bleeding has increased. what is the nurse most appropriate for actions? - D. Massage the uterine fundus A newborn is jaundice and is receiving phototherapy in a newborn nursery. What nursing intervention is appropriate when caring for a newborn with hyperbilirubinemia and receiving phototherapy? - C. Place eye shields over the newborn's closed eyes. A client asks the nurse when the "soft spots" on the newborns head will go away. The nurse's answer is based on the knowledge that the anterior fontanelle closes how long after birth? - D. 18 months A nurse is assessing a newborn 1 hour after birth. which of the following respiratory rate is within the expected reference range for a newborn? - B. 48/min The perinatal nurse prepares the laboring woman for an epidural anesthesia insertion. to prevent maternal hypotension. what should the nurse do? - C. Administer an IV fluid bolus of 800-1000 ML of normal Saline or LR.