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Terms in this set (60)
a nurse is assessing a client Respiratory rate 10 per min
who is 12 hr postpartum and A client who has received spinal anesthesia is at risk for
received spinal anesthesia for a respiratory depression and hypotension. A respiratory rate of
cesarean birth. which of the 10/min indicates bradypnea and requires
following findings requires immediate intervention.
immediate intervention by the
nurse?
a nurse is providing teaching to Placental insufficiency
the mother of a newborn born Placental insufficiency is a cause of small for gestational age. It can result
from
small for gestational age.
maternal infections, embryonic placental deficiency, teratogens, or
which of the following should
chromosomal abnormalities.
the
nurse include as a possible
cause of this condition?
Initiate early feeding
a nurse is caring for a newborn Prevention of jaundice can be facilitated best by early and frequent
4 hr after birth. which of the feeding, which stimulates intestinal activity and passage of
following actions should the meconium. Jaundice occurs due to
nurse include in the plan of elevated serum bilirubin, which is excreted primarily in the
care to newborn's stool. Physiologic jaundice manifests after 24 hr and
prevent jaundice? is considered benign. However,
bilirubin may accumulate to hazardous levels and lead to a pathologic
condition.
Position the client on her side
a nurse is caring for a client who Late decelerations stem from decreased blood perfusion to the
is in active labor and notes late placenta or compression of the placenta. A position change
decelerations on the fetal should increase perfusion or decrease compression, and it is the
monitor. which of the following first intervention the nurse should try. The
is the priority nursing action? greatest risk to the client is fetal hypoxia, so the priority action is
, the one that has the best chance of improving fetal perfusion.
a nurse is assessing a client Fundus three fingerbreadths above the umbilicus
who is 8 hr postpartum and A full bladder can raise the level of uterine fundus and possibly deviate it
to the side.
multiparous. which of the
following findings should alert
the nurse to the client's need
to urinate?
, a nurse is admitting a term Maternal/newborn blood group imcompatibility
newborn following a cesarean Maternal/newborn blood group incompatibility is the most
birth. the nurse common form of pathologic jaundice and the jaundice appears
observes that the newborn's within the first 24 hr of life.
skin is slightly yellow. this
finding indicates the newborn is
experiencing a complication
related to which of the
following?
a nurse is assisting a client who is "You should place your nipple and some of the areola into her mouth"
postpartum with her first Placing the nipple and 2 to 3 cm of areolar tissue around the
breastfeeding experience. when nipple into the baby's mouth aids in adequately compressing
the client asks how much of the the milk ducts. This placement decreases
nipple she should put into the stress on the nipple and prevents cracking and soreness.
newborn's mouth, which of the
following responses should the
nurse make?
a nurse is caring for a client Uterine atony
who is 5 hr postpartum A uterus that is over distended, such as from a macrosomic
following a vaginal birth of a fetus, has an increased risk of uterine atony.
newborn weighing 9 lb 6 oz.
(4252 g). the nurse should
recognize that this client is at
risk for which of the following
postpartum complications?
a nurse is teaching a newborn's Give a sponge bath until the cord stump falls off
parent to Immersing the umbilical cord stump in water can delay the
care for the umbilical cord process of drying, separation, and healing. Sponge baths are
stump. which of the following appropriate until the stump falls off.
instructions should the nurse
include?
a nurse is caring for a preterm Preterm newborns lack adequate temperature control mechanisms
newborn who is in an incubator Preterm newborns have poor body control of temperature and
to maintain a neutral thermal need support to avoid losing heat. They require an external heat
environment. the father of the source, such as an incubator.
newborn asks the nurse why
this is