A client in active labor is rushed from the emergency department to the labor and birth suite screaming, "Knock me out." Examination reveals that her cervix is 9 cm dilated. While trying to calm her, the nurse should respond:
"I'll rub your back, which will help ease your pain."
"You will get a shot when you reach the birthing room."
"I'm sure you're in pain, but try to bear with it for the baby's sake."
"Medication may interfere with the baby's first breaths; try to bear the pain."
A 45-year-old woman, with large intramural leiomyomas that did not respond to medical therapies, has been advised to have an abdominal hysterectomy. She asks the nurse whether there is any surgery other than an abdominal hysterectomy available. The nurse should respond:
"Sorry, there are no other options."
"You should ask your gynecologist."
"You seem uncertain about having the hysterectomy."
"A vaginal hysterectomy is a possible alternative for you."
A newly married client visits the women's health clinic because she has not been feeling well. The nurse suspects that the client may be pregnant when:
Her menses is a week late
Her urine immunoassay test is positive
She relates that she has urinary frequency
She complains that she has nausea every morning
A pregnant client's blood test reveals an elevated alpha-fetoprotein (AFP). The nurse is aware that this test result may indicate the presence of:
Cystic fibrosis
Phenylketonuria
Down syndrome
Neural tube defects
A 40-year-old primigravida is scheduled to have her first ultrasound scan. The nurse's instructions should include:
Postponing breakfast until after the test
Drinking 8 glasses of water before the test
Emptying the bladder immediately prior to the test
Inserting a suppository on arising on the day of the test
The nurse is interpreting the results of a nonstress test (NST) on a client at 41 weeks' gestation. After 20 minutes, the result that would be suggestive of fetal reactivity is:
Absent long-term variability
Above average fetal baseline heart rate
No late decelerations associated with contractions
Two accelerations of 15 beats per minute lasting 15 seconds
During labor the nurse encourages the client to void. The nurse recognizes that an overdistended urinary bladder during labor can:
Interfere with the expulsion of the placenta
Interfere with the assessment of cervical dilation
Prevent the diagnosis of cephalopelvic disproportion
Predispose to uterine hemorrhage immediately after birth
The most appropriate time for the nurse to administer an opioid analgesic to a client in active labor is:
Between contractions
When a contraction starts
At the peak of a contraction
Just before the end of a contraction
The nurse assesses a primigravida who had been in labor for 5 hours. The fetal heart rate tracing is reassuring. Contractions are of mild intensity lasting 30 seconds and are 3 to 5 minutes apart. An oxytocin infusion has been ordered. The priority nursing intervention at this time is to:
Check cervical dilation every hour
Keep the labor environment dark and quiet
Infuse oxytocin by piggybacking into the primary line
Position the client on the left side throughout the infusion
During labor a client has an internal fetal monitor applied. The nurse should take action in response to a fetal heart rate that:
Does not drop during contractions
Uniformly drops to 120 beats per minute with each contraction
Fluctuates from 130 to 140 beats per minute unrelated to contractions
Repeatedly drops abruptly to 90 beats per minute unrelated to contractions
Although a client in labor is prepared and plans to participate in the labor and birth process, she states that she is in severe discomfort. An order for butorphanol (Stadol) is given. The safest time during labor for the nurse to administer this medication is during the:
Early phase
Active phase
Transition phase
Expulsion phase
A client's membranes rupture. The nurse, observing an abrupt deceleration in the fetal heart rate, inspects the vaginal area and notes a prolapsed cord. The nurse should immediately:
Administer oxygen by face mask at 7 L per minute
Elevate the presenting part off the cord until birth
Notify the physician of the findings of the examination
Instruct the client to assume a dorsal recumbent position
Priority nursing intervention for a laboring client with a sudden prolapse of the umbilical cord protruding from the vagina should focus on:
Preparing the client for surgery
Gently replacing the cord in the vaginal vault
Checking the fetal heart rate every 15 minutes
Starting oxygen at 10 L per minute via a tight face mask
The nurse is aware that when a local anesthetic is used for birth of a neonate:
Labor is slowed after its administration
Maternal respirations may be depressed
There is a danger of maternal aspiration
Reactions such as a decreased blood pressure may occur
After a birth, the mother's vital signs are T, 99.4° F; P, 80 regular and strong; R, 16 slow and even; and BP, 148/92 mm Hg. The vital sign the nurse should monitor more frequently is the client's:
Pulse
Respiration
Temperature
Blood pressure
The nurse is aware that a client could be at increased risk for postpartum hemorrhage if the client:
Breastfed in the birthing room
Received a pudendal block for the birth
Had a third stage of labor that lasted 10 minutes
Gave birth to a baby weighing 9 pounds, 8 ounces
In the postpartum period, the nurse anticipates that a primipara with a second-degree laceration and repair is most likely to develop:
Posterior vaginal varicosities
Difficulty voiding spontaneously
Delayed onset of milk production
Maladaptive bonding with the infant
A new mother wishes to breastfeed her infant and asks the nurse whether she needs to alter her diet. The nurse can best respond:
"Just eat as you have been doing during your pregnancy."
