HESI PN Maternity 3 (1)

HESI PN MATERNITY EXAM PACK- BEST FOR 2022 EXAM HESI PN MATERNITY EXAM PACK- BEST FOR 2022 EXAM 1) At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The LPN/LVN obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse implement next? A. Check the hematocrit results. B. Administer pain medication. C. Increase the rate of IV fluids. D. Monitor client for contractions. Correct Answer: C 2) During a prenatal visit, the LPN/LVN discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have A. lower Apgar scores. B. lower birth weights. C. respiratory distress. D. a higher rate of congenital anomalies. Correct Answer: D 3) Which action should the LPN/LVN implement when preparing to measure the fundal height of a pregnant client? A. Have the client empty her bladder. B. Request the client lie on her left side. C. Perform Leopold's maneuvers first. D. Give the client some cold juice to drink. Correct Answer:A 4) The LPN/LVN identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform? A. Elicit a positive scarf sign on the affected side. B. Observe for an asymmetrical Moro (startle) reflex. C. Watch for swelling of fingers on the affected side. D. Note paralysis of affected extremity and muscles. Correct Answer: B 5) One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM Å~ 1. What action should the LPN/LVN take immediately? A. Give the medication as prescribed and monitor for efficacy. B. Encourage the client to breastfeed rather than bottle feed. C. Have the client empty her bladder and massage the fundus. D. Call the healthcare provider to question the prescription. Correct Answer: D 6) The LPN/LVN is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure? A. A gravida 6, para 5 who is 38 years of age and in early labor. B. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilatation, and a -1 station. C. A gravida 2, para 1 who is at 1 cm cervical dilatation and a 0 station admitted for induction of labor due to post dates. D. A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged. Correct Answer:D 7) A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the LPN/LVN to ask this client? A. Which symptom did you experience first? B. Are you eating large amounts of salty foods? C. Have you visited a foreign country recently? D. Do you have a history of rheumatic fever? Correct Answer: D 8) The LPN/LVN is assessing a client who is having a non-stress test (NST) at 41- weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take? A. Check the client for urinary bladder distention. B. Notify the healthcare provider of the nonreactive results. C. Have the mother stimulate the fetus to move. D. Ask the client if she has felt any fetal movement. Correct Answer: D 9) A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? A. Patellar reflex 4+ B. Blood pressure 158/80. C. Four-hour urine output 240 ml. D. Respiration 12/minute. Correct Answer: A 10) The LPN/LVN assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? A. Insert an internal fetal monitor. B. Assess for cervical changes q1h. C. Monitor bleeding from IV sites. D. Perform Leopold's maneuvers. Correct Answer: C 11) A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? A. 3+ deep tendon reflexes and hyperclonus. B. Periorbital edema, flashing lights, and aura. C. Epigastric pain in the third trimester. D. Recent decreased urinary output. Correct Answer: A 12) Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/ minute. What action should the LPN/LVN perform next? A. Initiate positive pressure ventilation. B. Intervene after the one minute Apgar is assessed. C. Initiate CPR on the infant. D. Assess the infant's blood glucose level. Correct Answer: A 13) A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the LPN/LVN document in this client's record? A. 3-1-2-0-3. B. 4-1-2-0-3. C. 2-1-2-1-2. D. 3-1-1-0-3. Correct Answer: D 14) The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before initiating this prescription, it is most important for the LPN/LVN to assess the client for which condition? A. Gestational diabetes. B. Elevated blood pressure. C. Urinary tract infection. D. Swelling in lower extremities. Correct Answer: A 15) A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the LPN/LVN that the drug is effective? A. Slowly increasing urinary output over the last week. B. Respiratory rate changes from the 40s to the 60s. C. Changes in apical heart rate from the 180s to the 140s. D. Change in indirect bilirubin from 12 mg/dl to 8 mg/dl. Correct Answer: C 16) The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, "What if I start having red bleeding after it changes?" What should the nurse instruct the client to do? A. Reduce activity level and notify the healthcare provider. B. Go to bed and assume a knee-chest position. C. Massage the uterus and go to the emergency room. D. Do not worry as this is a normal occurrence. Correct Answer: A 17) A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child? A. Exercise regimen of both partners includes running four miles each morning. B. History of having sexual intercourse 2 to 3 times per week. C. The woman's menstrual period occurs every 35 days. D. They use lubricants with each sexual encounter to decrease friction. Correct Answer: D 18) A pregnant client tells the LPN/LVN that the first day of her last menstrual period was August 2, 2006. Based on Nägele's rule, what is the estimated date of delivery? A. April 25, 2007. B. May 9, 2007. C. May 29, 2007. D. June 2, 2007. Correct Answer: B 19) A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the LPN/LVN to obtain? A. Gravidity and parity. B. Time and amount of last oral intake. C. Date of last normal menstrual period. D. Frequency and intensity of contractions. Correct Answer: C 20) The LPN/LVN is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.) A. Litmus paper. B. Fetal scalp electrode. C. A sterile glove. D. An amniotic hook. E. Sterile vaginal speculum. F. A Doppler. Correct Answer: C,D,F 21) The LPN/LVN should explain to a 30-year-old gravida client that alpha fetoprotein testing is recommended for which purpose? A. Detect cardiovascular disorders. B. Screen for neural tube defects. C. Monitor the placental functioning. D. Assess for maternal pre-eclampsia. Correct Answer: B 22) A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the LPN/LVN take? A. Apply cold compresses to both breasts for comfort. B. Instruct the client run warm water on her breasts. C. Wear a loose-fitting bra to prevent nipple irritation. D. Express small amounts of milk to relieve pressure. Correct Answer: A 23) A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the LPN/LVN perform first? A. Bathe the infant with an antimicrobial soap. B. Measure the head and chest circumference. C. Obtain the infant's footprints. D. Administer vitamin K (AquaMEPHYTON). Correct Answer: A 24) Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? A. The client's readiness to learn. B. The client's educational background. C. The order in which the information is presented. D. The extent to which the pregnancy was planned. Correct Answer: A 