Mother Baby Hesi - #2 questions and answers

28 year old client in active labor complains of cramps in her leg.What intervention should the nurse 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. B. Extend the leg and dorsiflex the foot. The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling finger and dizziness. What action should the nurse take? a. administer o2 by face mask b. notify the HCP for the client's syndrome c. have the client breathe into her cupped hands d. check the client's BP and fetal HR/ c. have the client breathe into her cupped hands. When assessing a client who is at 12 week gestation, the nurse 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 D. At 30 weeks gestation. In developing a teaching plan for expectant parents the nurse plans to include formation about when the parents can expect the infants fontanels to close. The nurse 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 D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month A 42 week gestational client is receiving an intravenous infusion of oxytocin(Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for with pattern of contractions? A. transition labor with contractions every 2 mins, lasting 90 seconds each. B. early labor with contractions every 5 min, lasting 40 seconds each. C. Active labor with contractions every 31 mins, lasting 60 seconds each. D. Active labor with contraction every 2 to 3 mins, lasting 70 to 80 seconds each. A. transition labor with contractions every 2 mins, lasting 90 seconds each. What action should the nurse implement to decrease the client's risk for hemorrhage after c-section. A. Monitor urinary output via an indwelling catheter. B. assess the abdominal dressings for drainage. C. Give the Ringer's lactated infusion at 125ml D. Check the firmness of the uterus every 15mins. D. Check the firmness of the uterus every 15mins. Which assessment finding should the nursery nurse report to the pediatric healthcare provider? A. blood glucose level of 45mg/dl B. blood pressure of 82/45 mmHG C. Non bulging anterior fontanel D. central cyanosis when crying D. central cyanosis when crying The nurse is assessing a 3 day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should the nurse report to the healthcare provider? A. yellowish tinge to the skin B. babinski reflex present bilaterally C. pink papular rash on the face D. moro reflex noted after a loud noise A. yellowish tinge to the skin A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated a nd the client is lying in a 6inch diameter pool of blood. A. Cleanse the perineum B. obtain a BP C. palpate the firmness of the fundus D; inspect the perineum for lacerations C. palpate the firmness of the fundus A 40 week gestation primigravida client is being induced with an ocytocin secondary infusion and complains of pain in her lower back. Which intervention should the nurse implement? A. Discontinue the oxytocin infusion B. place the client in a semi-fowler's position C. inform the healthcare provider D. apply firm pressure to sacral area D. apply firm pressure to sacral area A client with gestational htn is an active labor and receiving an infusion of magnesium sulfate. Which drug should the nurse available for signs of potential toxicity? A. oxytocin B. calcium gluconate C. terbutaline D. naloxone 9 B. calcium gluconate A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate. A. dark,red vaginal bleeding B. lower back pain C. premature rupture of membranes D. increased uterine irritability E. bilateral pitting edema F. Rigid abdomen A. dark,red vaginal bleeding D. increased uterine irritability F. Rigid abdomen A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately. A.heart rate of 100 beats min B. variable fetal HR C. Onset of uterine contractions D. Burning on urination Onset of uterine contractions. A multigravida client arrives at the L&D unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal HR is between 140 and 150 beats/min. What action should the nurse implement next? A. complete sterile vag exam B. take maternal temp every 2 hrs C. Prepare for an immediate cesarean bitrh D. Obtain sterile suction equipment A. complete sterile vag exam 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 HR of 80 beats/minute and respirations of 20 breaths/min. What action should be performed next? A. Initiate positive pressure ventilation B . Intervene after one min Apgar is assessed. C. Initiate CPR on the infant D. Assess the infant's blood glucose level A. Initiate positive pressure ventilation A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing hx, the client indicates that she has delivered premature twins, one full term baby and has had no abortions. Which GTPAL should the nurse 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 D. 3-1-1-0-3 The healthcare provider prescribes terbutaline for a client in preterm labor. Before initating this prescription, it is most important for the nurse to assess the client for which of condition. A. gestational diabetes B. Elevated BP C. UTI D Swelling in lower extremities A. gestational diabetes A 4 week old premature infant has been receiving epoetin alfa for the last 3 weeks. WHich assessment finding indicates to the nurse that the drug is effective. A.slowly increasing urinary output over the last week B.rr changes from 40s to the 60s C. changes in apical HR from the 180 to the 140 D.Change in indirect bilirubin from 12mg/dl to 8mg/dl. C. changes in apica HR from the 180 to the 140 The nurse should explain to a 30 year old gravid 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 B.screen for neural tube defects During labor, the nurse determine that a full term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions. 1. Reposition the client 2. Provide O2 via face mask 3. Increase IV fluid 4. Call the healthcare provider A vaginally delivered infant of an HIV positive mother is admitted to the newborn nursery. What intervention should the nurse 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). 