ATI Maternal Newborn Practice A

b) massage the fundus Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for hypovolemic shock. This can compromise the perfusion to the client's vital organs, which can lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood loss. All the other answers are actions the nurse should take, but the priority is massaging the fundus.

A) Late decelerations Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider. Moderate variability of the FHR is an expected assessment finding associated with normal fetal acid-base balance. It is not a contraindication to the administration of oxytocin. Cessation of uterine dilation is an indication for the initiation of an oxytocin infusion to augment the client's labor progression. A prolonged active phase of labor is an indication for the initiation of an oxytocin infusion to augment the client's labor progression.

d) Blurred vision The nurse should identify that a client who has severe preeclampsia can have arteriolar vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as blurred vision, double vision, or dark spots in the visual field. Patient would have 3+ or 4+ DTRs, proteinuria >500 mg, decreased urine output of 20 mL/hr

b) Vaginal pressure The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues. Patient will report persistent, not intermittent pain and lochia rubra.

a) Biophysical profile A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound. An amniocentesis is used to determine lung maturity, detect congenital anomalies, and diagnose fetal hemolytic disease. A cordocentesis is used to identify fetal blood type and RBC when there is a risk of isoimmune hemolytic anemia. The Kleihauer-Betke test is used to determine the amount of fetal blood in the maternal circulation when there is a risk of Rh-isoimmunization.

a) Depression The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness. Fluid retention can occur due to an excess of estrogen. Polyuria is not a common adverse effect of the medication. Hypertension, rather than hypotension, is a common adverse effect of combined oral contraceptives. Urticaria is not a common adverse effect of combined oral contraceptives.

b) Maintain the client on bed rest. The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. Elevation of the affected leg is recommended. A client receiving anticoagulant therapy, such as heparin, should not receive aspirin because it can lead to prolonged clotting times and increased risk of bleeding. The nurse should avoid massaging the affected leg to decrease the risk of dislodging the clot, which could cause a pulmonary embolism. The nurse should apply warm compresses to the affected area to promote circulation and decrease edema.

a) "I can administer oxytocin 4 hours after the insertion of the medication." The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor. The nurse should instruct the client to void prior to the administration of the medication. The nurse should instruct the client to remain in a side-lying position for 30 to 40 min after the insertion. The nurse should avoid administering aluminum hydroxide and magnesium-containing antacids with misoprostol.

d) A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F) An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider. Pink-tinged urine is an indication of uric acid crystals and is an expected finding for a newborn during the first week following birth. A newborn should pass the first meconium stool within the first 24 to 48 hr following birth. Failure to pass a meconium stool can indicate a bowel obstruction or congenital disorder. This finding is within the expected reference range. Erythema toxicum is a transient rash that can appear anywhere on a newborn's body during the first 24 to 72 hr following birth and can last up to 3 weeks. This finding requires no treatment.

c) Respiratory rate 10/min The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available. Oliguria is a manifestation of magnesium toxicity. The nurse should report a urinary output of less than 25 to 30 mL/hr to the provider. Nausea is an expected adverse effect of magnesium sulfate. The nurse should reassure the client and provide comfort measures. Flushing and feeling hot is an expected adverse effect of magnesium sulfate. The nurse should reassure the client and provide comfort measures.

d) "I should take 600 micrograms of folic acid each day." A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects. A client who is pregnant should increase protein intake to 71 g each day during the second and third trimesters. A client who is pregnant should consume 3 L of water each day. A client who is pregnant should increase caloric intake by 340 cal during the second trimester and by 452 cal during the third trimester.

d) Respiratory distress Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures. A hypoglycemic newborn can exhibit HYPOtonia, POOR feeding behaviors, and HYPOthermia.

a) A client who is at 11 weeks of gestation and reports abdominal cramping Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first. The other three findings are common discomforts related to pregnancy for their gestation.

The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty, approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus outward using plain water. The nurse should then wash the newborn's neck by lifting the newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump followed by washing the newborn's legs and feet. The last step of the bath should be to clean the newborn's diaper area.

c) "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr prior to testing. The universal newborn screening is mandated by law for all newborns. Therefore, the nurse does not need to obtain informed consent prior to obtaining the specimen. The nurse should collect a capillary blood sample via heel stick for the newborn screening. Urine is not collected for this test. Premature newborns have a delayed development of liver enzymes which can cause a false POSITIVE result.

a) Protect the client's head and feet from cold air. Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period. Bathing the client within 12 hr following birth should not be included in the plan of care because traditional Hispanic practices include delaying bathing for 14 days following birth. Ambulating the client within 24 hr following birth should not be included in the plan of care because traditional Hispanic practices include bed rest for 3 days following birth. Offering the client a glass of cold milk with her first meal should not be included in the plan of care because traditional Hispanic practices include drinking warm beverages following birth.