25) A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? A. Wear support stockings. B. Reduce salt in her diet. C. Move about every hour. D. Avoid constrictive clothing. Correct Answer: C 26) During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have A. lower Apgar scores. B. lower birth weights. C. respiratory distress. D. a higher rate of congenital anomalies. Correct Answer: B 27) A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when she could use a home pregnancy test to diagnose pregnancy. Which response is best? A. A home pregnancy test can be used right after your first missed period. B. These tests are most accurate after you have missed your second period. C. Home pregnancy tests often give false positives and should not be trusted. D. The test can provide accurate information when used right after ovulation. Correct Answer: A 28) A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28- weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The LPN/LVN plans to monitor for which primary side effect of terbutaline sulfate? A. Drowsiness and bradycardia. B. Depressed reflexes and increased respirations. C. Tachycardia and a feeling of nervousness. D. A flushed, warm feeling and a dry mouth. Correct Answer: C 29) A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness? A. Wear a cotton bra. B. Increase nursing time gradually. C. Correctly place the infant on the breast. D. Manually express a small amount of milk before nursing. Correct Answer: C 30) A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the LPN/LVN to receive when planning immediate care for the newborn? A. Length of labor and method of delivery. B. Infant's condition at birth and treatment received. C. Feeding method chosen by the parents. D. History of drugs given to the mother during labor. Correct Answer: B 31) In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The LPN/LVN bases the explanation on knowledge that for the normal newborn, the A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week. B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week. C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month. Correct Answer: D 32) When assessing a client who is at 12-weeks gestation, the LPN/LVN recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? A. At 16-weeks gestation. B. At 20-weeks gestation. C. At 24-weeks gestation. D. At 30-weeks gestation. Correct Answer: D 33) The LPN/LVN should encourage the laboring client to begin pushing when A. there is only an anterior or posterior lip of cervix left. B. the client describes the need to have a bowel movement. C. the cervix is completely dilated. D. the cervix is completely effaced. Correct Answer: C 34) The LPN/LVN is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs A. two weeks before menstruation. B. immediately after menstruation. C. immediately before menstruation. D. three weeks before menstruation. Correct Answer: A 35) The LPN/LVN caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention? A. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part. B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor. C. Urine specimens for glucose and protein must be obtained at certain intervals throughout labor. D. Frequent voiding minimizes the need for catheterization which increases the chance of bladder infection. Correct Answer: B 36) The LPN/LVN instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? A. Administer oxygen by face mask. B. Notify the healthcare provider of the client's symptoms. C. Have the client breathe into her cupped hands. D. Check the client's blood pressure and fetal heart rate. Correct Answer: C 37) A 28-year-old client in active labor complains of cramps in her leg. What intervention should the LPN/LVN implement? A. Massage the calf and foot. B. Extend the leg and dorsiflex the foot. C. Lower the leg off the side of the bed. D. Elevate the leg above the heart. Correct Answer: B 38) When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation? A. Milia are red marks made by forceps and will disappear within 7 to 10 days. B. Meconium is the first stool and is usually yellow gold in color. C. Vernix is a white, cheesy substance, predominantly located in the skin folds. D. Pseudostrabismus found in newborns is treated by minor surgery. Correct Answer: C 39) Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The LPN/LVN knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks. B. a subarachnoid hematoma, which requires immediate drainage to prevent further complications. C. molding, caused by pressure during labor and will disappear within 2 to 3 days. D. a subdural hematoma which can result in lifelong damage. Correct Answer: A 40) An expectant father tells the LPN/LVN he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse. B. Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed. C. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit. D. Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement. Correct Answer: D 41) A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the LPN/LVN is best? A. This is not an unusual shaped head, especially for a first baby. B. It may look funny to you, but newborn babies are often born with heads like your baby's. C. That is normal; the head will return to a round shape within 7 to 10 days. D. Your pelvis was too small, so the baby's head had to adjust to the birth canal. Correct Answer: C 42) A new mother asks the LPN/LVN, "How do I know that my daughter is getting enough breast milk?" Which explanation should the nurse provide? A. Weigh the baby daily, and if she is gaining weight, she is eating enough. B. Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day. C. Offer the baby extra bottle milk after her feeding, and see if she is still hungry. D. If you're concerned, you might consider bottle feeding so that you can monitor her intake. Correct Answer: B 43) After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil® Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac® Soy Isomil® Formula, a soy protein isolate based infant formula. What information should the LPN/LVN provide to the mother about the newly prescribed formula? A. The new formula is a coconut milk formula used with babies with impaired fat absorption. B. Enfamil® Formula is a demineralized whey formula that is needed with diarrhea. C. The new formula is a casein protein source that is low in phenylalanine. D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose. Correct Answer: D 44) A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant? A. Encourage the mother to provide total care for her infant. B. Provide privacy so the mother can develop a relationship with the infant. C. Encourage the father to provide most of the infant's care during hospitalization. D. Meet the mother's physical needs and demonstrate warmth toward the infant. Correct Answer: D 45) Which nursing intervention is most helpful in relieving postpartum uterine contractions or "afterpains?" A. Lying prone with a pillow on the abdomen. B. Using a breast pump. C. Massaging the abdomen. D. Giving oxytocic medications. Correct