"Just drink a lot of milk; you need the calcium to make your own milk."
"Don't be concerned, your body will produce the amount of milk your baby needs."
"You'll need greater amounts of the same foods you've been eating and more fluids."
A primagravida with pregestational type 1 diabetes is at her first prenatal visit. When discussing changes in insulin needs during pregnancy and after birth, the nurse explains that based on her blood glucose levels she should expect to increase her insulin dosage between the:
10th and 12th weeks of gestation
18th and 22nd weeks of gestation
24th and 28th weeks of gestation
36th week of gestation and the time of birth
During her first visit to the prenatal clinic, a client tells the nurse that she has a cat and is responsible for changing the cat's litter box. The client asks if doing this will be harmful to her or the fetus. The nurse should reply that:
Cat litter is not harmful during pregnancy
Exposure to cat litter for short periods of time is not harmful
There are several factors that determine a person's response to the toxins in cat litter
Fetal abnormalities are associated with exposure to cat litter, even after minimal contact
During their first visit to the prenatal clinic, a young couple asks the nurse whether the wife should have an amniocentesis for genetic studies. The nurse responds that the indications for these studies include:
Prior spontaneous abortions
A recent history of drug abuse
A family history of genetic problems
First pregnancies in women older than 30
A client at her first visit to the prenatal clinic states that she has missed three menstrual periods and thinks she is carrying twins because her abdomen is so large, but has started to have a brownish vaginal discharge. Her blood pressure is elevated, indicating that she may have gestational hypertension. The nurse must perform a further assessment because the client may have:
Renal failure
Placenta previa
Hydatidiform mole
Abruptio placentae
A client with pregestational type 1 diabetes is being counseled on what to expect during her recently confirmed pregnancy. The statement that indicates the client needs further education is:
"I can expect that my baby will be larger than average."
"My blood glucose levels may be lower during my first trimester."
"Additional insulin may be needed in the second half of my pregnancy."
"Drinking more water will decrease my risk of getting a urinary tract infection."
The nurse determines the fundal height of a healthy multipara, at 16 weeks' gestation, to be one finger-breadth above the umbilicus. The nurse should:
Assess for two distinct fetal heart rates
Ascertain birth weights of her other children
Inform the client that she may be mistaken about her dates
Instruct the client about appropriate weight gain during pregnancy
The nurse should plan to teach a client who is to have an amniocentesis that ultrasonography will be performed just before the procedure to determine the:
Fetal gestational age
Location of the umbilical cord
Amount of fluid in the amniotic sac
Position of the fetus and the placenta
A client is to have an amniocentesis at 38 weeks' gestation to determine fetal lung maturity. The nurse recognizes that lung maturity is adequate when the L/S ratio is:
1:1
1:2
2:1
1.5:1
After an amniocentesis, the priority nursing care should include:
Giving perineal care
Encouraging fluids every hour
Changing the abdominal dressing
Observing for signs of uterine contractions
The nurse explains to a pregnant client undergoing a nonstress test that the test is a way of evaluating the condition of the fetus by comparing the fetal heart rate with:
Fetal lie
Fetal movement
Maternal blood pressure
Maternal uterine contractions
Nursing care for a client, at 41 weeks' gestation, who is to have a contraction stress test (CST) should include:
Having the client empty her bladder
Placing the client in a supine position
Discussing the probability of a cesarean birth
Preparing the client for insertion of an internal monitor
A client at 42 weeks' gestation has a contraction stress test (CST). The nurse understands that a positive test indicates that the:
Placenta has stopped growing
Fetus is not ready to be delivered
Amniotic fluid is meconium stained
Function of the placenta has diminished
Laboratory studies reveal that a pregnant client's blood type is O and she is Rh positive. Problems related to incompatibility may develop in her infant if the infant is:
Rh negative
Type A or B
Born preterm
Type O, Rh positive
