ATI detailed answers (150 questions with detailed correct answers) 2023/2024

lOMoARcPSD| ATI detailed answers ATI detailed answers Maternal-Child Nursing (Chamberlain University) 1) A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? a. Painless red vaginal bleeding i. Rationale: Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester. 2) A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention? a. A newborn who is 12 hr post-delivery and has a temperature of 37.5° C (99.5° F) Rationale: Hyperthermia in the newborn requires immediately intervention. Hyperthermia is typically caused by increased heat production related to sepsis or decreased heat loss 3) A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? a. Document the findings and continue to monitor the client. b. Rationale: These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. Small clots are common. The nurse should document the findings and continue to monitor the client. 4) A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority 5) nursing action? 6) A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority 7) nursing action? 4. A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action? a. Dry the skin. b. Rationale: The newborn should be thoroughly dried, covered with a warm blanket, placed on the mother’s abdomen, and a cap applied to the newborn’s head to prevent cold stress. The newborn responds to the cooler environment by increasing his respiratory rate, which can lead to respiratory distress. Based on Maslow’s hierarchy of needs, this is the most important nursing action after securing the airway. 5. A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make? a. “It occurs during the first trimester and near the end of the pregnancy.” b. Rationale: Urinary frequency is due to increased bladder sensitivity during the first trimester and recurs near the end of the pregnancy as the enlarging uterus places pressure on the bladder 6. A nurse is caring for a client during the first trimester of pregnancy. After reviewing the client's blood work, the nurse notices she does not have immunity to rubella. Which of the following times should the nurse understand is recommended for rubella immunization? a. Shortly after giving birth Rationale: The rubella immunization should be offered to the client following birth, preferably prior to discharge from the hospital. This prevents the client from contracting rubella during the current or subsequent pregnancies, which would put her fetus at risk for rubella syndrome. 7. A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn? a. Clear the respiratory tract. b. Rationale: Clearing the airway of the infant is the first action the nurse should take immediately following delivery. 8. A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make? a. "What part of the exam makes you most nervous? b. "Rationale: This therapeutic response recognizes the client's feelings. It also uses the therapeutic technique of clarification to encourage the client to tell the nurse more about her concerns 9. A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord? a. Two arteries and one vein b. Rationale: The vein carried the oxygenated, nutrient-rich blood from the placenta to the fetus, and the two arteries returned the blood to the placenta. 10. A nurse is caring for a client who is considering several methods of contraception. Which of the following methods of contraception should the nurse identify as being most reliable? a. An intrauterine device (IUD) b. Rationale: An IUD is found to have a failure rate of less than 1 in 100 users, which makes it one of the most reliable methods of contraception. 11. A nurse is caring for a newborn and calculating the Apgar score. At 1 min after delivery, the following findings are noted: heart rate of 110/min; slow, weak cry; some flexion of extremities; grimace in response to suctioning of the nares; body pink in color with blue extremities. Calculate the newborn’s Apgar score. a. 6 points b. Correct Rationale: The Apgar score is 6 out of a possible 10. It is based on 5 signs evaluated at 1 and 5 min after delivery that indicate the physiologic state of the newborn as he transitions from intrauterine life to extrauterine life: heart rate over 100/min = 2; slow, weak cry = 1; some flexion of extremities = 1; grimace in response to suctioning of the nares = 1; body pink in color with blue extremities = 1. A score of 4 to 6 indicates moderate difficulty adjusting to life outside of the womb. 12. A nurse is caring for a client who is 12 hr postpartum following a vaginal delivery. Which of the following findings should the nurse expect? a. Fundus firm, at the level of the umbilicus b. Rationale: Within 12 hours after birth, the fundal tone is expected to be firm, and the location is typically palpated midline and at the level of the umbilicus. 13. A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take? 14. D. Assist the client to the bathroom to void. 15. Rationale: A full bladder causes the uterus to be displaced above the umbilicus and off to one side. This 16. prevents the uterus from contracting normally and increases the risk of hemorrhage a. Assist the client to the bathroom to void. b. Rationale: A full bladder causes the uterus to be displaced above the umbilicus and off to one side. This prevents the uterus from contracting normally and increases the risk of hemorrhage. 14. A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz.(4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications. a. Uterine atony b. Rationale: A uterus that is over distended, such as from a macrosomia fetus, has an increased risk of uterine atony. 15. A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first? a. Massage the client's fundus. b. Rationale: The initial management of excessive uterine bleeding is firm massage of the uterine fundus. This action stimulates contraction of the uterine muscles, which constrict the maternal uterine blood vessels. 16. A nurse in a prenatal clinic is teaching a group of clients about nutrition requirements during lactation. Which of the following statements should the nurse make? a. "Zinc intake should be at least 12 mg per day." b. Rationale: Zinc intake should be increased to 12 mg per day during lactation, which is above the recommended levels for pregnancy and nonpregnant female clients over age. 17. A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications? a. Disseminated intravascular coagulation b. Rationale: Clinical manifestations of disseminated intravascular coagulation (DIC) include oozing from intravenous access and venipuncture sites; petechiae, especially under the site of the blood pressure cuff; spontaneous bleeding from the gums and nose; other signs of bruising; and hematuria. 