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 nurse 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. C.Increase the rate of IV fluids. 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. ... 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. .DThe extent to which the pregnancy was planned. A. The client's readiness to learn. 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. Move about every hour. 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. 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. A. A home pregnancy test can be used right after your first missed period. 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 nurse 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 C. Tachycardia and a feeling of nervousness. 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. C.Correctly place the infant on the breast. A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse 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. B. Infant's condition at birth and treatment received. 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 nurse 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. D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month. When assessing a client who is at 12-weeks gestation, the nurse 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. D.At 30-weeks gestation. The nurse 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. C.the cervix is completely dilated. The nurse 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. immediately before menstruation. C. immediately before menstruation. D. three weeks before menstruation. A.two weeks before menstruation. The nurse 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. B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor. A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse 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. B. Extend the leg and dorsiflex the foot 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. C.Vernix is a white, cheesy substance, predominantly located in the skin folds. 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 nurse 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. C. That is normal; the head will return to a round shape within 7 to 10 days. An expectant father tells the nurse 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. D.Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement. A new mother asks the nurse, "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. B.Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day. 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 nurse 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. D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose. 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. D.Meet the mother's physical needs and demonstrate warmth toward the infant. 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. A. Lying prone with a pillow on the abdomen. hich maternal behavior is the nurse 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. She eagerly reaches for the infant and then holds the infant close to her own body. b. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. 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. a.November 22. The nurse 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 correctly 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. c. January 30-31. A client at 32-weeks gestation is hospitalized with severe pregnancy-induced 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. C.A decrease in respiratory rate from 24 to 16. 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 nurse 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. C.Place the woman in a lateral position. 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 nurse 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. A.Come to the clinic today for an ultrasound. An off-duty nurse 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 D.Put the newborn to breast 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 nurse 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. A.Complete bedrest decreases oxygen needs and demands on the heart muscle tissue. 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 nurse 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. C.Check the infant's oxygen saturation rate. 