HESI NGN MATERNITY OB EXAM VERSION 3 ANSWERS |ALREADY GRADED A+ (SCORE 1292)

HESI NGN MATERNITY OB EXAM VERSION 3 ANSWERS |ALREADY GRADED A+ (SCORE 1292)   1. A primipara has delivered a stillborn fetus at 30-weeks’ gestation. To assess the parents in the grieving process which intervention is most important for the nurse to implement ? A. explain the possible cause of the fetal demise B. Provide an opportunity for the parents to hold their infant in privacy C. Encourage the parents to seek counseling within the next few weeks D. Assist the couple to request autopsy 2. What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and atracheoesophageal (TE) fistula? A.) body temperature B.) level of pain C.) time of first void D.) number of vessels in the cord 3. What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40 weeks gestation? a. Maternal blood pressure b. Level of pain sensation c. Station of presenting part d. Variability of fetal heart rate 4. A 34 week primigravida woman with preeclampsia is receiving lactated ringers 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hours. How many ml/hour should the nurse program the infusion pump? 75 ml/hr 5. A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is the most important for the nurse to implement? a. Graph the daily weight for the past week b. Decrease IV flow rate c. Assess bilateral lung sounds d. Restrict intake of oral fluids 6. A mother of a 3-year-old boy has just given birth to a new baby girl. The little boy asks the nurse, "Why is my baby sister eating my mommy's breast?" How should the nurse respond? (Select all that apply) a. Explain that newborns get milk from their mothers in this way b. Reassure the older brother that it does not hurt his mother c. Remind him that his mother breastfed him too d. Suggest that the baby can also drink from a bottle e. Clarify that breastfeeding is his mother’s choice 7. The nurse is examining an infant for possible cryptorchidism. Which exam technique should be used? a. Place the infant in the side-lying position to facilitate the exam b. Hold the penis and retract the foreskin gently c. Cleanse the penis with an antiseptic soaked pad d. Place the infant in a warm room and use a calm approach Cryptorchidism is the failure of one or both testes to descend normally through inguinal canal. For the infant’s comfort, the infant should be examined in a warm room with the examiner’s hands warmed. Testes can retract into the inguinal canal if the infant is upset or cold. Examining the infant with cold hands is uncomfortable for the infant and likely to cause the infant’s testes to retract into the inguinal canal. It may also cause the infant to be uncooperative during the examination. A rectal temperature yields no information about cryptorchidism. Testes can retract into the inguinal canal if the cremasteric reflex is elicited. This can lead to an incorrect diagnosis. 8. The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome? A. Betamethasone (Celeston) 12 mg deep IM B. Butorphanol 1 mg IV push q2h PRN pain C. Ampicillin 1 Gram IV push q8h D. Terbutaline (Brethine) mg subcutaneously q15 minutes x3 9. Insulin therapy is initiated for a 12 year old child who is admitted with diabetic ketoacidosis (DKA). What action is most import for the nurse to include in the child’s plan of care? a. Monitor serum glucose for adjustment in infusion rate of Regular insulin (Novolin R) (please verify) b. Determine the child’s compliance schedule for subcutaneous NPH insulin (Humulin N) c. Demonstrate to parents how to program an insulin pen for daily glucose regulation d. Consult with healthcare provider about use of insulin detemir (Levemir Flex Pen) 10. A 3 month old with myelomeningocele and atonic bladder is catheterized every 4 hours to prevent urinary retention. The home health nurse notes that the child has development episodes of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take? a. Auscultate the lungs for respiratory pneumonia b. Change to latex free gloves when handling infant c. Draw blood to analyze for streptococcal infection (please verify) d. Apply zinc oxide to perineum with each diaper change 11. The healthcare provider prescribes Amoxicllin 500 mg PO every 8 hours for a child who weighs 77 pounds. The available suspension is labeled, Amoxicillin Suspension 250 mg/5 ml. The recommended maximum dose is 50 mg/kg/24 hour. How many ml should the nurse administer in a single dose based on the child’s weight? (round to whole number) 12. The nurse is caring for a female client, a primigravida with preeclampsia. Findings include +2 proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a severe frontal headache. Which medication should the nurse anticipate for this client? a. Clonidine hydrochloride b. Carbamazepine c. Furosemide d. Magnesium sulfate a. c . 13. A client at 35-weeks gestation complains of a "pain whenever the baby moves." On assessment, the nurse notes the client's temperature to be 101.2F, with severe abdominal or uterine tenderness on palpation. The nurse knows that these findings are indicative of what condition? Round ligament strain b. Chorioamnionitis Abruptio placenta d. Viral infection 14. A 4-year old boy was recently diagnosed with Duchenne muscular dystrophy. Which characteristic of the disease is most important for the nurse to focus on during the initial teaching? a. Lower legs become progressively weaker, causing a waddling, unsteady gait (please a verify) . b. Growth and development have been abnormal since birth b c. Muscular strength can be regained with physical exercise and therapy . d. Respiratory dysfunction and aspiration are prime concerns at this stage of the c disease. . d15. A male patient with a 2 day history of fever and diarrhea is brought to the clinic by his . mother who tells the nurse that the child refuses to drink anything. The nurse 17. Tdetermines that the child has a weak cry with no tears. Which prescription is most important to implement? hProvide a bottle of electrolyte solution eInfuse normal saline intravenously (please verify) Administer an antipyretic rectally Apply external cooling blanket n 16. After administering varicella vaccine to a five year old child, which instruction should the unurse provide the child’s parent? r a. Chewable childrens aspirin will help prevent inflammation sb. Keep the child home from daycare for the next two days (please verufy) c. Any level of fever is serious and should be reported right away e d. Apply a cool pack to the injection site to reduce discomfort i s p l anning care for a 4-year-old girl who is diagnosed as having a developmental disability. What should be the primary focus of treatment for this child? a. Teach her social skills b. Assist in preventing further disability c. Ensure her