a) Minimal arm recoil The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil. All other findings are indicators of physical maturity with increasing gestational age after 26 weeks.

d) Monitor the FHR. The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis. The check should also check temperature for infection, uterine contractions for preterm labor, and Rhogam to prevent Rh sensitiivation; however, these are not priority interventions.

a) Substernal retractions The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and tachypnea are manifestations of neonatal infection or respiratory distress in the newborn. The nurse should report these findings to the provider for immediate intervention. All other options are expected findings/variations/measurements.

b, d,ee Yellow sclera is incorrect. Yellow sclera is an indication of hyperbilirubinemia and is not an expected manifestation. Acrocyanosis is correct. Acrocyanosis is an expected finding for at least the first 24 hr following birth. Poor peripheral perfusion leads to bluish discoloration in the newborn's hands and feet.Posterior fontanel larger than the anterior fontanel is incorrect. The posterior fontanel is located on the back of the newborn's head and is a small triangular shape. The anterior fontanel is diamond shaped and approximately 5 cm (2 in) long. It is located on the top of the newborn's head and is larger than the posterior fontanel.Positive Babinski reflex is correct. Newborns should exhibit a positive Babinski sign following birth. The nurse should stroke the newborn's foot upward from the heel to the toes. The toes should hyperextend, and dorsal flexion of the big toe should occur. The absence of this finding requires neurological evaluation. The Babinski reflex is no longer present after 1 year of age.Two umbilical arteries visible is correct. The nurse should observe two arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly.

a) Calcium gluconate The nurse should anticipate administering calcium gluconate if the client develops magnesium toxicity. Calcium gluconate is the antidote. Hydralazine is an antihypertensive medication that can be administered to clients who have hypertension during pregnancy, Medroxyprogesterone acetate is an injectable contraceptive hormone Methylergonovine is used to treat postpartum hemorrhage

d) "You should press the handheld button when you feel your baby move." The nurse should instruct the client to press the handheld button when the fetus moves. This action will mark the fetal monitor tracing with the client's reports of fetal movement. This will assist in the interpretation of the nonstress test to determine if it is reactive or nonreactive. The nurse should instruct the client that the nonstress will take approximately 20 to 30 min, but more time might be required if the fetus is in a sleep state when the testing begins. The client is not required to be NPO before or during the procedure. The nurse can suggest the client drink orange juice to increase her blood glucose level which will stimulate fetal movements.

c. Obtain a gift from the newborn to present to the sibling. Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that they understand their role in the family. Allowing the sibling to hold the newborn during a bath is not an appropriate activity for a school-age child because of the safety risk. However, the parents could let the sibling assist with other things in regard to caring for the newborn. Forcing interactions between the sibling and the adoptive newborn can cause anger on the part of the sibling. It is more important to allow feelings to evolve naturally as the family unit bonds. Switching the sibling's room with the newborn's room might cause jealousy of the newborn or cause the sibling to feel that the newborn is taking their belongings.

c. Have the client change position. Having the client change position is an appropriate intervention for a variable deceleration to relieve umbilical cord compression. Giving the client orange juice is not an appropriate intervention for a variable deceleration in the FHR. Elevating the client's legs is an acceptable intervention for late decelerations associated with maternal hypotension. Establishing IV access is not indicated at this time.

c. Weight gain of 2.2 kg (4.8 lb) A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider. A blood pressure of 136/88 mm Hg is within the expected reference range for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provider. A regular occurrence of insomnia can be expected for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provider. Braxton Hicks contractions can be expected for a client who is at 38 weeks of gestation. Therefore, this finding does not need to be reported to the provider.

c. "The person who comes to take my baby's pictures will be wearing a photo identification badge." All personnel working on the unit should be wearing a photo identification badge. The nurse should instruct the parent to never allow anyone who is not wearing an identification badge to come in contact with the newborn. A newborn should always be transported in a bassinet when outside the parent's room. The nurse will match the newborn's identification number with the parent's identification number when they bring the newborn to the parent's room. The newborn should wear the electronic security bracelet at all times. The bracelet is set to alarm if anyone removes the bracelet or if the newborn is brought near an exit door.