Answer: A 46) Which maternal behavior is the LPN/LVN most likely to see when a new mother receives her infant for the first time? A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely. B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. C. Her arms and hands receive the infant and she then cuddles the infant to her own body. D. She eagerly reaches for the infant and then holds the infant close to her own body. Ans:B 47) On admission to the prenatal clinic, a 23-year-old woman tells the nurse that her last menstrual period began on February 15, and that previously her periods were regular. Her pregnancy test is positive. This client's expected date of delivery (EDD) is A. November 22. B. November 8. C. December 22. D. October 22. Ans: A 48) The LPN/LVN is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse ly calculates that the woman's next fertile period is A. January 14-15. B. January 22-23. C. January 30-31. D. February 6-7. Ans: C 49) A client at 32-weeks gestation is hospitalized with severe pregnancyinduced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved? A. 4+ reflexes. B. Urinary output of 50 ml per hour. C. A decrease in respiratory rate from 24 to 16. D. A decreased body temperature. Ans: C 50 Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the LPN/LVN take? A. Notify the healthcare provider or anesthesiologist immediately. B. Continue to assess the blood pressure q5 minutes. C. Place the woman in a lateral position. D. Turn off the continuous epidural. Ans: C 51) A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the LPN/LVN provide? A. Come to the clinic today for an ultrasound. B. Go immediately to the emergency room. C. Lie on your left side for about one hour and see if the bleeding stops. D. Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection. Ans: A 52) An off-duty LPN/LVN finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A. Use a thread to tie off the umbilical cord. B. Provide as much privacy as possible for the woman. C. Reassure the husband and try to keep him calm. D. Put the newborn to breast. Ans: D 53) A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the LPN/LVN to provide this client? A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue. B. We want your baby to be healthy, and this is the only way we can make sure that will happen. C. I know you're upset. Would you like to talk about some things you could do while in bed? D. Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties. Ans: A 54) A newborn infant is brought to the nursery from the birthing suite. The nurse notices that the infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first? A. Notify the pediatrician immediately. B. Suction the infant's nares, then the oral cavity. C. Check the infant's oxygen saturation rate. D. Position the infant on the right side. Ans: C 55) Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my first child, but I would like to try with this baby." Which intervention is best for the LPN/LVN to implement first? A. Assess the husband's feelings about his wife's decision to breastfeed their baby. B. Ask the client to describe why she was unsuccessful with breastfeeding her last child. C. Encourage the client to develop a positive attitude about breastfeeding to help ensure success. D. Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. Ans: D The nurse should identify that ketonuria is an indication of hyperemesis gravidarum. Ketonuria occurs due to the breakdown of fat secondary to malnutrition or starvation. The nurse should identify that a client who has hyperemesis gravidarum can exhibit tachypnea due to dehydration. The nurse should instruct the client that she will better tolerate foods that are served cold or at room temperature. The nurse should instruct the client to eat five to six small meals throughout the day. The client should avoid an empty stomach, as this increases nausea. Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal- newborn unit should transport newborns. Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal- newborn unit should transport newborns. In addition, transport of the newborn must be in a designated bassinet. HESI PN MATERNITY-EXAM 1. A nurse is caring for a client who is at 11 weeks of gestation and reports frequent vomiting. Which of the following findings should the nurse identify as an indication that the client has hyperemesis gravidarum? Ketonuria Bradycardia Bradypnea Proteinuria 2. A nurse is reinforcing teaching with a client who is at 9 weeks of gestation and reports frequent episodes of nausea and vomiting. Which of the following instructions should the nurse include? Eat foods that are served hot. Drink 360 mL (12 oz) of fluids during mealtimes Consume small meals frequently each day. Eat a high-protein snack before getting out of bed. 3. A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The newborn's grandfather asks if he may take the newborn to his daughter's room. Which of the following responses should the nurse make? "I'll first need to see your photo ID before I can release the baby to you." "Let me wash my hands and then I'll take your grandson to his mother." "Please wash your hands first, then I'll allow you to carry the baby to your daughter's room." "Have your daughter call the nursery so that the staff can release the baby to you." Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal- newborn unit should transport newborns Only facility personnel with appropriate identification badges that indicate that the individual works specifically in the maternal- newborn unit should transport newborns. The nurse should instruct the client to consume a snack high in carbohydrates, such as crackers, before getting out of bed in the morning to decrease nausea. of fluids and foods every 2 to 3 hr throughout the day. The client should avoid drinking liquid with meals because this increases the risk for nausea. The client should alternate consumption The nurse should identify that proteinuria is an indication of preeclampsia, rather than hyperemesis gravidarum. The nurse should identify that a client who has hyperemesis gravidarum can exhibit tachycardia due to dehydration. The nurse should instruct the client to use a breast pump during engorgement to soften the breasts prior to breastfeeding. The client can also use a breast pump after feedings to empty the breasts completely. The nurse should instruct the client to drink enough fluids each day to satisfy her thirst. Decreased fluid intake can decrease milk production. The nurse should identify that the greatest risk to this client is postpartum hemorrhage. Therefore, the first action the nurse should take is to provide fundal massage to increase uterine muscle tone and express blood clots from the uterus, which will decrease bleeding. Administering methylergonovine to enhance uterine contractions is an action the nurse should take to manage postpartum hemorrhage. However, this is not the first action the nurse should take. Butorphanol tartrate is an opioid medication that can cause dizziness, sedation, and hallucinations. Butorphanol tartrate is an opioid medication that has a duration of action of 3 to 4 hr. 4. A nurse is reinforcing teaching about interventions to treat breast engorgement with a client who is breastfeeding. Which of the following instructions should the nurse include in the teaching? Avoid using a breast pump during times of engorgement. Apply warm compresses to the breasts after feedings. Decrease daily fluid intake. Breastfeed the newborn at least every 2 hr. 5. A nurse on a postpartum unit is assisting with the care of a client who has a hypotonic uterus and excessive vaginal bleeding. Which of the following actions should the nurse take first? Provide fundal massage for the client. Insert an indwelling urinary catheter for the client. Administer methylergonovine IM to the client. Administer oxygen via nonrebreather face mask to the client. 