18. A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data? a. The client requires a rubella immunization following delivery. b. Rationale: A negative rubella titer indicates that the client is susceptible to the rubella virus and needs vaccination following delivery. Immunization during pregnancy is contraindicated because of possible injury to the developing fetus. Following rubella immunization, the client should be cautioned not to conceive for 1 month. 19. A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action? 20. Initiate IV access. 21. Rationale: Insertion of a large-bore IV catheter is the priority nursing action. The client is losing blood 22. rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be 23. administered quickly if hypovolemia develops a. Initiate IV access. b. Rationale: Insertion of a large-bore IV catheter is the priority nursing action. The client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops 20. A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client? a. Excessive uterine enlargement b. Rationale: A hydatidiform mole is a rare tumor that forms inside the uterus at the beginning of a pregnancy and results in the over-production of tissue that would normally develop into the placenta. This tissue consists of fluid-filled vesicles. A rapidly enlarging uterus is a classic finding in clients who have a molar pregnancy. It is often accompanied by severe nausea and vomiting, elevated human chorionic gonadotropin levels, signs of hyperthyroidism, and early onset of preeclampsia. 21. A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse? 22. This occurs because newborns lack muscle control to regulate eye movement." 23. Rationale: a. This occurs because newborns lack muscle control to regulate eye movement." b. Rationale: This addresses the client’s concerns because it provides information that addresses her concerns. The eyes of newborns are structurally incomplete and muscle control is not fully developed for 3 months. 22. A nurse is caring for a client who is having a nonstress test performed. The fetal heart rate (FHR) is 130 to150/min, but there has been no fetal movement for 15 min. Which of the following actions should the nurse perform? a. Offer the client a snack of orange juice and crackers. b. Rationale: A nonstress test depends upon fetal movement, and this fetus is most likely asleep. Most fetuses are more active after meals due to the increase in the mother's blood sugar. Giving the mother a snack will promote fetal movement 23. A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 min and a frequency of 3 min. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take? a. Position the client with one hip elevated. b. Rationale: Based on Maslow’s hierarchy of needs, the client's need for an adequate blood pressure to perfuse herself and her fetus is a physiological need that requires immediate intervention. Supine hypotension is a frequent cause of low blood pressure in clients who are pregnant. By turning the client on her side and retaking her blood pressure, the nurse is attempting to correct the low blood pressure and reassess 24. 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? a. Changes in the cervix b. Rationale: Assessment of progressive changes in the effacement and dilation of the cervix is the most accurate indication of true labor. 25. A nurse is preparing to administer magnesium sulfate IV to a client who is experiencing preterm labor. Which of the following is the priority nursing assessment for this client? a. Respiratory rate b. Rationale: Magnesium sulfate is typically administered to a client in preterm labor to achieve the tocolytic (uterine relaxation) effect. Magnesium sulfate depresses the function of the central nervous system, causing respiratory depression. Baseline assessment of respiratory status, checking the respiratory rate frequently, and reassessment of respiratory status with each change in dosage of magnesium sulfate is the primary focus when assessing the client. There is a narrow margin between what is considered a therapeutic dose and a toxic dose of magnesium sulfate 26. A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client's ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should be included in the newborn’s plan of care? a. Observe for meconium in respiratory secretions. 27. Rationale: When a fetus is SGA, there is an increased risk for intrauterine hypoxia due to the presence of meconium in the amniotic fluid. The nurse should observe for meconium in respiratory secretions when suctioning the newborn at delivery. Newborns who are SGA are at risk for perinatal asphyxia due to the stress of labor and are often depressed. They require careful resuscitation and suctioning at delivery. 28. A nurse is instructing a woman who is contemplating pregnancy about nutritional needs. To reduce the risk of giving birth to a newborn who has a neural tube defect, which of the following information should the nurse include in the teaching? a. Consume foods fortified with folic acid. b. Rationale: Increased consumption of folic acid in the 3 months prior to concetion, as well as throughout the pregnancy, reduces the incidence of neural tube defects in the developing fetus. 29. A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching? a. Vaginal intercourse can be resumed after 2 weeks. b. Rationale: The client should avoid vaginal intercourse and the use of tampons for 2 weeks following discharge 30. A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia? a. Deep tendon reflexes of +1 i. Rationale: Deep tendon reflexes of +1 are decreased. In a client who has preeclampsia, the nurse should expect to find an increased, rather than a decreased, deep tendon reflex. 31. A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.) 32. A nurse is caring for a client who is in her first trimester of pregnancy and asks the nurse if she can continue to exercise during pregnancy. Which of the following responses by the nurse is appropriate? a. "Daily jogging for up to 30 minutes is fine throughout the pregnancy." b. Rationale: While weight-bearing exercises might become uncomfortable in the last trimester, they are generally not contraindicated, providing the client stays hydrated and avoids becoming overheated for extended period. 