A 16-year-old primigravida, who appears to be at or close to term, arrives at the emergency department stating that she is in labor and is complaining of pain continuing between contractions. The nurse palpates the abdomen, which is firm with no signs of relaxation. The nurse concludes that the:
Fetus' birth may be imminent
Client may have placenta previa
Client may have abruptio placentae
Fetus may be in the breech presentation
A client who is pregnant for the first time and is carrying twins is scheduled for a cesarean birth. Preoperative teaching should include telling the client to expect to:
Ambulate frequently within 24 hours of surgery
Be discharged between 5 and 7 days postpartum
Need an enema to have an effective bowel movement
Take sponge baths until the incision is completely healed
The nurse understands that the postpartum client who is at the highest risk for developing a puerperal infection is a:
Woman who has lost 350 mL of blood during the birth process
Primipara who has given birth to an infant weighing 8 1/2 pounds
Multipara who had a hemoglobin level of 11 grams on admission to the hospital
Woman who requires catheterization because each voiding has been 75 to 80 mL
The nurse is caring for a group of postpartum clients. The one the nurse should observe most closely would be a:
Primipara who has had an 8-pound baby
Grand multipara who experienced a labor of only 1 hour
Primipara who received 100 mg of Demerol during her labor
Multipara whose placenta was expelled within 10 minutes of the birth of the fetus
On the first postpartum day, a major nursing intervention for a client who had a cesarean birth is:
Promoting dietary intake
Promoting bowel function
Relieving gaseous distention
Relieving postoperative pain
After the removal of an indwelling catheter, a client who has had a cesarean birth has difficulty voiding. The nurse can best evaluate whether the client has emptied her bladder by:
Catheterizing the client for residual urine
Gently palpating the client's suprapubic area
Measuring the amount of urine the client has voided
Asking the client whether she still feels the urge to void
On her first visit to the prenatal clinic a client with rheumatic heart disease asks the nurse if she will have special nutritional needs. The nurse should respond that in addition to the regular pregnancy diet she probably will need supplemental:
Vitamins C and D
Iron and folic acid
Vitamins B2 and B12
Calcium and magnesium
The nursing action that has the highest priority for a client with class I heart disease during the postpartum period should be:
Promotion of aggressive ambulation
Observation for signs of cardiac decompensation
Assessment of the mother's reaction to the birth
Advisement about activity levels during the postpartum period
A client, at 28 weeks' gestation, with previously diagnosed mitral valve stenosis is being evaluated in the clinic. The sign or symptom that would indicate the client is experiencing difficulty related to her heart disease is:
Heart palpitations
Syncope on exertion
A displaced apical pulse
A grade 2 systolic murmur
The position that the nurse should encourage a client with cardiac disease to assume during labor is:
Supine
High-Fowler's
Semi-Fowler's
Trendelenburg
While a client, at 30 weeks' gestation, is being examined in the prenatal clinic, the nurse notes a respiratory rate of 26, blood pressure of 100/60, diaphragmatic tenderness, and a reported increased urinary output. The finding that probably indicates the client may be experiencing a potential complication is her:
Blood pressure
Respiratory rate
Increased urinary output
Diaphragmatic tenderness
The nurse is aware that placenta previa occurs when:
There is premature separation of a normally implanted placenta
The placenta is not implanted securely in place on the uterine wall
There is premature aging of a placenta implanted in the uterine fundus
The placenta is implanted in the lower uterine segment, covering part or all of the os
A client with frank vaginal bleeding is admitted to the birthing unit at 30 weeks' gestation. The admission data indicate BP, 110/70; P, 90; R, 22; FHR, 132 and regular; uterus nontender and no contractions, and membranes are intact. Based on this information, the nurse suspects that this client has:
Preterm labor
Uterine inertia
Placenta previa
Abruptio placentae
The nurse has just admitted a client at 35 weeks' gestation with complete placenta previa. What is the most appropriate nursing intervention at this time?