6. A nurse is reinforcing teaching about butorphanol tartrate with a client who is in labor. Which of the following client statements indicates an understanding of the teaching? "This medication might make me dizzy." "This medication might cause me to breathe very fast." "This medication will last for 10 to 12 hours." "This medication will cause my stools to be loose and watery." Butorphanol tartrate is an opioid medication that has adverse effects of constipation, nausea, vomiting, confusion, and sedation. Butorphanol tartrate is an opioid medication that can cause respiratory depression. Administering oxygen via nonrebreather face mask is an action the nurse should take to enhance oxygenation to the cells. However, this is not the first action the nurse should take Inserting an indwelling urinary catheter is important to eliminate bladder distention and monitor urinary output. However, this is not the first action the nurse should take. The nurse should instruct the client to breastfeed the newborn every 2 hr during engorgement. Frequent feedings soften the breasts and decrease pain. The nurse should instruct the client to apply cold compresses to the breasts after feedings to decrease discomfort. The client can take a warm shower immediately before breastfeeding to soften the breasts. Increased leukorrhea is a whitish discharge which is an expected finding due to the hormonal changes that occur during pregnancy. Varicose veins are an expected finding during pregnancy due to hormonal influence on the smooth muscle walls of veins. The growing fetus can exacerbate varicose veins in a pregnant woman. The nurse should not expect saturation of one perineal pad every 15 min as this indicates postpartum hemorrhage, which could lead to hypovolemic shock. The nurse should identify that a temperature higher than 38° C (100.4° F) after the first 24 hr can indicate infection in a client who is 32 hr postpartum. The nurse should identify that a calcium level of 9.2 mg/dL is within the expected reference range of 7.6 to 10.4 mg/dL for a newborn. The nurse should identify that a blood glucose of 28 mg/dL is below the expected reference range of 30 to 60 mg/dL for a newborn. Therefore, the nurse should report this finding to the provider. 7. A nurse is collecting data from a client who is in her second trimester of pregnancy. Which of the following findings should the nurse report to the provider? Increased leukorrhea Hyperpigmentation of the face Varicose veins Frequent uterine contractions 8. A nurse is collecting data from a client who is 32 hr postpartum. Which of the following findings should the nurse expect? Saturation of one perineal pad every 15 min Fundus 2 cm above the umbilicus Temperature of 39° C (102.2° F) Urine output of 3,000 mL in 24 hr 9. A nurse is collecting data from a newborn whose mother had gestational diabetes mellitus. Which of the following findings should the nurse report to the provider? Calcium 9.2 mg/dL Heart rate 160/min Blood glucose 28 mg/dL Axillary temperature 36.5 C(97.7 F) 10. A nurse is collecting data from a client who is at 33 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential complication of pregnancy? The nurse should identify that a temperature for a healthy newborn averages 37 C (98.6 F), with a range of 36.5C to 37.5 C (97.7F to 99.5 F). rate of 80 to 100/min while asleep and up to 180/min while crying is an expected finding for a newborn. The nurse should identify that a heart rate of 160/min is within the expected reference range of 110 to 160/min for a newborn. A heart The nurse should expect postpartum diuresis to begin approximately 12 hr after delivery. Therefore, a urine output of 3,000 mL in 24 hr is an expected finding for this client. At 32 hr postpartum, the client's fundus should be 1 to 2 cm below the umbilicus. The fundus should descend 1 cm per day after birth. The nurse should report frequent uterine contractions during the second trimester to the provider because they can cause the cervix to open early and subject the client to preterm labor. stimulate melanocytes that occur during pregnancy. Hyperpigmentation of the face is also known as the "mask of pregnancy" and is an expected finding due to the hormonal changes that The nurse should identify leg cramps as a common discomfort during pregnancy caused by compression of the nerves by the enlarged uterus. The nurse should identify that varicose veins are a common discomfort of pregnancy caused by increased blood volume and relaxation of vascular smooth muscle. The nurse should identify that labial edema is an expected finding following a vaginal birth. The nurse can apply ice packs to minimize edema and pain. The nurse should identify that a WBC count of 15,000/mm3 is an expected finding 6 hr following birth. The nurse should identify that vernix in the skin folds is an expected finding in a newborn. It is a normal protective substance that is present at birth. The nurse should identify that an apneic episode of 20 seconds or less is an expected finding in a newborn. Newborns' respirations are normally shallow and irregular. Leg cramps Tingling of fingers Varicose veins Epigastric pain 11. A nurse is caring for a client who delivered vaginally 6 hr ago. Which of the following findings should the nurse report to the provider? Labial edema Fundus firm at the umbilicus WBC count 15,000/mm3 Perineal pad soaked in 15 min 12. A nurse is collecting data from a newborn who is 8 hr old. Which of the following findings should the nurse report to the provider? Vernix in the skin folds Positive Moro reflex Apneic episode of 10 seconds Apical heart rate of 90/min while crying 13. A nurse is reviewing the medication administration record for a client who is receiving nifedipine for gestational hypertension. The nurse should identify that which of the following medications is contraindicated for use with nifedipine? Magnesium sulfate The nurse should identify that an apical heart rate of 90/min while crying is below the expected reference range of 110 to 160/min for a newborn. A heart rate of 80 to 100/min while asleep and up to 180/min while crying is an expected finding for a newborn The nurse should identify that a positive Moro reflex is an expected finding in a newborn which is present