participation in group activities d. Help her achieve her maximum potential (please verify) 18. A 6 month old child who had a cleft lip repair has elbow restrains in place. What nursing intervention should the nurse plan to implement? a. Obtain the healthcare providers advice as to when the restraints should be removed b. Remove the restraints one at a time to provide a range of motion exercises c. Record observation of the restraints q2h and ensure that they are in place at all times (please verify) d. Remove restraints q4h for 30 minutes and place gloves on the childs hands 19. Cant see parts of the question . Daughter to the clinic because they are concerned that she is not……… Which developmental characteristic should the nurse expect the ….. to exhibit? (unable to complete without knowing childs age) a.Sits alone unsupported b. Takes a first step alone c. Pulls self to sitting position d. Can feed self-finger food 20. A NEW MOTHER CALLS THE NURSE STATING THAT SHE WANTS TO START FEEDING HER 6-MONTH-OLD CHILD, something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond? a. Advise the mother to wait at least another month before starting any solid foods b. Instruct the mother to offer a few spoons of 2 or 3 pureed fruits at each meal c. Reassure the mother that the infant is old enough to eat iron fortified cereal (please verify) d. Encourage the mother to schedule a developmental assessment of the infant 21. A 10 year old is admitted to the orthopedic unit with a diagnosis of slipped femoral capital epyphysis (SFCE). What focus should the nurse include in this childs plan of care? a. Ambulation with a walking cast b. Pin and incisional care after surgery (please verify) c. Use of injections for pain control d. Administration of growth hormone 22. While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that falls and rises abruptly with a “V” shaped appearance. What action should the nurse take first? a. Change the maternal position (please verify) b. Administer oxygen at 10/L by mask c. Prepare for a potential cesarean d. Allow the client to begin pushing 23. A postpartum client who is Rh-negative refuses to receive Rho (D) immune globulin (RhoGam) after delivery of an infant who is Rh-positive. Which information should the nurse provide this client? a. Rhogam prevents maternal antibody formation for future Rh-positive babies (please verify) b. RhoGAM is not necessary unless all her pregnancies are Rh-positive c. The R-positive factor from the fetus threatens her blood cells d. The mother should receive RhoGam when the baby is Rh-negative 24. The nurse observes a mother giving her 11 month old ferrous sulfate (iron drops) , followed by 2 ounces of orange juice. What should the nurse do next? a. Tell the mother to follow the iron drops with infant formula instead of orange juice. b. Suggest placing the iron drops in the orange juice and then feeding the infant (please verify) c. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops d. Give the mother positive feedback about the way she administered the medication 25. A 6 week old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated? a. Weak cry without any tears (please verify) b. Bulging fontanel c. Visible peristaltic wave d. Palpable mass in the right upper quadrant 26. A full term, 24 hour old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first? a. Suction the oral and nasal passages b. Give oxygen by positive pressure c. Stimulate the infant to cry d. Turn the infant onto the right side Po wered by TCPDF( df.o rg) RN HESI Maternity VERSION 2 GRADED A LATEST UPDATED 2023 1. A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What assessment finding confirms to the nurse that the client is not labor at this time? Correct answer Contractions decrease with walking. 2. A primipara has delivered a stillborn fetus at 30 weeks gestation. To asses the parents in the grieving process which intervention is most for the nurse to implement ? A. explain the possible cause of the fetal demise B. Provide a time for the parents to hold their infant in privacy C. Encourage the parents to seek counseling within the next few weeks D. Assist the couple to request autopsy Correct answer B. provide a time for the parents to hold their infant in privacy What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (the) fistula ? A. body temperature B. level of pain C. time of first void D. number of vessels in the cord Correct answer A. body temperature What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation? A. Level of pain sensation B. Station of presenting part C. Variability of fetal heart rate D. Maternal blood pressure Correct answer D. Maternal blood pressure A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse program the infusion pump? (Enter numeric value only) A. 120 B. 70 C. 65 D. 75 Correct answer D. 75 A mother of a 3-year-old boy has just given birth to a new baby girl. The little boy asks the nurse, "Why is my baby sister eating my mommy's breast?" How should the nurse respond? (Select all that apply) A. Explain that newborns get milk from their mothers in this way B. Reassure the older brother that it does not hurt his mother C. Remind him that his mother breastfed him too D. Suggest that the baby can also drink from a bottle E. Clarify that breastfeeding is his mother's choice Correct answer A. Explain that newborns get milk from their mothers in this way B. Reassure the older brother that it does not hurt his mother C. Remind him that his mother breastfed him too The nurse is examining an infant for possible cryptorchidism. Which exam technique should be used? A. Place the infant in side-lying to facilitate the exam B. Hold the penis and retract the foreskin gently C. Cleanse the penis with an antiseptic-soaked pad D. Place the infant in warm room and use a calm approach Correct answer D. Place the infant in warm room and use a calm approach The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome? A. Betamethasone (Celestone) 12 mg deep IM B. Butorphanol 1 mg IV push q2h PRN pain C. Ampicillin 1 Gram IV push q8h D. Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x3 Correct answer A. Betamethasone (Celestone) 12 mg deep IM A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take? A. Auscultate the lungs for respiratory pneumonia. B. Draw blood to analyze for streptococcal infection C. Change to latex-free gloves when handling infant D. Apply zinc oxide to perineum with each diaper change Correct answer C. Change to latex-free gloves when handling infant The nurse is caring for a female client, a primigravida, with preeclampsia. Findings include +2 proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a severe frontal headache. Which medication should the nurse anticipate for this client? A. Clonidine hydrochloride B. Carbamazepine C. Furosemide D. Magnesium sulfate Correct answer D. Magnesium sulfate A client at 35-weeks gestation complains of a "pain whenever the baby moves." On assessment, the nurse notes the client's temperature to be 101.2F, with severe abdominal or uterine tenderness on palpation. The nurse knows that these findings are indicative of what condition? A. Round ligament strain B. Chorioamnionitis C. Abruptio placenta D. Viral infection. Correct answer B. Chorioamnionitis A male infant with a 2-day history of fever and diarrhea is brought to a clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which prescription is most important to implement? A. Provide a bottle of electrolyte solution B. Infuse normal saline intravenously C. Administer an antipyretic rectally D. Apply external cooling blanket Correct answer B. Infuse normal saline intravenously A 6-month old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement? A. remove restraints q4h for 30 minutes and place gloves on the child's hands B. record observations of the restraints q2h and ensure that they are in place at all times C. obtain the HCP advice as to when the restraints should be removed D. remove restraints one at a time to provide ROM exercises Correct answer D. remove restraints one at a time to provide ROM exercises A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond? A. encourage the mother to schedule a developmental assessment of the infant B. advise the mother to wait at least another month before starting any solid foods C. instruct the mother to offer a few spoons of 2-3 pureed fruit at each meal D. reassure the mother that the infant is old enough to eat iron-fortified cereal Correct answer D. reassure the mother that the infant is old enough to eat iron-fortified cereal While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that falls and rises abruptly with a "V" shaped appearance. What action should the nurse take first? A. Prepare for a potential cesarean B. Allow the client to begin pushing C. Administer oxygen at 10/L by mask D. Change the maternal position Correct answer D. Change the maternal position A postpartum client who is Rh-negative refuses to receive Rho (D) immune globulin (RhoGam) after delivery of an infant who is Rh-positive. Which information should the nure provide this client? A. RhoGam is not necessary unless all her pregnancies are Rh-positive B. The R-positive factor from the fetus threatens her blood cells C. The mother should receive RhoGam when the baby is Rh-negative D. RhoGam prevents maternal antibody formation for future Rh-positive babies Correct answer D. RhoGam prevents maternal antibody formation for future Rh-positive babies A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated? A. Weak cry without any tears B. Bulging fontanel C. Visible peristaltic wave. D. Palpable mass in the right upper quadrant Correct answer A. Weak cry without any tears A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first? A. Suction the oral and nasal passages B. Give oxygen by positive pressure C. Stimulate the infant to cry D. Turn the infant onto the right side Correct answer C. Stimulate the infant to cry A client at 40-weeks' gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor and feels the need to bear down and push. What information is most important for the nurse to obtain first? A. the estimated amount of fluid B. time the membranes ruptured C. color and consistency of the fluid D. any odor noted when membranes ruptured. Correct answer C. color and consistency of the fluid An infant with tetralogy of Fallot becomes acutely cyanotic and hyper apneic. Which action should the nurse implement first?A. Administer morphine sulphate. B. Start IV fluids. C. Place the infant in a knee-chest position D. Provide 100% oxygen by face mask. Correct answer C. Place the infant in a knee-chest position A one-day-old neonate develops a cephalohematoma. The nurse should closely assess this neonate for which common complication? A. jaundice B. poor appetite C. brain damage D. hypoglycemia Correct answer A. jaundice The nurse is reviewing the serum laboratory finding for a 5-day-old infant with congenital adrenal hyperplasia. Which laboratory results should be reported to the healthcare provider immediatly? A. Bilirubin of 1.5 mg/dl B. Glucose of 80 mg/dl C. Potassium of 4.5 mEq/L D. Sodium of 119 mEq/L Correct answer D. Sodium of 119 mEq/L At 39-weeks gestation, a multigravida is having a non-stress test (NST). The fetal heart rate (FHR) has remained nonreactive during the 30 minutes of evaluation. Based on this finding, which action should the nurse implement? A. Initiate an intravenous infusion B. Observe the FHR pattern for 30 more minutes C. Schedule a biophysical profile D. Place an acoustic stimulator on the abdomen Correct answer D. Place an acoustic stimulator on the abdomen A community health nurse visits a family in which a 16-year-old unmarried daughter is pregnant with her first child and is at 32-weeks gestation. The client tells the nurse that she has been having intermittent back pain since the night before. What is the priority nursing intervention? A. Ask the clients mother to call an ambulance for transport to the hospital immediately. B. Determine what physical activities the client has performed for the past 24 hours C. Teach the client if she has experienced any recent changes in vaginal discharge. Correct answer C. Teach the client if she has experienced any recent changes in vaginal discharge. Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect? A. Weight gain B. Reduction of fever C. Improved caloric intake D. Reduction of edema Correct answer D. Reduction of edema The nurse is conducting postpartum teaching with a mother who is breastfeeding here infant. When discussing birth control, which method should the nurse recommend to this client as beneficial for her to use in preventing an unwanted pregnancy? A. Breastfeed exclusively at least every 3-4 hours B. Condoms and contraceptive foam or gel C. Rhythm method (natural family planning) D. Combined estrogen progesterone oral contraceptives. Correct answer B. Condoms and contraceptive foam or gel One day after a vaginal delivery of a full-term baby, a postpartum client's white blood cell count is 15,000/mm2. What action should the nurse take first? A. Check he differential, since the WBC is normal for this client. B. Assess the clients temperature, pulse, and respirations q4h. C. Notify the healthcare provider, since this finding is indicative of infection D. Assess the clients perineal area for signs of a perineal hematoma. Correct answer A. Check he differential, since the WBC is normal for this client. The parents of a newborn tell the nurse that their baby is already trying to walk. How