Have oxygen available at the bedside
Allow bathroom privileges with assistance
Apply a perineal pad to measure bleeding if it occurs
Educate the client regarding the intensive care nursery
The nurse gently performs Leopold's maneuvers on a client with a suspected placenta previa and expects to find the:
Fetal head firmly engaged
Small fetal parts difficult to palpate
Uterus hard and tetanically contracted
Fetal presenting part high and floating
If the practitioner plans to do a speculum examination of a client with a marginal placenta previa, the nurse should have available:
One unit of freeze-dried plasma
Vitamin K for intramuscular injection
Two units of typed and screened blood
Heparin sodium for intravenous injection
A client arrives in the birthing area from the emergency department with blood running down both legs. The primary intervention is to:
Assess fetal heart tones
Observe for a prolapsed cord
Insert a uterine pressure catheter
Start an IV with an 18-gauge needle
The husband of a client, who at 24 weeks' gestation has been admitted to the hospital for preeclampsia, screams to the nurse that his wife just had a seizure. The nurse's immediate action should be to:
Turn the client's head to the side
Place an airway into the client's mouth
Check the client for a spontaneous birth
Assess the fetal heart rate for decelerations
A pregnant client is admitted to the hospital with abdominal pain and heavy vaginal bleeding. After assessment the nurse makes a nursing diagnosis of Decreased Cardiac Output related to hemorrhage. A priority nursing action should be to:
Administer oxygen
Elevate the head of the bed
Draw blood for a hematocrit
Give an opioid intramuscularly for pain
The nurse recognizes that stimulation of labor with an oxytocin infusion would be contraindicated if the client had:
Diabetes
Mild preeclampsia
Total placenta previa
Premature rupture of the membranes
Dietary counseling for a pregnant client with sickle cell anemia should include supplemental folic acid. The nurse recognizes that this is important because it:
Prevents sickle cell crises
Decreases the sickling of RBCs
Lessens the oxygen needs of cells
Compensates for a rapid turnover of RBCs
When a breech presentation is suspected, the nurse should diligently observe the client for signs of:
Precipitate labor
Prolapse of the cord
Progression of labor
Primary uterine inertia
A laboring client is admitted and assessment reveals that the fetus is in a footling breech position. The nurse should be aware that:
Meconium in the amniotic fluid is a sign of fetal hypoxia
Severe back discomfort occurs with the fetus in this position
The length of the labor often is shortened with the fetus in this position
Because of the presentation, the client will probably have a cesarean birth
When entering the room of a client in active labor to answer the call light, the nurse identifies that the client is an ashen gray color, is clutching her chest, and is dyspneic. The nurse should push the emergency light in the client's room and then:
Increase the IV fluid rate
Begin oxygen by face mask
Check for rupture of membranes
Start cardiopulmonary resuscitation
A client who is in the first trimester is being discharged after a week of hospitalization for hyperemesis gravidarum. She is to be maintained at home with rehydration infusion therapy. The priority nursing activity for the home health nurse should be to:
Determine fetal well-being
Monitor for signs of infection
Observe for signs of electrolyte imbalances
Teach about changes in nutritional needs during pregnancy
A client with type 1 diabetes is scheduled for an amniocentesis at 36 weeks' gestation. She asks the nurse why this is done so late in her pregnancy. The nurse explains that it is done to:
Ascertain the age of the fetus
Evaluate the fetal lung maturity
Schedule a cesarean birth early to avoid labor
Determine if the fetus is getting too large for a vaginal delivery
When caring for a client with type 1 diabetes on the first postpartum day, the nurse expects her insulin requirements to:
Slowly decrease
Quickly increase
Suddenly decrease
Remain unchanged
A client who has had tocolytic therapy for preterm labor is being discharged. The nurse should include in the teaching plan that the client should:
Limit daily activities
Restrict her fluid intake
Monitor her urine for protein
Continue deep-breathing exercises
The husband of a client in labor asks what the indentation is on his wife's abdomen. The nurse recognizes that it is a retraction ring (Bandl's ring). The nurse should:
Notify the practitioner immediately because this is a danger sign
Inform him that it is a sign of the fetus descending toward the birth canal
Tell him that this indentation is expected and reflects the strength of the contractions
