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A charge nurse is discussing STIs w/ a newly licensed nurse. Which of the
following infections should the nurse include in the teaching as an
indication for a cesarean birth p . 50 ch 8
1. Gonorrhea- spread genital to genital
2. Chlamydia
3. HIV
4. Syphilis
- INDICATIONS for C-Section
::::::: Malpresentation, Non-reassuring fetal heart tones
Placental abnormalities, Placenta previa, Abruptio placentae, active
genital herpes, DM, eclampsia, previous C-birth, dystocia, multiple
gestations, umbilical cord prolapse
A nurse is planning care for a newborn who has neonatal abstinence
syndrome. Which of the following interventions should the nurse include
in the plan of care? Ch 27 p. 318
1. Increase the newborn’s visual stimulation
2. Swaddle the newborn in a flexed position - to reduce self
stimulation and protect skin from abrasions.
3. Weigh the newborn every other day
4. Discourage prenatal interaction until after a social service evaluation
Interventions-offer small feedings, swaddle newborn with legs flexed,
reduce environmental stimuli,
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A nurse is providing discharge instructions to a client who is breastfeeding
her newborn. Which of the following instructions should the nurse include?
1. Offer the newborn 30mL (1 oz) of water between feedings
2. Allow the baby to feed at least every 2 hrs
3. Feed the newborn 5-10 mins per breast - 15-20 minutes per breast
4. Expect 2 -4 wet diapers every 24 hrs -6-8 a day
-should breastfeed every 2-3 hours for the first 6 months. Should occur 8-12
times a day. And feed on demand. Cramps are normal during breastfeeding.
Stimulating the nipple causes let down reflex of milk.
A nurse is assessing a client immediately following the placement of an
epidural. The nurse obtains a maternal blood pressure of 96/54 mmHg
and a fetal heart rate of 102/min. Which of the following actions should
the nurse take?
1. Administer naloxone to the client
2. Position the client in a lateral position- is this the same as side
lying?
3. Place the client in knee chest position - do this for variable
deceleration od FHR
4. Prepare the client for an amnioinfusion - process of instilling normal
saline in amniotic cavity into the uterus to supplement the amount of
fluids to reduce variable decelerations causs by cord compression
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• Administer a bolus of IV fluids to help offset maternal hypotension.
Side lying, oxygen, IV fluids
A nurse is caring for a client who is in labor and is prescribed an
amnioinfusion. Which of the following findings is an indication for this
procedure p . 102 ch 15
1. Fetal macrosomia
2. Variable decelerations -process of instilling normal saline in
amniotic cavity into the uterus to supplement the amount of fluids to
reduce variable decelerations causs by cord compression
3. Early decelerations- slowing of the FHR with the start of
contraction with return of the FHR to baseline at the end of
contraction
4. Increased uterine tone
A nurse is providing discharge instructions to a client who delivered a
newborn via cesarean birth 4 days ago. The nurse should instruct the client
to contact the provider for which of the following findings.
1. Newborn has fewer than 4 wet diapers in 24hrs-6-8/day
2. The newborns cord stump will detach after 1 week- falls off around 10-
14 days
3. The newborn sleeps 16hrs a day- normal 16-19 hours/day
4. The newborn has loose stools - normal from milk
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A nurse is performing an initial assessment of a newborn who was
delivered with a nuchal cord. Which of the following clinical findings
should the nurse expect?
Telangiectatic nevi- “stork bites” flat pink marks found on face
that easily blanch. NORMAL
Periauricular papillomas
Erythema toxic -pink rash on newborn. normal
Facial petechiae- seen over the presenting part with soft tissue injuries
-nuchal cord: umbilical cord around fetal neck. Will cause variable
deceleration of FHR. Intervention: reposition client from side to side or into
knee chest, discontinue oxytocin if being infused, oxygen
A nurse is monitoring a newborn whose mother reports recent opiate use for
neonatal abstinence syndrome. Which of the following findings indicates
narcotic withdrawal?
Respiratory rate 50/min
Unequal pupils
Hypotonia
Excessive crying
• Substance withdrawal in the newborn occurs when the mother
uses drugs during pregnancy.
• Hitch pitch shrill cries, incessant crying, tremors, increae deep
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