should the nurse respond? A. Encourage the parents to report this to the healthcare provider B. Acknowledge the parents' observation. C. Schedule the newborn for further neurological testing. D. Explain the newborn's normal stepping reflex. Correct answer D. Explain the newborn's normal stepping reflex. A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (t4) and high levels of thyroid stimulating hormone (TSH)/ What is the best explanation for this finding? A. The thyroxine level is low because the TSH level is high. B. High thyroxine levels normally occur in breastfeeding infants. C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth D. The TSH is high because of the low production of T4 by the thyroid. Correct answer D. The TSH is high because of the low production of T4 by the thyroid. The nurse is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation. Which assessment finding should receive the highest priority when planning this infants care? A. Blood pressure 76/42 mm/Hg B. Faint heart murmur C. Respiratory rate 76 breaths/min D. Blood glucose 45 mg/dl Correct answer C. Respiratory rate 76 breaths/min At 20-weeks gestation, a client who has gained 20 pounds during this pregnancy tells the nurse that she is feeling fetal movement. Fundal height measurement is 20 cm, and the clients only complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation? A. Presence of fetal movements. B. Gestational weight gain C. Fundal height measurement D. Leakage from breasts Correct answer B. Gestational weight gain The nurse is planning discharge teaching for a client who had an evacuation of gestational trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to include in this client's teaching plan? Correct answer Oral contraceptive use for at least one year. A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a hematocrit of 25.1%. What food should the nurse encourage this client to include in her diet? A. Carrots B. Chicken C. Yogurt D. Cheese Correct answer B. Chicken The newborn nursery admission protocol includes a prescption for phytonadione (Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule provides 2 mg/ml. How many ml should the nurse administer? Correct answer 0.3 The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which information should the nurse provide the client about this finding? Correct answer Both the lower uterine segment and the fundus must be massaged. The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? D. Contraction pattern Correct answer D. Contraction pattern. A client delivers a viable infant , but begins to have excessive uncontrolled vaginal .. notifying the healthcare provider of the clients condition ,What information is most important A. Maternal blood pressure B. Maternal apical pulse C. Time pitocin infusion completed D. Total amount of pitocin infused Correct answer A. Maternal blood pressure. A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? A. Discuss the need for cortisol and aldosterone replacement therapy after discharge B. Support the parents in their decision to assign sex of their child according to their preference C. Offer information about ultrasonography and genotyping to determine sex assignment D. Explain that corrective surgical procedures consistent with sex assignment can be delayed Correct answer C. Offer information about ultrasonography and genotyping to determine sex assignment During a 26-week gestation prenatal exam, a client reports occasional dizziness and lightheadness when she is lying down. What intervention is best for the nurse to recommend to this client. Correct answer Elevate the head with two pillows while sleeping. The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74. What action should the nurse implement? Correct answer Document the vital signs in the record. A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she does not know if she can continue to breastfeed her infant. What instruction is best for the nurse to provide? Correct answer Apply hot packs just before each feeding. A loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the solution should the nurse administer? (Enter numeric value only) Correct answer 13 A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first? Correct answer Place the infant on the abdomen to protect the sac. The mother of a 5-week-old tells the nurse that her baby has acne and asks if she can use her teenage son's acne cream, benzoyl peroxide, on the baby's face. Which answer should the nurse to provide? Correct answer " Your baby may be showing signs of a systemic disease and needs to be seen by a healthcare provider" An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is the first action that the nurse should take? A. Notify the health care provider immediately B. Increase the temperature of the radiant warmer C. Assess infant heart rate D. Determine the infants blood sugar level Correct answer D. Determine the infant's blood sugar level. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? A. Alert the neonatal team and prepare for neonatal resuscitation B. Notify the healthcare provider from the client's bedside C. Obtain written consent for an emergency cesarean section D. Draw a blood sample for stat hemoglobin and hematocrit Correct answer B. Notify the healthcare provider from the client's bedside A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? A. Turn the client to her left side B. Contact the healthcare provider C. Assess the fetal heart rate D. Check the cervical dilation Correct answer C. Assess the fetal heart rate The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has triple compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? Correct answer "What food does your baby usually eat in a normal day?" Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. What intervention has the greatest priority? Correct answer Have a meconium aspirator available at delivery. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilatation, 60% effacement, and a -2 station. What action should the nurse implement first? A. Decrease the oxytocin infusion rate B. Determine current cervical dilation C. Request placement of the epidural D. Give a bolus of intravenous fluids Correct answer B. Determine current cervical dilation A client with gestational diabetes is undergoing a non-stress test at 34 weeks gestation. Fetal heart beat is 144 beats / min. The client is instructed to mark the fetal monitor paper by pressing each time the baby moves. After 20 mins the nurse evaluates the fetal monitor strip A. The mother perceives and marks at least four fetal movements B. Fetal movements must be elicited with a vibroacoustic stimulator C. Two fetal heart accelerations of 15 beats/ min x 15 seconds are recorded D. No FHR late decelerations occur in response to fetal movement Correct answer C. Two FHR accelerations of 15 beats/minute x 15 seconds are recorded. A newborn who was a breech presentation is admitted to the nursery. Which assessment procedure is a priority for the nurse to perform? Correct answer Babinski's reflex. The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life? Correct answer Cries vigorously when stimulated. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan? Correct answer Monitor Blood pressure, pulse, and respirations q4h. What goal is most important for the nurse to include in the plan of care for a client with gestational diabetes? Correct answer Restrict carbohydrate intake. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply.) A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad. D. Expresses suicidal thoughts. E. Has a disheveled appearance. Correct answer A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad. D. Expresses suicidal thoughts. The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. A. Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x 3 B. Ampicillin 1 gram IV push q8h. C. Betamethasone (Celestone) 12 mg deep IM D. Butorphanol (Stadol) 1 mg IV push q2h PRN pain Correct answer A. Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x 3 In preparing a gravid client for a triple screen analysis, which action should the nurse take? A. Prepare to draw blood for analysis. B. Encourage the client to drink 8 oz of water. C. Assist the client to left lateral tilt position. D. Apply an external fetal monitor to the abdomen. Correct answer A. Prepare to draw blood for analysis. During a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. What action should the nurse implement? A. Inform her that this is a normal physiological change. B. Notify the healthcare provider of the complaint. C. Recommend an over-the-counter yeast medication. D. Prepare the client for a sterile speculum exam. Correct answer A. Inform her that this is a normal physiological change. Following a precipitous labor, a postpartum client has a continuous trickling of bright red blood from her vagina. Her uterus is firm and her vital signs are within normal limits. The nurse determines that this sign may indicate which condition? A. Early postpartum hemorrhage. B. Laceration on the cervix C. Expected course in the fourth stage of labor. D. A full urinary bladder. Correct answer B. Laceration on the cervix A new mother asks the nurse about an area of swelling on her baby's head near the posterior fontanel that lies across the suture line. How should the nurse respond? A. "This is called caput succedaneum. It will absorb and cause no problems." B. "This is called caput succedaneum. It will have to be drained." C. "This is called a cephalhematoma. It will cause no problems." D. "This is called cephalhematome. It can cause jaundice as it is absorbed." Correct answer A. "This is called caput succedaneum. It will absorb and cause no problems." The parents of a male newborn have signed an informed consent for circumcision. What priority intervention should the nurse implement upon completion of the circumcision? A. Offer a pacifier dipped in glucose water. B. Give PRN dose of liquid acetaminophen. C. Place petrolatum gauze dressing on the site. D. Wrap the infant in warm receiving blankets. Correct answer C. Place petrolatum gauze dressing on the site. The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10 inches. Based on these physical findings, assessment for which condition has the highest priority? A. Hyperthermia B. Hyperbilirubinemia C. Polycythemia D. Hypoglycemia Correct answer D. Hypoglycemia A primipara at 20-weeks gestation is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information? A. Sex and size of the infant. B. Fetal growth and gestational age. C. Chromosomal abnormalities. D. Lecithin-sphingomyelin ration. Correct answer B. Fetal growth and gestational age. A 38-week primigravida is admitted to labor and delivery after a non-reactive stress test (NST). The nurse begins a contraction stress test (CST) with an oxytocin (Pitocin) infusion. Which finding is most important for the nurse to report to the healthcare provider? A. Spontaneous rupture of membranes. B. Fetal heart rate accelerations with fetal movement. C. Absences of uterine contraction of 20 minutes. D. A pattern of fetal late decelerations. Correct answer D. A pattern of fetal late decelerations. In determining the one minute Apgar score of a male infant the nurse asses a heart rate of 120 per min... respiration.. He has a loud cry with stimualtion, good muscle tone, color is acrocyanotic . What should the nurse assign? A. 7 B. 8 C. 9 D. 10 Correct answer C. 9 The nurses assessment on a preterm infant reveals decreased muscle tone , sign of respiratory distress , irritability , mottled cool skin.Which intervention should the nurse implement first ? A. Position a radiant warmer on the crib B. Asses infant blood glucose level C. Place infant in side lying position D. Nipple feed 1 ounce of 5%glucose in water Correct answer A. Position a radiant warmer on the crib Vaginal prostiglandin gel is used to induce labor women who are 42 weeks of gestation. Thirty minutes after insertion of the gel , the client complains of vaginal warmth, and is experiencing 90 second contractions with fetal heart deceleration. What action should the nurse implement first A. Assess maternal vital signs B. Notify the healthcare provider C. Increase the IV infusion rate D. Turn to a side lying position Correct answer D. Turn to a side lying position A primigravida at 40 weeks gestation is contraction q2 minutes her cervix is 9cm dilated and 100% effaced. The fetus heart rate is 120 beats per minute. The client is screaming and her husband is alarmed. What intervention should the nurse do?A. Notify rapid response B. Have delivery table set up C. Ask husband to step out D. Administer a PRN narcotic Correct answer B. Have delivery table set up The nurse is assessing a client at 29 weeks gestation. Which assessment measure would provide the most accurate determination of fetal position? A. Ultrasound B. Vaginal examination C. Leopolds maneuver D. Doppler Correct answer A. Ultrasound A client at 28 weeks gestation is admitted to the obstetrical unit following her involvement in a motor vehicle collision. While stabilizing the patient , the nurse obtains fetal monitor reading. Which action should the nurse take if the fetus is tachycardic is on the monitor? A. Recount the heart rate manually to confirm a monitor malfunction B. Explain that there is no indication the fetal heart rate is due to trauma C. Evaluate the presence of preterm labor by performing a vaginal D. Contact the healthcare provider after initiating oxygen per face mask Correct answer D. Contact the healthcare provider after initiating oxygen per face mask On the first postpartum day, the nurse examines the breasts of the new mother. Which condition is the nurse most likely to. A. Slightly firm with immediate let down response B. Filing and secreting colostrum C. Soft, with no change from before delivery D. Firm, larger very tender to touch Correct answer B. Filling and secreting colostrum The nurse who is working at a prenatal clinic notes a woman that is at 18 weeks of gestation has two elevated maternal alpha feto-protein (MSAFP) values. What action should the nurse implement? A. Instruct the client to increase intake of folic acid supplements B. Request a consultation with genetic counselor C. Schedule a sonogram in the radiology department D. Send the client to the laboratory for repeat MSAFP Correct answer C. schedule a sonogram in the radiology department Following a minor vehicle collision , a client 36 weeks gestation is brought to the emergency center. She is lying supine on a backboard , is awake , denies any complaints. Her blood pressure is 80/50 mm Hg and heart rate is 130 beats per min. What action should the nurse implement first? A. Turn the board sideways to displace the uterus lateral B. Palpate the abdomen for contractions C. Infuse 1,000 normal saline using a large bore IV D. Obtain blood sample for a complete blood count Correct answer A. Turn the board sideways to displace the uterus lateral When assessing a pregnant woman who is 39 weeks gestation who is admitted to labor and delivery, which finding is most important to report the health care provider? A. + 1 proteinuria B. 130/70 blood pressure C. 102 oral temperature D. +1 pedal edema Correct answer C. 102 oral temperature During a routine prenatal vital a client 32 weeks gestation complains of urinary frequency has increased during the day as well at night. The nurse determines the client is having irregular uterine contractions. What should the nurse implement ? A. Ask the client if she had sexual intercourse yesterday B. Determine if she has change in vaginal discharge C. Collect urine sample from dipstick analysis D. Obtain a midstream urine specimen for culture Correct answer D. Obtain a midstream urine specimen for culture The nurse teaching a preconception preparation class is discussing ways to improve dietary folic acid intake. Which evening snack contains the most folic acid? A. Fresh strawberries B. Roasted peanuts in shell C. Unflavored yogurt D. Vanilla milkshake with protein supplement Correct answer B. roasted peanut in shell A 38 week primigravida is admitted to labor and delivery after a non-reactive result on a non-stress test (NST) .The nurse begins contraction stress test (CST) with an oxytocin ( Pitocin ) infusion. Which finding is most important for the nurse to report to the health care provider ? A. Spontaneous rupture of membrane B. Fetal heart rate accelerations with fetal movement C. Absence of uterine contractions within 20 mins D. A pattern of late fetal decelerations Correct answer D. A pattern of late fetal decelerations A primigravida is 36 weeks gestation, is Rh negative is experienced abdominal trauma in a motor vehicle collision. Which assessment finding is most important for the nurse to report to the healthcare provider? A. Positive fetal hemoglobin test B. Fetal heart rate is 162 beats / min C. Trace of protein in urine D. Mild contractions every 10 mins Correct answer A. Positive fetal hemoglobin test The nurse is caring for an newborn who is 18 inches long, weighs 4 pounds , 14 ounces, has a head circumference of 13 inches and chest circumference is of 10 inches. Based on these physical findings , assessment for which condition has the highest priority? A. Hyperthermia B. Hyperbillirubinemia C. Polycythemia D. Hypoglycemia Correct answer D. Hypoglycemia A school nurse is preparing a seminar to address the concerns of pregnant adolescent. What information is most important for the nurse to include in this program? A. Nutritional requirements during pregnancy B. Pain management options for labor C. Comparison of infant feeding method D. Symptoms to report to the healthcare provider Correct answer A. Nutritional requirements during pregnancy A postpartal client who is bottle feeding develops engorgement . What is the best recommendation for nurse to provide this client ? A. Avoid stimulation to breast and wear a tight bra B. Express small amount of breast milk in your hand C. Take a prescribed analgesic and express the breast to air D. Place warm packs on both sides of breast Correct answer A. Avoid stimulation to breast and wear tight bra The nurse is assessing a patient who is 36 hours post delivery. Which finding should the nurse report to the healthcare provider? A. White blood cell count 19,000 B. Oral temperature of 100.6 C. Fundus deviated to the right D. Breast are firm when palpated Correct answer B. Oral temperature of 100.6 A full term infant is admitted to the newborn nursery 2 hours after delivery. The delivery record reports that the mother is positive for HIV and received AZT intravenously during labor. What action should the nurse implement first? A. Ensure that AZT is given within 6 hours after birth B. Collect venous specimen for serum glucose level C. Asses for the presence of the Moro reflex D. Obtain consent for the Hep B vaccine Correct answer A. Ensure that AZT is given within 6 hours after birth The healthcare provider prescribe Pitocin 2milliunits / min to induce labor for a client at 41 weeks gestation. The nurse initiates an infusion of Lactated Ringer 1000 ml with Pitocin 10 units. How many ml/ hr should the nurse program the infusion pump? Correct answer 12 The nurse is counseling a patient who is at 6 weeks gestation and is experiencing morning sickness , but does not want to take any drugs for this discomfort. Which herbal supplement is likely to help this client with the nausea she is experiencing ? A. Ginger B. Chamomile C. Peppermint D. Ginko Correct answer A. Ginger At 0600 while admitting a woman for a scheduled repeat c-section the client tells the nurse that she had coffee at 0400 because she wanted avoid getting a headache. What action should the nurse take first? A. Ensure preoperative lab results are available B. Start IV presecribed Lactated ringers C. Inform the anesthesia care provider D. Contact the client obstetrician Correct answer C. Inform the anesthesia care provider A mother spontaneously delivers her infant in a taxi cab on the way to the hospital. The emergency room nurse reports that the mother has active herpes (HSVII) lesion on the vulva. What intervention should the nurse implement first when admitting the neonate in the nursery? A. Obtain blood specimen for serum glucose level B. Document the temperature on the