c. Naloxone Morphine is a common opioid analgesic used for postoperative pain management that can cause central nervous system depression and can cause respiratory depression. The nurse should administer naloxone, an opioid antagonist, to reverse the opioid-induced respiratory depression in the client. The nurse should administer fentanyl to the client for the relief of severe, recurrent, or persistent pain during labor. Fentanyl is most commonly administered via PCA pump or epidural, alone or with a local anesthetic agent. An adverse effect of this medication is respiratory depression. The nurse should administer butorphanol to the client for the relief of labor pain and severe postoperative pain after cesarean birth. An adverse effect of this medication is respiratory depression. The nurse should administer meperidine to the client for the relief of severe, persistent pain. An adverse effect of this medication is respiratory depression.

d. FHR 152/min The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse. Deep tendon reflexes (DTRs) are an indication of the balance between the cerebral cortex and spinal cord. The nurse should expect the client's DTR to be 2+. Therefore, a DTR of 4+ indicates hyperreflexia. From gestational weeks 18 to 32, the height of the fundus is approximately equal to the number of weeks of gestation plus or minus 2 cm. Therefore, the nurse should expect the fundal height for this client should be 16 to 20 cm. The nurse should expect the urine protein for this client to be less than 1+. A urine protein concentration of 2+ is an indication of preeclampsia. Therefore, the nurse should investigate this finding further.

Fundal height measurement A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider. A glucose tolerance test result of 120 mg/dL is within the expected reference range for this client. A value of 130 to 140 mg/dL or greater for a 1-hr glucose tolerance test indicates a positive test result and should be reported to the provider. A hematocrit of 34% is within the expected reference range for this client. The level should be greater than 33%. This FHR is within the expected reference range of 110/min to 160/min for a client at 26 weeks of gestation.

Remove all clothing from the newborn except the diaper. The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin. The nurse should not feed the newborn any water or glucose water. Hydration can be maintained through regular breastfeeding or formula feeding. Water and glucose water do not increase the excretion rate of bilirubin in the stool or provide nutritional value. The nurse should not apply lotion, ointments, or creams to a newborn who is undergoing phototherapy. Lotions, ointments, and creams can absorb heat and lead to burns. The nurse should not discontinue phototherapy if the newborn develops a rash. A temporary, fine rash can occur during therapy. This rash requires no treatment.

Petechiae over the head Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck. A breech birth can cause bruising over the buttocks and swollen genitalia. Inclusion cysts, or whitish hard nodules on the gums or roof of the mouth, can be an expected finding. These are also called Epstein pearls. Bilateral periauricular papillomas are benign skin tags that can be an expected finding.

Perform Leopold maneuvers. The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer. The nurse should determine the client's dilation and effacement prior to applying an internal monitor. This action is not required prior to applying an external transducer for fetal monitoring. A sterile speculum examination should be performed by the provider and is not required prior to applying an external transducer for fetal monitoring. A Nitrazine paper test is performed to assess the components (pH level) of vaginal fluid to determine if the membranes have ruptured. This action is not required prior to applying an external transducer for fetal monitoring.

Jaundice Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider. Acrocyanosis is a bluish discoloration of the hands and feet and is an expected finding in a newborn 24 to 48 hr after birth. Transient strabismus is a normal variation in the newborn's eyes that can persist until the third or fourth month of age. Caput succedaneum is a benign, edematous area of the scalp and is commonly found on the occiput.

Verify that the parent's identification band matches the newborn's identification band. The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the information on the parent's identification band to the information on the newborn's identification band. Scanning the newborn's identification band to verify their identity does not ensure the newborn is being transferred to the correct parent. Comparing the newborn's security tag number to the newborn's medical record does not ensure the newborn is being transferred to the correct parent. It is not necessary for the nurse to check the parent's medical record. The nurse should match the information on the parent's identification band to the information on the newborn's identification band.

Premature rupture of membranes The nurse should identify that a client who is pregnant and has gonorrhea is at an increased risk for premature rupture of membranes, chorioamnionitis, preterm birth, neonatal sepsis, and intrauterine growth restriction. Oligohydramnios is a decrease in amniotic fluid and is associated with congenital anomalies such as renal agenesis and intrauterine growth restriction. Proteinuria is associated with preeclampsia.

Hemoglobin 10 g/dL A hemoglobin of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this finding to the provider to obtain a prescription for ferrous iron supplementation because of anemia.

Report of decreased fetal movement The nurse should identify that a client who reports decreased fetal movement could be experiencing a complication related to fetal well-being. A decrease in fetal movement can indicate fetal distress. A client who is at 32 weeks of gestation should have a fundal height about the same as the number of weeks of gestation, plus or minus 2 cm. The nurse should identify that occasional ankle edema is a common discomfort associated with a client who is at 32 weeks of gestation. The nurse should identify that during pregnancy the client's blood pressure should remain the same or be slightly decreased. A blood pressure of 110/80 mm Hg is within the expected reference range of less than 120 mm Hg systolic and less than 80 mm Hg diastolic.