from birth up to 8 weeks. The nurse should identify that soaking a perineal pad in 15 min or less is a manifestation of postpartum hemorrhage. Therefore, the nurse should report this finding to the provider The nurse should identify that a firm fundus at the level of the umbilicus 6 hr following birth is an expected finding. The nurse should identify epigastric pain as a potential complication of pregnancy. Epigastric pain is a manifestation of preeclampsia. The nurse should identify tingling of the fingers as a common discomfort of pregnancy caused by traction on the brachial plexus due to slumping of the shoulders. Acetaminophen is a nonopioid analgesic, which is administered for the treatment of mild pain or fever. This medication is safe to administer with nifedipine. Oxytocin is a hormone, which is used to facilitate the induction of labor or to control postpartum bleeding after expulsion of the placenta. This medication is safe to administer with nifedipine Terbutaline relaxes the smooth muscles and inhibits uterine activity. It should be administered subcutaneously every 4 hr. Terbutaline cannot be administered intramuscularly. Terbutaline relaxes the smooth muscles and inhibits uterine activity. This medication should be administered subcutaneously every 4 hr. The nurse should instruct the client to continue breastfeeding from both breasts, because that will assist in emptying the breasts and decreasing pressure on the infected area. Emptying the breasts also prevents milk stasis, which decreases bacterial growth. The nurse should instruct the client to apply warm compresses to the breast, which will decrease inflammation and edema. This will enable more effective emptying of the breast to prevent milk stasis, which decreases bacterial growth. Acetaminophen Promethazine Oxytocin 14. A nurse is planning to administer terbutaline to a client who is experiencing preterm labor. Which of the following routes of administration should the nurse plan to use? Intramuscular Intradermal Subcutaneous Topical 15. A nurse is assisting with planning care for a client who is breastfeeding and has mastitis. Which of the following recommendations should the nurse include? Instruct the client to discontinue feeding from the affected breast. Tell the client to wear an underwire bra. Instruct the client to apply warm compresses to the affected breast. Administer an antiviral medication. 16. A nurse is reviewing the prenatal record of a client who is at 34 weeks of gestation. Which of the following results should the nurse identify as a desirable outcome? The nurse should plan to administer an antibiotic medication to a client who has mastitis. The client should take the antibiotic for 10 to 14 days to eradicate the infection The nurse should discourage the use of underwire and poorly fitting bras because they can cause plugged milk ducts, increasing the risk of mastitis. Terbutaline relaxes the smooth muscles and inhibits uterine activity. It should be administered subcutaneously every 4 hr. Terbutaline cannot be administered topically. Terbutaline relaxes the smooth muscles and inhibits uterine activity. It should be administered subcutaneously every 4 hr. Terbutaline cannot be administered intradermally. Promethazine is an antiemetic, which is administered for the prevention of nausea and vomiting. This medication is safe to administer with nifedipine. Magnesium sulfate is administered for the treatment of hypertension or to prevent seizures in clients who have preeclampsia. This medication is contraindicated for use with nifedipine because it can cause skeletal muscle blockade, resulting in muscle weakness or paralysis. The nurse should identify that a negative rubella titer indicates that the client is not immune to rubella and will require immunization in the postpartum period. The nurse should identify that a glucose value of 140 mg/dL or higher 1 hr after ingesting 50 g of glucose indicates the need for further testing to determine if the client has gestational diabetes mellitus. The diaphragm should be left in place for at least 6 hr following intercourse. The sponge should be left in place for at least 6 hr, but less than 24 hr, following intercourse. Leaving the sponge in for 24 hr or longer increases the risk of toxic shock syndrome. Assistive personnel caring for newborns should always wear identification. The parent should not allow anyone without proper identification to care for or remove the newborn from the room. The nurse should instruct the parent to ask the nurse to care for her baby if she needs to take a nap because a newborn should never be left unattended. Negative rubella titer Reactive nonstress test 1-hr glucose tolerance screening test result of 150 mg/dL Hemoglobin 9.5 g/dL 17. A nurse is discussing family planning with a client who is requesting information about available contraceptive methods. Which of the following client statements indicates an understanding of the teaching? "When I use the diaphragm, I should remove it 2 hours after intercourse." "I should use water-soluble lubricant when my partner wears a condom." "I should remove the birth control sponge 24 hours after intercourse." "When I use the birth control patch, it must be changed once a month." 18. A nurse is reinforcing teaching with a new parent about the prevention of newborn abduction. Which of the following statements by the parent indicates an understanding of the teaching? "Some assistive personnel may not have name badges." "A nurse will carry my baby back to the nursery in his arms for routine care when it is needed." "I will ask the nurse to take care of my baby in the nursery if I need to take a nap." "I can remove my baby's security band if she is in my room." 19. A nurse is caring for a client who is at 20 weeks of gestation and is in the clinic for a routine prenatal visit. Which of the following findings in the data from the client's medical record should the nurse report to the provider? (Click on the "Exhibit" button below for additional information about the client. There are three tabs that contain separate categories of data.) The parent should always make sure the newborn's security band is in place because the band helps to ensure the safety of the newborn. If the security band is removed, the alarm will sound immediately A newborn should always be wheeled in a bassinet when transported from one location to another to prevent the risk for injury and abduction. The patch is changed weekly for 3 weeks, followed by 1 week in which the client does not wear the patch integrity of the condom. Only water-soluble lubricants should be used with male condoms, because the use of any other lubricant may compromise the The nurse should identify that a hemoglobin level of 9.5 g/dL indicates anemia, which is an undesirable test result and will require treatment The nurse should identify that a reactive nonstress test indicates fetal well-being and is a desirable outcome. The height of the fundus in centimeters at 20 weeks of gestation is approximately the same as the number of weeks of gestation plus or minus 2 