Explain that his wife is entering the second stage of labor and she should push at the next contraction
A client's membranes rupture spontaneously during the latent phase of the first stage of labor, and the fluid is greenish brown. The nurse understands that this indicates that:
An infection is present
A cesarean birth is necessary
The client may have a precipitate birth
The fetus may have been compromised in utero
While a multiparous client is in active labor her membranes rupture spontaneously, and the nurse observes a loop of umbilical cord protruding from her vagina. The priority nursing action should be directed toward:
Monitoring the fetal heart rate
Covering the cord with a wet saline dressing
Moving the cord away from the presenting part
Holding the presenting part away from the cord
Aware of a client's history of opiate abuse, the nurse's initial plans for providing pain relief measures during labor should include:
Scheduling pain medication at regular intervals
Administering the medication only when the pain is severe
Avoiding the administration of medication unless it is requested
Recognizing that she will not need as much pain medication as others
A client who is 4 cm dilated and in labor is admitted to the birthing room. An electronic fetal monitor is applied. The observation that should alert the nurse to notify the practitioner is:
Beat-to-beat variability between contractions
Contractions every minute, lasting 120 seconds each
Fetal heart accelerations at the beginning of a contraction
Early fetal heart rate decelerations before the peak of a contraction
A client is admitted with the diagnosis of placenta previa. The nurse is aware that this diagnosis usually is confirmed by:
A laparoscopy
A nonstress test
An ultrasonogram
An amniocentesis
A client is admitted to the unit with uterine tenderness and minimal, dark red vaginal bleeding. She is diagnosed as having a marginal abruptio placentae. On admission, the priority assessment should include fetal status, vital signs, skin color, urine output, and:
Fundal height
Past obstetric history
Time of the last meal
Family history of bleeding disorders
A pregnant client has been diagnosed with gestational hypertension. The nurse should teach her that her pregnancy diet now requires:
No changes
Limited proteins
Restricted sodium
Increased carbohydrates
A nonstress test is scheduled for a client with preeclampsia. During the nonstress test the nurse should be aware that if nonperiodic accelerations of the fetal heart rate occur with fetal movement, it probably indicates:
Fetal well-being
Head compression
Uteroplacental insufficiency
Umbilical cord compression
A nurse admits a client with preeclampsia to the unit. After obtaining the vital signs, the nurse should:
Call the practitioner
Check the client's reflexes
Determine the client's blood type
Administer intravenous normal saline
A client at 36 weeks' gestation is admitted because of a weight gain of 5 pounds in the previous week and a pronounced rise in blood pressure. Appropriate nursing care includes:
Preparing for an imminent cesarean birth
Providing a dark, quiet room with minimal stimuli
Instituting prescribed furosemide IV therapy to promote diuresis
Administering prescribed calcium gluconate to lower blood pressure
Before administering IV magnesium sulfate therapy to a client with preeclampsia, the nurse should assess the client's:
Temperature and respirations
Urinary glucose and specific gravity
Urinary output and patellar reflexes
Level of consciousness and funduscopic appearance
A client with preeclampsia is admitted to the labor and birthing suite. Her blood pressure is 130/90, she has 2+ protein in her urine, and edema of the hands and face. As part of the admission history, the nurse should ask the client about:
Constipation, edema, visual problems, and headache
Visual disturbances, headache, constipation, and bleeding
Headache, visual disturbances, edema, and abdominal pain
Leakage of amniotic fluid, bleeding, edema, and abdominal pain
A client with severe preeclampsia is admitted to the unit and given an IV infusion of magnesium sulfate. The nurse recognizes that for this client magnesium sulfate is being given primarily because it is a:
Hypotensive that relaxes smooth muscles
Cholinergic that increases the release of acetylcholine
Muscle relaxant that decreases the severity of uterine contractions
Central nervous system depressant that blocks neuromuscular transmissions
The nurse on the high-risk unit assesses a client admitted with severe preeclampsia. The client has audible crackles in the lower left lobe, slight blurring of vision in the right eye, generalized facial edema, and epigastric discomfort. Which sign or symptom would most likely indicate the potential for a seizure?