33. A nurse at a prenatal clinic is caring for a client who is in her first trimester of pregnancy. The client tells the nurse that she is upset because, although she and her husband planned this pregnancy, she has been having many doubts and second thoughts about the upcoming changes in her life. Which of the following is an appropriate response by the nurse? a. "Ambivalent feelings are quite common for women early in pregnancy." b. Rationale: This response uses the therapeutic communication technique of providing information while addressing the client's concerns and feelings. This statement is true and gives the client the information she needs; many antepartum women experience similar feelings in early pregnancy. 34. 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? a. Dyspnea b. Rationale: The presence of dyspnea is a manifestation of pulmonary edema, which is a potentially life-threatening complication of terbutaline. This finding should be reported to the provider immediately. 35. A nurse is caring for a client who is breastfeeding and states that her nipples are sore. Which of the following interventions should the nurse suggest? a. Change the newborn’s position on the nipples with each feeding. b. Rationale: When the client’s nipple is sore due to breastfeeding, the client should break the suction withher finger, remove the newborn from the breast, and try a different position. The newborn’smouth should be open wide before connecting with the nipple. 36. 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. A client who is experiencing preterm labor at 26 weeks of gestation b. Rationale: Tocolytic medications, such as terbutaline, indomethacin, and nifedipine are used to relax the uterus in preterm labor. A client who is in preterm labor at 26 weeks of gestation is a candidate for tocolytic therapy. 37. A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding? a. Cephalhematoma b. Rationale: A cephalhematoma is a swelling, indicating bleeding under the subcutaneous tissues of the newborn’s scalp. The collection of blood is beneath the periosteum of the cranial bone and therefore does not cross the suture line. 38. 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, a heart rate of 130/min, and cries in response to suctioning. The nurse should document what Apgar score for this infant? a. 8 is the correct answer. b. Correct Rationale: Apgar scoring is an assessment of five areas of newborn well- being: respiratory effort, heart rate, muscle tone, reflex irritability, and color. This newborn scores 2 each for heartrate, muscle tone, and reflex irritability. The weak cry and acrocyanosis of the hands and feet score 1 each, for a total of 8 39. A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective? a. Fundus firm to palpation i. Rationale: Methylergonovine is an oxytocic medication that is administered to promote uterine contractions. This medication is indicated for treatment of postpartum hemorrhage caused by uterine atony or subinvolution; the desired effect is an increase in uterine tone. 40. A nurse is teaching a client who is breastfeeding about dietary recommendations. Which of the following statements by the client indicates understanding of the teaching? a. "I'll eat more protein at each meal." b. Rationale: During lactation, clients should consume about 25 g of additional protein per day, which is more than what is required by non-pregnant and nonlactating female clients. 41. A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care? a. Cluster the newborn's care activities. b. Rationale: By clustering activities and organizing care, the nurse prevents excessive interruptions and allows the newborn extended periods of rest and energy conservation that promote development 42. A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rho (D)immunoglobulin. Which of the following should be included in the teaching? a. It prevents the formation of Rh antibodies in mothers who are Rh negative. i. Rationale: Rho (D) immunoglobulin prevents the immune system of a client who is Rh negative from reacting to accidental exposure to fetal blood during pregnancy or delivery. If the client has another Rh-positive fetus in the future, these antibodies can destroy the blood cells of the fetus (D) immunoglobulin is administered routinely to Rh negative mothers at 28 weeks of gestation and following any pregnancy outcome (including birth or any planned or unintentional fetal loss) 43. A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress, and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following? a. Location of the placenta Rationale: Painless, spontaneous vaginal bleeding might indicate that the client has placenta previa. Placenta previa is a condition in which the placenta is implanted low in the uterus, sometimes to the point of covering the cervical os. As the cervix effaces, the client begins to bleed. The ultrasound will show the location of the placenta and help to determine what sort of delivery the client requires and how emergent it is. 44. A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make? a. "The cause might be too short or infrequent feedings." i. Rationale: Breastfed newborns typically lose 5% to 6% of body weight before gaining weight. Slow weight gain might be due to inadequate breastfeeding, incorrect feeding techniques, or maternal factors such as breasts not emptying, stress, and fatigue. 45. A nurse in a prenatal clinic overhears a newly licensed nurse discussing conception with a client. Which of the following statements by the newly licensed nurse requires intervention by the nurse? a. Implantation occurs between 2 and 3 weeks after conception." b. Rationale: This statement requires clarification because implantation occurs between 6 to 10 days following conception. 46. A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor? a. A surge of energy Rationale: Prior to the onset of labor, the pregnant client experiences a surge of energy. 47. A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching? 48. "I will reduce my exercise schedule to 3 days a week." 49. Rationale: Increased exercise benefits the client and can result in improved management of gestationa a. "I will reduce my exercise schedule to 3 days a week." Rationale: Increased exercise benefits the client and can result in improved management of gestational diabetes. 