flow sheet C. Place newborn in the isolation area of the nursery D. Administer Vitamin K injection Correct answer C. Place newborn in the isolation area of the nursery Upon admission to the nursery, the nurse places a newborn supine under radiant warmer , an external heat source. What should the nurse implement first to ensure safe thermoregulation? A. Dry the newborns scalp and place a stockinet cap on the head B. Move the temperature probe over the ribs when turning to a lateral position C. Place temperature probe on the abdomen in the line with the radiant heat source D. Wrap the infant in two blankets and place the radiant warmer on low Correct answer C. Place temperature probe on the abdomen in the line with the radiant heat source When planning care for a laboring client , the nurse identifies the need to withhold solid foods while the client is in labor . What is the most important reason for this nursing intervention? A. Gastric emptying time decreases during labor B. Nausea occurs from analgesic used during labor C. An increased risk for aspiration can occur if general analgesic is needed D. Autonomic nervous system stimulation during labor decreases peristalsis Correct answer C. An increased risk for aspiration can occur if general analgesic is needed A new mother who is breastfeeding her 4 week old infant has type 1 diabetes , reports that her insulin needs have decreased after the birth of her child. What action should the nurse implement ? A. Schedule an appointment with diabetic nurse educator B. Advise the client to breastfeed more frequently C. Counsel her to increase calorie intake D. Inform her that a decreased need for insulin occurs while breastfeeding Correct answer D. Inform her that a decreased need for insulin occurs while breastfeeding A multiparous women at 38 weeks gestation with a history of rapid progression of labor is admitted for induction due to signs and symptoms of pregnancy induced hypertension (PIH). One hour after the oxytocin infusion is initiated she complains of a headache. Her contractions are occurring every 1-2 mins , lasting 60-75 seconds and a vaginal exam reveals that her cervix is 90% and dilated 6 cm.What intervention is most important for the nurse to implement? A. Prepare for immediate delivery B. Measure deep tendon reflexes C. Discontinue the Pitocin infusion D. Turn the client to her left side Correct answer C. Discontinue the Pitocin infusion An infant born to a heorin addict mother is admitted to the neonatal care unit. . What behaviors can the baby exhibit? A. Lethargy and a poor suck B. Facial abnormalities and microcephaly C. Irritability and high pitched cry D. Low birth weight and intrauterine growth retardation Correct answer C. Irritability and high pitched cry A multigravida full term , laboring client complains of back labor. Vaginal examine reveals that the client is 3cm with 50% effacement , and the fetal head is at -1 station. What action should the nurse implement first? A. Apply counter - pressure to the sacral area B. Turn the client lateral position C. Notify the scrub nurse to prepare the OR D. Ambulate the client between contractions Correct answer A. Apply counter - pressure to the sacral area A postpartal client complains that she has the urge to urinate every hour but is only able to void a small amount. What interventions provides the nurse with the most useful information? A. Initiate a perineal pad count B. Catheterize for residual urine after next voiding C. Assess for perineal hematoma D. Determine the clients usual voiding pattern Correct answer B. Catheterize for residual urine after next voiding During a 26 week gestation prenatal exam, a client reports occasional dizziness. What intervention is best for the nurse to recommend the client? A. Elevate the head with two pillows while sleeping B. Lie on the left or right side when sleeping or resting C. Increase intake of foods that are high in iron D. Decrease the amount of carbohydrates in the diet Correct answer B. Lie on the left or right side when sleeping or resting Artifical rupture of the membrane of laboring client reveals meconium stained fluid. What is the priority? A. Clean perineal area to prevent infection B. Assess the mothers blood pressure to check for signs of preclampsia C. Assess mothers temperature to check for development of sepsis D. Have meconium aspirator available at delivery Correct answer D. Have meconium aspirator available at delivery A toddler with a history of acyanotic defect is admitted to the pediatric intensive care. Respiration rate 60 beats / min and heart 150 beats/ min.What action should the nurse take first? A. Obtain a pulse ox reading B. Assess childs blood pressure C. Perform a neurological assessment D. Initiate peripheral intravenous access Correct answer A. Obtain a pulse ox reading A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? A. Altered nutrition, less than body requirements for lactation B. Alteration in comfort related to nausea and abdominal distention C. Impaired bowel motility related to pain medication and immobility D. Fatigue related to cesarean delivery and physical care demands of infant Correct answer C. Impaired bowel motility related to pain medication and immobility The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? A. Herpes B. Trichomonas C. Gonorrhea D. Syphilis Correct answer C. Gonorrhea A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. B. Hold the infant's head firmly against the breast until he latches onto the nipple. C. Encourage the mother to stop feeding for a few minutes and comfort the infant. D. Provide formula for the infant until he becomes calm, and then offer the breast again. Correct answer C. Encourage the mother to stop feeding for a few minutes and comfort the infant. The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? A. Two weeks before menstruation B. Immediately after menstruation C. Immediately before menstruation D. Three weeks before menstruation Correct answer A. Two weeks before menstruation The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take? A. Administer oxygen by face mask. B. Notify the health care provider of the client's symptoms. C. Have the client breathe into her cupped hands. D. Check the client's blood pressure and fetal heart rate. Correct answer C. Have the client breathe into her cupped hands. When assessing a client at 12 weeks of 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 of gestation B. At 20 weeks of gestation C. At 24 weeks of gestation D. At 30 weeks of gestation Correct answer D. At 30 weeks of gestation One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first? A. Stimulate the infant to cry. B. Wrap the infant in warm blankets. C. Feed the infant formula. D. Obtain a serum glucose level. Correct answer D. Obtain a serum glucose level. Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn? A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." B. "Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk." C. "I can start smoking cigarettes while breastfeeding because it will not affect my breast milk." D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings." Correct answer A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide? A. Lie on your left side and call 911 for emergency assistance. B. Take an antacid and call back if the pain has not subsided. C. Take your blood pressure now and if it is seriously elevated, go to the hospital. D. See your health care provider to obtain a prescription for a histamine blocking agent. Correct answer C. Take your blood pressure now and if it is seriously elevated, go to the hospital. The nurse observes that an antepartum client who is on bed rest for preterm labor is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse? A. Remove all ice from the client's room. B. Ask the client what foods she might consider eating. C. Remind the client that what she eats affects her baby. D. Notify the health care provider. Correct answer D. Notify the health care provider. Which finding(s) is (are) of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.) A. Cramping with bright red spotting B. Extreme tenderness of the breast C. Lack of tenderness of the breast D. Increased amounts of discharge E. Increased right-side flank pain Correct answer A. Cramping with bright red spotting C. Lack of tenderness of the breast E. Increased right-side flank pain Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home? A. Wash the cord frequently with mild soap and water. B. Cover the cord with a sterile dressing. C. Allow the cord to air-dry as much as possible. D. Apply baby lotion after the baby's daily bath. Correct answer C. Allow the cord to air-dry as much as possible. The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with intact membranes. The monitor indicates that the FHR decelerates at the onset of several contractions and returns to baseline before each contraction ends. Which action should the nurse take? A. Reapply the external transducer. B. Insert intrauterine pressure catheter. C. Discontinue the oxytocin infusion. D. Continue to monitor labor progress. Correct answer D. Continue to monitor labor progress. The nurse is counseling a client who wants to become pregnant. She tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. When will the client's next fertile period occur? A. January 14 to 15 B. January 22 to 23 C. January 29 to 30 D. February 6 to 7 Correct answer C. January 29 to 30 A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is getting lighter in color and asks when the flow will stop. How should the nurse respond? A. 2 weeks B. 10 days C. When the placental site has healed D. After the first time ovulation occurs Correct answer C. When the placental site has healed Which 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. D. She eagerly reaches for the infant and then holds the infant close to her own body. Correct answer B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she had expected. Her partner is also becoming anxious. Which of the following should be the focus of the nurse's response? A. Telling the client and her partner that the labor process is often unpredictable B. Informing the client that this means she will give birth sooner than expected C. Asking the client and her partner if they would like the nurse to stay in the room D. Affirming that the fetal heart rate is remaining within normal limits Correct answer C. Asking the client and her partner if they would like the nurse to stay in the room In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan? A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week. B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second week. C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first month. D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month. Correct answer D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month. Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 mm Hg to 90/60 mm Hg. Which action should the nurse take immediately? A. Notify the health care provider or anesthesiologist. B. Continue to assess the blood pressure every 5 minutes. C. Place the client in a lateral position. D. Turn off the continuous epidural. Correct answer C. Place the client in a lateral position. A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become HIV-infected. Which explanation should the nurse provide? A. Most infants of HIV-positive women will continue to test positive for HIV antibodies. B. Infants who have HIV-positive mothers carry the virus and will eventually develop the disease. C. Medication taken during pregnancy to reduce the mother's viral load ensures that the infant is HIV- negative. D. HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present. Correct answer D. HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer present. When preparing a class on newborn care for expectant parents, which is correct for the nurse to teach concerning the newborn infant born at term gestation? A. Milia are red marks made by forceps and will disappear within 7 to 10 days. B. Meconium is the first stool and is usually yellow gold in color. C. Vernix is a white cheesy substance, predominantly located in the skin folds. D. Pseudostrabismus found in newborns is treated by minor surgery. Correct answer C. Vernix is a white cheesy substance, predominantly located in the skin folds. A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding? A. Cyanosis of the hands and feet B. Skin color that is slightly jaundiced C. Tiny white papules on the nose or chin D. Red patches on the cheeks and trunk Correct answer B. Skin color that is slightly jaundiced 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 unusually shaped head, especially for a first baby." B. "It may look odd, but newborn babies are often born with heads like that." 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 head had to adjust to the birth canal." Correct answer C. "That is normal. The head will return to a round shape within 7 to 10 days." A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? A. Breastfeed the infant, ensuring that both breasts are completely emptied. B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast. C.Breastfeed on the unaffected breast only until the mastitis subsides. D. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant. Correct answer A. Breastfeed the infant, ensuring that both breasts are completely emptied. The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? A. Avoid alcohol because it is excreted in breast milk. B. Eat a high-r