Audible crackles
Blurring of vision
Epigastric discomfort
Generalized facial edema
An infusion of oxytocin is administered to a client for induction of labor. After several minutes the fetal monitor indicates contractions lasting 100 seconds with a frequency of 95 seconds. The nurse should:
Check the fetal heart rate
Slow the oxytocin flow rate
Turn the client on her left side
Discontinue the oxytocin infusion
A client with a history of phenylketonuria, who was maintained on a low-phenylalanine diet until 9 years of age, is now pregnant. The nurse teaches this client that:
The baby may be mentally retarded because of her history of PKU
Reinstitution of the low-phenylalanine diet will protect her baby from PKU
The fetus is not at risk prenatally but will require immediate care at birth to prevent PKU
Phenylalanine should be avoided even when not pregnant so that her body is able to support a pregnancy
Diet counseling for a breastfeeding client with a history of phenylketonuria should include providing a list displaying foods containing:
Lactose
Glucose
Fatty acids
Amino acids
A client at 6 weeks' gestation who has type 1 diabetes is attending the prenatal clinic for the first time. The nurse explains that during the first trimester insulin requirements may decrease because:
Body metabolism is sluggish in the first trimester
Morning sickness may lead to decreased food intake
Fetal requirements of glucose in this period are minimal
Hormones of pregnancy decrease the body's need for insulin
The nurse teaching a prenatal class is asked why babies of mothers with diabetes are larger than those who do not have diabetes. The nurse should respond that these mothers:
Take exogenous insulin, which stimulates fetal growth
Have extra circulating glucose that causes fatty deposits in the fetus
Consume extra calories to cover the insulin manufactured by the fetus
Are usually overweight, with some of the calories being utilized by the fetus
In her 37th week of gestation, a client with type 1 diabetes has an amniocentesis to determine fetal lung maturity. The L/S ratio is 2:1, phosphatidylglycerol is present, and creatinine is 2 mg/dL. Based on this information the nurse assesses that:
A cesarean birth will be scheduled
A birth must be scheduled immediately
There is no need for further fetal monitoring
The newborn should be free from respiratory problems
The nurse is aware that the client at highest risk of disseminated intravascular coagulation would be a:
Gravida III with twins
Gravida V with endometriosis
Gravida II with a 9-pound baby
Gravida I with intrauterine fetal death
A client at 36 hours postpartum is being treated with IV heparin for left calf deep vein thrombosis. While monitoring the client, which would be of most concern to the nurse?
Dyspnea
Pulse rate of 62
Blood pressure of 136/88
Positive left leg Homans' sign
The nurse places an electronic fetal monitor on the abdomen of a client in labor. When observing the relationship between the fetal heart rate and uterine contractions, the nurse identifies four late decelerations. The nurse recognizes that late decelerations are most frequently associated with:
Head compression
Maternal hypothyroidism
Umbilical cord compression
Uteroplacental insufficiency
A client with an abruptio placentae had an emergency cesarean birth. Subsequently the nurse observes that there is bloody urine in the indwelling catheter collection bag. The nurse recognizes that this is significant because the client may have:
An incisional nick in the bladder
A urinary infection from the catheter
Uterine relaxation with increased lochia
Disseminated intravascular coagulopathy
Two hours after giving birth, a client's physical assessment includes BP 86/40; TPR 98/100/22; fundus firm, four finger-breadths above umbilicus; small spots of lochia rubra on perineal pad; bladder distended. After catheterization the client's fundus remains firm and four finger-breadths above the umbilicus. The nurse should:
Catheterize the client again in 1 hour
Notify the client's practitioner immediately
Palpate the client's fundus every 2 hours
Recheck the client's vital signs in 30 minutes
Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. The drying of the newborn's skin helps to prevent body heat loss via:
Radiation
Convection
Conduction
Evaporation
The nurse is planning to use a newborn's foot to obtain blood for the required newborn metabolic testing. The best site to use is the:
Big toe
Foot pad
Inner sole
Outer heel
A newborn weighing 9 pounds, 14 ounces has a cesarean birth because of cephalopelvic disproportion. The baby has an Apgar score of 7 at 1 minute and 9 at 5 minutes. Based on this assessment, an additional measure initiated by the nurse would be the:
Administration of 23% oxygen by hood
Determination of the blood glucose level
Passage of a gavage tube to give a formula feeding
Transfer of the infant to the neonatal intensive care unit
The mother who is formula feeding her 1-month-old infant asks the nurse whether any vitamin or mineral supplements are required. The nurse bases the reply on the knowledge that infants who are fed with ready-to-use formula require:
Iron
Fluoride
Vitamin K
Vitamin B12
On admission to the nursery a newborn is observed to be experiencing cold stress. The basis for the nursing intervention at this time is to minimize:
Shivering
Hyperglycemia
Oxygen consumption
Metabolism of fat stores
A mother asks the neonatal nurse why her infant must be monitored for hypoglycemia when her type 1 diabetes was in excellent control during her pregnancy. The best response by the nurse is:
"Newborns' glucose levels drop after birth, so we are especially cautious with your baby because of your diabetes."
