Rn Maternal Latest Update

RN Maternal LATEST UPDATE 01. A nurse on the postpartum unit is caring for a client following a cesarean birth. Which of the following assessments is the nurse's priority? Amount of lochia When using the airway, breathing, circulation approach to client care, the nurse should place the priority in the immediate postpartum period on assessing the amount of postpartum lochia. The greatest risk to the client is bleeding and postpartum hemorrhage. 02. A nurse is caring for a client who is in labor and whose fetus is in the right occiput posterior position. The client is dilated to 8 cm and reports back pain. Which of the following actions should the nurse take? Apply sacral counterpressure The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position. 03. A nurse is demonstrating to a client how to bathe her newborn. In which order should the nurse perform the following actions? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Wipe the newborn’s eyes from the inner canthus outward. Wash the newborn’s neck by lifting the newborn’s chin. Cleanse the skin around the newborn’s umbilical cord stump. Wash the newborn’s legs and feet. Clean the newborn’s diaper area. The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus outward using plain water. The nurse should then wash the newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump followed by washing the newborn's legs and feet. The last step of the bath should be to clean the newborn's diaper area. 04. A nurse is caring for a client and her partner who have experienced a fetal death. Which of the following actions should the nurse take? Take photos of the newborn to give to the parents. The nurse should create a memory box that includes mementos of the newborn (for example, photos, the newborn's ID bands, the newborn's hat, and the newborn's blanket). 05. A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? Biophysical profile A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with real-time ultrasound. 06. A nurse is reviewing the medical record of a client who is postpartum and has preeclampsia. Which of the following laboratory results should the nurse report to the provider? Platelets 50,000/mm3 A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider. 07. A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? Minimal arm recoil The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil. 08. A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain? Chin quivering Behavioral responses to a newborn's pain include facial expressions (for example, chin quivering, grimacing, and furrowing of the brow).