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 nurse 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. D.Provide assistance to the mother to begin breastfeeding as soon as possible after delivery. The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? A.Two vessels: one artery and one vein. B.Two vessels: two arteries and no veins. C.Three vessels: two arteries and one vein. D.Three vessels: two veins and one artery C.Three vessels: two arteries and one vein. The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? A. Between the time the temperature falls and rises. B. Between 36 and 48 hours after the temperature rises. C. When the temperature falls and remains low for 36 hours. D. Within 72 hours before the temperature falls. A. Between the time the temperature falls and rises. The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? A.Edema, basilar rales, and an irregular pulse. B. Increased urinary output and tachycardia. C.Shortness of breath, bradycardia, and hypertension. D.Regular heart rate and hypertension. A.Edema, basilar rales, and an irregular pulse. client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first? A. Raise the foot of the bed. B.Assess for vaginal bleeding. C.Evaluate the fetal heart rate. D.Take the client's blood pressure. A. Raise the foot of the bed. The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the nurse implement? A.Provide phototherapy for 30 minutes q8h. B. Feed the newborn sterile water hourly. C.Encourage the mother to breastfeed frequently. D.Assess the newborn's blood glucose level. C.Encourage the mother to breastfeed frequently. A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity? A.Deep tendon reflexes 2+. B.Blood pressure 140/90. C.Respiratory rate 18/minute. D.Urine output 90 ml/4 hours. D.Urine output 90 ml/4 hours. 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks' gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous. Which assessment is the highest priority for the nurse to monitor during the administration of this drug? A. Maternal blood pressure and respirations. B.Maternal and fetal heart rates. C.Hourly urinary output. D.Deep tendon reflexes. B.Maternal and fetal heart rates. The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abortion at 8-weeks gestation. What type of emotional response should the nurse anticipate? A.Grief related to her perceptions about the loss of this child. B.Relief of ambivalent feelings experienced with this pregnancy. C.Shock because she may not have realized that she was pregnant. D. Guilt because she had not followed her healthcare provider's instructions. A.Grief related to her perceptions about the loss of this child. The nurse is teaching breastfeeding to prospective parents in a childbirth education class. Which instruction should the nurse include as content in the class? A.Begin as soon as your baby is born to establish a four-hour feeding schedule. B.Resting helps with milk production. Ask that your baby be fed at night in the nursery. C.Feed your baby every 2 to 3 hours or on demand, whichever comes first. D. Do not allow your baby to nurse any longer than the prescribed number of minutes. C.Feed your baby every 2 to 3 hours or on demand, whichever comes first. A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client? A.Some care is required when touching the large soft area on top of your baby's head until the bones fuse together. B.That's just an 'old wives' tale' so don't worry, you can't harm your baby's head by touching the soft spot. C.The soft spot will disappear within 6 weeks and is very unlikely to cause any problems for your baby. D.There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair. D.There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb his/her hair. A couple, concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure complaint indicates that the fallopian tubes are patent? A.Back pain B.Abdominal pain. C.Shoulder pain. D. Leg cramps. C.Shoulder pain. client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets. The nurse's response is based on what knowledge? A. Supplementary iron is more efficiently utilized during pregnancy. B. It is difficult to consume 18 mg of additional iron by diet alone. C. Iron absorption is decreased in the GI tract during pregnancy. D. Iron is needed to prevent megaloblastic anemia in the last trimester. B. It is difficult to consume 18 mg of additional iron by diet alone. Which nursing intervention is helpful in relieving "afterpains" (postpartum uterine contractions)? A.Using relaxation breathing techniques. B.Using a breast pump. C.Massaging the abdomen. D.Giving oxytocic medications. A.Using relaxation breathing techniques. A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first? A.Provide oral hydration. B.Have a complete blood count (CBC) drawn. C.Obtain a specimen for urine analysis. D.Place the client on strict bedrest. C.Obtain a specimen for urine analysis. The nurse is performing a gestational age assessment on a full-term newborn during the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small for gestational age (SGA)? (Select all that apply.) A.Admission weight of 4 pounds, 15 ounces (2244 grams) B.Head to heel length of 17 inches (42.5 cm). C.Frontal occipital circumference of 12.5 inches (31.25 cm). D.Skin smooth with visible veins and abundant vernix. E.Anterior plantar crease and smooth heel surfaces. F. Full flexion of all extremities in resting supine position. A.Admission weight of 4 pounds, 15 ounces (2244 grams) B.Head to heel length of 17 inches (42.5 cm). C.Frontal occipital circumference of 12.5 inches (31.25 cm). A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the nurse to provide