To locate a pocket of fluid An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus.

Administer oxygen via a nonrebreather mask. When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask at 10 L/min to ensure adequate oxygenation to the fetus. All other actions are appropriate, but not priority.

Report the client's condition to the local health department. The nurse should report the condition to the local health department. HIV is one of the conditions on the list of Nationally Notifiable Infectious Conditions that is required to be reported. The nurse should administer penicillin G 2.4 million units IM to a client who has syphilis. The nurse should instruct the client to schedule a pelvic examination every 6 months. The nurse should tell the client that treatment for HIV will be during the prenatal and perinatal periods. Treatment with antiretroviral prophylaxis such as zidovudine, triple-drug antiretroviral therapy (ART), or highly active antiretroviral therapy (HAART) during pregnancy have been reported to decrease the transmission of the virus to the newborn.

BUN 25 mg/dL The nurse should report an elevated BUN to the provider since it can indicate dehydration. Testing the urine for ketones is the most important laboratory test for a client who has hyperemesis gravidarum. Urine testing positive for ketones is an indication of dehydration, which increases the risk of preterm labor. A negative test result is an expected finding.

Schedule an ultrasound examination. The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth. Currently, there are no antiviral medications available to treat fifth disease. The Haemophilus influenzae type b vaccine is given during infancy and childhood to protect against multiple infections caused by Haemophilus influenzae type b, not fifth disease. An indirect Coombs' test determines whether the client has antibodies to the Rh antigen. The titer determines the prenatal client's sensitization and if there is Rh incompatibility.

Monitor the FHR continuously. Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The FHR and uterine contractions should be monitored continuously while the client is receiving magnesium sulfate. The nurse should monitor the client's vital signs, including blood pressure, every 15 to 30 min. Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a high-alert medication that requires close monitoring. The nurse should restrict the client's total hourly intake to no more than 125 mL. Clients who have preeclampsia can have an alteration in kidney function, leading to increases in edema. The nurse should administer calcium gluconate if the client shows manifestations of magnesium sulfate toxicity. Findings of toxicity include loss of deep-tendon reflexes, respiratory depression, slurred speech, and cardiac arrest.

Pregestational diabetes mellitus Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis. Multifetal gestation, rather than a single fetus pregnancy, increases a client's risk for the development of preeclampsia. Having a BMI greater than 30 increases a client's risk for the development of preeclampsia. A maternal age of younger than 19 or older than 40 increases the client's risk for the development of preeclampsia.

"I will likely need to use alternative positions for sexual intercourse." The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This client statement indicates that she understands the nurse's teaching about the physiological changes that occur during pregnancy. The recommended weight gain during pregnancy for a client who has a BMI within the expected reference range is 25 to 35 lb (11.3 to 15.9 kg). The recommended weight gain during pregnancy for a client who has a BMI above the expected reference range is 15 to 20 lb (6.8 to 9.1 kg). The mammary glands of the breasts grow during pregnancy, causing progressive enlargement during the second and third trimesters of pregnancy. A breast reduction will not prevent this from occurring. Stretch marks can occur as a response to pregnancy regardless of the client's complexion.

Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. The nurse should quickly apply gloves and insert two fingers into the vagina toward the cervix, exerting upward pressure onto the presenting part to relieve umbilical cord compression and increase oxygenation to the fetus. The nurse should wrap the visible cord with a loose sterile towel saturated with warm 0.9% sodium chloride solution, rather than with sterile, dry gauze. The nurse should apply oxygen to the client at 8 to 10 L/min via nonbreather mask. The nurse should place the client into a modified Sims position, knee-chest position, or extreme Trendelenburg to attempt to relieve the compression of the umbilical cord.

"You can still become pregnant if you are breastfeeding." The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding. The nurse should instruct the client that it is safe to resume sexual activity once all vaginal bleeding has stopped and the incision has healed, which can take 2 to 6 weeks. However, it is highly recommended that the client wait until after her 6-week follow-up with the provider because the incision and healing process should be assessed before sexual activity is resumed. The nurse should instruct the client to continue to perform Kegel exercises to maintain tone of the pelvic muscles. Maintaining tone of the pelvic floor muscles helps to maintain urinary continence in the future. The nurse should instruct the client to avoid abdominal exercises for 4 to 6 weeks following a cesarean birth. The nurse can instruct the client to perform other exercises such as walking, arm raises, and leg rolls.