48. A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client’s amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take? Have the client pant during the next contractions Rationale: Panting is rapid, continuous, shallow breathing. It helps a client in labor refrain from pushing before her cervix reaches full dilation. Observe for hyperventilation and have the client exhale slowly through pursed lips. 49.A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, “Is there a chance that I could deliver my next baby without having a cesarean section?" Which of the following responses should the nurse provide? b. "The primary consideration is what type of incision was performed this time." Rationale: The most common type of incision during a cesarean birth is transverse, which is made across the lower, thinner part of the uterus. It is the primary criteria that permits a vaginal birth after a cesarean (VBAC). Other types of incisions increase the risk of uterine rupture. Additional criteria for VBAC include an adequate maternal pelvis, no uterine scars or history of rupture, the availability of a provider to monitor labor, and personnel to perform a cesarean birth if needed. 50. A nurse is caring for a client who is at 6 weeks of gestation with her first pregnancy and asks the nurse when she can expect to experience quickening. Which of the following responses should the nurse make? a. "This will occur between the fourth and fifth months of pregnancy." i. Rationale: Quickening is defined as the first time the client is able to feel her fetus move. In a primigravida client, this usually occurs at 18 weeks of gestation or later. In a multigravida client, this can occur as early as 14 to 16 weeks. 51. A nurse is instructing a female client about how to check basal temperature to determine if the client is ovulating. The nurse should instruct the client to check her temperature at which of the following times? a. Every morning before arising Rationale: To measure basal temperature, the client must take her temperature every morning at the same exact time before getting out of bed. The client must try not to move too much, as any activity can raise the body temperature slightly. 52. A nurse is caring for a client who experienced a vaginal birth 12 hr ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase? Expressions of excitement Rationale: Expressing excitement and being talkative are characteristic of this phase. 53. 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? I will tip the nipple so air is present as my baby sucks." Rationale: The nipple should be held so it fills only with formula. The infant should not be permitted to suck air. 54. A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take? a. Discontinue the medication infusion. b. Rationale: Magnesium toxicity is manifested by bradypnea (respiratory rate less than 12/min) and absent deep tendon reflexes. The magnesium sulfate infusion should be discontinued, and calcium gluconate administered via IV. 55. A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn’s mouth, which of the following responses should the nurse make? "You should place your nipple and some of the areola into her mouth." Rationale: Placing the nipple and 2 to 3 cm of areolar tissue around the nipple into the baby’s mouth aids in adequately compressing the milk ducts. This placement decreases stress on the nipple and prevents cracking and soreness. 56. A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.) "I’ll expect the plastic ring to fall off by itself within a week." "I’ll call the doctor if I see any bleeding." "I’ll make sure his diaper is loose in the front." 57. A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer? "You must be feeling scared and powerless." Rationale: This response illustrates the therapeutic communication technique of restatement. The nurse shows empathy for the client by recognizing that the client is concerned about the safety of the fetus and is powerless to do anything about the situation. This open-ended statement encourages further communication by the client. 58. A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following? a. Uteroplacental insufficiency Rationale: The pattern of the fetal heart rate during labor is an indicator of fetal well-being. Late decelerations are the result of uteroplacental insufficiency, and the fetus becomes hypoxemic. They are an ominous sign if they cannot be corrected and place the fetus at risk for a low Apgar score 59. A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to 60. which of the following clients 59. A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first? 60. nsert a gloved hand into the vagina to relieve pressure on the cord. 61. Rationale: This is the first nursing action because it is essential to prevent any pressure on the umbilical 62. cord to promote oxygenation of the fetus a. Insert a gloved hand into the vagina to relieve pressure on the cord. Rationale: This is the first nursing action because it is essential to prevent any pressure on the umbilical cord to promote oxygenation of the fetus. 60.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? a. "I’ll feed my baby every 2 hours." b. Rationale: Breast engorgement is relieved by emptying both breasts. The client might be able to accomplish this with more frequent feedings. Otherwise, she can pump her breasts after breastfeeding to ensure optimal emptying. 61. .A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest reducing discomfort during breastfeeding? (Select all that apply.) a. Apply breast milk to the nipples before each feeding. b. D. Start breastfeeding with the nipple that is less sore. c. E. Change the infant’s position on the nipples. d. Rationale: Apply breast milk to the nipples before each feeding is correct. The application of colostrum and breast milk to the nipples moistens them and prepares them for breastfeeding. This can prevent and reduce nipple tenderness. Place breast pads inside the nursing bra is incorrect. Sore nipples should be exposed to the air as much as possible. The use of breast shells or cups inside the nursing bra is another 62. A nurse in a prenatal clinic is teaching a client who has a new prescription for dinoprostone gel. Which of the following statements should the nurse include in the teaching? a. "This medication promotes softening of the cervix." b. Rationale: Dinoprostone is used to prepare (or ripen) the cervix for the induction of labor in clients who are at term. 63. A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take? a. Document this as an expected finding. Rationale: The expected reference range for an apical pulse in a newborn who is awake is 120 to160/min. The nurse should document this as an expected finding. 