cm. Therefore, a fundal height of 25 cm is greater than the expected finding for 20 weeks of gestation. A maternal blood pressure of 130/80 mm Hg is below the reportable value of 140/90 mm Hg The nurse should inform the client that adequate folic acid intake prior to and early during pregnancy is necessary to help prevent neural tube defects. Folic acid will not aid in the absorption of other important nutrients, but it is used to prevent neural tube defects in the newborn One cup of dried prunes contains 3 mcg of folate. Therefore, there is another food the nurse should recommend. Graphic Record BP Week 16: 120/70 mm Hg Week 20: 130/80 mm Hg Weight Week 16: 61.7 kg (136 lb) Week 20: 63 kg (138.9 lb) Nurses' Notes Fundal Height Week 16: 16 cm Week 20: 25 cm Fetal Heart Rate Week 16: 156/min Week 20: 160/min Diagnostic Results Week 16: Urine negative for albumin and glucose Week 20: Urine negative for albumin and glucose Weight Fundal height Fetal heart rate Blood pressure 20. A nurse is caring for a client who is planning to become pregnant. The client asks the nurse why folic acid supplements are necessary. The nurse should inform the client that the purpose of the folic acid supplement is to do which of the following? Facilitate the storage of iron in the fetus' liver Prevent certain kinds of birth defects Inhibit premature labor Aid in the absorption of other important nutrients 21. A nurse is reinforcing teaching about food sources that are high in folate with a group of women who are pregnant. Which of the following foods should the nurse recommend to this group as the best source of folate? 1 cup dried prunes Folic acid will not inhibit preterm labor; rather, it prevents the development of neural tube defects in the newborn. Folic acid supplements are used to prevent neural tube defects in the newborn. Maternal supplemental iron facilitates the storage of iron in the fetus' liver. A fetal heart rate of 160/min at 20 weeks of gestation is within the expected reference range of 110 to 160/min. A client in the second trimester of pregnancy should gain approximately 0.4 kg (0.9 lb) per week. Therefore, a weight gain of 1.3 kg (2.9 lb) in 4 weeks is an expected finding. A half cup of boiled potatoes contains 4 mcg of folate. Therefore, there is another food the nurse should recommend. One cup of grapes contains 3 mcg of folate. Therefore, there is another food the nurse should recommend The nurse should identify this as the crawling reflex. When the newborn is placed on the abdomen, he will appear to make crawling 1/2 cup boiled potatoes 1/2 cup dried peas 1 cup grapes 22. A nurse is assisting with the neuromuscular assessment of a newborn by eliciting primitive reflexes. Which of the following images indicates a characteristic response of the tonic neck reflex? movements with the arms and legs. same side extend, while the arm and leg on the opposite side flex. The nurse should identify this as the tonic neck reflex. When the newborn's head is quickly turned to one side, the arm and leg on the and is the best of these sources of folate for the nurse to recommend. Women who are pregnant should consume 600 mcg of folate per day. A half cup of dried green split peas provides 270 mcg of folate The client should not massage her breasts to treat engorgement during lactation suppression. Breast stimulation through massage can promote milk production. The client should not pump her breasts to treat engorgement during lactation suppression because it can cause an increase in milk production. When using the urgent vs. nonurgent approach to care, the nurse should determine that the priority finding is a client who is at 37 weeks gestation and reports a persistent headache. The nurse should identify that a persistent headache is a manifestation of preeclampsia and recommend that the provider see this client first. 23. A nurse is reinforcing discharge teaching about methods to prevent engorgement during lactation suppression with a client who is bottle-feeding her newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "I will massage my breasts while I take a shower." "I should wear an underwire bra during the day." "I should use a breast pump several times a day to relieve discomfort." "I will apply cold cabbage leaves to my breasts throughout the day." 24. A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should the nurse recommend the provider see first? A client who is at 37 weeks of gestation and reports a persistent headache A client who is at 38 weeks of gestation and reports irregular uterine contractions A client who is at 12 weeks of gestation and reports abdominal cramping The nurse should identify that a client who is at 38 weeks of gestation and is having irregular uterine contractions might be in the latent phase of labor. However, the nurse should recommend that the provider see another client first. Frequent application of cold cabbage leaves to the breasts can prevent engorgement during lactation suppression for a client who is bottle-feeding her newborn. The client should also apply ice packs or cold compresses to her breasts, take mild analgesics, and wear a well-fitting and supportive bra The client should not wear an underwire bra to treat engorgement during lactation suppression because it can cause plugged milk ducts, which can result in a breast infection. abdomen fingers widely open and the thumb and index finger form a "C" shape. The lower extremities may also extend then abduct toward the The nurse should identify this as the Moro reflex. When the newborn hears a loud noise, he will abduct then extend the arms with the the soles of the newborn's feet. The nurse should identify this as the magnet reflex. The newborn will push against the examiner's hands when pressure is applied to The nurse should identify that a client who is at 26 weeks of gestation and reports periodic numbness in the fingers might be experiencing brachial plexus traction syndrome from drooping of the shoulders. However, the nurse should recommend that the provider see another client first The nurse should position the client on her side, or elevate her right hip. The client's legs should be elevated to at least a 30 angle to increase venous return. The nurse should apply oxygen at 10 L/min via a nonrebreather face mask to improve the client's oxygenation. The nurse should instruct the parent that newborns will drink 15 to 30 mL (0.5 to 1 oz) of formula per feeding during the first 24 hr while gradually increasing intake as they grow. By the end of the second week of life, most newborns consume 90 to 150 mL (3 to 5 oz) of formula at each feeding. The nurse should instruct the parent to allow the newborn to self-regulate formula intake. Forcing intake can cause vomiting due to overeating. A client who is at 26 weeks of gestation and reports periodic numbness in the fingers 25. A nurse on a postpartum unit is assisting in the care of a client who is experiencing hypovolemic shock. Which of the following actions should the nurse take? Place the client in high-Fowler's position. Administer terbutaline subcutaneously. Apply oxygen at 2 L/min via nasal cannula. Insert an indwelling urinary catheter. 