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During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take? - ANSWER Have her cup both hands over her nose and mouth while breathing. Rationale: Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes transient respiratory alkalosis, so the client should cup both hands over her mouth and nose so she can rebreathe carbon dioxide. A client who delivered by cesarean section 24 hours ago is using a 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? - ANSWER Impaired bowel motility related to pain medication and immobility.Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation is appropriate? - ANSWER "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day." The urine will be dilute (straw-colored) and frequent (6 to 10 times/day) , if the infant is adequately hydrated. Although a weight gain of 30 grams/day is indicative of adequate nutrition, most home scales do not measure this accurately and this suggestion is likely to make the mother very anxious. 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? - ANSWER Two weeks before menstruation. Ovulation occurs 14 days before the first day of the menstrual period . While ovulation can occur in the middle of the cycle, or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of their menstrual cycle varies. The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The nurse determines the client is dilated 7 cm, is 100% effaced at 0 station, with intact membranes. The monitor indicates the fetal heart rate (FHR) decelerates at the onset of several contractions and returns to baseline before each contraction ends. What action should the nurse take? - ANSWER Continue to monitor labor progress. The fetal heart rate indicates early decelerations, which are not an ominous sign, so the nurse should continue to monitor the labor progress and document the findings in the client's record. The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? - ANSWER Have the client breathe into her cupped hands. Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands . Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. What is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line in a newborn? - ANSWER A cephalhematoma, which is caused by forceps trauma. Cephalhematoma , a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and the skull. 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, his hands shake. What intervention should the nurse implement first? - ANSWER Obtain a serum glucose level. This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level . A client in active labor is becoming increasingly fearful because her contractions are occurring more often than she expected. Her partner is also becoming anxious. The nurse's response should focus on which content? - ANSWER Asking the client and her partner if they would like the nurse stay in the room. Offering to remain with the client and her partner (C) offers support without providing false reassurance. The length of labor is not always predictable, but (A and B) do not offer the client the support that is needed at this time. (D) may be reassuring regarding the fetal heart rate, but it does not provide the client the emotional support she needs at this time during the labor process. A breastfeeding postpartum client is diagnosed with mastitis and antibiotic therapy is prescribed. What instruction should the nurse provide to this client? - ANSWER Breastfeed the infant, ensuring that both breasts are completely emptied. Mastitis (caused by plugged milk ducts) is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts , eliminating the pressure on the inflamed breast tissue. 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 immediately? - ANSWER Place the client in a lateral position. The nurse should immediately turn the client to a lateral position or place a pillow or wedge under one hip to deflect the uterus. Other immediate interventions include increasing the rate of the main line IV infusion and administering oxygen by face mask at 10 to 12 L/min. If the blood pressure remains low after these interventions or decreases further, the anesthesiologist/healthcare provider should be notified . immediately 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. What statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan? - ANSWER The anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month. In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel by the end of the second month (D). These growth and development milestones are frequently included in questions on the licensure exam. 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? - ANSWER "That is normal. The head will return to a round shape within 7 to 10 days."