"Newborns' pancreases produce increased amounts of insulin during the first day of birth so we are checking to see if hypoglycemia has occurred."
"Babies of mothers with diabetes do not have a large supply of glucose stores at birth, so it is difficult for them to maintain their blood glucose levels within an acceptable range."
"Babies of mothers with diabetes have a higher than average insulin level because of the glucose received from their mothers during pregnancy, so their glucose level may drop."
In her 36th week of gestation, a client with type 1 diabetes has a 9-pound, 10-ounce infant by cesarean birth. When caring for an infant of a diabetic mother (IDM), the nurse should monitor for signs of:
Meconium ileus
Physiologic jaundice
Increased intracranial pressure
Respiratory distress syndrome
A client at 24 weeks' gestation is admitted in early labor. Based on the nurse's knowledge of preterm births it is understood that:
If contractions are regular, labor cannot effectively be stopped
Birth at this gestational age usually results in a severely compromised neonate
Attempts will be made to sustain the pregnancy for 2 more weeks to ensure neonatal survival
Infants born at 30 to 34 weeks' gestation have a low morbidity rate because of advances in neonatal health care
A client expresses a desire to breastfeed her preterm infant who is in the neonatal intensive care unit (NICU). The nurse should:
Tell the client this is not possible because the infant is being fed by gavage
Discourage the client because of the time and effort it will take to pump her breasts
Support the client's decision and explain that even if her infant is able to breastfeed, the infant may be easily exhausted
Instruct the client that breast milk is inadequate for a preterm infant because it does not contain all the necessary nutrients
A neonate, born at 34 weeks' gestation and weighing 6 pounds, 10 ounces (2750 grams), is admitted to the nursery. The vital signs are apical heart rate 130; respirations 58; blood pressure 60/20; temperature 98° F; Apgar scores of 4 and 8. The nurse should designate the highest priority health outcome to be:
Oxygenation will remain adequate
Body temperature will remain stable
Weight will increase by 30 grams per day
Heart rate will recover to an acceptable range
Respiratory acidosis is confirmed in a neonate with respiratory distress syndrome when the nurse notes that the laboratory report reveals:
A pH of 7.35
A potassium level of 4.6 mEq/L
An elevated PaCO2 of 55 mm Hg
An arterial O2 pressure of 80 mm Hg
When teaching the mother of a newborn with exstrophy of the bladder, the nurse should include how to:
Maintain sterility of the exposed bladder
Measure output from the exposed bladder
Protect the skin surrounding the exposed bladder
Apply a pressure dressing to the exposed bladder
A nursing intervention for a neonate with respiratory distress syndrome should be:
Position to promote respiratory efforts
Observe for possible congenital birth defects
Set the incubator temperature at 85° F to prevent shivering
Avoid handling to minimize stimulation while conserving energy
After an emergency cesarean birth, a neonate born at 35 weeks' gestation, is admitted to the neonatal intensive care unit (NICU). The neonate has a Silverman-Anderson score of 6, which reflects a need for:
Continuous cardiac monitoring
Increased caloric intake and fluids
Assessment of neurologic reflexes
Respiratory support and observation
A client has a girl by cesarean birth. The nurse monitors the newborn's respirations because these infants are more apt to have atelectasis because:
The rib cage is not compressed then released during birth
Oxygen deprivation of the infant occurs following a cesarean birth
The sudden change in temperature at birth causes the infant to aspirate
There is no chance during the birth for gravity to drain the fluid from the lungs