26. A nurse is reinforcing teaching about formula feeding a newborn with a group of new parents. Which of the following instructions should the nurse include? Give approximately 240 mL (8 oz) per feeding. Allow 20 to 30 min for feedings. Ensure that the newborn empties the bottle. Wait to burp the newborn until the end of the feeding. 27. A nurse is caring for a client 6 hr after a vaginal birth who is going to breastfeed her newborn. The client reports perineal pain of 6 on a scale from 0 to 10. The nurse also notes mild perineal edema and ecchymosis, with a fundus that is 2 cm above the umbilicus with deviation to the right. Which of the following actions is the nurse's priority? Administer analgesics. The nurse should administer analgesics to relieve the client's pain; however, another action is the nurse's priority. Apply an ice pack to the perineum. The nurse should instruct the parent to burp the newborn periodically throughout feedings to relieve gas and decrease the risk for vomiting. The nurse should instruct the parent to allow the newborn to feed for 20 to 30 min. This prevents the newborn from eating quickly and swallowing too much air. to oliguria The nurse should insert an indwelling urinary catheter to monitor output closely. Decreased kidney perfusion caused by shock can lead The nurse should administer an oxytocic medication, such as oxytocin or methylergonovine, to increase uterine contraction. Terbutaline is a tocolytic that causes uterine relaxation, which will increase bleeding. The nurse should identify that a client who is at 12 weeks of gestation and reports abdominal cramping might be experiencing a miscarriage. However, the nurse should recommend that the provider see another client first. The nurse should assist the client with breastfeeding to promote uterine involution; however, another action is the nurse's priority. The nurse should reinforce to the parent that the current recommendations include keeping infants in a rear-facing car seat until they are at the maximum height and weight for the car seat or at a minimum of 2 years of age. The nurse should reinforce to the parent to use the vehicle's seat belts to secure the newborn's seat and provide adequate protection in a motor-vehicle crash. Diuresis is correct. This is an expected finding that results from the loss of excess fluid that is retained during pregnancy. Soft, boggy uterus upon palpation is incorrect. This is not an expected finding in the postpartum period and can cause excessive bleeding. The nurse will perform intermittent monitoring of the FHR with a Doppler stethoscope while the client is in the shower or bathtub. Placement of an internal fetal monitor is contraindicated for hydrotherapy due to the risk of electric shock. Assist the client with breastfeeding. Help the client ambulate to the toilet. 28. A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "My baby should be in a rear-facing car seat until he is 6 months old and 15 pounds." "If my baby rides in a car with no back seat, the passenger air bag must be turned off." "It is dangerous to secure the car seat using the vehicle's seat belts." "I will place my baby's car seat at a 90 degree angle in the back seat." 29. A nurse is caring for a client during the postpartum period. Which of the following findings should the nurse expect during the first 24 hr following delivery? (Select all that apply.) Diuresis Soft, boggy uterus upon palpation Discharge of clear, yellow fluid from the breasts Lochia serosa Lower abdominal cramping 30. A nurse is reinforcing teaching with a client who requests hydrotherapy for pain management during labor. Which of the following statements should the nurse include? "You will have an internal fetal monitor applied prior to hydrotherapy." Lower abdominal cramping is correct. This is an expected finding and results from the contraction of the uterus as it decreases in size Lochia serosa is incorrect. Lochia serosa is vaginal discharge that is pink or brown, which occurs 3 to 4 days after delivery. pregnancy. Colostrum is present for 3 to 5 days until the mother's milk appears and can leak from the breasts beginning in the third trimester of Discharge of clear, yellow fluid from the breasts is correct. This fluid, called colostrum, is an expected finding in the postpartum period. The nurse should reinforce to the parent to avoid placing the car seat at a 90 angle because it can compromise the newborn's airway. The parent should position the seat so that the newborn is at a 45 angle The nurse should reinforce to the parent that in the event that a newborn cannot ride in the rear seat, the parent must disable the front passenger air bag to prevent potential injuries caused by air bag deployment. assist the client to empty her bladder, which will allow the uterus to contract The greatest risk for this client is postpartum hemorrhage from uterine atony. Therefore, the priority intervention by the nurse is to The nurse should apply an ice pack to the client's perineum to reduce swelling and relieve the client's pain; however, another action is the nurse's priority. The client may remain in the tub for as long as she desires and as long as the FHR remains within the expected reference range. Using hydrotherapy for 30 to 60 min, followed by a break, can alleviate pain more effectively than remaining in the water for extended periods of time. The water temperature should be between 36° to 37° C (96.8° to 98.6° F) during hydrotherapy to prevent the client from overheating. The client's shoulders should remain out of the water during hydrotherapy to allow dissipation of heat. The nurse should inform the client that her blood pressure will be taken every 15 to 30 min while receiving magnesium sulfate. Hypotension is an adverse effect of this medication. The nurse should identify that magnesium sulfate causes respiratory depression. The nurse should monitor the client's respiratory rate every 15 min. The nurse should identify that a Hgb level of 20 g/dL is within the expected reference range of 14 to 24 g/dL for a newborn. The nurse should identify that a glucose level of 50 mg/dL is within the expected reference range of 30 to 60 mg/dL for a newborn. The nurse should expect a glucocorticoid, such as dexamethasone, to promote the acceleration of fetal lung maturity. "You will need to limit your time in the tub to no more than 20 minutes." "You will need to be in active labor before using hydrotherapy." "You will need to keep the water temperature above 98.6 degrees Fahrenheit during hydrotherapy." 