Cold cabbage leaves The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement. The nurse should instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the application for two to three sessions as needed. More frequent applications could decrease the client's milk supply. Purified lanolin cream is an over-the-counter product that is recommended for the treatment of sore nipples. A snug-fitting support bra is recommended to suppress lactation for a client who is not breastfeeding. The bra prevents strain on the breast muscles and places the breasts in proper alignment to decrease engorgement. Breast shells are recommended for clients who are postpartum and have sore nipples. They are used as a barrier to keep clothing away from the nipples and to allow air to circulate.

Lays the newborn across her lap and gently sways This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn. The parent should place the infant in the supine position, not a prone position, in the bassinet or crib because of the risk of sudden infant death syndrome. Pacifiers may be used for a newborn who needs extra sucking for self-soothing. However, formula should not be placed on the tip of the pacifier because the newborn might become accustomed to it and refuse to take the pacifier in the future without added supplement. Rice cereal should not be added to the bottle of a newborn because solids should not be introduced until 4 to 6 months of age.

Hypertension The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension. Fever is a common adverse effect of carboprost. Diarrhea is a common adverse effect of carboprost. Muscle weakness is not an adverse effect of carboprost.

Place the newborn skin to skin on the mother's chest. Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure. A cool pack will constrict the blood vessels, making it more difficult to obtain an adequate specimen. The nurse should apply a warm pack prior to the puncture. The pain experienced from a heel stick is too brief to warrant risking the adverse effects of parenteral analgesia. A spring-loaded, automatic puncture device is recommended to minimize pain by ensuring that the depth of the puncture is not too deep, avoiding injury to the newborn.

Reports increased urinary output Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain, constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations include weak rapid pulse, fruity breath odor, urine positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL. Diaphoresis or clammy skin is a finding of hypoglycemia. Flushed, dry skin is a manifestation of hyperglycemia. Blurred or double vision is a finding of hypoglycemia. A report of dim vision is a manifestation of hyperglycemia. Shallow respirations are a finding of hypoglycemia. Rapid breathing is a manifestation of hyperglycemia.

Evidence-based practice indicates the nurse should perform this step first when performing Leopold maneuvers. During this step, the nurse palpates the client's abdomen with the palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus.

Begin FHR monitoring. The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take. The nurse should perform a Nitrazine test to determine the pH of the fluid. An alkaline pH can indicate rupture of membranes. However, this is not the first action the nurse should take. The nurse should observe the characteristics of the fluid to document color, odor, and amount. However, this is not the first action the nurse should take. The nurse should check the client's cervical dilation to assess progress of labor. However, this is not the first action the nurse should take.

Kleihauer-Betke test The nurse should expect the provider to prescribe a Kleihauer-Betke test for a client who has suspected placental abruption to determine if fetal blood is in maternal circulation. This test is useful to determine if Rho-(D) immune globulin therapy should be administered to a client who is Rh-negative. A progesterone serum level helps to determine if a client is pregnant and if the pregnancy is ectopic. Lecithin/sphingomyelin (L/S) ratio is done as a part of an amniocentesis to evaluate fetal lung maturity. Maternal Alpha-fetoprotein (AFP) is a laboratory test used to assess for neural tube defects or chromosome disorders.

Heart rate 154/min Respiratory rate 58/min Weight 2,600 g (5 lb 12 oz) The expected reference range for a newborn's heart rate is from 110/min to 160/min while awake. A healthy newborn's temperature averages 37° C (98.6° F), with a range of 36.5° to 37.5° C (97.7° to 99.5° F). The expected reference range for a newborn's respiratory rate is from 30/min to 60/min. The expected reference range for a newborn's length is from 45 to 55 cm (17.7 to 21.7 in). The expected reference range for a newborn's weight is from 2,500 to 4,000 g (5.5 lb to 8.8 lb).

Report of visual disturbances Visual disturbances such as blurred vision are a potential prenatal complication associated with hypertension. The nurse should report this finding to the provider so that additional fetal and maternal evaluation can be performed. Tingling or numbness of the fingers is called brachial plexus traction syndrome resulting from drooping of shoulders during pregnancy. This is a common discomfort that occurs during the second trimester. Reports of urinary frequency is a common discomfort that occurs during the third trimester because of the reduction in bladder capacity due to the enlarged uterus. Leg cramps are a common discomfort that occurs during the third trimester because the nerves that supply lower extremities are compressed due to the enlarging uterus.

50 mL/hr 20 g/ 500 mL = 2 g/X mL X mL = 50 mL

Abruptio placenta Cocaine use increases the risk for vasoconstriction and possible abruptio placenta. None of the other options are associated with cocaine use.

A reduction in respiratory distress in the newborn Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress.