Maternal A

The nurse should not administer a rectal suppository or enema to a client who has a fourth-degree perineal laceration. These can cause separation of the suture line, bleeding, or infection.

STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 10 mcg/mL and the prescription reads 5 mcg, it makes sense to administer 0.5 mL. The nurse should administer hepatitis B immunoglobulin 0.5 mL IM.

The nurse should instruct the client to engage in 30 min of moderate exercise every day to improve muscle tone throughout her pregnancy.

The nurse should identify fetal head compression as a likely cause of the early decelerations on the fetal monitor. Early decelerations are an expected fetal pattern caused by fetal head compression due to uterine contractions, fundal pressure, and vaginal examinations.

Take photos of the newborn to give to the parents. The nurse should create a memory box that includes mementos of the newborn (for example, photos, the newborn's ID bands, the newborn's hat, and the newborn's blanket).

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.

Epigastric pain is a clinical manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority.

Flaccid uterus is correct. Oxytocin increases the contractility of the uterus. Cervical laceration is incorrect. Bleeding resulting from a cervical laceration continues even when the uterus is contracted and firm. It will require repair by the provider. Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing vaginal bleeding. Increased afterbirth cramping is incorrect. The use of oxytocin will increase, rather than decrease, afterbirth cramping. Increased maternal temperature is incorrect. The use of oxytocin will have no effect on maternal temperature.

Room-sharing is recommended during the first few weeks. This allows the parents to be readily available to the newborn and learn the newborn's cues. However, the nurse should instruct the parents to avoid placing the newborn in their bed as it increases the risk for sudden infant death syndrome.

When using Naegele's rule to calculate the estimated date of birth for a client, the nurse should subtract 3 months from the first day of the client's last menstrual cycle and then add 7 days. November 27th minus 3 months equals August 27th. August 27th plus 7 days equals September 3rd.

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 her 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.

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 manager should take into account the staff nurse's moral beliefs and recognize that she also has rights and responsibilities concerning the care of a client who is undergoing an induced abortion. Therefore, the nurse manager should reassign the care of the client to another staff nurse.

At the end of the first trimester of pregnancy, the client's uterus is approximately the size of a grapefruit and is positioned low in the pelvis slightly above the symphysis pubis. Therefore, the nurse should begin assessing for FHTs just above the symphysis pubis.

Fetal movement may not be evident on the fetal monitor and tracing. Instructing the client to press the button when she detects fetal movement will ensure that the fetal movement is noted.

The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many women experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.

The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops.

Having the client change position is an appropriate intervention for a variable deceleration to relieve umbilical cord compression.

The nurse should suggest applying cold compresses or ice packs to alleviate the discomforts of engorgement in the client who is breastfeeding.

Insertion of an intrauterine pressure catheter is necessary to determine uterine contraction intensity, which will identify whether or not the contractions are adequate for progression of labor.

Progress Notes Fundal height 30 cm Good fetal movement Not experiencing headache, dizziness, blurred vision, or vaginal bleeding Fetal heart rate 110/min 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.

Swelling of the face, sacral area, and hands can indicate gestational hypertension or preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid moves out of the intravascular compartment into the tissues, causing edema.

A client who is at 11 weeks of gestation and reports abdominal cramping When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is 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. Wrong Answers A client who is at 15 weeks of gestation and reports tingling and numbness in her right hand A client who is at 20 weeks of gestation and reports constipation for the past 4 days A client who is at 8 weeks of gestation and reports having three bloody noses in the past week

Plant sterols and salicylates from cabbage leaves can help to relieve swelling and discomfort caused by breast engorgement.

The nurse should realize that this value exceeds the expected reference range for a postpartum client and indicates an infection.

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.

The greatest risk to the client is hemorrhage. Therefore, the next action the nurse should take is to massage the client's fundus to expel clots and promote contractions.

When using the urgent vs. nonurgent approach to client care, the nurse should determine that the greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take immediately after delivery is to dry the newborn.

The nurse should instruct the client to eat high-carbohydrate foods (for example, toast, potatoes, and rice) to decrease nausea and vomiting. The nurse should also instruct the client to avoid spicy, fatty, or fried foods.

The nurse should assist the client to empty her bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage.

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 to ensure adequate oxygenation to the fetus.

The nurse should teach the client that all staff members that care for newborns are required to wear a photo identification badge so that the client will be reassured of her newborn's safety.

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.

Amenorrhea is a presumptive sign of pregnancy, not a positive sign. Therefore, the nurse should explore the client's menstrual cycle to determine other necessary interventions.

Rho(D) immune globulin is given following an amniocentesis because of the potential of fetal RBCs entering the maternal circulation.

The nurse should inform the client that a sign of true labor is the bloody show, which is a blood-tinged discharge from the vagina that occurs when the cervix begins to efface and dilate. This is an indication that the client should go to the hospital.

A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with real-time ultrasound.

Expected clinical manifestation associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days. Tachypnea Hypoglycemia Low birth weight

Behavioral responses to a newborn's pain include facial expressions (for example, chin quivering, grimacing, and furrowing of the brow).

The client should remain on bed rest to decrease the risk of dislodging the clot, which could cause a pulmonary embolism.

The client should keep the diaphragm in place for at least 6 hr after intercourse to provide protection against pregnancy.

Leakage of fluid from the vagina could indicate premature leakage of amniotic fluid and should be reported to the provider.

The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr prior to testing.

The nurse should report an elevated BUN to the provider since it can indicate dehydration.

The nurse should instruct the client to get a 2-hr oral glucose tolerance test 6 to 12 weeks postpartum and every 3 years to screen for type 2 diabetes mellitus

Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress.

An adverse effect of terbutaline is hypokalemia. Terbutaline is administered subcutaneously every 4 hr for no longer than 24 hr. An adverse effect of terbutaline is hypotension. An adverse effect of terbutaline is hyperglycemia.

A platelet count of 50,000/mm3 is below the expected reference range, which can indicate disseminated intravascular coagulation. The nurse should report this result to the provider. An Hct of 39% is within the expected reference range and is not indicative of a postpartum complication. A serum albumin level of 4.5 g/dL is within the expected reference range. This finding is consistent with mild preeclampsia and does not indicate a worsening of the condition. A WBC of 9,000/mm3 is within the expected reference range.

When using the airway, breathing, circulation approach to client care, the nurse should place the priority in the immediate postpartum period on assessing the amount of postpartum lochia. The greatest risk to the client is bleeding and postpartum hemorrhage.

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

A headache that is unrelieved by analgesia may indicate preeclampsia and should be reported to the provider. Braxton Hicks contractions are an indication that the uterus is preparing for labor and is an expected clinical manifestation at 35 weeks of gestation. Shortness of breath is related to the enlarging uterus interfering with the expansion of the diaphragm and is an expected clinical manifestation at 35 weeks of gestation. Swelling of feet and ankles is due to the enlarging uterus interfering with blood return to the heart and is an expected clinical manifestation at 35 weeks of gestation.

The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation.

The nurse should apply sacral counterpressure to assist in relieving back labor pain related to fetal posterior position.

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. 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. Bathing the client within 12 hr following delivery should not be included in the plan of care because traditional Hispanic practices include delaying bathing for 14 days following delivery. Ambulating the client within 24 hr following delivery should not be included in the plan of care because traditional Hispanic practices include bed rest for 3 days following delivery.

A heart rate of 154/min is correct. The expected reference range for a newborn's heart rate is from 110/min to 160/min while awake. An axillary temperature of 36° C (96.8° F) is incorrect. The expected reference range for a newborn's axillary temperature is from 36.5° C (97.7° F) to 37.8° C (100.0° F). A respiratory rate of 58/min is correct. The expected reference range for a newborn's respiratory rate is from 30/min to 60/min. A length of 43 cm (16.9 in) is incorrect. The expected reference range for a newborn's length is from 45 to 55 cm (17.7 to 21.7 in). A weight of 2.6 kg (5 lb 12 oz) is correct. The expected reference range for a newborn's weight is from 2.5 to 4 kg (5.5 lb to 8.8 lb).

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. 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 greatest risk for a client following amniotomy is infection. Therefore, the nurse should identify that the priority assessment is the client's temperature.

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

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.

The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil. A popliteal angle of 90° is an indicator of physical maturity with increasing gestational age after 26 weeks. Creases over the entire sole of a newborn's foot are an indicator of physical maturity with increasing gestational age after 26 weeks. Raised areolas with 3 to 4 mm buds is an indicator of physical maturity with increasing gestational age after 26 weeks.