31. A nurse is reinforcing teaching with a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. Which of the following statements should the nurse include in the teaching? "We will monitor your blood pressure every 2 hours." "Your fluid intake will be limited to no more than 125 milliliters per hour." "You might notice that you will begin breathing faster than normal." "We will monitor your baby's heart rate once per hour." 32. A nurse is reviewing the laboratory results of a 4-hr-old newborn. Which of the following findings should the nurse report to the provider? Hemoglobin 20 g/dL Platelet count 120,000/mm3 Glucose 50 mg/dL WBC count 20,000/mm3 33. A nurse is caring for a client who is pregnant and has a prescription for nifedipine. Which of the following outcomes should the nurse expect from this medication? Fetal lung maturity Maternal blood glucose control The nurse should expect an oral hypoglycemic agent, such as glyburide, to help control blood glucose. newborn The nurse should identify that a WBC count of 20,000/mm3 is within the expected reference range of 9,000 to 30,000/mm3 for a for a newborn. Therefore, the nurse should report this finding to the provider. The nurse should identify that a platelet count of 120,000/mm3 is below the expected reference range of 150,000 to 300,000/mm 3 The nurse should inform the client that the fetal heart rate will be continually monitored while she is receiving magnesium sulfate to assess for changes that might indicate fetal distress The nurse should restrict the client's fluid intake to no more than 125 mL per hr to prevent fluid overload. The nurse should instruct the client that hydrotherapy is initiated once active labor begins. The use of hydrotherapy during the latent phase of labor can decrease the strength and frequency of contractions and slow the progression of labor. Nifedipine is a calcium channel blocker used to decrease uterine contractions by relaxing the smooth muscle of the uterus. Acrocyanosis is incorrect. Acrocyanosis is a bluish discoloration of the hands and feet of the newborn and is an expected finding during The nurse should administer phytonadione using a 5/8-inch needle. A needle that is too long can cause injury to the nerves. The nurse should administer a single dose of phytonadione to the newborn and instruct the guardian that the injection does not need to be repeated The nurse should identify that 2+ proteinuria is a manifestation of preeclampsia. Therefore, the nurse should report this finding to the provider. The nurse should identify that spider nevi, or vascular spiders, are an expected finding during pregnancy due to an increase in estrogen production. Cessation of uterine contractions Resolution of maternal nausea 34. A nurse is assisting with collecting data from a newborn who was born 2 hr ago and has respiratory distress. Which of the following findings should the nurse report to the provider? (Select all that apply.) Acrocyanosis Tachypnea Nasal flaring Retractions Expiratory grunting newborn. Nasal flaring is correct. Nasal flaring is a finding associated with respiratory distress in the newborn. Retractions is correct. Retractions are a finding associated with respiratory distress in the newborn. 35. A nurse is planning to administer phytonadione to a newborn. Which of the following actions should the nurse take? Administer phytonadione 24 hr after birth. Use a 1-inch needle for administration. Use the vastus lateralis as the injection site. Reinforce to the guardian that the injection should be repeated in 2 weeks. 36. A nurse is caring for a client who is at 30 weeks of gestation. Which of the following findings should the nurse report to the provider? 2+ urinary protein Leukorrhea Spider nevi 30 cm fundal height The nurse should identify that leukorrhea is a greyish, mucus-like discharge and is an expected finding throughout pregnancy due to hormonal changes that cause the cervix to produce this mucoid fluid. The nurse should inject phytonadione into the vastus lateralis because this is the most developed muscle in the newborn. The nurse should administer phytonadione immediately after birth or after initial breastfeeding to prevent hemorrhagic disease. the first 24 hr after birth. Tachypnea is correct. Tachypnea is a respiratory rate greater than 60/min and is a finding associated with respiratory distress in the The nurse should expect an antiemetic, such as metoclopramide, to decrease maternal nausea Expiratory grunting is correct. Expiratory grunting is a finding associated with respiratory distress in the newborn The nurse should identify that contractions occurring every 3 to 5 min is an expected finding for a client who is in active labor. The nurse should report a prolonged deceleration of the FHR to the charge nurse because it can be a manifestation of an emergent condition, such as uterine rupture or umbilical cord prolapse. The charge nurse should notify the provider about this change in FHR pattern The nurse should not prepare the client for a pudendal nerve block during the active phase of labor. A pudendal nerve block should be administered during the second stage of labor, 10 to 20 min before the birth of the newborn. The nurse should encourage the client to push during the second stage of labor, when the cervix is dilated to 10 cm. The first action the nurse should take using the nursing process is to collect data from the client; therefore, the first action the nurse should take is to check the newborn's blood glucose level. The nurse might need to provide nonnutritive sucking to help the newborn conserve energy. However, there is another action the nurse should take first. 37. A nurse is assisting with the care of a client who is at 40 weeks of gestation and is in active labor. Which of the following findings should the nurse report to the charge nurse? Maternal temperature of 37.5 C (99.5 F) Contractions every 3 min Presence of bloody show Prolonged deceleration of FHR 38. A nurse is assisting in the care of a client during the active phase of labor. Which of the following actions should the nurse take to promote the client's comfort? Prepare the client for a pudendal nerve block. Administer a sedative to the client. Encourage the client to push. Have the client perform relaxing breathing techniques. 39. A nurse is caring for a newborn who is large for gestational age and is jittery. Which of the following actions should the nurse take first? Check the newborn's blood glucose level. Place the newborn under a radiant warmer. Provide nonnutritive sucking. Swaddle the newborn. The nurse might need to swaddle the newborn to minimize energy expenditure. However, there is another action the nurse should take first The nurse might need to place the newborn under a radiant warmer to prevent cold stress. However, there is another action the nurse should take first. The nurse should encourage the client to perform relaxation techniques to promote comfort during the active phase of labor The nurse should not administer a sedative to the client during the active phase of labor, as it can cause respiratory depression in the newborn. Sedatives should be administered no less than 12 hr prior to birth of the newborn. progresses. The nurse should identify that bloody show is an expected finding for a client who is in active labor. Bloody show can increase as labor The nurse should identify that a maternal temperature greater than 38 C (100.4 F) is elevated and indicative of complications such as infection. The nurse should identify that a fundal height of 30 cm is an expected finding f