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Terms in this set (66)
, A nurse is caring for a client who is pregnant in an - Uterine contractions.
antepartum clinic. Which of the following findings should The client is experiencing regular uterine contractions and cervical change,
the nurse report to the provider? which are indicators of preterm labor; therefore, the nurse should notify the
provider about this finding.
- Gestational age.
The client is at 32 weeks of gestation and is experiencing regular uterine
contractions and cervical dilation, which indicates that the client is in preterm
labor; therefore, the nurse should notify the provider about this finding.
- Vaginal examination.
The client's cervix is dilated to 2 cm and is 50% effaced, which indicate the client
is in preterm labor; therefore, the nurse should notify the provider about this
finding.
The client's blood pressure is within the expected reference range . Blood
pressure 130/70 mm Hg? what is normal.
A nurse is caring for a client who is at 22 weeks of Report the client's condition to the local health department.
gestation and is HIV positive. Which of the following
actions should the nurse take? Rationale:
The nurse should report the condition to the local health department. HIV is one
of the conditions on the list of Nationally Notifiable Infectious Conditions that is
required to be reported.
Other considerations:
The nurse should tell the client that treatment for HIV will be during the prenatal
and perinatal periods. Treatment with antiretroviral prophylaxis such as
zidovudine, triple-drug antiretroviral therapy (ART), or highly active antiretroviral
therapy (HAART) during pregnancy have been reported to decrease the
transmission of the virus to the newborn.
A nurse is assessing a client who is postpartum and has Decreased platelet count
idiopathic thrombocytopenia purpura (ITP). Which of the
following findings should the nurse expect? Rationale:
A client who has ITP has an autoimmune response that results in a decreased
platelet count.
Other considerations:
- An increased ESR is an indication of chronic renal failure.
- An increased WBC is an indication of infection.
A nurse in the antepartum clinic is assessing a client's Emotional lability
adaptation to pregnancy. The client states that they are
"happy one minute and crying the next." The nurse Rationale:
should interpret the client's statement as an indication of The nurse should recognize and interpret the client's statement as an indication
which of the following? of emotional lability. Many clients experience rapid and unpredictable changes in
mood during pregnancy. Intense hormonal changes may be responsible for mood
changes that occur during pregnancy. Tears and anger alternate with feelings of
joy or cheerfulness for little or no reason.
A nurse is assessing the newborn of a client who took a Vomiting
selective serotonin reuptake inhibitor (SSRI) during
pregnancy. Which of the following manifestations should Rationale:
the nurse identify as an indication of withdrawal from an Expected manifestations associated with fetal exposure to SSRIs include
SSRI? irritability, agitation, tremors, diarrhea, and vomiting. These manifestations
typically last 2 days.
Manifestations of fetal exposure to SSRIs. include: Low birth weight,
Hypoglycemia, Tachypnea.
A nurse is assessing four newborns. Which of the A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
following findings should the nurse report to the
provider? Rationale
An axillary temperature greater than 37.5° C (99.5° F) is above the expected
reference range of 36.5 - 37.5 ° C for a newborn and can be an indication of
sepsis. Therefore, the nurse should report this finding to the provider.
other considerations:
- A newborn should pass the first meconium stool within the first 24 to 48 hr
following birth. Failure to pass a meconium stool can indicate a bowel obstruction
or congenital disorder.
- Pink-tinged urine is an indication of uric acid crystals and is an expected finding
for a newborn during the first week following birth.
- Erythema toxicum is a transient rash that can appear anywhere on a newborn's
body during the first 24 to 72 hr following birth and can last up to 3 weeks. This
finding requires no treatment.
A
TI
M
A
T
E
R
N
A
L
N
E
W
B
O
R
N
Students
also
studied
Terms in this set (66)
, A nurse is caring for a client who is pregnant in an - Uterine contractions.
antepartum clinic. Which of the following findings should The client is experiencing regular uterine contractions and cervical change,
the nurse report to the provider? which are indicators of preterm labor; therefore, the nurse should notify the
provider about this finding.
- Gestational age.
The client is at 32 weeks of gestation and is experiencing regular uterine
contractions and cervical dilation, which indicates that the client is in preterm
labor; therefore, the nurse should notify the provider about this finding.
- Vaginal examination.
The client's cervix is dilated to 2 cm and is 50% effaced, which indicate the client
is in preterm labor; therefore, the nurse should notify the provider about this
finding.
The client's blood pressure is within the expected reference range . Blood
pressure 130/70 mm Hg? what is normal.
A nurse is caring for a client who is at 22 weeks of Report the client's condition to the local health department.
gestation and is HIV positive. Which of the following
actions should the nurse take? Rationale:
The nurse should report the condition to the local health department. HIV is one
of the conditions on the list of Nationally Notifiable Infectious Conditions that is
required to be reported.
Other considerations:
The nurse should tell the client that treatment for HIV will be during the prenatal
and perinatal periods. Treatment with antiretroviral prophylaxis such as
zidovudine, triple-drug antiretroviral therapy (ART), or highly active antiretroviral
therapy (HAART) during pregnancy have been reported to decrease the
transmission of the virus to the newborn.
A nurse is assessing a client who is postpartum and has Decreased platelet count
idiopathic thrombocytopenia purpura (ITP). Which of the
following findings should the nurse expect? Rationale:
A client who has ITP has an autoimmune response that results in a decreased
platelet count.
Other considerations:
- An increased ESR is an indication of chronic renal failure.
- An increased WBC is an indication of infection.
A nurse in the antepartum clinic is assessing a client's Emotional lability
adaptation to pregnancy. The client states that they are
"happy one minute and crying the next." The nurse Rationale:
should interpret the client's statement as an indication of The nurse should recognize and interpret the client's statement as an indication
which of the following? of emotional lability. Many clients experience rapid and unpredictable changes in
mood during pregnancy. Intense hormonal changes may be responsible for mood
changes that occur during pregnancy. Tears and anger alternate with feelings of
joy or cheerfulness for little or no reason.
A nurse is assessing the newborn of a client who took a Vomiting
selective serotonin reuptake inhibitor (SSRI) during
pregnancy. Which of the following manifestations should Rationale:
the nurse identify as an indication of withdrawal from an Expected manifestations associated with fetal exposure to SSRIs include
SSRI? irritability, agitation, tremors, diarrhea, and vomiting. These manifestations
typically last 2 days.
Manifestations of fetal exposure to SSRIs. include: Low birth weight,
Hypoglycemia, Tachypnea.
A nurse is assessing four newborns. Which of the A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)
following findings should the nurse report to the
provider? Rationale
An axillary temperature greater than 37.5° C (99.5° F) is above the expected
reference range of 36.5 - 37.5 ° C for a newborn and can be an indication of
sepsis. Therefore, the nurse should report this finding to the provider.
other considerations:
- A newborn should pass the first meconium stool within the first 24 to 48 hr
following birth. Failure to pass a meconium stool can indicate a bowel obstruction
or congenital disorder.
- Pink-tinged urine is an indication of uric acid crystals and is an expected finding
for a newborn during the first week following birth.
- Erythema toxicum is a transient rash that can appear anywhere on a newborn's
body during the first 24 to 72 hr following birth and can last up to 3 weeks. This
finding requires no treatment.