this client? A.Elevate lower legs while resting. b.Increase caloric intake by 200 to 300 calories per day. c.Increase water intake to 8 full glasses per day. d.Take prescribed multivitamin and mineral supplements. D. Take prescribed multivitamin and mineral supplements. A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited? a. Choking, coughing, and cyanosis. b. Projectile vomiting and cyanosis. c. Apneic spells and grunting. d. organomegaly. a. Choking, coughing, and cyanosis. The nurse is teaching care of the newborn to a group of prospective parents and describes the need for administering antibiotic ointment into the eyes of the newborn. Which infectious organism will this treatment prevent from harming the infant? a.Herpes. b.Staphylococcus c.Gonorrhea. d. Syphilis. c.Gonorrhea. A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider? a.Cervical dilation of 5 cm with 90% effacement. b.White blood cell count of 12,000/mm3. c.Hemoglobin of 12 mg/dl and hematocrit of 38%. d.A platelet count of 67,000/mm3. d.A platelet count of 67,000/mm3. A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? a. Describe diet changes that can improve the management of her diabetes. b.Inform the client that oral hypoglycemic agents are teratogenic during pregnancy. c. Demonstrate self-administration of insulin. d. Evaluate the client's ability to do glucose monitoring. a. Describe diet changes that can improve the management of her diabetes. A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and abdomen. What action should the nurse implement? a.Notify the healthcare provider. b.Move the newborn to an isolation nursery. c.Document the finding in the infant's record. d.Obtain a culture of the vesicles. c.Document the finding in the infant's record. the nurse is planning preconception care for a new female client. Which information should the nurse provide the client? a.Discuss various contraceptive methods to use until pregnancy is desired. b.Provide written or verbal information about prenatal care. c.Ask the client about risk factors associated with complications of pregnancy. d.Encourage healthy lifestyles for families desiring pregnancy. d.Encourage healthy lifestyles for families desiring pregnancy. The nurse is calculating the estimated date of confinement (EDC) using Nägele's rule for a client whose last menstrual period started on December 1. Which date is most accurate? a.August 1. b.August 10. c.September 3. d.September 8. d.September 8. A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal therapy. Which response is best for the nurse to provide? a.Herbs are a cornerstone of good health to include in your treatment. b.Touch is also therapeutic in relieving discomfort and anxiety. c.Your healthcare provider should direct treatment options for herbal therapy. d.It is important that you want to take part in your care. d.It is important that you want to take part in your care. The nurse observes a new mother is rooming-in and caring for her newborn infant. Which observation indicates the need for further teaching? a.Cuddles the baby close to her. b.Rocks and soothes the infant in her arms. c.Places the infant prone in the bassinet. d. Wraps the baby in a warm blanket after bathing. c.Places the infant prone in the bassinet. A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of transmission of the disorder to an infant. The nurse's response should be based on what information? a.Males inherit the disorder with a greater frequency than females. b.Each pregnancy carries a 50% chance of inheriting the disorder. c.The disorder occurs in 25% of pregnancies. d.All children will be carriers of the disorder. b.Each pregnancy carries a 50% chance of inheriting the disorder. A 30-year-old multiparous woman who has a 3-year-old boy and an newborn girl tells the nurse, "My son is so jealous of my daughter, I don't know how I'll ever manage both children when I get home." How should the nurse respond? a.Tell the older child that he is a big boy now and should love his new sister. b.Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him. c.Let the older child stay with his grandparents for the first six weeks to allow him to adjust to the newborn. d.Regression in behaviors in the older child is a typical reaction so he needs attention at this time. ... When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.) a.Mood swings. b.Panic attacks. c.Tearfulness d.Decreased need for sleep. e. Disinterest in the infant a.Mood swings. c.Tearfulness A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin? a.Dehydration. b.Hyperstimulation. c. Galactorrhea. d.Fetal tachycardia. b.Hyperstimulation. While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should the nurse provide this new mother? a.The infant should be positioned to reduce the swelling. b.The swelling is a subperiosteal collection of blood. c.The pediatrician will aspirate the blood if it gets larger. d.The scalp edema will subside in a few days after birth. d.The scalp edema will subside in a few days after birth. The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take? a.Ask the mother why she won't look at the infant. b.Observe the mother for other attachment behaviors. c.Examine the newborn's eyes for the ability to focus. d.Recognize this as a common reaction in new mothers. b.Observe the mother for other attachment behaviors.