64. A nurse is caring for a client who is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The nurse provides which of the following explanations about this test to the client? a. It is a screening test for spinal defects in the fetus. Rationale: The maternal serum alpha-fetoprotein (MSAFP) screening test is used to identify suspected neural tube defects (NTDs) and abdominal wall defects. These include spina bifida, microcephaly, and anencephaly. This tool is the basis for further testing, such as amniocentesis and specialized ultrasounds. 65. A nurse is caring for a client who has a positive pregnancy test. The nurse is teaching the client about common discomforts in the first trimester of pregnancy as well as warning signs of potential danger. The nurse should instruct the client to call the clinic if she experiences which of the following manifestations? a. Facial edema Rationale: Facial edema is a warning sign of a hypertensive condition or preeclampsia and should be reported immediately to the provider 66. A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor? a. Cervical dilation Rationale: Cervical dilation and effacement are indications of true labor 67. A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse? a. Ask the client if she has considered harming her newborn. Rationale: When using the nursing process in caring for a client, the first action should focus on assessment of the client’s mood, ability to concentrate, thought processes, and if the client has had thoughts of self-harm or of injuring her newborn. 68. A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis? 69. Unilateral, cramp-like abdominal pain 70. Rationale: An ectopic pregnancy is one in which the fertilized egg implants in tissue outside of the uterus 71. and the placenta and fetus begin to develop in this area. The most common site is within a 72. fallopian tube; however, ectopic pregnancies can occur in the ovary, the abdomen, and in the 73. cervix a. Unilateral, cramp-like abdominal pain Rationale: An ectopic pregnancy is one in which the fertilized egg implants in tissue outside of the uterus and the placenta and fetus begin to develop in this area. The most common site is within a fallopian tube; however, ectopic pregnancies can occur in the ovary, the abdomen, and in the cervix. 69. A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time? i. Palpate the client’s uterine fundus. 1. Rationale: Although the expectation is moderate bleeding in the first 2 hr after delivery, saturating a perineal pad in 15 min or less indicates excessive blood loss. The priority nursing intervention is to palpate the client’s fundus to determine the presence of uterine atony, followed by fundal massage to stimulate uterine muscle tone 70. A nurse is teaching about nutrition guidelines to a parent of a newborn. Which of the following statements by the parent indicates understanding of the teaching? a. "I should wait to give fruit juice until my baby is 6 months of age." b. Rationale: Fruit juice provides minimal nutritional value to the infant’s diet. Therefore, fruit juices should be limited and not offered until the infant is 6 months of age. 71. A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and undergoing a contraction stress test. The test results are negative. Which of the following interpretations of this finding should the nurse make? a. There is no evidence of uteroplacental insufficiency. b. Rationale: A contraction stress test determines how well the fetus tolerates the stress of uterine contractions. A test is negative when there are at least 3 uterine contractions in a 10-minperiod with no late or significant variable decelerations during electronic fetal monitoring. Uteroplacental insufficiency produces late decelerations. 72. A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching? 73. Moderate exercise improves circulation." 74. Rationale: Improving circulation is just one of the many benefits of moderate exercise during pregnancy. 75. It enhances well-being, promotes rest and relaxation, and improves muscle tone a. Moderate exercise improves circulation." b. Rationale: Improving circulation is just one of the many benefits of moderate exercise during pregnancy. It enhances well-being, promotes rest and relaxation, and improves muscle tone. 73.A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion? Respiratory rate of 16/min Rationale: The client’s respiratory rate should be at least 12/min to maintain adequate respiratory function. Magnesium toxicity causes bradypnea. Based on this finding, the nurse may continue the infusion. 74. A nurse in a clinic is teaching the mother of a 4-month-old infant who has been breastfed. The mother plans to switch her infant to an iron-fortified formula. Which of the following should be included in the teaching? a. Iron stores in infants begin to deplete. Rationale: Iron stores in infants are adequate until about 6 months of age. Infants who are weaned before 6 months of age should be given iron-fortified formula until 12 months of age. Iron stores will also be supplemented with the addition of iron-fortified cereals and iron-rich foods to the infant’s diet at 6 months of age 75. A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time? a. Have the client urinate. Rationale: A full bladder displaces the uterine fundus and elevates it above the level of the umbilicus. This can lead to uterine atony and excessive bleeding. Having the client urinate allows the uterus to return to midline and remain below the umbilicus. 76. A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client’s tolerance of the procedure, which of the following assessments should the nurse perform? a. Pulse rate Rationale: A sitz bath causes vasodilation; therefore, the nurse should monitor the client’s pulse rate. Orthostatic hypotension can occur upon standing causing the client to feel faint. 77. A nurse in a pediatric clinic is caring for a client who is postpartum and asks the nurse what to do when her newborn cries persistently. Which of the following strategies should the nurse suggest? (Select all that apply.) a. Take the newborn for a ride in the car. b. Carry the newborn in a front or backpack. c. Swaddle the newborn in a receiving blanket. Rationale: Take the newborn for a ride in the car is correct. Movement and rhythmic noise are soothing to newborns. Keep the newborn in the center of a large crib is incorrect. Newborns prefer small, warm, close spaces like the intrauterine environment. Carry the newborn in a front or backpack is correct. Carrying the newborn in a front or back carrier provides the comfort of close contact and gentle movement that is soothing to newborns. Swaddle the newborn in a receiving blanket is correct. Swaddling simulates the intrauterine environment, position-wise, and provides security to the newborn. Allow the newborn to continue crying is incorrect. Responsiveness to crying fosters trust as the newborn associate’s comfort with the caregiver. 78. A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching? a. Drink 48 to 64 ounces of water daily. Rationale: The client who has preeclampsia is encouraged to drink six to eight 8- ounce glasses of water (48 to 64 ounces) per day. She should avoid alcohol and limit intake of caffeinated beverages. 79. A nurse is caring for a newborn who has myelomeningocele. Which of the following nursing goals has the priority in the care of this infant? a. Maintain the integrity of the sac Rationale: Myelomeningocele is a congenital disorder that causes the spine and spinal canal to not close prior to birth, which results in the spinal cord, meninges, and nerve roots protruding out of the child’s back in a fluid-filled sac. Before surgery, the infant must be handled carefully to reduce damage to the exposed spinal cord and to maintain the integrity of the sac. 80. A nurse in a college health clinic is speaking to a group of adolescents about toxic shock syndrome (TSS). Which of the following should the nurse include in the teaching as increasing the risk for contracting TSS? a. High absorbency tampons Rationale: Toxic shock syndrome, a severe disease caused by a toxin made by Staphylococcus aureus, is characterized by shock and multiple organ dysfunction. Approximately 50% of all cases involve menstruating women using highly absorbent tampons 81. 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? a. Your baby should wet 6 to 8 diapers per day." Rationale: Newborns should wet 6 to 8 diapers per day. This is an indication that the newborn is getting enough fluids. 82. A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the following statements should the nurse make? 83. We can time your pain medication so that you have an hour or two before the next feeding." 84. Rationale: This answer provides the client an option that allows for administration of pain medication but 85. minimizes the effect it will have on the newborn while breastfeeding. a. We can time your pain medication so that you have an hour or two before the next feeding." Rationale: This answer provides the client an option that allows for administration of pain medication but minimizes the effect it will have on the newborn while breastfeeding. 83.A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide? a."This infection is treated with one dose of azithromycin. “ Rationale: A single dose of azithromycin is an appropriate treatment for a chlamydial infection. An acceptable alternative is doxycycline twice a day for 7 days. 84.A nurse is providing preconception counseling for a client who is planning a pregnancy. Which of the following supplements should the nurse recommend helping prevent neural tube defects in the fetus? Folic acid Rationale: Adequate amounts of folic acid before conception and during the first trimester of pregnancy are necessary for fetal neural tube development. This vitamin helps prevent spina bifida and other neurological disorders. 85.A nurse in a prenatal clinic is completing a skin assessment of a client who is in the second trimester. Which of the following findings should the nurse expect? (Select all that apply. C. Linea nigra D. Chloasma E. Striae gravidarum Rationale: Eczema is incorrect. Eczema manifests as red, swollen, and itchy skin and is not an expected finding during pregnancy. Psoriasis is incorrect. Psoriasis manifests as thick red patches or plagues covered by silver scales on the skin and is not an expected finding during pregnancy. Linea nigra is correct. Linea nigra manifests as a line of pigmentation extending from the symphysis pubis to the top of the fundus and is an expected finding during pregnancy. Chloasma is correct. Chloasma, or the mask of pregnancy, manifests as blotchy, brownish hyperpigmentation of the skin over the forehead, nose, and cheeks and is an expected finding during pregnancy. Striae gravidarum is correct. Striae gravidarum, or stretch marks, occur because of the separation of underlying connective tissue on the breasts, thighs, and abdomen. They are an expected finding during pregnancy 24. A nurse is reviewing the health history of a client who has a new prescription for a combined oral contraceptive (COC). The nurse recognizes that which of the following client medications can interfere with the effectiveness of the COC? a. Anticonvulsants Rationale: Anticonvulsants when taken simultaneously with COCs can decrease their effectiveness. The anticonvulsants included are, phenytoin, phenobarbital, carbamazepine, oxcarbazepine, topiramate, and primidone. 25. A nurse in a clinic is assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following findings should the nurse expect? (Select all that apply.) a. History of migraines. Nulliparous. Twin gestations 26. A nurse is caring for a client who has rubella at the time of delivery and asks why her newborn is being placed in isolation. Which of the following responses by the nurse is appropriate? a. "The newborn might be actively shedding the virus." Rationale: Infants born to mothers who have rubella will continue to shed the rubella virus for up to 18months postdelivery. 27. A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother’s room. Which of the following is an appropriate response by the nurse? a. "Have the mother call and I will take the baby to the room. "Rationale: Safety precautions include the use of identification bracelets placed on the parents and newborn, which nursery personnel must verify before permitting an infant to remain in the mother’s room. 28. A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding? a. The lowermost portion of the fetus is at the level of the ischial spines. Rationale: The presenting part is at 0 station when its lowermost portion is at the level of an imaginary line drawn between the client’s ischial spines. Levels above the ischial spines are negative values: –1, –2, –3. Levels below the ischial spines are positive values: +1, +2, +3. 29. A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse’s priority? a. Respiratory distress Rationale: Shortly before labor, there is a decreased production of fetal lung fluid and a catecholamine surge that promotes fluid clearance from the lungs. Newborns born by cesarean, in which labor did not occur, can experience lung fluid retention, which leads to respiratory distress. The priority assessment when using the airway, breathing, circulation (ABC) approach to client care is to monitor the newborn for respiratory distress. 30. A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make? a. Before I can help you, I need to know more about your sexual activity." Rationale: This is an example of providing a general lead when using therapeutic communication. It allows the client to provide information that will enhance effective consultation about the best form of contraception for her. 31. A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect? a. Dry, cracked skin Rationale: A newborn who is postmature has dry, cracked skin 32. A nurse is providing teaching about nutrition to a client at her first prenatal visit. Which of the following statements by the nurse should be included in the teaching? a. You will need to double your intake of iron during pregnancy." Rationale: During pregnancy, the need for iron increases to allow transfer of the appropriate amounts to the fetus and to support expansion of the client’s red blood cell volume. 33. A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as an indication of inhibition of parental attachment? a. "I wish he had more hair. I will keep a hat on his head until he grows some." Rationale: This client statement expresses disappointment in the newborn’s appearance and a need to hide what the client perceives as an undesirable feature. This is an indication of inhibited parental attachment. 34. A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client’s newborn at risk for which of the following complications? a. Intrauterine growth restriction Rationale: Clients who smoke place their newborns and themselves at risk for diverse complications, including fetal intrauterine growth restriction, placental abruption, placenta previa, preterm delivery, and fetal death. 35. A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make? a. Additional interventions are not indicated at this time. Rationale: For this postpartum day, the client’s fundal location and lochia characteristics are within the expected reference range. Breast engorgement is typical, as this is the time when the breasts begin producing milk. Frequent breastfeeding and routine care can help relieve engorgement. 36. A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make? a. The recommendation for you is about 15 to 25 pounds." Rationale: Clients who are overweight, having a BMI of 25 to 29.9, should be advised that the recommended weight gain is 7 to 11.5 kg (15 to 25 lb.). The pattern of weight gain is also important, with minimal gain in the first trimester. 37. A nurse in the emergency department is admitting a client who is at 40 weeks of gestation, has ruptured membranes, and the nurse observes the newborn’s head is crowning. The client tells the nurse she wants to push. Which of the following statements should the nurse make? a. "You should try to pant as the delivery proceeds." Rationale: Panting allows uterine forces to expel the fetus and permits controlled muscle expansion to avoid rapid expulsion of the fetal head 38. A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest reducing discomfort during breastfeeding? (Select all that apply.) Apply breast milk to the nipples before each feeding. Start breastfeeding with the nipple that is less sore Change the infant’s position on the nipples. Rationale: Apply breast milk to the nipples before each feeding is correct. The application of colostrum and breast milk to the nipples moistens them and prepares them for breastfeeding. This can prevent and reduce nipple tenderness. Place breast pads inside the nursing bra is incorrect. Sore nipples should be exposed to the air as much as possible. The use of breast shells or cups inside the nursing bra is another option to reduce discomfort. Massage the breasts and nipples prior to feeding is incorrect.</b>Massage can irritate nipple tissue. Massage is effective in promoting emptying of the engorged breast. Start breastfeeding with the nipple that is less sore is correct. The client who is breastfeeding should start with the nipple that is less sore, as the newborns initial sucking motions are the strongest. Change the infants position on the nipples is correct.</b> Changing the newborns position on the nipples reduces discomfort and prevents nipple soreness. Repositioning of the mother can also prevent nipple discomfort. 39. A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn? a. 48/min Rationale: The expected reference range for a newborn’s resting respiratory rate is 30 to 60/min 40. A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn’s plan of care? a. Monitor blood glucose levels. Rationale: Decreased stores of glycogen and a lower rate of gluconeogenesis place newborns who are SGA at higher risk for hypoglycemia. Monitoring of blood glucose levels is a priority intervention. 41. A nurse is preparing to administer methylergonovine IM to a client who experienced a vaginal delivery. The nurse should explain to the client that the purpose of this medication is to prevent which of the following conditions? a. Postpartum hemorrhage Rationale: Methylergonovine is an oxytocic medication. It causes uterine contractions, which control postpartum bleeding. 42. A nurse is caring for a client who experienced a vaginal delivery 12 hr. ago. When palpating the client’s abdomen, at which of the following positions should the nurse expect to find the uterine fundus? a. At the level of the umbilicus Rationale: Within 12 hr., the fundus should be palpable at the level of the umbilicus and then recede 1 to 2cm each day. 43. A nurse is providing teaching about Kegel exercises to a group of clients who are in the third trimester of pregnancy. Which of the following statements by a client indicates understanding of the teaching? a. These exercises help pelvic muscles to stretch during birth." Rationale: Kegel exercises improve the strength of perineal muscles, facilitating stretching and contracting during childbirth. 44. A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding? a. Variable decelerations are due to umbilical cord compression. Rationale: Variable decelerations are decreases in the fetal heart rate with an abrupt onset, followed by a gradual return to baseline. Variable decelerations coincide with umbilical cord compression, which decreases the oxygen supply to the fetus. 45. A nurse is assisting a client with breastfeeding. The nurse explains that which of the following reflexes will promote the newborn to latch? a. Rooting Rationale: The rooting reflex is elicited when the client strokes the newborn’s lips, cheek, or corner of the mouth with her nipple. The newborn will turn his head while making sucking motions with his mouth and latch onto the nipple. 46. A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn’s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make? 47. We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital." 48. Rationale: Most states mandate hearing screening for all newborns. The two tests in use do not diagnose 49. hearing loss, but determine whether or not a newborn requires further evaluation. a. We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital." Rationale: Most states mandate hearing screening for all newborns. The two tests in use do not diagnose hearing loss but determine whether or not a newborn requires further evaluation. 109.A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make? b. In 3 to 5 days Rationale: By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breastmilk. 110.A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. The nurse locates the fetal heart tones above the client’s umbilicus at midline. The nurse should suspect that the fetus is in which of the following positions? c. Frank breech d. Rationale: With a frank breech presentation, the fetal heart is generally above the level of the client's umbilicus. 111.A nurse is assessing a client who is 8 hr. postpartum and multiparous. Which of the following findings should alert the nurse to the client’s need to urinate? e. Fundus three fingerbreadths above the umbilicus Rationale: A full bladder can raise the level of uterine fundus and possibly deviate it to the side. 50. A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus? a. Slightly above the umbilicus Rationale: At 22 weeks of gestation, the fundal height should be just above the level of the umbilicus. The distance in centimeters from the symphysis pubis to the top of the fundus is a gross estimate of the weeks of gestation. 51. 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 52. dilation and 100% cervical effacement. The nurse obtains the client’s blood pressure reading as 82/52 mm Hg. 53. Which of the following nursing interventions should the nurse perform? 113.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 client’s blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform? a. Assist the client to turn onto her side. Rationale: Maternal hypotension results from the pressure of the enlarged uterus on the inferior vena cava. Turning the client to her right side relieves this pressure and restores blood pressure to the expected reference range. 114.A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption? b. Hypertension Rationale: Maternal hypertension, either chronic or related to pregnancy, is the most common risk factor for placental abruption. 115.A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following? Quickening Rationale: Clients describe quickening as a fluttering sensation, which can be felt as early as the 14thweek of gestation. It reflects fetal movement 54. A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference? a. Nipple line b. Rationale: The nurse should measure the newborn’s chest circumference at the nipple line 55. A nurse is teaching a newborn’s parent to care for the umbilical cord stump. Which of the following instructions should the nurse include? a. Give a sponge bath until the cord stump falls off. b. Rationale: Immersing the umbilical cord stump in water can delay the process of drying, separation, and healing. Sponge baths are appropriate until the stump falls off. 56. A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain? a. C. Massage the client's back. b. Rationale: The gate control theory of pain is based on the concept of blocking or preventing the transmission of pain signals to the brain by using distraction techniques such as massage. c. Massaging the client’s back focuses on neuromuscular and cognitive changes. 57. A nurse on the labor and delivery unit is caring for a client following a vaginal examination by the provider which is documented as: –1. Which of the following interpretations of this finding should the nurse make? a. The presenting part is 1 cm above the ischial spines. b. Rationale: Station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is minus (-) 1, then the presenting part is 1 cm above the ischial spines. 58. A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify? a. Fetal position is persistent occiput posterior. b. Rationale: The persistent occiput posterior position of the fetus is a common cause of prolonged, difficult labor with severe back pain as spinal nerves are being compressed. Counterpressure or a hands-and-knees position can offer pain relief. 59. A nurse in is caring for a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure? a. Assess the fetal heart rate pattern. b. Rationale: Variable fetal heart rate decelerations and bradycardia can occur with an amniotomy because of umbilical cord prolapse or compression. Cord prolapse necessitates an emergent delivery. 60. A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider’s orders. Which of the following orders requires clarification? Ambulate twice daily. a. Rationale: A provider’s order to allow the client to ambulate requires clarification. The client who has severe preeclampsia should be placed on bedrest in a quiet, no stimulating environment to prevent seizures and promote optimal placental blood flow. 61. A nurse is admitting a client who is at 36 weeks’ gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions? a. B. Placenta previa b. Rationale: Painless, bright red vaginal bleeding in the second or third trimester is a manifestation of placenta previa. 62. A nurse is caring for